|Two days before Valentine’s, a 72-year-old man suffering from heart disease was transferred to Emory Crawford Long Hospital for bypass surgery. He arrived with a stack of records from the previous hospital. In the process of transcribing his many medications, a 2-mg dose of Cardura, a blood pressure medicine, was inadvertently copied as 20 mg—a 10-fold increase. It’s easy to imagine the consequences if the patient had received that dose—a fall, even an injury.
The overdose, however, wasn’t given. A new electronic medication reconciliation procedure being tested that very day caught the discrepancy.
The procedure is but one example in a wide-reaching quality and safety initiative being implemented in the Woodruff Health Sciences Center (WHSC). Under the direction of the newly established Office of Quality in Emory Healthcare, processes are being scrutinized and revamped at all levels. That includes new chief quality officer (CQO) positions at Emory Hospital, Emory Crawford Long Hospital, and The Emory Clinic. It also expands the role of chief medical officers—who provide adminstrative leadership in areas such as credentialing, accreditation, and budgeting at the hospitals to cover responsibilities for quality initiatives.
“As an academic medical center, we have tended to focus on the brilliant—the cutting-edge procedures, the medical innovations—because we push those envelopes really well,” says William Bornstein, CQO for Emory Healthcare. “This current movement is about looking at more routine care and being able to deliver it reliably for every patient every time.”
Often, physicians disparagingly refer to such standardizations as “cookbook medicine,” voiced by the comment, “I didn’t go to medical school to practice cookbook medicine.” But it is failure in handling the routine that generally leads to medical errors.
In 2003, for example, a surgeon at Duke University Medical Center transplanted a heart and lungs of the wrong blood type into 17-year-old Jesica Santillan. Her body rejected the organs, and despite another transplant, she died. Although the surgeon on the case accepted full responsibility, the error could be traced back to several process failures not only at Duke but also in the national organ-transplant system. The organs were originally meant for another patient, but that patient was deemed too weak for surgery. Santillan’s surgeon asked if his patient could have the organs instead, bypassing usual protocol that would have verified compatible blood type. When the regional donor services coordinator forwarded the request to the national organ sharing network, he incorrectly identified Santillan’s blood type. The Duke resident who picked up the organs in Boston failed to catch the mistake. Neither did the surgical team, despite procedures to verify blood type compatibility prior to surgery.
Medical mistakes can, and do, happen virtually everywhere. At Virginia Mason Medical Center in Seattle, a patient who was supposed to receive a contrast injection for a radiology study was instead injected with an antiseptic solution and as a result died. At Methodist Hospital in Indianapolis, three premature babies died after being administered an adult dose of a blood thinner 1,000 times stronger than what was appropriate. At Memorial Sloan-Kettering Cancer Center in Manhattan, a surgeon operated on the wrong side of a patient’s brain because of a mix-up with X-ray films.
A by now well-known 1999 report by the Institute of Medicine (IOM), To Err is Human, estimated that 44,000 to 98,000 people die in U.S. hospitals each year because of medical errors. For every mistake that ends in death, countless more occur with less severe outcomes. The IOM also reported that, on average, a hospital patient experiences one medication error every single day during the hospital stay. And a 2006 RAND study found that health care providers delivered only 50% to 60% of the care that patients should have received based on the best available evidence.
To Err is Human focused national attention on a problem that had been largely ignored or denied. “Most Americans, it seems, think the care they receive is better than what others receive,” says Bornstein. “I’m not sure the IOM report really changed that, but it played a big part in creating a sense of urgency in the health care industry.”
The IOM report placed the blame for failures on the systems in which medical care is delivered. “The processes in health care tend to rely on people being brilliant—highly skilled, ever vigilant, and nearly infallible—to get good outcomes,” says Richard Gitomer, CQO at Emory Crawford Long. “We need to have more brilliant processes that do the work and allow humans to make errors.”
After all, humans, no matter how intelligent or well-intentioned, make mistakes, and expecting them not to is a recipe for disaster. Too often, a series of mistakes by various members of the health care team line up, allowing an error to reach the patient. “When an error actually occurs, we know that generally between 10 and 20 things have gone wrong,” says Bornstein. “There’s even a name for it: the Swiss cheese model. Unless the safety measures have been developed in a coordinated way, frequently the holes line up and cause a medical error.”
