Profiles in Improvement: Gerald Healy, MD, IHI Senior Fellow

Healy_Gerry.jpgGerald B. Healy, MD, FACS, FRCS(h), FRCSI(h), Emeritus Gerald B. Healy Chair in Otolaryngology, Children's Hospital, Boston, is former Surgeon-in-Chief at Children's and currently Professor of Otology and Laryngology at Harvard Medical School. He has served as president of several associations and societies, including the Massachusetts Chapter of the American College of Surgeons and the American Society of Pediatric Otolaryngology, among others. Dr. Healy was previously Secretary and President of the American Laryngological Association, and Chairman of the Board of Regents and Past-president of the American College of Surgeons. He is an Honorary Fellow of the Royal College of Surgeons in both Ireland and England. An active scholar and lecturer, Dr. Healy publishes extensively in professional journals and books, and he lectures internationally on health care reform, patient safety, the need to restructure medical education, and international medical collaboration. As a Senior Fellow at IHI, Dr. Healy is focusing on surgical safety, peer-review, and quality and safety programming for department chairs.
 
Q: What are the highlights of your work in health care?
 
My passion is centered around patient safety and improving quality and cost effectiveness in care. It’s what drew me to IHI because my goals align with the goals of IHI and its leadership. In the past, the surgical profession has not engaged effectively with IHI so I am trying to promote an improved relationship between the surgical world and IHI’s work. And, at the same time, I am trying to educate IHI about why surgeons are wired so differently than other physicians. 
 
Q: Why do you think surgeons are wired so differently than other physicians?
 
I think it’s an inherent thing that drives people into surgery. Surgeons are usually people who are interested in making decisions quickly, effectively, and executing a plan without a lot of delay. Medical doctors are very used to discussing and thinking. Thus surgical training promotes coming to conclusions and making decisions very quickly. Unfortunately we don’t always make the right ones so one of the characteristics you look for in prospective surgeons is what kind of judgment skills they possess. Having good judgment is also part of making good decisions. I have tried to think about how to process the IHI philosophy with the surgical world and how to bridge this connection? I watch how IHI does its work — with lots of collaborative discussion and input from many parties — and I think the surgical world would approach improvement a little bit differently. I am trying to learn the process that IHI promotes in making decisions on critical events? What drives IHI to conclusions? And how can we take the best elements of that and inject them into the surgical thinking and surgical way of doing things?
 
Q: Was there a turning point in your life that made you become such an advocate for patient safety and quality care?
 
Yes. I actually wrote an Op-Ed for the Boston Globe in January 2008.  It happened when I was a young surgeon in the operating room ― very busy, very rushed. I had a patient with an obstructing cancer of the airway who needed to have a tracheotomy, but it didn’t need to be done that second.  It could’ve been done later that afternoon. But I was busy.  I had to go to the office, I had to do this, do that ― it was all about “I.”  So, I rushed the process. I didn’t have the anesthesiologist that I always worked with on airway cases. I didn’t have the nursing team I usually worked with because they were all at lunch, but that was okay, I thought they were just the people who handed you the instruments and were the appendages to the operation. I thought, “I am the great surgeon and I don’t need all these people.” Well, what happened was the patient had a cardiac arrest. The anesthesiologist on this particular case was inexperienced with airway problems, and the nursing team that was covering during lunch time was from a different service and had never taken care of patients with airway obstruction. None of these people were able to help me because they were inexperienced and I was arrogant!
 
I barely saved this patient and this was a wake-up call for me. I suddenly realized I could have caused this person’s death because, whether it was my ego or my self-centeredness, I was thinking about me and not about the patient. What I did was not in the best interest for that patient and it could have certainly ruined that patient’s and family’s lives; it could have also ruined my career. And at that moment I said, “You had better take a look at where you are headed, this frenzy that you’re in, this treadmill that you’re on, and you need to start changing. You need to educate yourself on proper behavior ― not this concept that you don’t need anyone else because you are so great.”
 
That was my first experience with team training and working with teams in health care. It was my first awakening of stepping back to do the right thing for the patient.  Interestingly enough, a day after I wrote the Op-Ed piece, I got a phone call from the general manager of the Pilgrim Nuclear Power Plant in Plymouth, Massachusetts, who said he was impressed with my patient safety ideas and wanted me to visit the power plant facility to see what they do around safety.  
 
My colleague, Jeff Cooper, who runs the Center for Medical Simulation, and I visited the power plant and spent a whole day there. I was so impressed. They had a simulation center about two miles from the power plant where they completely recreated a control room. They had seven trained teams that run Pilgrim and each team is on for a week at a time, rotating day, night, and so forth. Once every seven weeks, an entire team comes offline and spends a week in the simulation center, simulating potential accidents and how they would deal with them ― a leak in this, a shut down of that, etc.
 
I came away realizing that nuclear power in their hands is far safer than what we were doing in American health care. It was mind boggling. After that, I recognized that health care and medicine had a lot to learn from other industries about safety.
 
Q: Now that you’re working more closely with IHI, what do you think are the best things IHI has to offer?
 
Passion, commitment, engagement, and core values. The commitment and dedication of the people that work at IHI is quite unlike anything I’ve ever seen anywhere else. I don’t think IHI staff look at what they do here as a job, they look at it as a mission. The first or second day I was at IHI was the annual staff retreat. I was quite blown away by the commitment and passion. But I knew right away that surgeons might have a problem being in that room. There were a lot of sticky notes on the walls with various ideas ― surgeons don’t seem to have time for that sort of thing. That doesn’t play in the surgical world. Maybe it needs to find a place. So, I’m working with others at IHI to develop a different way of attracting and engaging surgeons in quality improvement and safety.
 
