Encouraging, promoting, and supporting the development of current and future leaders in patient safety activities is one of the important missions of the Anesthesia Patient Safety Foundation. A significant element of this effort has been the APSF sponsorship of participants in a fellowship program for the training and development of leaders in patient safety. That fellowship program was organized by the Health Research & Educational Trust (HRET) under the joint sponsorship of the American Hospital Association (AHA) and the National Patient Safety Foundation (NPSF). This article includes reflections on that experience in years past and also the general concept of patient safety leadership development from 4 APSF-affiliated fellowship participants.
Leading the Way in Patient Safety
As the most recent recipient of the Ellison C. “Jeep” Pierce Scholarship for the Comprehensive Patient Safety Leadership Fellowship of the AHA/NPSF, I offer a summary of effective strategies for becoming a leader in patient safety. In doing so, I hope to foster the interest that others may have in this developing field. One of the best ways to start would be to quote Dr. Pierce, when he eloquently stated, “Patient safety is not a fad. It is not a preoccupation of the past. It is not an objective that has been fulfilled or a reflection of a problem that has been solved. Patient safety is an ongoing necessity. It must be sustained by research, training, and daily application in the workplace.”1 The goal in patient safety efforts should be to prevent harm to our future patients, not simply reviewing incidents, which have already occurred.
Among many things learned in the leadership fellowship was a broad perspective on the basic concepts of patient safety. A logical way to organize patient safety efforts can be to break them down to the categories of people, processes, and product. Several types of people are stakeholders in patient safety. First and foremost is the patient; after all, the patient has the most to gain from a safe medical experience and, of course, the most to lose. Patients must be involved in the safety process; for instance, hospital patient safety committees should have patient representatives. Patients often give a unique perspective quite different from those of clinicians. Patients and their families can also become engaged in the safety process. One hospital executive told me that when his wife was in the hospital, the hand hygiene compliance rate was 100%. This was due to his asking everyone who came into the room if they had washed their hands and if not, to please do so. It was not because of training, policy, or even his leadership position. Surgical patients can be given a set of questions on a card that prompts them to ask questions such as, “Will you use a surgical checklist before my surgery?” or, “What is the plan for antibiotics?” Patients or families can also become a voice after a medical error. For instance, they can participate in the root cause analysis (RCA). Nothing is a more compelling story than listening to the patients relate what happened during their care. Patients want their providers to get the message that mistakes made should not happen again. Involving patients in the improvement process allows them to tell their stories and see first-hand that improvements are made.
Providers are other key stakeholders in patient safety. They should blend knowledge, experience, teamwork, and technology to create a maximally safe environment for patients. Knowledge can be maintained by keeping up with the latest professional guidelines for evidence-based practice, participating in courses and classes that focus on patient safety, or even by obtaining one of the many types of certification in patient safety offered by various national organizations. Experience may improve patient safety via the reporting of threats to the safety, whether by institutional incident reporting systems or by departmental conference presentations. Experience does not have to be at the expense of real patients; simulations and drills should be used to refine skills and identify opportunities for improvement.
Providers must incorporate others in their efforts and foster teamwork. Effective teams have a clear leader, clear goals, a cause greater than themselves, willingness to fight, standards of excellence, and team members who actually can interact with mutual respect. Providers should also “keep up with the times.” We must constantly explore new technology, which supports safer care for the patient. Modern communication devices can allow us access to nearly unlimited information and puts references at our fingertips. However, this technology can also become a distraction if not used strategically and at appropriate times. Advances in artificial reasoning and intelligence can analyze data presented either by direct entry or even with image acquisition. For example, analytical software can detect several subclinical changes in vital signs and other measured clinical variables and subsequently alert clinicians to impending shock or respiratory failure well before it is evident to the human provider. Safe practitioners should critically appraise this technology and embrace useful devices and not hide behind the concept of “that is how we have always done things.”
