CEO SUMMARY: One of the most exciting developments in patient safety is that it is now possible to begin eliminating adverse events in healthcare, declared Lucien Leape, M.D., Professor of Health Policy at the Harvard School of Public Health. Leape bases his prediction on how pioneer hospitals have achieved a zero rate of infection in ICUs and other specific areas of care. He believes the U.S. healthcare system is poised to achieve new breakthroughs in the quality of care.
IMPROVEMENTS IN PATIENT SAFETY are coming so quickly that zero defects are possible. That’s the view of Lucien Leape, M.D., Professor of Health Policy at the Harvard School of Public Health in Cambridge, Massachusetts.
“The most exciting thing that has happened recently in patient safety—something that has truly changed our agenda—is that it is now apparent that we can use perfection as a benchmark,” declared Leape in an interview published by the policy journal Health Affairs.
“We now have convincing demonstrations that when the effort is made and new practices are implemented, we can actually eliminate certain adverse events,” explained Leape. “There is no reason to think that this cannot be expanded to the whole universe of adverse events.”
Leape is enthusiastic about the potential to use quality management tools in healthcare to achieve three goals: 1) zero defects, 2) teamwork training, and, 3) the development of tools to identify and fix potential problems and the sources of error before they cause harm to patients. He believes these three developments (zero defects, team training, and trigger tools) are transforming the way healthcare is delivered.
These developments are significant for lab directors and pathologists because Leape recognizes that healthcare is on the verge of pursuing performance goals and quality outcomes that are common to non-healthcare industries around the world.
THE DARK REPORT has regularly discussed the steady introduction of national goals, accreditation guidelines, and pay-for-performance programs that measure the results of hospitals and physicians in improving patient safety and raising health- care outcomes. Leape is assessing the results of these early efforts and programs. He believes these early demonstrations validate the goals of zero defects, quality improvement, and will help lower the overall cost of care.
Leape explained how previously unthinkable results are possible. When Peter Pronovost, M.D., a physician in the intensive care unit at Johns Hopkins Hospital in Baltimore, Maryland, demonstrated the ability to eliminate central-line infections, the event was significant, noted Leape.
“Let’s put this in perspective,” he commented. “Thirty-six million people are hospitalized in the United States every year. Approximately 11% receive care in an ICU, so the total number of ICU days is 18 million or so. Approximately half of the patients in ICUs have a central venous catheter, so the best estimate is that there are 9.7 million catheter days per year, and 48,600 central-line bloodstream infections. Approximately one-third of those patients die because of those infections. The figures for ventilator-associated pneumonia—another major cause of morbidity and mortality—are similar.
“The team at Hopkins was able to eliminate both of these types of infections by implementing protocols and rigidly enforcing them: ensuring that the five or six things that needed to be done every time were done and done right. The secret was a major team effort and commitment,” Leape explained.
Then, another exciting development occurred when Pronovost used the proto- cols in hospitals in Michigan, got the support of Blue Cross and Blue Shield, and reported that 100 hospitals had reduced central-line infections to zero. “For more than six months, 68 hospitals had no central-line infections and no ventilator-associated pneumonia,” Leape observed. “I call this ‘getting to zero.’
“What Pronovost has shown is that this [achieving zero infections] is not just something that one or two ‘safety nuts’ can do, but, rather, anybody can do it if they put their mind to it,” he stated. “If 68 hospitals in Michigan can achieve these results, then so can all 5,000 hospitals in the United States. We have a new ball game and a new benchmark, and it is a very exciting development.”
One key to Pronovost’s success was the use of teamwork. “Indeed, my second hot topic is team training, an idea that has finally caught on and has been greatly facilitated by simulation,”Leape said. “Although simulation is expensive, it is a very powerful teaching tool. Everyone likes the idea of doctors, nurses, and anesthesiologists experiencing their first crisis on a plastic patient as they learn how to put a tube in, tap a chest, or give a medication.
“Simulation is sweeping the country and with it a new emphasis on increased sophistication in team training,” he noted. “Many of us in healthcare think that this is second only to implementing new practices in terms of its power to create a culture of safety and reduce accidental injuries.
Using Trigger Tools
“The third important new development, in my opinion, is the use of more sophisticated ways to identify adverse events,” he added. The Institute for Healthcare Improvement (IHI) in Cambridge, Massachusetts, has developed a trigger tool that is very effective. The tool is a list of approximately 50 elements that can be found in the patient record, many of them laboratory tests or simple clinical observations.
“One searches for these, either in the electronic record or by going through a paper record, reviewing lab tests and so forth,” he explained. “You identify abnormal findings and investigate whether a patient has suffered an adverse event. We are moving away from looking at deaths (which is a rather crude measure)—in fact, even away from errors, because injuries are what count. It does not make any difference if we are preventing errors if we can’t prevent the injury.”
THE DARK REPORT observes that Leape has identified how medical errors can be eliminated and healthcare outcomes improved by the use of these proven quality management methods. Previously, the thinking was that medicine was as much art as science and so it was impossible to predict adverse events. By focusing on eliminating defects, it is possible to pre- vent injuries and death.