Tejal Gandhi, MD, MPH, CPPS, is IHI’s Chief Clinical & Safety Officer and former President and CEO of the National Patient Safety Foundation (NPSF). In the following interview, she describes what she sees ahead for patient safety and how she started her patient safety journey.
What is your vision for what the merged IHI and NPSF can accomplish together?
I think the merged organization can greatly accelerate our efforts to improve patient safety. We’ll have one voice, a stronger voice, and a more unified message. I also think our resources are synergistic, so combining them will make us more effective in many ways. NPSF has always dedicated resources to thought leadership, for example; IHI excels in implementation and has a much broader reach. Combining those strengths, and bringing together all of our collective experts, gives us the potential to figure out how we’re going to advance the movement.
NPSF’s sole focus is patient safety, while IHI’s is using improvement methodology to improve health and health care worldwide. How are these goals in sync?
Patient safety has also been at the heart of IHI’s mission since its founding; it has been an early and constant focus. And ensuring we do no harm is central to improving health and health care. To me, safety is so foundational it spans everything we do to help protect patients and keep people healthy. If you look anywhere in IHI’s portfolio of work — person- and family-centered care, Triple Aim, 100 Million Healthier Lives — safety is a key component. So I see our work as complementary and feel confident that, working together, we will be able to accomplish more, at a faster pace, toward enhancing safety.
Where have we come in the two decades or so of collective work in patient safety? And what does the future look like?
We published a report in 2015, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, in which we looked at that very question. It was written by an expert panel we convened that was co-chaired by Don Berwick (IHI President Emeritus and Senior Fellow), and Kaveh Shojania (editor of BMJ Quality and Safety).
One of our key messages in Free from Harm is that in the last 15 years we have made progress. It’s easy to get frustrated, but we have many examples of progress. The report points to improvements in infections and medication errors resulting from greater use of evidenced-based care, for example.
But to accelerate the pace of progress, we need a new strategy. We have to address safety with a total systems approach, as opposed to the piecemeal, initiative-by-initiative method common today — “Let’s do infections,” “Let’s do medication reconciliation,” “Let’s do surgical checklists.” We must address the foundational areas that are going to raise all boats.
The expert panel laid out eight recommendations tied to those foundational areas, including: create centralized and coordinated oversight of patient safety; create a common set of safety metrics; address safety across the entire care continuum; and support the health care work force. But the number one recommendation, by far, was about leadership and culture: ensure that leaders establish and sustain a culture of safety.
The NPSF Lucian Leape Institute, which is our think tank, is now focusing on leadership and culture as the most critical foundational factors in improving safety. We just released Leading a Culture of Safety: A Blueprint for Success, a report on strategies and tactics to drive culture change, designed for CEOs. It’s the product of an 18-month effort by the Lucian Leape Institute, in partnership with the American College of Healthcare Executives (ACHE). Derek (Feeley, IHI President and CEO) was part of both roundtables of experts that helped create the content of the report. The focus is on practical strategies for CEOs, because we realize we’ve been saying to executives for 15 years, “Create a culture of safety,” but we needed to be clearer about what CEOs actually need to do to accomplish that.
Shifting to a holistic, total systems approach to our safety mission, with a spotlight on leadership and culture, is the direction we’re heading. And really using IHI’s expertise in the areas of leadership and culture, as well as in systems thinking in quality improvement and implementation, will facilitate putting ideas into practice. So that’s work we’re very excited about.
What do you mean when you say that preventable harm in health care is a public health crisis?
This is a message we’ve been promoting for some time, including in the Free from Harm report. We recently published a call to action challenging all stakeholders — health care organizations, leaders, policy makers, foundations, nonprofits — to join together and build a public health campaign targeting patient safety.
The sense of urgency stems in part from estimates of the number of people killed or harmed by medical errors. One in ten patients develops a health care-acquired condition (infection, pressure ulcer, fall, adverse drug event) during hospitalization.
But primarily it’s a recognition that we have to collaborate and, again, start from a total systems perspective. This is not a problem that individual hospitals working individually are going to solve. We need a national set of goals, metrics, and interventions identified in a unified national initiative. And we have models of successful national public health campaigns: think about seat belts or bicycle helmets.
The CDC (Centers for Disease Control and Prevention) led a national effort on reducing hospital-acquired infections, working in partnership with many organizations including the US Department of Labor and the Department of Veterans Affairs. It was a really effective program that led to significant reductions.
So the challenge now is, can we take the CDC infection model and move from a discrete condition like infections to patient safety as a whole?
Tell me about your journey to becoming a physician.
I grew up outside Washington, DC, in the Maryland suburbs, in a family of engineers and computer scientists. But I had a grandfather in India who was a primary care doctor, working for the government. He took care of everybody. People who couldn’t pay with money would bring him food or supplies or nothing at all. I got to see him in action during my family’s visits to India.
I remember going to a little shop one time to buy bangles, and the store owner refused to let me pay for them because I was his doctor’s granddaughter (and my grandfather didn’t charge him for many services). My grandfather had a strong influence on me from a very young age. My mom still has notes I scribbled when I was five years old saying, “I’m going to be a doctor.”
