This past month I read The Safety Playbook, by John Byrnes, MD and Susan Teman, RN, which gives healthcare leaders the tools they need to improve quality and safety at their hospitals, and frankly I was blown away. First, I did not fully appreciate the severity of the problem in the United States, as summarized by the following two statistics shared by the authors:
To put that latter number into perspective, in the five minutes or so that it will take you to read this post, three or four patients in America will suffer a fatal medical error.
I was also thoroughly engaged by the approach Byrnes and Teman recommend. Blending insights from other high-reliability industries with their own years of experience on the frontlines in healthcare, the authors outline a practical approach which they have successfully used at many health systems. Their methods engage everyone – from the board to the frontline caregiver – to create a single unified approach to reducing medical errors.
Q+A with Dr. John Byrnes, MD—Revamp Safety Training to Decrease Medical Errors and Save Lives
This week I reached out to Dr. Byrnes to ask him a few follow-up questions. I hope you’ll find his answers as thought-provoking and insightful as I did.
Q: John, your latest book just hit the market last month. Why this (patient safety) and why now?
A: Sue and I wanted to tackle patient safety because we’re incredibly passionate about the topic, and we’re unsatisfied with the progress that our industry has made to date. We’ve only made a small dent in medical error rates, and patient safety is still America’s number one health problem. Medical errors are the third leading cause of death in the United States.
We also saw a glaring need in the available literature. There are a very limited number of healthcare books on patient safety. And many of the available books are jargon-filled, research-centric, academic treatises. There was nothing we felt really addressed the problem in a practical way. If you don’t work in healthcare, you may find this surprising, but most healthcare professionals receive very little safety training during medical school and their clinical rotations. In fact, John Nance and I discussed this recently and we feel medical professionals have two (or more) semesters of material to learn in order to make our organizations error free. So we wanted to put together a book for healthcare that was practical, free from jargon and purely theoretical discussions, and that every healthcare worker and professional could immediately use on the front lines of healthcare.
Q: Since the Institute of Medicine released its landmark report in 1999, “To Err Is Human: Building a Safer Health System,” which focused on the shocking number of fatalities caused by preventable medical errors, it seems we’ve hardly moved the needle as a nation when it comes to preventable errors. In fact, the better we get at reporting and documentation, the more it seems that the IOM may have understated the problem. Why do you think this is?
A: I still remember some of the conversations shortly after the 1999 report was released. I had the opportunity to speak with several of the authors and one of them said very frankly that they were purposely conservative in their estimates for fear of creating a panic among the public. But it’s also fair to say that our understanding of medical errors has evolved significantly in the past 20 years. We do a better job of tracking and reporting those errors, and so it seems reasonable that our early estimates would have been underestimated.
It’s also important to keep in mind that the estimates placing medical errors as the third leading cause of death in the United States are only considering the incidents for inpatient care in America’s hospitals. We certainly don’t have good figures on the rate of occurrence in the outpatient setting. So my fear is that the medical error rate is still even larger than we already believe when we factor in all the mishaps that occur in the thousands of outpatient settings across the United States.
Q: I’m sure in your conversations you’ve had a lot of discussions about these numbers. What is the biggest misconception leaders in healthcare have about safety?
A: The biggest misconception among healthcare leaders is that they “do not believe they have a problem within their own institutions.” However, when I look at the publicly available data from these very same institutions, often the leaders are misinformed, or they discount the results from the various reporting agencies.
I still remember a conversation with a CEO friend. He was telling me about the performance of his organization—they were top in patient experience and they were doing well financially. As a result, he assumed they were also doing well from a clinical and patient safety standpoint. I was so impressed by the excitement shown by this CEO that I checked the Healthgrades and Leapfrog websites shortly after our conversation. What I saw left me speechless. The organization had been receiving letter grades of “D” from Leapfrog. They had many one-star conditions on Healthgrades and very few five-star ratings.
I called my friend the next day and asked him about this. He told me the methodology of both organizations mentioned above was highly flawed and his organization didn’t pay attention to the ratings.
What followed was a good discussion about the methodologies the rating agencies use. I told my friend that when we received a one-star rating at my previous organization and compared it to our internally generated data, we deserved the one star. When we received a five-star rating and compared it to our internal data, we deserved the five-star rating as well.
Long story short, my CEO friend is now working diligently to improve clinical outcomes and patient safety within his organization. The moral of the story—we need to take the external rating agencies very seriously, as they provide us with data that helps inform our priorities for improvement, and we can track and trend our performance over time using the same resources in combination with our internal data sources.
Q: You’ve had a lot of success in your career at helping organizations make improvements in safety. What have been the keys to the success of your approach?
A: First, we need to engage our clinical workforce, the physicians and nurses and other clinical caregivers who are truly dedicated to improving care. Most of what passes for safety education today is mind-numbingly boring and is done, at best, as a check-the-box activity. It’s never integrated into daily workflow, and it’s not inspiring. We go directly to the clinical teams and engage them where they are today. When properly engaged, I have found that clinical professionals willingly accept that we have a problem, and are eager to get busy making improvements in the daily practice of medicine. These dedicated caregivers don’t argue about the numbers or whether we have a problem. They are, however, a small army who work every day to eradicate errors from patient care.
The second must-have is data, and a lot of it. I don’t accept the premise that we are measuring too much related to quality and safety. Many pundits often say we only need 10 to 12 measures to evaluate how our entire organization is doing in clinical quality and patient safety. A position such as this is frankly preposterous. It’s akin to a finance professional saying we only need to measure our financial performance on two or three departments to know how we are doing as an entire organization.
I see this as one of the most unfortunate misunderstandings, and bad advice that we’ve received from the leaders in the quality and safety movement. Our key to success at Spectrum was our ability to report our performance for all high-volume procedures and medical conditions, across every unit of the hospital.