We need safety leaders to lead by example. We also need facilities and institutions to support endeavors in patient safety. It is the most important core value within any health care practice. Executives should stand behind employees who chose safety over taking the easy way or cutting corners (particularly in the name of cost-savings). Managers should reinforce sound decisions and examine cases where unsafe practices and resulting near misses arise. Academic institutions should lead by factoring in formal efforts in patient safety by faculty as promotion criteria. Leaders should be chosen based upon how they foster the safety culture.
Processes should be developed to decrease or eliminate opportunities for human error to be introduced (preventing the alignment of the holes in James Reason’s Swiss cheese model).2 Many times root cause analysis outcomes suggest further training of personnel or the development of policies and training sessions, but these are seldom effective. In all likelihood, the only effective means of prevention is to design products and use “smart” devices that help prevent the creep of human error. Error proofing by engineering and design is a concept used in other high reliability organizations, which could easily be incorporated into the practice of medicine and nursing.2
Best practices should not be kept as proprietary trade secrets, but rather shared for the benefit of all patients everywhere. Safe practices usually become the most cost effective and efficient manner of doing things. As an example, a simple pre-incision time-out can identify issues such as availability of instruments and blood products and anticipated complications; this simple step can reduce non-productive surgical time. These pauses in relevant cases can also identify issues such as the presence of high risk for a surgical fire and the plans to mitigate such a situation
One of my mentors told me once: “You are only as good as your last anesthetic given.” Current business trends are certainly reinforcing that statement. Most of us are using TripAdvisor or similar sites to review travelers’ experiences with hotels and resorts; Yelp and Chowhound let us know what others have experienced in helping make restaurant-dining decisions. Consumers of health care are from the same population. Now care providers can plug their own name or facility into a search engine and instantly find sites that rate them based on patients’ experience. Blogs are commonplace among those with chronic diseases, and they will name providers with whom they are satisfied (or dissatisfied). Government agencies and accreditors are maintaining searchable databases to catalogue outcomes information. We should seek out those who are highly rated and see what they are doing and see if we can replicate or even improve their methods of care delivery. Everyone knows the professionals we personally see or to whom we refer our family members. It is time to critically examine what makes those folks different. What is it exactly that make us believe they are highly qualified and safe practitioners? Professional societies promulgate guidelines and practice advisories to guide us on the safest manner of care and, although there maybe the few patients whose care doesn’t quite fit the guideline, for the most part these protocols can be used as a routine and efficient way to practice anesthesia care.
Finally, I never set out with a goal in life to be a leader in patient safety. However, I learned that by always choosing the safer way to approach patient care and leading by example, co-workers and even administrative leaders will seek you out for solutions to safety issues. Being a patient safety leader is not a title, but rather a mindset for how you take care of patients, interact with others, and teach by example.
Additional Aspects Added
In spite of best patient safety efforts, the seminal Institute of Medicine report from 1999, “To Err is Human,” reported that as many as 98,000 U.S. patient deaths annually could be attributed to medical error.3 With improved event reporting and transparency, this estimate of catastrophic harm has recently been increased to greater than 200,000 U.S. annual patient deaths.4 The magnitude of the numbers reported defies comprehension and becomes impersonal; however, every death represents a personal patient safety “story.” Every one of these patient safety “stories” are multifaceted, and all too often the resultant emotional harm not only touches the affected patients and family members but also the involved caregivers and organizations at-large. In addition to the impact that catastrophic adverse events have on patients and families, the impact that these events have on providers and their ability to provide safe care in the aftermath has only recently been recognized.
While it is essential for patient safety leaders to employ effective strategies and tactics to improve patient safety and prevent future patient harm, the Patient Safety Leadership Fellowship impressed upon me the need for patient safety leaders to also implement support initiatives when these preventive patient safety measures fail. Research has increasingly demonstrated the scarcity of formal organizational support programs available to impacted care providers after adverse events, and the potential risk that this gap poses in enabling them to return to their emotional and functional baseline of providing safe patient care.
