Gordon Sprenger doesn't sleep as well as he used to. The retiring chief executive officer of Allina Health System in Minneapolis has become an industry icon when it comes to addressing patient safety, but it hasn't come without personal cost.
As soon as he hears of an error of any significance involving a patient at his 18-hospital system, Sprenger calls the divisional manager responsible for the facility where it occurred. He finds out what happened, whether the patient's family has been informed and taken care of, what support the caregivers involved are getting, and whether a team has been put together to fully analyze the incident.
It was a chore he used to leave to others-clinicians and risk managers-until three years ago when he says he "got religion" regarding patient safety. What he now exposes himself to keeps him awake at night. He says he is troubled by the knowledge of how his organization's occasional mistakes hurt patients and their families. He is also disturbed when he thinks of the trauma inflicted upon the caregivers involved, many of whom he believes are innocently at the end of a faulty process.
"I am much more aware of it-the devastation to the employees," Sprenger says.
Sprenger's colleagues say that the burden the 63-year-old executive bears has helped make Allina a shining example for U.S. hospitals working to respond to an Institute of Medicine report released in late 1999 that stated medical mistakes at hospitals kill as many 98,000 people annually.
"It is the single largest symbolic thing he did in the organization to change the culture," Barbara Balik, CEO of Allina's 483-bed United Hospital in St. Paul, Minn., says of Sprenger's direct involvement with each error.
Industry observers agree that Sprenger provides his peers with a benchmark through his commitment to confronting the patient-safety issue. Sprenger has taken his message on the road, speaking to healthcare leaders at national conferences on how to avoid medical errors.
"I think for healthcare to become safer, leaders at Gordon's level are going to have to take a personal interest," says Donald Berwick, M.D., CEO of the Boston-based Institute for Healthcare Improvement. "He sure has set the stage in terms of commitment in a way very few others have."
Michael Cohen, president of the Institute for Safe Medication Practices, says Allina has been a groundbreaker in promoting the idea of involving individuals who have made mistakes to help establish processes to help avoid errors in the future.
Last October, Allina received two medical safety awards from the ISMP, a Huntingdon Valley, Pa.-based not-for-profit organization.
Sprenger's personal crusade to implement change began three years ago when he-along with other leaders from inside and outside the hospital industry-attended a Harvard University educational forum devoted to patient safety. Struck by the magnitude of a problem that in human life terms equates to a jumbo passenger jet crashing and killing all on board every day of the year, Sprenger, a former American Hospital Association board chairman, developed a keen passion for the patient-safety issue and executives' role in addressing it.
He formed a personal philosophy that any error is one too many if you are the patient. Reducing patient-safety errors by 50% over five years, the goal the Institute of Medicine set for the nation in its 1999 To Err is Human report, wasn't acceptable. Reducing errors to zero is the only objective that makes sense, he says.
"Yeah, it's climbing Mount Everest, but you don't change the goal," says Sprenger, who will retire in July after working for more than 33 years as an administrator within the system that has been called Allina since 1995. His replacement, Allina Chief Operating Officer David Strand, shares the same commitment to patient safety.
When Sprenger returned from his Harvard indoctrination, he spent a year laying the groundwork for change with the Allina board of directors. The first hurdle was to gain support for a nonpunitive culture-one that would encourage reporting of mistakes and close calls. "I told them (the board) they need to applaud when the number of incidences goes up," Sprenger says. Core to Sprenger's belief is that the questions associated with medical errors shouldn't be who did it, but what happened and what can be done to fix it.
After working with his board, Sprenger worked to fire up his management team. His executive group made reduction of medication errors one of five systemwide goals for 2000. And each Allina facility developed its own list of patient-safety initiatives.
Eight patient-safety collaborations, which brought together teams of clinicians from throughout the system, were created at the beginning of 2000 to work on projects ranging from improving chemotherapy administration to reducing errors resulting from physicians' poor handwriting on medication orders.
All the teams have seen significant improvement in their projects, Balik says. However Allina declined to provide any data related to its patient-safety initiatives.
Although Allina plans to spend five years and more than $25 million on an organizationwide provider order entry and bar-coding system to address medication errors, the low-hanging fruit is at its fingertips.
The physician handwriting project has come down to basics-setting rules to eliminate confusion over decimal points and discouraging the use of the letter "u" as shorthand for units (which is often misread as the number "four").
"We are trying hard to reinforce with our physicians if there is any doubt on the part of the direct caregiver, you will be called," says Skip Valusek, director of decision-support services at Allina's 642-bed Abbott Northwestern Hospital in Minneapolis.
All front-line caregivers, when they have to call physicians to question the intent of their handwriting, have been told to begin the conversation with the statement, "In the interest of your patient's safety, I felt it was important that I call you." Valusek says that getting staff to use that phrase has been one of the organization's major accomplishments this year.
It's often the simple victories that eventually help solve a complex problem.
"I don't want to give you the impression that on a scale of 1 to 10 we are a 10," Sprenger says of Allina's efforts. "This is a journey."