Consider an incident at Emory’s own Crawford Long Hospital. A patient was admitted and placed on a blood thinner to prevent clots. After surgery, a physician prescribed a different blood thinner, but the first medication wasn’t stopped. As a result, the patient received a potentially harmful dose of blood thinners.
“Several things had to go wrong for this to happen,” says Gitomer. “The physician should have ordered the pre-op medication be stopped post op. He didn’t. The pharmacist who entered the order is supposed to check what other medications the patient is on. He didn’t. The nurse is supposed to check the list of medications before she administers a new one. She didn’t. Although the patient escaped without harm in this instance, it shows how a whole series of mistakes can line up unless you have better processes in place to prevent or catch them.”
It also emphasizes that all people—even well-trained and hard-working professionals—make mistakes, especially in the high-stress multi-tasking environment of health care. So how can processes help?
"The processes in health care tend to rely on people being brilliant—highly skilled, ever vigilant, and nearly infallible—to get good outcomes. We need to have more brilliant processes that do the work and allow humans to make errors."
-Richard Gitomer, CQO, Emory Crawford Long
Trying the LEAN diet
Emory’s recent quality initiatives are striving to plug the holes in the Swiss cheese by borrowing a page from an unlikely source—a car manufacturer. Specifically, Emory is adopting the LEAN process-improvement program originally developed by Toyota. In a nutshell, LEAN is a philosophy committed to customer service, elimination of waste, and continuous improvement. It provides tools to intentionally and thoughtfully design processes to meet these goals.
“The manufacturing industry has done a great job in pioneering many of these principles,” says Hal Jones, director of quality support services for Emory Healthcare. “For example, those of us who are prone to locking our keys in the car are grateful to car companies for building processes that now make that virtually impossible. We, in health care, need to learn to do the same thing—to build processes that make it virtually impossible not to do the right thing.”
To follow the LEAN model, health care needs to standardize processes as much as possible, quite a switch for an industry built on autonomy and individual accountability. “This philosophy definitely goes against the grain of what many of us have learned over the years,” says Bornstein. “Also, critics say health care is not the same as making cars or widgets. That is absolutely true. Patients are individuals. But there can be some similarities between making cars and treating patients. If, for example, we decide that every patient who meets certain criteria should get a flu shot, then we can use manufacturing and production principles to achieve that goal. And we can reach a higher success rate with that approach than if we wait until we see each patient and then decide on the fly.”
Emory Healthcare is testing this recipe in key areas that hold the most promise for improving care and reducing waste and harm. Specifically, it is applying LEAN procedures to complex, laborious, and error-prone processes: flow through the emergency department and the operating room, medication reconciliation, the discharge process, management of laboratory results, even in hiring the right people and getting them rapidly up-to-speed on using the tools they need. “Each of these is an area in which we think we can dramatically improve and that will translate into improving care and saving lives,” says Bornstein.
Although some solutions, once reached, seem obvious, they are sometimes difficult to find in the crush of treating patients. Take the goal of preventing central IV line infections. Emory procedures call for anyone putting in a central IV line to clean their hands, drape the patient, wear a sterile gown and gloves, clean the site with a special cleanser, and follow septic techniques. However, the staff sometimes skip one or more of these steps, which can lead to an infection. The reason? “All those supplies weren’t in one place, and people would have to run around to find them,” says Betsy Hackman, director of infection control for Emory Healthcare. “So we’ve made what we call a central line bundle. It’s a bag filled with everything someone needs to properly start a central line. Now a doctor can grab one of these bags and be ready to go.”
Other solutions being cooked up are more high-tech, such as the electronic prescription writer adopted by Emory. Medication errors are among the leading cause of harm in health care, according to the IOM. Either the wrong medication or wrong dose is prescribed, or the medication reacts adversely with another drug prescribed. Often, errors stem from the doctor being unaware of other medications the patient is taking or the pharmacist’s inability to decipher a prescription. To reduce these errors, the electronic prescription writer not only checks for reactions with other drugs but also has standard doses for every medication so doctors don’t have to rely on memory. The tool prints out a typewritten prescription so the chances of a pharmacist misreading a prescription are virtually eliminated. “Any doctor in our system can give you a personal example of the electronic prescription writer catching a medication error that was about to be made,” says Penny Castellano, CQO for The Emory Clinic.
