Challenges in patient safety and quality: replacing discouragement with hope.

"Trying to achieve safety and quality in health care is continuously frustrating."

"We have to care before we can improve, and I don't see a lot of caring."

"Improving safety and quality is simply ... overwhelming!"

Do you identify with the frustrations expressed by these physician leaders? Are their laments depressingly familiar? Are you too overwhelmed by the obstacles to achieving safety and quality in your organization? If so, you're not alone.

A majority of ACPE Quality of Care Survey respondents said they have struggled with finding an appropriate balance between what they believe is best for patients and what's best for their health care organization when it comes to implementing patient safety and quality initiatives.

Given the very real obstacles to patient safety and quality care, what is the best course of action? After all, there are no "Get Out of Jail Free" cards for physician executives. You don't get to bypass safety and quality initiatives just because they're difficult to design and implement.

We asked four physician executives to share their successes in overcoming the all-too-common obstacles to quality and patient safety. We think you'll find their collective experience illuminating. We hope it restores your sense of hope. Remember, big change is often realized with a series of very small steps.

Physician engagement

Lack of physician engagement is a substantial barrier to effective implementation of quality and safety initiatives, according to a majority of survey respondents. Almost one third consider physician resistance to the use of evidence-based care to be a major obstacle in their institutions.

Only 34 percent reported that physicians were very supportive of quality and patient safety improvement projects. When asked to share their opinions on the obstacles in general, a number complained that physicians refused to adhere to program interventions and required documentation, that overcoming resistance to standardization was a major problem, and that their physicians were "too busy and not taking the problem seriously."

William Thomas, MD, FACP, executive vice president of medical affairs at MedStar Health in Columbia, Maryland, believes that the key to physician engagement is asking "the right question in the right way."

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In his experience, physicians are quick to become involved when initiatives are conceived and implemented in ways that approach the system as a whole--rather than the particular portion in which the physician is involved--and when they offer opportunities for physicians to help design processes to solve the identified inefficiencies.

An important role of the physician executive, Thomas asserts, is helping physicians to become involved by selecting problems to address for which the solutions will both improve care and provide a benefit to the physicians--in time or practice efficiency, for example.

Steven Tremain, MD, CPE, FACPE, senior medical director and director of system redesign at Contra Costa Regional Medical Center and Health Centers, in Martinez, California, also finds a WIIFM (What's In It For Me?) focus to be essential to physician engagement.

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He described an initiative to improve medication reconciliation that improved care and reduced paperwork for physicians. Prior to the intervention, medications were listed in at least three locations: within the history and physical section of the patient's chart, on the physician order form, and on the nursing intake form. Systematic crosschecking between the lists was not performed.

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Using rapid cycles of change (six cycles within the first two weeks), the group created a single form that is placed on top of the physician order sheet--in the path of their customary work stream. This form serves as the history and the reconciliation form, and is used by the nurses to crosscheck with the intake form.

Since use of the single form was instituted two years ago, the percentage of patients with every medication reconciled on admission has increased from 47 percent to 95 percent.

Another component that Tremain finds essential to engagement is providing physicians with adequate data--both in the form of evidence-based literature on particular clinical issues and data on the practice of other physicians.

"Don't go in with a stick," he warns. "Instead, give physicians information and provide them with leadership." It's important to provide information on improvement methodologies as well, according to Tremain. "Don't tell them 'to do better,' show them how others have done it."

Barry Silbaugh, MD, MS, FACPE, senior healthcare partner at the Creative Management Group in Sandia Park, New Mexico, also believes that education is a key component to physician engagement.

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He recommends training physicians on the use of a specific improvement methodology, such as LEAN, Six Sigma, or methodologies developed by the Institute for Healthcare Improvement (IHI).

But what should a physician leader do when nurses are frustrated and ready to institute change, but physicians are satisfied with the status quo?

When professionals are at differing levels of engagement with an initiative, Silbaugh tactfully points out that frustration indicates a problem in the process, a waste or inefficiency, and is reflective of a issue that needs to be addressed.

