Improving patient safety and satisfaction can start with improving the job satisfaction of hospital staff, said speakers at a conference last week in Chicago sponsored by Joint Commission Resources and the American Medical Association. In communicating that message, they often took a blunt approach in identifying what needs to be done and what is actually being done to improve healthcare quality.
Conference themes included building cultures where quality and excellence are encouraged and acknowledging that people will always make mistakes, so systems need to be in place to prevent errors from causing patient harm.
Strategies to improve teamwork and the quality of care included borrowing concepts developed by the aviation industry. These included using simulators and reviewing errors or difficult cases as soon as possible while people still had details fresh in their minds.
For these strategies to work, speakers said everyone on staff has to feel they can make a difference -- and this requires replacing medicine's traditional hierarchical culture with one in which everyone on staff feels empowered to change the problems they encounter.
"Culture eats strategy for lunch," said speaker Henry Russell, M.D., vice president for clinical affairs at VHA Central Atlantic, who added that merely developing "motherhood and apple pie" value statements do little to change an organization's culture.
To drive this home, Russell cited one corporation's core value statement that included a commitment to "communication, respect, integrity and excellence." He then paused before mentioning that these were the values that the disgraced Enron Corp. had purported to base its operations on.
"Would it be fair to say there might be a gap?" Russell asked.
When citing a report that found that surgical residents and surgeons reported observing high levels of teamwork but the rest of the surgical staff did not, Russell noted that "Fish don't know they're wet."
Paul Uhlig, M.D., associate chief of staff for clinical improvement at Cincinnati's University Hospital, noted how this attitude is common in institutions where a nurse may say "Good teamwork means I'm asked for my input," but the physician's attitude is "Good teamwork means they do what I say."
Statistics, go figure
Richard Shannon, M.D., medical director at Allegheny General Hospital in Pittsburgh and a member of the Pittsburgh Regional Healthcare Initiative's executive committee, talked about how statistics can lull a staff into complacency.
Data are collected to be reported but not acted upon, Shannon said, creating an illusion that there are acceptable numbers for errors and preventable deaths. When a facility's statistics fall within "normal" levels, he said some organizations become convinced they are high performers but they're really only "the cream of the crap."
Shannon showed how statistics for central-line-associated blood stream infections, or CLAB, can be manipulated to show better infection "rates" for an institution even though the risk of death from infection is much greater. The problem with benchmarking, he said, is that millions of dollars are being spent to collect data and generate reports--which people don't understand and do nothing to illustrate the human cost of medical errors.
After removing the complacency the statistics had generated, he said his hospital attacked the problem and learned how there were wide variations in how central lines were placed. By borrowing standardization processes from the manufacturing industry, Shannon said the risk of patients acquiring a CLAB infection dropped from one in 28 central lines installed in fiscal 2003 to one in 167 today.
"Work standardization allows you to see a defect before it becomes an error," Shannon said, adding that it's also important to "eliminate the idea that a certain number (of infections) is acceptable."