"Any doctor in our system can give you a personal example of the electronic prescription writer catching a medication error that was about to be made."
-Penny Castellano, CQO, The Emory Clinic
Stir manufacturing in the mix
The ambulatory setting has its own set of quality issues, especially important to address since the average patient receives the bulk of heath care during her lifetime there.
In addition to medication management, The Emory Clinic is focusing on improving results management, preventive care, and comprehensive chronic care—the three areas where research studies have identified a failure to deliver in the ambulatory world, according to Castellano. “We do all these tests on patients, but then we need to make sure both the doctor and the patient get the results, understand them, and act on them. We fail to do that reliably. We also fail to deliver all the care we think we do.” Citing the RAND study, Castellano says, “If I were treating diabetic patients, I know that the American Diabetic Association stipulates that I do a number of things every time I see each patient. According to this study, I would get it right only about half of the time.”
To try to move that number closer to 100%, Castellano and her team are retraining themselves to think like manufacturers. Although the process is only in the early stages of implementation, the clinic has already seen some success. For example, clinic physicians previously experienced routine delays in getting specimen results from pathology, which in turn delayed diagnosis and treatment. When the quality team looked more closely at the turnaround time, they discovered physicians were having a difficult time listing all the necessary information in the correct part of the lab requisition form, which in turn caused the lab to send the form back. “We redesigned the front end of the process, and now we have dropped the turnaround time from five days to 24-48 hours,” says Castellano. “It wasn’t until we stepped back and looked at it with a disciplined set of eyes that we were able to see what the problem was.”
Technology promises to provide what may be the clinic’s biggest boost in quality of care. Recently, the Emory electronic medical record system (EeMR) allowed clinic physicians to notify patients who were on drugs that were being withdrawn from the market. “When we got the notice that two drugs were being withdrawn, thanks to EeMR, we could immediately pull up all the names of patients who were taking one of those drugs,” says Castellano. “Our physicians could then contact them and make medically appropriate changes. We were able to get the whole thing wrapped up in two to three days, which is pretty amazing.”
When used to its fullest potential, EeMR will act as “the ultimate record keeper and reference tool,” says Castellano. “When we have this system fully implemented, it will tell me, for example, whether the 50-year-old woman I am seeing in my OB/GYN practice is past due for having her cholesterol checked. It will allow the physician to concentrate energy on the patient rather than the record keeping.”
"Our goal is to advertise who we are, that we are available, and that we truly care about fixing things. We specifically ask people to share any concerns they have about patient safety so we can address them."
-Nathan Spell, CQO, Emory Hospital
Add a cup of culture
For quality and safety initiatives to truly work, they must be imbedded in the culture of the entire system. “We have to build a culture where people at all levels understand that mistakes and errors are opportunities for improvement,” says quality support director Jones. In an ideal situation, an employee who realizes a mistake has been made would alert the supervisor. In turn, the supervisor would respond with thanks first, then regret that a faulty process allowed that mistake to happen. Then the two would work together, perhaps drawing in others, to redesign that process to prevent the error from happening again.
The impetus for supporting such ideas in quality and safety starts at the top with a recently created quality council. Led by the CEOs of the WHSC and Emory Healthcare, the council is advised and governed by a quality subcommittee of the Emory Healthcare Board of Directors, headed by John Rice, vice chair of General Electric.
“Having the weight of people in these positions behind the quality initiatives sends a powerful message,” says Bornstein.
But just in case anyone missed that message, Emory Healthcare recently began patient safety “WalkRounds,” in which a group of senior officers—chief quality, medical, operations, and nursing officers—drop by, unannounced, in various departments and talk with the staff about their concerns. “Our goal is to advertise who we are, that we are available, and that we truly care about fixing things,” says Nathan Spell, CQO of Emory Hospital. “We specifically ask people to share any concerns they have about patient safety so we can address them.”
