First, Do No Harm

The Institute of Medicine in 1999 issued a landmark report, To Err Is Human, recommending national and local measures to reduce medical errors and increase the quality of health care in the U.S. The Patient Safety and Quality Improvement Act of 2005 resulted from the IOM report. Darrell “Skip” Campbell, M.D., (Residency 1978) professor of surgery and chief of clinical affairs, updates us on progress — at Michigan and nationally.

Q: How did medical errors become such a serious national concern?

A: The IOM report was a wake-up call. The number of deaths each year due to medical errors was staggering — estimates ranged from 44,000 to 98,000. That really got everybody’s attention. Nobody had recognized the scope of the problem, and everything we’ve done to improve patient safety has really followed from that report.

Q: What are the costs?

A: There’s a huge impact on the total bill for health care — hundreds of millions of dollars. In our own small analysis, we found for instance that simply developing a medically-associated trauma after surgery adds about $57,000 to a patient’s hospital bill. That type of money from one complication multiplied manifold reaches alarming proportions.

But there’s another major cost. We depend on the trust of the public, of the patient. The report detailing so many errors and potential deaths made the public somewhat distrustful of the medical profession. Who’s minding the store? Who’s making sure these kinds of things don’t take place? Another cost is almost the converse: It’s demoralizing to the health care professional to see that a mistake has been made. These are good-hearted people, and when they think they’ve done something that hurt a person, it gets directly at the heart of our mission and has a demoralizing effect.

Q: What are the biggest hurdles in creating a culture of patient safety?

A: The biggest challenge has to do with two issues: transparency and blamelessness. Getting the medical culture to embrace those concepts has been difficult but very important. We want people to be able to talk about errors in an open way so we can actually learn from them and do something about them. That’s hindered by concern that there might be some sort of retribution in terms of job or reputation, and that relates to getting away from finger-pointing and blaming. We try to not point the finger at caregivers, but instead say, what in the system allowed this error to happen?

Q: How does this relate to our shift in malpractice thinking — to openly acknowledge and disclose errors?

A: It’s surprising and somewhat counterintuitive. We stated several years ago that we would be as open and forthright as possible with regard to quality and safety issues in the hospital. There’s also a full disclosure policy where we emphasize our obligation to be honest with patients about whatever happened. People thought that would cause the sky to fall in terms of malpractice exposure, and in fact just the opposite happened — our policy of being forthright with the patient, and honest, has caused a substantial reduction in our malpractice expense over time, and that is something the whole country has taken notice of because everybody before had been in a ‘defend and deny’ mindset. That, we think, is a great problem in advancing patient safety because we don’t learn anything under those circumstances. How can you learn anything if you’re denying the problem exists?

Q: What steps have we taken to improve the safety and quality of the patient experience?

A: The IOM report gave us primary goals to aspire to, including safety, efficiency, timeliness, and patient-centeredness. We’ve used those goals to design what we call the ideal patient experience at our hospital. Safety is No. 1.

One major step we’ve taken here is called CareLink, where we’ve computerized all patient orders eliminating many opportunities for human error in dispensing medication, ordering tests and procedures, and accessing test results. We’ve adopted patient safety rounds in which the leadership of the hospital — myself, the head of nursing, the CEO of the hospital — and administrators and clerks at all levels of the hierarchy go to a different unit of the hospital every two weeks; we’ve done that for five years now. We ask, what is your worst nightmare, what do you worry about? We get a wealth of information so we can solve potential problems before they become problems.

When a report of an error comes in, we get back to people within 48 hours to explain what we did to correct the situation. And nurses are empowered to activate a Rapid Response Team of very experienced caregivers who quickly gather to decide what needs to be done in problem situations — a wonderful failsafe among our many patient safety procedures.

We measure the safety culture in our hospital. Every two-to-three years we conduct a standardized patient safety culture survey, and that helps identify certain areas within the hospital that may feel they don’t have a safe culture, as well as those who work in a very safe culture. That helps us target our strategy by knowing exactly what the caregivers feel about their environment. Culture is everything in patient safety — how you feel about it.

Q: In what ways are we involved in patient safety and quality at state and national levels?

A: The U-M Health System’s philosophy and experience formed the basis for a very important paper published by Senators Clinton and Obama in the New England Journal of Medicine titled “Making Patient Safety the Centerpiece for Malpractice Reform.” That article was timed to coincide with a bill that was introduced to Congress called the MEDic Act, sponsored by Clinton and Obama, which fostered the ideas of transparency and blamelessness. The bill died in committee, but it’s being reintroduced by Clinton for the upcoming administration. Rick Boothman, our risk manager, has met with Clinton’s office several times to talk about the basics of this bill. Our patient safety experience and philosophy being translated into legislation is a great example of U-M leadership on the national level.

We’ve been very active in the state in trying to improve quality across a broad spectrum of efforts, such as the Michigan Surgical Quality Collaborative — a group of 34 hospitals that use the same reporting system, so we have a common database for evaluating quality and safety. Using this common database, we can analyze and understand within our group what the best practices are, and we distribute that information so that everybody improves as a result. That program has been very successful at decreasing the incidence of surgical complications across the state. The Health System administers six similar collaborative projects, funded by Blue Cross Blue Shield of Michigan. Collaboration is very important in terms of improving safety.

The National Surgical Quality Improvement Program is something I’ve been interested in and have had a role in distributing to more than 200 hospitals nationally — the goal is 2,000 hospitals.

Has the way we educate medical students, residents and nursing students changed to include more about patient safety, or is the new safety culture just part of the environment in which they’re learning?
I think it’s both. We certainly like to lead by example, but we’re also developing a patient safety certification program for house officers. Every trainee before ever touching a patient will have to demonstrate competency in a variety of aspects of patient safety and how to actually do things safely, like sterile technique or how to put in a central venous pressure line — that can be very dangerous. Before we’re finished every single person will have completed this certification. Then we’ll offer that service to other hospitals in the state so they can come to U-M and have their house officers and staff certified in patient safety — that’s the ultimate vision.

It’s important for leadership to set audacious goals, and our goal is to be the safest hospital in the country. We’ve said that publicly, and everything we do is focused on that one goal. We’re not there yet, but people have embraced the goal. When patients walk through the doors of our hospital, we want them to feel completely safe in that environment and to know that they’re going to get the best care available. It’s important to have that as a strategy because a lot of our policies and procedures derive from that goal.

Q: What would a follow-up to To Err Is Human find?

A: I think we’ve made progress, but I’m not sure it can be quantified in that same way, and it’s not as fast as it should be. Nobody’s satisfied with patient safety right now even though we’ve made tremendous strides.

Q: What work remains to be done?

A: The big work is to create a reliable national registry with a standardized taxonomy of what patient safety is, so that we can really get a more accurate idea of where the problems are and how to address them.

Interview by Rick Krupinski