Once the issue is seen in such a way, Silbaugh finds that physicians do step up to the plate. In his experience most physicians have an innate desire to help fix problems. He uses this insight to encourage their engagement. Silbaugh also steers the attention of nursing and medical staff to the patient experience--a focus that serves as a common ground for all professionals and encourages their support.

Culture of safety

Two significant obstacles to establishing and maintaining a culture of safety exist in health care: a pervasive culture of blame that hinders acknowledgment of error, and professional "silos" that slow the process of instituting change. (1)

And, as one survey respondent articulated, implementing quality improvement programs without a culture of safety doesn't translate into safety for patients: "I don't think the difference in a culture of safety and culture of quality is distinct enough yet in people's mind. We can be putting quality improvement measures in place, and still be unsafe. We need to do both."

Silbaugh finds the Hospital Survey on Patient Safety developed by the Agency for Healthcare Research and Quality (ARHQ; available at http://www.ahrq.gov/QUAL/hospculture/) to be a useful tool for assessing an organization's culture at baseline.

Using the survey helped one organization he worked with identify four key areas of frustration:

1. Handoffs and transitions

2. Teamwork across clinical units

3. Desire for a non-punitive atmosphere

4. Staffing concerns

Tying executive compensation to improvements in some of these problem areas provided effective organizational incentives for safety.

In his work with the safety program at a national health care system, Silbaugh recommended addressing critical communication issues by forming rapid response teams at each hospital within the system and improving system-wide communication about safety.

First, the formation of rapid response teams at every hospital in the system enhanced front-line, or bedside, communication. Although the composition of the teams at each hospital varied in size, health professional availability and medical staff preferences, the goals of each team were the same: respond quickly to safety issues and have a standardized, non-punitive approach to "uphill communication."

Uphill communication is the sharing of concerns or questions with an individual in a superior role of authority. The group was awarded a grant from the Robert Wood Johnson Foundation to help train clinical leaders and track results, illustrating the importance of this work.

Second, Silbaugh and his colleagues reviewed the timeliness of system-wide communication about safety hazards and the appropriateness of resulting action steps. As a result of this analysis, they were able to trim months off the average time for adverse events reports to reach senior clinical and risk management executives--exemplifying the importance of a culture of safety and quality in rapid "uphill" travel of such information.

The team also decided to use a one-page safety alert to warn staff in system hospitals about potential safety issues, whenever an issue of high importance came to their attention. At one hospital, an operating room nurse discovered that only one of the surgical site marker pens used at the hospital was clearly visible on the skin after a routine surgical prep. This information--along with a picture of the intact and faded markings--was emailed to the system hospitals. Use of the non-fading marking pen subsequently increased throughout the system.

Richard Guthrie, MD, medical director at the Ochsner Medical Center in New Orleans, looks to other high-risk industries for insights applicable to the development of a culture of safety in medicine.

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Aeronautics is a field that maintains a high level of accountability and sets the expectation that the goal for adverse events is zero. Airlines don't set a goal of reducing in-air collisions by 75 percent, he points out. Instead, they set the bar at zero and pursue activities to attain that goal.

Guthrie admits that creating the same sort of accountability links in medicine is challenging due to the complexity and lack of predictability inherent in patient care. However, he believes that medical staff can be held accountable for providing quality care and for reaching measurable targeted goals.

Resources

Lack of resources--time, staff, funding--is a common challenge, according to survey responders. As Tremain puts it, "Quality doesn't come free. Hospitals must dedicate resources to quality and patient safety initiatives." However, demonstrating the return on investment (ROI) on quality and safety initiatives can be difficult. Tremain observes that "the cost of these programs is finite, but the return is abstract."

It is possible, however, to document the savings associated with improved quality. Tremain helped facilitate an initiative to reduce ventilator-associated pneumonia (VAP) in his organization. By implementing elements of standardized care with an opt-in protocol, the cases of VAP declined from 20 per 1,000 to 8 per 1,000 ventilator-days.