The executives on the WalkRounds are often able to offer a quick fix for vexing problems. On a recent WalkRound, for example, Emory Hospital nurses complained they often had a difficult time locating intravenous infusion pumps when they needed them. The solution: the hospital is installing a system that uses radio frequency identification (one similar to what WalMart uses) to track the pumps. A transmitter will be attached to each pump. During another WalkRound in Crawford Long’s neonatal ICU, nurses felt they had been inadequately trained in the use of a new type of ventilator. The quality team immediately secured instructors from respiratory therapy to bring them quickly up to speed.
A critical ingredient in the success of the WalkRounds—or any of the safety initiatives—is the ability for anyone to feel safe to speak up and raise questions. Operating rooms have led the way in this area, taking their lead from the airline industry. Just as cockpit crews run through a checklist before every takeoff, ORs now routinely have a “time out” or “call to order” before any surgery or procedure. “The idea is the whole team—from the surgeon to the OR tech—stops and together verifies that they have the correct patient, the correct procedure, and the correct site,” says Bornstein. “Any member of the team is encouraged, is in fact obligated, to raise a question if they think something is wrong. The ultimate goal is to provide care that in the absence of unique circumstances is the same for all patients with equivalent problems cared for in our system, regardless of who their doctors or nurses are.”
Creating that climate outside the OR is a work in progress. “I know of examples where one person on the health care team says to another, ‘Wait a minute! Did you wash your hands?’ and the other person says, ‘No, thanks for reminding me.’ And I know of examples when the other person responds with, ‘Mind your own business.’ It’s something we must continually work on,” says Susan Grant, Emory Healthcare chief nursing officer.
Another key ingredient in a recipe focused on quality and safety is transparency—both transparency in processes, so it’s easy to see when something is not happening the way it is supposed to, and transparency in patient relations, so mistakes are openly admitted to patients and their families.
Emory is taking the latter concept to a new level with its newly designed neuro ICU, where families are allowed to be present 24/7. “It is a totally new paradigm, and we are using this unit to learn about family presence and how we can integrate it into our health care practices,” says Grant.
Family members are ever present to see how things are done, and when there is a turn for the worse, the new paradigm potentially eliminates feelings of confusion and mistrust between the family and the medical team. “This is a level of transparency that has just not existed before,” says Grant.
"When an error actually occurs, we know that generally between 10 and 20 things have gone wrong. There's even a name for it: the Swiss cheese model. Unless the safety measures have been developed in a coordinated way, frequently the holes line up and cause a medical error."
-William Bornstein, CQO, Emory Healthcare
Refining the recipe
Perhaps the greatest test of Emory Healthcare’s commitment to transparency occurred three years ago. An Emory team performed a biopsy on the brain of a patient who was subsequently diagnosed with Creutzfeldt-Jakob disease (CJD), a rare brain disorder somewhat similar to mad cow disease in animals. Destroying the abnormal protein that causes CJD may require sterilization beyond normal methods. However, since CJD was unsuspected, the instruments used in the biopsy received only normal sterilization before being used in other procedures. As soon as physicians realized the biopsy patient had CJD, they re-sterilized all surgical instruments. However, by that point, they had operated on some 500 patients.
“That’s when we had to make a decision,” says Bornstein. “Since modern sterilization techniques have been in place, no one has ever gotten CJD through a surgical instrument. There is no evidence that these abnormal proteins can move from one instrument to another. Moreover the bulk of these patients had procedures that did not involve the central nervous system, and the procedures they received are an unprecedented route of transmission. So the chances these patients could be affected were as close to zero as they could be without our being able to say they were actually zero.”
Despite the long odds, EHC officials decided to inform all the patients. “It was the right thing to do,” says Bornstein. “And we redesigned our processes so that we are more certain that we will be able to identify a patient with any potential for CJD from the start and treat the instruments accordingly.”
It’s hard to overstate the lessons learned from the CJD incident, says Bornstein. “When people ask what has been the single most effective thing your organization has done to help create progress toward a culture of safety, that is the event. It’s not that one has to have such an event to make progress, and I wouldn’t wish it on anyone. But when such an event occurs, the whole staff stops and asks, ‘Is the organization going to walk the walk?’ That’s when your actions make the difference. It is one of those defining moments.”
Martha McKenzie is a freelance writer in Atlanta.
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