In college, I was drawn to both medicine and computer science. Thinking about graduate school was tough — probably a 50/50 decision. At the last minute I chose medical school, but have maintained my interest in technology, and particularly how it can improve quality and safety.
What led you to patient safety?
I started out in internal medicine and did my residency at Duke. It was a great clinical training experience, but also very challenging. There were the long hours — this was before limits on resident duty hours. Also, there were many times when I felt I was being put in situations where I didn’t feel comfortable, as a trainee, because there wasn’t appropriate supervision. And it was a culture where you didn’t ask for help. (This was not an issue unique to Duke, but was really the way resident trainee programs were run across the country at that time.)
These years provided an early experience of gaps in the health care system, in care delivery and training. And I just kept thinking, “There’s got to be a way to make this a better environment, for me and for my patients.”
I spent part of my residency training at the VA Medical Center in Durham, NC, where, by chance, they were implementing a computerized physician order entry system. So suddenly, here was something that brought together my interests in computer science and improving health care. Watching the system in use, I saw some things that worked well and some that didn’t. But I could tell this would be a really good area for me to study: How could technology make care better? It was a natural fit for me.
Pretty quickly, everyone started saying, “If you’re interested in that, you have to go to Boston and work with David Bates at Brigham and Women’s Hospital.” It made me laugh because, one thing I learned in my medical school years in Boston (at Harvard) was how much I hate cold weather! But eventually I was convinced. I decided, okay, I’ll go north for two years, do my fellowship, and then move somewhere warmer.
It almost worked out that way, because when I’d been working with David for two years, I got a job offer at UCSF (University of California San Francisco). It was so tempting! But I decided to stay in Boston, because David was an amazing mentor, and I knew how important that is, especially when you’re going into academics.
It was the right decision. Here I am, more than 15 years later.
When did you connect safety and improvement science?
During the first summer of my fellowship, I took a course in an MPH program at Harvard taught by Maureen Bisognano (IHI President Emerita and Senior Fellow), which had a profound impact on me. I got to hear from quality pioneers like Brent James and Bob Lloyd, who all talked about drawing from high-reliability industries into health care to make things better.
For me a light bulb went off and I thought, “This makes so much sense.” When I think back on the challenges I faced in my residency, and the systems that didn’t work well, I wondered, “Why can’t medicine be like these other industries?” And I knew this is the field I want to be in.
My research was studying how technology can improve quality and safety in primary care, which was new at the time; the focus in safety had been hospitals. We did some of the earliest work on safety issues in outpatient settings, publishing studies on adverse drug events, diagnostic error, test result follow-up, and medication decision support, in the New England Journal of Medicine and other peer-reviewed journals.
At some point I started realizing, it’s one thing to write a paper, but how do you actually implement change? Who’s doing the work to implement what we’re saying people need to do? So I got interested in operations. I wrote a proposal to create a safety team at Brigham and Women’s around 2000 and was named the first Director of Safety in the hospital’s first patient safety program.
There was no playbook for this, and I was only funded for 20 percent of my time, with two FTEs in support. My small team and I just had to figure out how we were going to build a safety program. It was really exciting and fun. I give a lot of credit to the Brigham leadership; they really stepped up. Today, people can’t imagine a time when there wasn’t a safety program.
So I did that for about 10 years, then I became Chief Quality and Safety Officer for Partners HealthCare, the parent organization of Brigham and Women’s, because I got interested in how you think about safety at a health system level. And then, in 2013 NPSF came calling, and I couldn’t pass up the chance to do this work at a national level.
What keeps you up at night — what are the toughest challenges you see on the patient safety and health & health care quality landscape?
Lots of things. For safety, what worries me is the “been there, done that” attitude. Because as I said earlier, we have made progress. We have safety tools and programs, and hospitals have patient safety officers and patient safety departments. Twenty years ago, none of this existed. But the positive changes also make it easy for clinicians and leaders to move on to other problems. Patient safety isn’t in the spotlight anymore, but we still have so much work to do.
This hits home for me every time I talk to anyone who’s had a family member hospitalized. Everyone has a story, including me. My mother had surgery in April and a lot of things didn’t go exactly right. And I was there at the bedside advocating for her. What keeps me up at night is, most people don’t have advocates like me at their bedside. So, if things are not going correctly with someone like me at the bedside, then what is happening for everybody else?
I also see the focus on health versus illness as critical: the need to change the way we reimburse so we put the value on keeping people healthy as opposed to taking care of them when they get sick. Not that that’s not important. But the whole system is set up to care for people when they’re really sick, yet we should be focusing on prevention and public health strategies.
I think about that same thing in safety. Today, safety is very reactive: people get harmed and then we react. We need to move to prevention, how we prevent the harm in the first place.
What are you most excited about?
I‘m excited about the potential to have more impact. It’s all about what we can do to help patients have safer, healthier lives. So the IHI-NPSF merger really excites me because I feel like the impact can be greater. And for me personally, I’m excited about a learning curve, because there’s so much at IHI that I do not know about. It’s going to be like drinking from a firehose, but that’s the fun part.