While there was plenty of synergy at the National Patient Safety Foundation's ninth annual Patient Safety Congress thanks to some simultaneous events involving the same cast of experts, that may have sapped some of the event's overall energy.
The May 2-4 meeting in Washington came on the heels of the announcement of the World Health Organization's new collaboration with Joint Commission International, and was also linked with activities involving the WHOs World Alliance for Patient Safety program.
Indeed, three of the six people on Modern Healthcare's cover photo from last week's WHO-JCI news conference also spoke at the NPSF event. But, while there were some benefits, it also made the NPSF seem a little like an add-on to someone else's main event. And, although spring had definitely sprung in our nation's capital, the sunshine and blooming vegetation were lost on the 1,186 attendees viewing PowerPoint presentations in the windowless meeting rooms of the Marriott Wardman Park Hotel. One sign of the lack of energy was that there appeared to be more people sitting through the presentations with their heads down and eyes closed than at the typical healthcare conference.
Presenter and pediatrician Neil Seidberg, who led the computerized physician order-entry rollout at the 355-bed State University of New York's University Hospital in Syracuse, did his best to liven things up and he offered some advice that was different from the usual messages you get at these conferences.
"Avoid consensus," he said.
According to Seidberg, the product of consensus is something with no color, no sharp edges and "everyone hates it."
The question you have to keep asking is "will it let the user kick butt?" (Except he didn't say "butt.")
He also said one key to success was to "make it easy to do the right thing, make it hard to do the wrong thing."
Tell people why you're doing what you're doing, Seidberg advised, and "never let a barrier remain a barrier for long."
A major theme of the meeting was looking to outside industries for teamwork models and cross-pollination of ideas. With this in mind, the morning plenary speakers included authors Tom Kelley and Doris Kearns Goodwin, talking about their respective books, The Ten Faces of Innovation and Team of Rivals: The Political Genius of Abraham Lincoln.
While interesting in their own right, this pair didn't seem to deliver the "Go forth and conquer" message to attendees that only a fellow healthcare professional could provide. They also lacked the spark given off by outside-the-industry speakers Colin Powell or Dana Carvey, who appeared at recent Healthcare Information and Management Systems Society meetings.
But there were new ideas being presented. Although the usual suspects of nuclear power and aviation were mentioned as industries healthcare could look to for safety and teamwork models, others that were mentioned were auto racing pit crews and environmental regulators.
Institute for Healthcare Improvement President and Chief Executive Officer Donald Berwick said that medical errors could be looked at as a form of pollution and, consequently, suggested that anti-pollution regulations may contain guidance for medical-error-prevention policies. IHI Senior Vice President James Conway suggested that there was one model too many healthcare organizations were looking to: the television show "Pimp My Ride."
The MTV program consists of episodes where jalopies are customized to turn heads wherever they go. Conway, an NPSF adviser and the former executive vice president and chief operating officer of the Dana-Farber Cancer Institute, Boston, noted that "Nobody works on the engine." Instead of working on core issues, there is too much tinkering on the edges, Conway said.
The conference could have used a few more speakers like Conway. Along with appearing on a "distinguished advisers" panel, Conway also gave an update on the IHI's Protecting 5 Million Lives from Harm campaign. Instead of just reciting a laundry list of campaign initiatives, Conway told inspirational anecdotes, asked and took questions from the audience, and also had people tell their own stories. He recognized one woman in the audience as an IHI organizer in Colorado and asked her to tell her story.
She talked about how her 15-year-old daughter died from medical errors related to the "routine" removal of an ovarian cyst. After she told her emotional story, she encouraged the healthcare professionals in the room to take patient safety seriously: "No more harm, people! Save some lives."
It would have been interesting to hear Goodwin say something like that.
The Colorado woman noted that she wasn't a healthcare professional, and identified herself as a "mom" and an engineer. In an earlier session, presenter William Jessee, who is chairman of the Exempla Healthcare board of directors in Denver and also president and CEO of the Medical Group Management Association, talked about the importance of having lay members on the board.
A major plank in the IHI campaign is a "Get Boards on Board" initiative, and "leadership and accountability" was also the theme of one of the meeting's program tracks. Jessee spoke during a program on the role of trustees in ensuring patient safety and noted how clinicians learn to accept a certain amount of medical errors as part of the healthcare landscape.
Lay members, however, help hospitals "regain a sense of outrage" over errors, he said, which can be good if it can be focused into making people do the right thing.
Jessee told of how Exempla board members each shadowed individuals on the clinical staff for three hours prior to a board meeting to experience what life was like "in the trenches" and it was an eye-opening experience. One significant observation was how all the money spent on technology had not done much to improve care on the front lines, he said.
"We have made huge investments in technology," Jessee said. "But we have invested much more in capturing the charge than in delivering the right medication to the right patient at the right time."
Celebrate your successes, Jessee concluded, but also show outrage at failure and determination not to repeat it.
Maybe a little more outrage would have done more than the free coffee to energize the attendees.What do you think? Write us with your comments at [email protected]. Please include your name, title and hometown.