So many elements of the IHI Improvement Map can be incorporated into the surgical world. They might require a little wordsmithing to be more attractive to surgeons, but many of the improvement ideas would be very useful for surgeons to understand.
 
There are also some things that would be very useful for IHI to consider. For example, what are the impediments to making improvements? I think all of us, IHI included, want to talk about improving outcomes and improving patients’ experiences, but we have to embrace a large family of people to do that. This requires effective teamwork and communication. It would be problematic, for example, to hold surgeons accountable for all the outcomes of surgery because there are a lot of people involved to ensure a positive surgical outcome. For instance, I used to do a lot of reconstructive airway surgery on children that entails a four- to seven-hour operation and then the patient gets admitted to the ICU, where nurses are given specific instructions by the surgeon for post-surgical care. If all the specific care instructions don’t get communicated to the next shift of nurses who come on duty, this can affect the patient’s recovery and outcomes. 
 
The inability to communicate effectively with all members of the care team is an impediment that we ― the collective health care world ― still haven’t figured out how to get right. Handoffs and residents in training, particularly those at big academic centers where most complex operations are done, are key pieces. Care in these centers depends a lot on surgical residents to be the day-to-day, hour-to-hour caregivers, and if a complication arises post-surgery it’s usually the resident on call in the department who is expected to respond if the surgeon is unavailable. The resident may not have participated in the patient’s operation, so may not be familiar with the case. As the surgeon, I need to ask myself, “Have I effectively made the “handoff” to ensure that I’ve transmitted the information the resident and other care team members need to know to effectively care for the patient?”
  
We still have a lot of work to do around team communication, interpersonal skills, handoffs, and so forth in the surgical field. One big obstacle is that surgeons are not trained that way. Historically, most surgical specialties have been like guilds, and if you join the guild you play by its rules. The only two people of primary importance in the surgical encounter are the surgeon and the patient; all others on the care team are peripheral to that relationship.    
 
But that’s not the way it is anymore. In the 21st century, the surgeon is only one player in a much larger process of the surgical encounter that includes numerous others to make it successful. Perhaps the best role for surgeons is to become leaders of what are “high performance teams.” In many ways it is like a pilot ― the pilot is in command of the plane, but if it weren’t for the co-pilot, the flight attendants, and the ground crew, the plane wouldn’t take off. All members of the team are needed for success.  That’s the mentality we need to bring to surgery.
 
Q: What are the main things that you are focusing on here at IHI?
 
There are three main things I am focusing on here at IHI. 
 
First, I am here to form a closer relationship with the American College of Surgeons (ACS) around a program called the National Surgical Quality Improvement Program (NSQIP). It’s a risk-adjusted quality improvement program that enables participating hospitals to improve their surgical outcomes by identifying where their problems are and how they compare to their peers. The program is getting rave reviews and starting to make a difference in cost containment. 
 
However, NSQIP doesn’t tell hospitals how to improve once these problem areas (e.g., surgical site infections) are identified. My hope is that’s where IHI could come in. IHI could partner with the ACS in the NSQIP program to help hospitals identify the most effective ways to make improvements once the problems themselves have been identified.
 
Second, I am working with a team to try to reform the peer-review process for hospitals. We had a unique program with Children’s Hospital in Boston that totally changed the culture around the peer-review process for adverse events from a punitive one to one in which the staff was requesting to present their cases to the peer-review committee. It turned into such a valuable educational experience for care teams.
 
Most adverse events are a confluence of things lining up to have a bad outcome, and not the result of just one person’s actions. The surgeon writes the wrong order, the pharmacist takes it at face value and fills the prescription, and the wrong dose of drug is delivered to the patient. None of the people actually question what they receive. It’s not part of the culture.
 
The team at Children’s turned the punitive peer-review process into an educational program. It ceased being a process based around blame and shame, and became about learning from colleagues’ experiences so the problems could be fixed and prevented from happening again. We would then schedule a meeting in three months to see how the policies we put in place worked. Were things better than before? Did they get worse? It became a very popular process.
 
Now in my work with the ACS, we are trying to develop guidelines to support hospitals in creating cultures that promote educational, non-punitive peer-review processes. This work focuses more on the culture change aspects than on the checklist of items a hospital needs to have in place to do peer review. There is a lot written about that, but not about how you change the culture so that is what the ACS is trying to figure out.
 
Third, I have also been working on the Kaiser Permanente program, specifically on the NSQIP program in their hospitals. They have 33 hospitals, of which 18 are engaged in this program. We’re working on trying to get the rest of their hospitals to buy into this program and have a more uniform process.
 
Q:  One of your interests is surgical education reform. Why is that important?
 
I am concerned for medical students and the disruptive behavior that physicians, can sometimes display. Some surgeons exhibit this inappropriate role-modeling, specifically around anger management.  Some  surgeons may throw instruments when they get angry, or become frustrated when they don’t have the correct instruments or are required to mark the site of surgery themselves. We must start educating medical students early in their education about safety, quality, and professionalism. Dr. Lucian Leape’s publication, “Unmet Needs: Teaching Physicians to Provide Safe Patient Care,” focused on some of these issues. We need to make a better effort to engage students in open discussions about what they observe, what’s right or wrong about their observations, how would they change it if they had an opportunity in leadership, etc. Discussions around such issues are vital and, I would suggest, should also be required. That’s something I hope the IHI Open School can help support, and I’d like to see more surgeons become aware of the IHI Open School and what it has to offer. In addition, I’d also like to see the IHI Open School reach out and more actively engage surgeons and surgical students.
 
References
Healy G. Ending medical errors with airline industry's help. The Boston Globe. January 8, 2008
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