The availability of support services and the provision of a support venue that is safe and accessible are essential for those who are accustomed to working in a culture that retains strong elements of autonomy and individual blame. Implementing a peer support program, where care providers are trained to provide “emotional first aid” to colleagues impacted by adverse patient events, can serve as an important entry point into a more comprehensive organizational support response. Patient safety leaders must leverage their skills and their understanding of organizational dynamics, system-based improvement, and human emotion to create this needed support. Combined with a strong commitment to the prevention of harm, enabling a supportive environment at the sharp end of care, particularly in the aftermath of a catastrophic event, provides a holistic patient safety approach, which is a critical step in the ongoing transformation of health care.
Defining and Extracting Patient Safety
For a long time, I had a difficult time defining what “patient safety” really was. With all due respect to the United States Supreme Court and Justice Stewart, “I knew safety when I saw it,” and more importantly, I saw what was NOT safety. Patient safety may be, in most people’s minds, the concept that if everything is done correctly to (and for) a patient, then the result is “good” and that the patient “will do well.” This definition does not work nearly as well in some specialties like anesthesiology, since our patients’ outcomes are not always “good”: sometimes, our patients do not do well intraoperatively or postoperatively, not because of our lack of providing sufficient safety, but because of the patients’ own disease. Safety means much more than a good patient outcome without complications—we have all been involved in caring for patients in various circumstances in which major errors were committed, yet the patients withstood the insults without negative sequela. Does this mean that the care we provided was “safe”?
The Patient Safety Leadership Fellowship did for my professional career, and me in one year, what I had not been able to crystallize in my own mind for decades—understand that safety is a journey. It is a process through which even small changes can improve everything in the patient’s course of care, not just the ultimate outcome. Being able to interact with professionals involved in the provision of health care—physicians, nurses, administrators, coders, insurance underwriters, computer programmers, etc.—was one of the great educational opportunities of an entire career. There, we learned how developing a safe episode of care can involve, for example, “big data” and pulling thousands of records full of clinical information; analyzing these data such that patterns and associations can be recognized; testing these connected clinical data in other clinical scenarios to establish a stronger relationship; and sharing the data with other clinicians so that external validation can occur. These steps seem obvious and mundane, until one tries to make use of these data and realizes that the data have to be accessed from secure sites; have to be in the correct format; have to pass innumerable HIPAA and security tests; have to be protected and perhaps encrypted for storage and later retrieval; and many other steps intended to keep the data anonymous and safe. Medical school, residency, fellowship, and clinical practice do not prepare us with the special skills required for effective use of these data. The Patient Safety Fellowship did.
Leadership Levels Evolve Perspective on Patient Safety Improvement
While anesthesia patient safety as a concept keys off the idea that “no patient shall be harmed by anesthesia care” (the APSF mission), “leadership” in the application of that concept involves multiple issues that can be harder to define. The Patient Safety Leadership Fellowship experience was very important in first cementing in a foundation of background knowledge in the rather highly specialized area of patient safety research and experience. Then, over time, interaction and reciprocal learning with diverse very knowledgeable faculty and extremely diverse classmates facilitated a perspective on leadership in patient safety. This perspective naturally sorts into different levels, all of which are important to the advancement of the “cause” of patient safety.
First (and particularly in the specialty of anesthesiology), leadership involves personal behavior and setting a personal example of delivering maximally safe care. Whether teaching residents, working with advanced practice providers, or providing one-on-one anesthesia care, the true patient safety leader will always practice what he or she preaches. With the current climate of “production pressure” in the perioperative environment, one central component is to resist constantly the coercive push to cut corners. Potential examples abound. Suffice it to say that, in my department, I am known as the faculty member who will take the additional minute or minutes immediately pre-op in Holding to call and get the dialysis patient’s current potassium value, or find the CT image of the airway in the electronic record, all the while discussing the issue out loud so everyone involved knows why. The strength and resolve to be resistant to production pressure (which is, arguably, now the greatest threat to anesthesia patient safety) was significantly bolstered by the leadership fellowship experience and resulting mindset.
