No One Is Free From Harm: Applying lessons from perfect patient care to broader quality and safety improvement
My youngest brother David almost died last March. It started as a fever, but in a few hours it had become a raging case of sepsis from Legionnaire's disease. His organs began to fail, and the academic medical center where he had been admitted rushed him into the ICU.
We were sure we were going to lose him because recovery rates from adult respiratory distress syndrome, acute renal failure and overwhelming sepsis are not high.
Quality in healthcare has been the focus of my career for four decades, and I have so often been consumed by what is wrong. But in this unwelcome episode in my brother's life and mine, I got to see the care I dream of. Nearly perfect care.
Once in the ICU, technology took over David's failing organs—a ventilator, a bedside dialysis machine, IV lines, monitors and computer screens offering the clinicians instant online access to his medical records, lab reports, X-rays and CT scans. It was a convergence of magnificent biotechnology.
Most impressive was the care team itself, consisting of 20 or 30 people—doctors, nurses, pharmacists, technicians—who seemed ever-present at David's bedside. It's extraordinary to think about how care this complicated comes together. The ICU team had a method for complete coordination of their efforts.
Several times a day, the entire team huddled just outside David's room, with a half a dozen computer screens, paper graphs and charts, protocols and checklists. They methodically worked their way down the list of problems—renal function, lung function, infection status, fluid status, sedation, pain control, mental status, nutrition, electrolytes, diabetes management and more.
Everyone talked, making sure the problem list was attended to completely and that every component knew about every other component. It was astounding.
Amazingly and movingly, they included our family in all of that. They treated us completely as partners in David's care. “Any questions?” they would ask us. “Any ideas you want to share?” We were not watching the team; we were on the team.
Everyone had a voice, including the student nurse. At one point I saw the ventilator technician politely but directly challenge the senior supervising resident. “That's not correct,” the technician said. “Thank you,” the resident replied. “Maybe I'm wrong.”
The lowest points for David came on days four, five and six, when each managed support was pushed to its limits, and we waited for the moment when there was no more room to push in oxygen, no more reserve in his heart muscle, and no more hope that his kidneys would return.
But then, little by little, the graphs started to change and the lines turned upward. More oxygen was getting through, small amounts of urine started to come, and David began to come back to us.
On the ninth day, they pulled out his breathing tube and reduced his sedation, and David opened his eyes. On the 11th day, he left the ICU. On the 20th day, he went to rehab. On Day 40, David went home. Three weeks later, he returned to work. He beat the odds.
The more I think about it the past few months, the more I believe we in the healthcare system have moved away from quality improvement as the core agenda. If we redid the classic quality studies of the past several decades today, I'm pretty sure the results would be about the same as when those studies were done. That's a serious indictment.
But if healthcare providers can do what they did for my brother, how do we take those lessons and apply them to system improvement? How did that world-class teamwork happen?
What saved my brother wasn't telling people they weren't trying hard enough or using pay-for-performance or tighter enforcement of rules. It was measuring, learning, customizing, and everyone working together and taking pride and joy in the work with a single, shared aim—save David.
The job we have now is to take what we now know about the roots of excellence—the excellence that saved my brother's life—and, as healthcare leaders, clinicians, government officials and patients, use those principles to guide our action together.
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