Patricia McGaffigan, RN, MS, CPPS, is IHI's Vice President, Patient Safety Programs. In a new installment of IHI’s Profiles in Improvement series, she describes her health care journey and why the safety movement needs a “reboot.”
How did you begin your career in health care?
I knew in kindergarten that I wanted to be a nurse. My mom has a drawing of mine that says, in the writing of a young child, “When I grow up I want to be a nurse.”
One of my earliest experiences as a student nurse was the privilege of following a baby into surgery. Students in the operating room are repeatedly warned not to go anywhere near sterile fields, or to get too close to people and equipment. I couldn’t see too much of the surgical field, so I tuned into the sounds of the operating room.
I knew that this was one of the first hospitals in the world that was testing a new technology called pulse oximetry. This technology has a beep tone that sounds with each pulse; the tone is higher when oxygen saturation levels are high, and it deepens when oxygen levels begin to drop. At one point during the surgery, I heard the tone begin to deepen. And I remember thinking, “I’m worried. Why isn’t anyone responding?” The pulse kept slowing and the pitch deepened further; ultimately, the baby’s heart stopped beating and resuscitation was begun. The baby was resuscitated very quickly; that’s the good news.
But when we went out to give a report to the parents, the surgeon said, “Everything went fine. Your son’s heart slowed down for a little bit, but everything is fine.” And I remember having this sense of what I now recognize as moral distress about whether that was the right thing to say when the care team actually had to do compressions on the baby’s chest to get his heart started again.
Was this what led you to focus on patient safety?
This experience caused me to think about a lot of things, including what my role was as a student. How could a student possibly speak up? Why wasn’t there an earlier response to the warning sounds? Should the surgeon have described the event to the family differently?
Several years later, while I was in clinical practice and teaching nursing, I received a request to interview for a position with the company that made this very pulse oximeter and was now ready to commercialize it. I had cared for many infants and children with congenital heart defects and lung defects, so I lived oxygenation issues every day, and was now focusing on this area in my faculty responsibilities. I had the right clinical interests and education for a potential transition into the medical device industry.
At the time, such a shift was relatively uncommon, and many of my colleagues saw joining the business world as going over to the “dark side.” My mentor, a faculty member at Boston College, said, “We need nurses like you to do this work and to be in industry. Go do it.” So, I said, okay, I’ll give it one year.
Well, my one year turned into 12. In many ways, this was a move of pure luck; I landed in a company where the leadership, culture, and commitment to our mission was incredibly strong. It was also a time when malpractice premiums related to morbidity and mortality from hypoxemia were at their peak, so there was a clear problem to address. It was life changing to be at the forefront of a movement that declared this type of harm was preventable, and to work with leading safety organizations such as the Anesthesia Patient Safety Foundation on changing the culture.
What led you to the National Patient Safety Foundation (NPSF)?
I had followed the work of NPSF since its founding. I used resources from their website and attended their meetings over the years. Our family’s journey through my daughter’s diagnosis and treatment of ovarian cancer led us to begin volunteering for an ovarian cancer nonprofit, and I became a recipient of the value a nonprofit. Around this time, NPSF had relocated their offices to the Boston area. I responded to a posted job opportunity and joined NPSF in 2012 as a program vice president. My experience as a clinician, educator, business person, safety technology champion, and nonprofit volunteer and beneficiary made this a winning combination in my career path.
How far have we come in the two decades-plus of collective work in patient safety — as a nation, and as an industry?
In 2015 NPSF convened a panel of experts from around the world to ask this very question: Are we any safer today? The panel published a report, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human (the 1999 Institute of Medicine report that put a spotlight on medical errors). The panel’s report found that, when we focus on very circumscribed problems like catheter-related urinary tract infections or ventilator-associated pneumonia, and when we invest in focused, well-defined initiatives, we are making a difference. Such results have helped put safety in the consciousness of our health care system in a meaningful way.
At the same time, our panel concluded that preventable health care error remained unacceptably high. While we have, understandably, focused on specific, targeted initiatives, we have not made wholesale and sustainable progress. We have a long way to go in ensuring that safety is at the core of why every health care organization exists, and what every health care leader believes is their purpose. I describe this as moving safety from a priority to a purpose. A priority is something that we can rate . . . higher or lower. A purpose is timeless and nonnegotiable.
Tell me about the patient safety “reboot” here at IHI.
It’s around taking a firm position that we cannot continue to make progress unless we are committed to a total systems approach to safety. The best of humans under the best of circumstances make errors. We have to accept this reality, as nearly every other industry does, and shore up the systems in which we work to mitigate risk and error.
This reboot involves ensuring that health care leaders and boards commit to zero harm as a core value. It involves being able to understand, create, and sustain cultures of safety within an organization. The culture is set by and dependent upon leaders who recognize that safety is their purpose. It requires looking at safety not just from a departmental or a unit perspective, but spanning the total trajectory of the patient and family through the health care system. Every point a patient touches in their journey requires this leadership commitment and know-how, and we’ve developed resources like our leadership blueprint to ensure that leaders have diagnostic tools and practical recommendations for creating cultures of safety.
What’s an example of something that keeps you up at night — the toughest challenges you see?
Workforce safety keeps me up at night. We know that the physical and emotional safety of our staff are essential to a safe and productive culture. Health care is dangerous environment. Acts of violence and incivility continue to grow, and in response, we are seeing substantial impact on our workforce with respect to burnout, fatigue, injury, absenteeism, presenteeism, attrition, moral distress, depression, and even suicide. We can’t simply put a Band-Aid on these problems; we need to understand and address their root causes, which often tie back to unacceptable leadership and cultural behaviors that have accepted this harm as a collateral part of doing business.
We are working to change this by raising awareness — many boards never see workforce safety dashboards, for example — and by creating zero-tolerance policies for accountability. We’re also working to raise awareness of emotional harm for patients, families, and our workforce.
What are some bright spots you see in patient safety?
A big bright spot is the recognition that patients and families are an integral part of the care team, and that partnering with them as co-designers of their care will only help improve their care and safety. While there’s still a long way to go, we are also seeing an era where expectations for transparency with patients, within and across organizations, and with the public, is expected.
Another bright spot is the reformation of academic professional programs, with a growing focus on interprofessional learning environments, where safety is embedded into the DNA at the most formative stages of students’ careers. Teaching safety from an individual perspective can merely “check the box”; however, the critical role of culture and learning systems is best taught in teams, and is essential for highly reliable care.
I’m excited by signs that patient safety is become its own profession. We have all kinds of pathways to build skills and capability in safety, including credentialing via the Certified Professional in Patient Safety (CPPS) exam. We now have over 2,200 credentialed professionals, and these people have unique and proven skills to be able to lead organizations in safety. And we have a range of offerings for individuals at all levels, from beginners taking our Open School classes to clinicians and senior managers ready for patient safety executive programs.
What are you most excited about?
We just announced the formation of a National Steering Committee to develop a national action plan for patient safety, convening representatives from about 25 organizations from the health care, policy, regulatory, and advocacy communities. This new effort stems from a 2017 NPSF Call to Action that identified preventable harm as a public health crisis.
These organizations, which share similar goals, now have the opportunity to work together to become more united in our efforts, with more wholesale collaboration across key parties. This was a key recommendation from To Err Is Human . . . and while we’ve seen more shared learning and partnership in recent years, this represents a critical milestone; an opportunity for everyone in health care to create a world where patients and those who care for them are free from harm.
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