Next is translating the example of personal behavior to the challenge of leadership at the “institutional” level. Today, this may involve one hospital or medical center or, increasingly, a “system” of related locations within one practice organization. Beyond cultivating an environment of resistance to dangerous practice omissions or commissions from pressures to cut corners, institutional leadership in patient safety today must address the subject of standardization. Anesthesiology practice is both science and art, combined into a process. The study of process improvement exemplified by Deming, six-sigma, “lean,” the Toyota method, and/or high-reliability organizations, allows application to the challenge of patient safety. In anesthesia especially, but for all fields, striking a viable balance in all members of a professional group between individual clinical habits/preferences and more standardized evidence-based and safe “best practices” is among the major challenges for an institutional patient safety leader. Learning how to do that can be inspired by a course or fellowship, but it usually takes significant trial-and-error experience to actually accomplish.
Finally, patient safety leadership can involve the highest level: influencing and improving national or even international policy and practice. Organizations such as the APSF, the ASA, the IARS, the AANA, the AAAA, and the WFSA—all with major publications, internet, and social media networks, meetings, advocacy mechanisms, etc.—offer broad and powerful platforms for safety leaders to proffer and promote advances in anesthesia patient safety. Again, examples abound, but the APSF campaign, involving Dr. Cowles, to prevent surgical fires has been a dramatic success in “getting the word out” and changing practice. Impact can be generated by published and publicized research and epidemiology (such as through mining “big data” as suggested by Dr. Brull above) to elucidate the safest best practices and develop ways to get them implemented. There seems sometimes to be an element of luck (“right place, right time, coincidence of favorable conditions, etc.”) in the spread of patient safety advances, but it is always the original enthusiasm, dedication, and persistence of the creative leaders that starts the ball rolling.
As noted, learning how to be a leader in patient safety can be inspired by a course or fellowship, but it usually takes significant trial-and-error experience to actually accomplish. This should never deter those genuinely interested in making anesthesia practice, or anything in health care, safer for patients. Evolving into a patient safety leader can take significant time and effort, but the enormous satisfaction of promoting policy and practice that improve safety—of the patients of one practitioner or for millions of patients across the globe—can never be measured.
Dr. Cowles is a consultant to the APSF for surgical fire prevention and Associate Professor of Anesthesiology and Perioperative Medicine, MD Anderson Cancer Center, Houston; Dr. Van Pelt is a member of the APSF Executive Committee, Chair of the APSF Committee on Education and Training, and the Nurse Anesthesia Team Leader for the Divisions of Neurosurgery, Vascular & Thoracic at the Massachusetts General Hospital, Department of Anesthesia, Critical Care & Pain Medicine; Dr. Brull has been a member of the APSF Executive Committee and Chair of the APSF Scientific Evaluation Committee and is Professor of Anesthesiology, Mayo Clinic, FL.; Dr. Eichhorn is the founding Editor of the APSF Newsletter and currently Consultant to the APSF Executive Committee and Professor of Anesthesiology at the University of Kentucky College of Medicine.
- Pierce EC. The 34th Rovenstine Lecture: 40 years behind the mask: safety revisited. Anesthesiology 1996;84:965–975.
- Reason J. Human Error. Cambridge: Cambridge University Press, 1990.
- Kohn LT, Corrigan JM, and Donaldson MS, eds. To err is human: building a safer health system. Vol. 6. National Academies Press, 2000.
- James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf 2013;9:122-8.
As of late 2015, the HRET reports that the previously existing AHA/NPSF CPSLF program has been suspended and is not accepting another class of fellows. At this time, the National Patient Safety Foundation is looking at suitable ways to support this fellowship in the future with the intention of adding a new venture to an already rich legacy.
If you would like your name to be added to a contact list for future opportunities and updates, please email Patricia McGaffigan ([email protected]) or visit the NPSF website to see the exciting, innovative work being done.