Author + information
- Prashant Vaishnava, MD∗ ()
- Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Medical Center, New York, New York
- ↵∗Reprint requests and correspondence:
Dr. Prashant Vaishnava, The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Medical Center, 1468 Madison Avenue, Box 1030, New York, New York 10029.
I recently accepted a new role to serve as a quality officer at my institution. In this role, I have been charged with a range of responsibilities, from oversight of our performance on quality indicators, such as medication errors, to patient satisfaction. I have been struggling to understand why we, as a profession, fall short on such common and simple metrics as hand hygiene compliance—which is routinely in the range of 40% (1). In trying to understand why we are not doing better with such simple compliance issues as hand washing, I think back several years.
I vividly remember my first day of internship. I recall the camaraderie of the time, the fear and elation of carrying a pager, and the shallow white coat pockets overflowing with papers and handbooks. From this time, there is an incident that has stayed with me. I called a fellow to request a consult. In my naïveté, I did not think it would matter that I was calling “late” in the evening. I fully expected a friend at the other end, a colleague excited to lend a helping hand. Instead, I had awakened a hibernating bear, grumpy and vocal about the lateness of the consult and my inadequacies as a physician who could not manage the issue by himself. Left in tears, I was not even capable of a response as he flatly refused to see my patient. My supervising resident at the time was very sympathetic, but not surprised. I was encouraged to move on and not be affected by such interactions that were not rare and actually part of an intern’s life. One sage resident told me that I had something to learn from every colleague and consultant; sometimes that something was how not to act. For weeks following this incident, I was nervous when calling in consults. As months passed, my skin grew thicker and the fear subsided, although there continued to be less-than-pleasant interactions with some consultants. As a fellow—often overwhelmed—I found myself sometimes fractious when accepting consults.
When considering quality and safety in health care, I cannot help but recall these formative experiences. We are sometimes forced to accept a culture of intimidation from some consultants, and as a participant of this culture, we need to acknowledge our short-temperedness when responding to clinical requests. My interaction on my first day of internship is especially memorable, because it was discordant with what I expected as an eager, unjaded intern. Were we not all thrilled to be providers and eager to help each other? I entered internship with high expectations that I ultimately had to dilute. I had to establish lower expectations, accepting a different culture in which such interactions were part of the norm.
But how can health care achieve near-zero patient harm and cultivate a culture of safety when we lower our expectations from our first days of care-taking? Shades of unprofessionalism stymie our ability to achieve near-perfect safety and near-zero harm. Health care stands in sharp contrast to other industries, like commercial aviation or nuclear power, which are able to operate under dangerous conditions but achieve an exceptional margin of safety (2). Health care is sapped by such iatrogenic difficulties as health care–associated infections, preventable medication errors, flawed handoffs, imperfect transitions of care, inadequate hand hygiene, and alarm fatigue. The list goes on. My view on why health care may differ from other industries that achieve high reliability and superior performance is that we are standing in our own way.
In the current landscape, where many of us are victims to intimidating behavior, it is not surprising that we have difficulty in attaining “collective mindfulness,” which has been described as a culture in which all workers or participants report small problems or unsafe conditions before they escalate into larger risks (2). In describing the attributes of a culture of safety, Reason and Hobbs (3) draw attention to the centrality of trust in an organization. The elimination of intimidating behavior is 1 prerequisite to building trust, where workers trust each other and their organization to recognize, report, and respond to errors. Consider modern aviation as an enterprise that displays remarkable safety, with 1 passenger’s life lost per 10 million flights, compared with the health care industry, where 13.5% of hospitalized Medicare beneficiaries experience an adverse event (4). Counter-heroism is a key tenet of safety in public transport aviation (5). The principle of counter-heroism shifts the onus away from individual pilots and emphasizes team dynamics. If a problem is encountered in flight, a pilot’s response is to follow a standardized set of procedures; in contrast, the response in medicine is often not so homogenous or predictable. Improvised reactions, though ingenuous and often successful, may perpetuate a culture of heroism and discourage others from being vocal about perceived errors. An ethos of counter-heroism diminishes the expectation out of a select group and shifts the emphasis to a team that is “collectively mindful.”
The path to health care quality—getting the right care to the right patient at the right time (6)—begins with a cultural shift away from accepting low expectations from each other. It is not acceptable to intimidate each other; intimidation is a significant barrier to building and sustaining a culture of safety in health care.
The achievement of patient safety and quality starts with us; let us challenge ourselves to be professional, kind, and collegial in all interactions. Such a demeanor is a prerequisite to nurturing a culture of safety for our patients. Maybe we would wash our hands more than 40% of the time if we felt empowered to tell each other when we did not.
RESPONSE: Safety and Trust, Above All Else
Dr. Vaishnava discusses the importance of building trust in the delivery of safe and quality care. Trust remains an essential element in medicine and is the core of our professionalism as physicians. As health care rapidly transforms from volume- to value-based metrics, we will be challenged, measured, and judged in ways that may feel uncomfortable. Appropriate use, readmission rates, and performance score cards will not only be commonplace, but likely will be tied to reimbursement and efforts focused on cost savings. Importantly, we need to remind ourselves of our role as physicians to be patient advocates, as well as stewards of supportive, interdisciplinary care in the midst of complex health care systems. Patient safety needs to be a critical focus of excellent patient-centered care. We are taught early in our careers the Latin phrase primum non nocere, “first do no harm.” In cardiology, we should continue to reduce radiation doses delivered during imaging, preventable drug interactions, and procedure-related complications.
Dr. Vaishnava mentions barriers to patient safety, including the lack of effective teamwork and a culture of heroism. Since 2007, I have had the privilege of serving as a society mentor for medical students in Emory’s small group-based curriculum. This past week, in a gathering of our group to both congratulate the M2’s on completing Step I of their boards and to provide them with a “pep talk” as they embark upon their clinical journey in medicine, I shared with them the same message I have shared with students past: “Being a good doctor is not about you.” Being a good doctor is about caring for your patients and your colleagues. A culture of safety and trust is imperative. However, to deliver safe, cost-effective care, more will be needed. In cardiology, we have appropriately focused on exploring the biology of vulnerable plaques in addition to identifying and treating vulnerable patients. We must, though, recognize that there are vulnerable circumstances in health care delivery, such as care transitions that increase the likelihood for predictable and preventable safety issues. We must first identify safety concerns and then create strategies to eliminate them. As in the commercial aviation and nuclear power industries, we must shift our focus away from individuals to teams, in addition to the development of effectively implemented processes and systems. Registries and performance measures will inform us. Moreover, implementation scientists, systems engineers, and technology-supported information ecosystems will be required to improve quality, safety, and ultimately, trust (1).
Expectations for safety and quality have never been more rigorous. Our patients, communities, and payers are demanding new approaches to the delivery of health care for both individual and economic reasons. It is critical that we acknowledge and address our challenges. We should embrace the importance of safety for our patients and provide leadership in this transformative time. Although medicine is swiftly changing, we must not lose sight of the importance of safety and trust, above all else.
- American College of Cardiology Foundation
- Reason J.,
- Hobbs A.
- ↵Levinson DR. Adverse Events in Hospitals: National Incidence among Medicare beneficiaries. 2010. Available at: http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf. Accessed February 28, 2015.
- ↵Clancy CM. What Is Health Care Quality and Who Decides? Statement to Committee on Finance Subcommittee on Health Care. United States Senate. March 18, 2009.