Teaching Physicians to Provide
Safe Patient Care
Lucian L. Leape, MD
Harvard School of Public Health
UT Clinical Safety and Effectiveness
Conference
Austin, TX
November 4, 2010
02138
Perhaps the most opinionated zip
code in America
The New York Times
A Great Success Story
 Every hospital has a safety program
 Hospital mortality has been going down
 Government funding of safety research –
AHRQ
 NQF 34 safe practices
 Voluntary regional coalitions all over the
country
 IHI: training; 100,000 lives campaign
 Joint Commission safe practices (“Goals”)
IHI 100,000 Lives - Results
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2 years: 12/04 – 12/06
3100 Hospitals
Implement 6 safe practices
122,300 lives saved
“Getting to Zero”: The Michigan
Experience
68 Hospitals
March 04-June 05
No CLBI or VAP for more than 6
months
- Lives saved: 1578
- Hospital days saved: 81,000
- Costs saved: $165 million
Surgical Checklist Pilot Study
Deaths and Complications
14
Complications %
12
10
8
Before
6
4
2
0
Complications
Deaths
After
Patient Safety in Texas
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Clinical Safety and Effectiveness Course – all 6
campuses - 608 graduates
 Multiple innovations in systems
UT System Disclosure Training – all 6 UT
Medical Education initiatives – quality and safety
curriculum, scholarly concentration
UT sponsored research and education grants
Externally funded research
A Great Failure Story
 Evidence of overall impact is sparse
 No one has implemented all of the NQF 34
 Leapfrog 1256 – 30% compliance with any of 6 s.p.
 Shocking rates of wrong site surgery and
retained foreign bodies persist
 Recurring scandals: Indiana babies; vincristine
Patient Safety as a Lens

Big new insight:
It’s not primarily about systems, it’s about
us
Patient Safety as a Lens
1.
2.
3.
4.
Systems / Organization
Accountability
Teamwork and Collaboration
Patient Engagement
Patient Safety as a Lens
1.
Systems / Organization
Complex – just “grew”
 Accept long waits, “silos”, variation,
preferences
 Making changes is difficult

Patient Safety as a Lens
2. Accountability
Institution

To the public
 To other hospitals
 To our patients
 To our staff
Patient Safety as a Lens
Institution - to our staff
 Provide a safe and supportive environment
 Implement known safe practices
 Monitor compliance with safe practices
 Provide resources to develop safe practices
 Ensure that all caregivers are qualified
 Monitor performance
 Take corrective action
Patient Safety as a Lens
Individual accountability

To hospital: Follow safe practices
 To patients: “ “ “, be open and honest
 To colleagues: respectful, cooperative,
support when things go wrong
 To self: Maintain competency, physical and
mental health
Patient Safety as a Lens
3. Teamwork and Collaboration
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IHI initial experience
Pronovost
Gawande
Patient Safety as a Lens
1.
2.
3.
4.
Systems / Organization
Accountability
Teamwork and Collaboration
Patient Engagement
Patient Safety as a Lens
4. Patient Engagement
 Shared decision-making
 Chronic disease
 Hospital care
 Transparency when things go wrong
 Participation in the design of care
“We are guests in their house”
Some progress in all areas
1. Systems / Organization

ERs: some have reduced waiting substantitally

Virginia Mason Medical Center: no waiting rooms in
its cancer center

Cleveland Clinic: multispecialty centers focused on
disease groups, such as cardiac disease, neurological
disease, etc.
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Implementing and enforcing standard practices such
as SBAR and handwashing

Surgical residents at Harvard now have laminated
cards that spell out when to call the attending.
Some progress in all areas
2. Accountability

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Some states now require hospitals to report
SREs
Hospital compare is just the beginning of
public release of quality and safety data
Most hospitals have or are moving to
meaningful policies about full disclosure – and,
as you are doing, training people to do it
Many hospitals have implemented some safe
practices, especially hand hygiene
Some progress in all areas
3. Teams and Collaboration
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Concord Cardiac Surgery reduced mortality
and complications
BIDMC Labor and Delivery complications
halved
8 Harvard OB programs: 46% fewer claims
Pronovost: Central Line infections eliminated
Gawande: Surgical mortality and complications
halved
VA surgical mortality halved
Patient Safety as a Lens
What have we learned?
It’s about relationships
The Lucian Leape Institute of the NPSF
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Donald Berwick
Carolyn Clancy
James Conway
James Guest
David Lawrence
Julianne Morath
Dennis O’Leary
Paul O’Neill
Diane Pinakiewicz
Paul Gluck
Five Transforming Concepts
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Integrating Health Care
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Transparency
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Consumer Engagement
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Finding Joy and Meaning in Work
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Reforming Medical Education
Paul O’Neill on Safety
Every worker’s experience, every day:
•
I am treated with respect by everyone else,
regardless of position, education or pay
•
I have the education and training, the tools,
and the support to develop to my full potential
•
My work is noticed and appreciated
Paul O’Neill on Safety
Every worker’s experience, every day:
•
I am treated with respect by everyone else,
regardless of position, education or pay
•
I have the education and training, the tools,
and the support to develop to my full
potential
•
My work is noticed and appreciated
Paul O’Neill on Safety
A hospital can not be safe for its
patients if it is not safe for its staff
Patient Safety as a Lens
“Safe” = freedom from injury
 Physical
safety
 Psychological
 Freedom
safety
from abuse – physical, psychological
Common theme: Respect
FAILURE TO PROVIDE A SAFE AND SUPPORTIVE
ENVIRONMENT IS TREATING YOUR STAFF
WITH DISRESPECT
What do we mean by a culture of
respect?

