Why It Matters
IHI's Tejal Gandhi shares her thoughts about patient safety's successes, lessons learned, and opportunities to accelerate progress.
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Learning from Patient Safety's Past, Creating Its Future

By Tejal Gandhi | Thursday, May 25, 2017
Learning from the Past, Creating the Future

The 2017 NPSF Patient Safety Congress took place last week in Orlando. This year’s meeting was the first since the NPSF merger with the Institute for Healthcare Improvement, and as such, it was an appropriate time to consider what the patient safety field has achieved thus far and to envision a future we hope for where patients and those who care for them are free from harm.

Free from Harm was the theme this year, and it remains an aspirational vision for the patient safety field. Although it’s never easy to summarize lessons learned from the meeting, I’ve found myself reflecting on a few in particular.

  • The safety roadmap should be re-examined — Don Berwick, MD, MPP, former Administrator of the Centers for Medicare & Medicaid Services and President Emeritus and Senior Fellow at IHI, gave the opening keynote presentation. Providing a short history of the patient safety movement as “an enormous PDSA cycle,” Dr. Berwick noted milestones that helped raise awareness of the human toll of medical error as well as those that helped advance patient safety science and practice.

    More important, he noted some of the missteps along the way, including the separation of safety from quality and the enduring, but wrong, thinking that links error to blame. He remarked on the trend of money driving quality and safety further down the list of priorities as boards and leaders struggle with changing reimbursement models and low morale and burnout among staff.

    “Markets will not solve the patient safety problem,” Dr. Berwick said. “Cooperation, systems thinking, and generosity will.”

    Among his recommendations for moving the field forward: include the patient voice in all matters, develop system-level aims, streamline and improve measures, commit to science, and make safety a matter of “moral values.” Quoting James Reason, he noted that “Safety is not a goal; it is a continually emerging, dynamic property of a system.” That is an important concept for anyone in health care to remember.

Want to shape smarter, safer care for patients? Attend the IHI/NPSF Patient Safety Congress, May 23-25 2018, in Boston, MA. Learn more and register.

  • Safety outside of hospitals needs to be addressed — A breakout track devoted to “Safety Beyond the Walls of the Hospital” drew strong interest from attendees, which is not surprising. It is now widely acknowledged that while we’ve made progress in some areas of patient safety, most of the research, funding, work, and knowledge gained has been in hospitals, while most care is now provided outside of hospitals.

    For example, with a grant from the Moore Foundation, the Institute for Healthcare Improvement/National Patient Safety Foundation is researching challenges associated with home care. Care in the home falls to patients and their family caregivers, but while there may be some comfort in familiar surroundings, risks like falls, infections, and medication errors presented special challenges for caregivers who are unpaid, untrained, and emotionally invested in the work.

    The home environment is less controlled than a health care setting, largely unregulated, and may present particular hazards. With the Bureau of Labor Statistics predicting 5 percent growth in home health services by 2024, it is clear this is an issue that needs further research and focus.
  • Kinder, safer, more effective health care is possible, but achieving it will not be easy — In the closing keynote, Zubin Damania, MD, also known as ZDoggMD (“off-white rapper”), told his personal story of career burnout. Health care 1.0, he said, was his father’s era: A primary care physician could practice independently with a focus on really knowing his or her patients. In our current state, what he calls health care 2.0, doctors spend more time looking at computers than patients and most face productivity pressures.

    When his daughter said she wanted to become a doctor, Dr. Damania realized he didn’t want her to, which led to an internal crisis about his own career.

    It was during this time of introspection that ZDoggMD was born. Using song and video, Dr. Damania reaches people with messaging that is memorable, fun, and provocative.

    At the same time, he created an innovative health care startup that focused on preventive care and social determinants of health as much as on healing the sick. His team included health coaches who talked to patients one-on-one to interpret the doctor’s language and help patients cope with treatment plans. In essence it brought back the relationships of health 1.0 while incorporating current knowledge about nutrition, stress, and prevention. He calls this approach health care 3.0, and it remains a vision for the future.

It’s amazing how quickly three days go by when we are as engaged as we were last week. I really enjoyed meeting so many of the attendees and learning from the presenters. It is never easy to take time away from our regular jobs, but I hope those who attended the Congress came away glad that they did and ready to advance progress in patient safety. We hope to see you next year in Boston for the 20th Annual Congress on May 23-25.

What are your patient safety priorities? Comment on this post below.

Tejal K. Gandhi, MD, MPH, CPPS, is IHI’s Chief Clinical and Safety Officer.

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