Bundling these elements together and using an opt-out protocol reduced the rate to just 1 case per 1,000 ventilator-days. Tremain estimates that 9 fewer VAP cases over a two-year period translates into a savings of $400,000 to his organization.

Silbaugh also has documented a positive ROI for quality programs at institutions with which he's worked.

At one hospital emergency department (ED), the staff decided to find a solution to the high dissatisfaction with wait times and unacceptable elopement rates. Although the hospital incurred upfront personnel and equipment costs to implement bedside registration, the changes translated into more ED visits and an incremental increase in admissions. In addition, the overall financial impact on the system as a whole was positive when patients flowed through the ED faster.

Tremain said it's critical to have your chief financial officer on board with your improvement goals. To get funding and dedicated staff time, he or she must be one of your stakeholders for change.

Unexplained variance in care

Unexplained variance in care was reported to be a major problem by almost one third of survey respondents and sometimes a problem by an additional 61 percent. Many respondents described reluctance on the part of physicians at their organizations to providing standardized care.

As one respondent stated, "Physicians do not want to follow the guidelines that we set forth."

Another replied similarly, "We have a number of physicians in our multispecialty group that act more as independent practitioners. When it comes to standardizing treatments or care plans, they want to do it in their own way, rather than use evidence-based medicine."

For physicians who remain resistant to the notion of standardization of care, likening it to "cookbook medicine," Thomas has this rejoinder: "We were taught cookbook medicine in training--from our mentors. That type of 'cookbook medicine' just wasn't written down."

According to Thomas, the goal of standardization is not to limit care options, but to hold physicians accountable for use of best practices and for explaining exceptions to their use. He added, "If there is a poor outcome, we want you to go back and look at what happened."

Thomas provided proof of the strength of standardization in reducing avoidable errors. A system-wide obstetrical physician-nurse team was created at his organization to improve perinatal care. The teams implemented care guidelines that were conceived as opt-in rather than opt-out protocols. The teams worked diligently implementing a variety of initiatives and as a result reduced the number of obstetric malpractice claims by approximately 75 percent over the past five years.

Tremain pointed out that physicians can use their well-honed clinical skills to identify characteristics about a particular case that would necessitate deviation from a standard care set.

"We need to focus physician skills on the places where patient exceptions occur or where are no bundles of care." He predicted that once data on physician practices are made more transparent through Centers for Medicaid and Medicare report cards and other means, patients will seek out physicians who provide an individualized connection with the patient--and also deliver evidence-based standardized care.

Patient flow problems

Over 90 percent of survey respondents reported that patient flow is a problem at their institutions. For the vast majority of physician leaders, backlogs in patient flow, especially from the ED to the inpatient floors, is a major headache.

Silbaugh found that the ED at one hospital for which he consulted was an optimal setting for a quality improvement project: both the staff and the hospital CEO were frustrated with the current state of affairs. In addition, the physician who chaired the ED was interested in applying improvement principles gleaned from other industries.

Using value stream mapping to find inefficiencies in the care processes within the ED, the group set out to determine the amount of time wasted from both patient and staff perspectives.

Value stream mapping is a methodology that involves plotting the time spent by a patient or a staff member over the course of a visit. Time spent is then divided into segments and assessed for waste and inefficiency.

Silbaugh and his colleagues--stopwatches in hand--charted the course of patients through the ED and carefully considered what processes added the most value to the patient. They also conducted value stream mapping with key members of the ED, literally documenting their travels on a floor plan of the unit.

The group then used small and rapid cycles of change to evaluate potential improvements. Overall, the group reduced the average wait time in the ED by 50 percent--a reduction that has been sustained for three years.

Silbaugh found that an initial obstacle to the project was the tendency to blame long wait times on other hospital departments--radiology, for example. He encouraged the improvement group to keep their focus squarely on the activities over which they had control.