This is the culture problem: a culture of
disrespect

It is inappropriate and incredibly damaging
to the psychological well-being and mental
health of everyone – staff and patients – to
permit disrespectful behavior

And, it is unsafe for our patients
What do we mean by a culture of
respect?
It is disrespectful to insult, humiliate, demean, or
be condescending to anyone
At the Individual Level – treatment of:

Nurses
What do we mean by a culture of
respect?
Response to humiliating or demeaning behavior:
1. Psychological reaction – anger, fear, depression,
self-doubt clouds judgment and impairs thinking

More likely to make a mistake – forget, mis-read, etc.
2. Avoidance – a normal reaction

Communication block
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Call only when absolutely necessary
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Communicate only what is necessary
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Don’t share concerns, worries
Results of surveys of nurses about
disruptive behavior
NURSES reporting:
 Witnessing or receiving it
 Verbal abuse every 2-3 months
 Believe it is a cause of nurses leaving
 Percent of doctors exhibiting it
95%
64%
37%
5.7%
What do we mean by a culture of
respect?
It is disrespectful to insult, humiliate, demean, or
be condescending to anyone
At the Individual Level – treatment of:

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Nurses
Students and residents
Relationship between burnout and
professional conduct

2009 Survey of all medical students at 7 medical
schools:
2682 responders (61%)

Burnout:
53%
All
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Unprof. Behavior OK
27
Report omitted test as Normal 43
Can impact med. Underserved 64
Burnout
Yes No
35
49
59
22
36
71
Dyrbe, Massie, et al, 2010, JAMA 304:1173
Depression, stigma and suicidal
ideation in medical students
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Moderate-severe depression:
Women: 18.0%
Men: 9.0%
Seriously considered suicide:
depressed: 12.5%
Considered dropping out, past mo.:
depressed: 43.1%
Resid. application less competitive
depressed: 76.2%
14.3%
4.4%
15.2%
66.1%
Schwenk, Davis, Wimsatt, 2010 JAMA 304:1181
What do we mean by a culture of
respect?
It is disrespectful to insult, humiliate, demean, or
be condescending to anyone
At the Individual Level – treatment of:



Nurses
Students and residents
Patients
 Passive: no SDM, disclosure, engagement
 Active: disrespectful comments, attitude
MPH Students: Patient’s Needs
Assessments
Of 41 interviews, 30 patients had serious
problems with:
•
Care coordination
•
Knowing what was happening, what to
expect
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Physicians who did not listen, would not
explain, were rude, demeaning, or
disrespectful
The Power of Words

Doctors and nurses greatly underestimate the
power of their words and attitudes

By our manner, our comments, our concerns, we
make patients’ fears and worries much better --or much worse
What do we mean by a culture of
respect?
At the Institution level
We have institutionalized disrespect
 Working conditions
 Hazards
 Hours
 Work loads
 Punishing for error
 Toleration
of bad behavior
We have institutionalized disrespect
A sense of entitlement

Disrespect underlies:
Nurse resignations
Student / nurse abuse
The “hidden curriculum”
Physician resistance to safety changes
Creating a culture of respect
 Correct
 Set
working conditions
and enforce behavioral standards
 Policies: zero tolerance for disrespect
 Leadership commitment
 Enforcement
What can you do?
1. Mobilize like-minded
2. Decide what kind of an institution you
want to be
3. Agree on policies, set expectations
4. Monitor behavior
5. Follow through with deviant performers
Paul O’Neill on Safety
Every worker’s experience, every day:
•
I am treated with respect by everyone else,
regardless of position, education or pay
•
I have the education and training, the tools,
and the support to develop to my full
potential
•
My work is noticed and appreciated