Interestingly, the group discovered that once they addressed the ED inefficiencies, problems in other departments became all the more obvious. In this case, the radiology department embarked on a similar improvement process, following the lead of the ED staff.

Physician executives as change agents

Guthrie believes that his primary role as a physician executive is to help physicians understand a new-way of thinking about patient care. Until about a decade ago, Guthrie maintains, the physician approach to quality was to be devoted to improving care, becoming well-educated about the relevant issue or problem, choosing what appeared to be the best clinical path, implementing the appropriate changes, and evaluating how much he or she improved the situation.

Using this model, physicians could be pleased with a 60 percent reduction in adverse events, regardless of what the ideal goal should have been. Such an approach has been ingrained in physicians by societal expectations and training.

Through experiences in medical school, residency, fellowship training, and practice, physicians are taught, Guthrie asserts, to approach each patient as an individual and to use an independent provider mentality in choosing among diagnostic and treatment options. Rather than using the one-patient-one-doctor model, physicians now must consider in a general sense the best way to consistently and predictably treat patients with a particular condition.

The modern approach to quality, Guthrie believes, requires the development and use of standardized care, with exceptions used only as needed due to patient-related factors. He points out that other high-risk industries start with the endpoint in mind, decide on target goals, and develop processes based on these targets.

When adapted to medicine, this would mean approaching all patients with pneumonia, for example, in the same way, unless a patient-related factor indicated the need for a variation from care guidelines. Such an approach would involve planning an end goal, such as "This patient will not die and will be discharged in eight days," and then planning processes to achieve these goals.

This scenario may seem farfetched, but it well illustrates the type of thinking necessary for achieving maximum success in quality improvement. Better approaches to quality also require the choice of the right end goal. Rather than striving for a 60 percent reduction in central line infections, for example, institutions using this approach would aim to achieve zero central line infections.

The shift to standardized processes and planning with the end goal in mind is essential, Guthrie believes, for physicians to be able to provide quality care and to be effective leaders, because the same underlying principles applies to both quality and leadership.

In his organization, Guthrie has fostered this shift in physician understanding through mentoring. Previously, he had 30 to 40 department chairs directly reporting to him--too many to provide direct mentoring.

To remedy the situation, Guthrie named five associate medical directors. These physician leaders mentor and lead the chairs of the various clinical departments, who in turn spread key quality and leadership principles to others. The department heads work with pre-established annual goals and are held accountable for meeting these goals.

Soon Guthrie will begin applying the same goal-setting and accountability principles to all clinicians, with performance reviews based on goals set at the beginning of the year. Guthrie emphasizes that goal-setting and accountability are not used in a punitive fashion, but to provide both physicians and physician leaders with clear expectations about their roles and priorities, honest feedback on their performance, and a means for identifying opportunities to improve.

The ACPE Quality of Care Survey demonstrates that physicians executives are frustrated by a number of barriers to providing quality care and ensuring patient safety within their institutions. Fellow physician leaders have much to teach about effective ways to overcome these challenges. (1)

In addition to adapting their specific interventions to your own institution, ask yourself these questions:

* Have I accepted that increased accountability is the way of the future?

* Am I prepared to foster change?

* Do I have the skills I need to effectively lead other physicians?

* Do I know enough about improvement methodologies to apply them and to teach them to others?

* Do I blame individuals for errors that are due to ineffective systems?

* Do I know how to ask the right questions in the right ways to engage physicians in quality and safety initiatives?

* Do I blame other departments to avoid focusing on areas under my control?

As a physician executive, you have an opportunity to help your physician colleagues navigate the changing environment that is medicine today. And by proactively fostering change, you can begin to replace discouragement with hope for the future.

Diane Shannon, MD, MPH, is a freelance medical writer. She can be reached at [e-mail]

References

1 Pizzi LT, Goldfarb NI, Nash DB. Promoting a culture of Safety. In: ARHQ. Evidence Report No. 43. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Available at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1.section.61719. Accessed March 11, 2007.

By Diane Shannon, MD, MPH