The Institute of Medicine reports To Err is Human: Building a Safer Health System, published 20 years ago, followed by Crossing the Quality Chasm: The IOM Health Care Quality Initiative two years later, have led to considerable efforts to improve healthcare. Despite that work, no one can be satisfied with the levels of safety and quality we have attained so far.
Familiar quality problems persist at unacceptably high rates. Hand-hygiene noncompliance, patient falls with injury, and wrong-site surgery are just a few. Best estimates, for example, suggest that invasive procedures on the wrong patient or body part occur about 45 times every week in the U.S. The success that the IOM reports achieved by raising awareness of the seriousness and ubiquity of safety and quality problems has not been matched by our ability to solve them. The challenge now is to reap far larger gains from all the resources devoted to improvement. Doing so will require three major changes in the way we carry out quality improvement.
First, we must articulate a much more ambitious goal. Healthcare leaders should commit themselves to achieve the ultimate goal of zero harm, meaning zero complications of care, zero injuries to caregivers, zero episodes of overuse, and zero missed opportunities to provide effective care. The passionate commitment to zero harm lies at the heart of industries in the U.S. like commercial aviation and nuclear power that have established such exemplary safety records and earned them recognition as high-reliability organizations. Clearly, this is a heavy lift for healthcare, and it will not be achieved rapidly. But if zero harm is not the right goal, then how much harm is acceptable?
Second, leaders must drastically overhaul the culture within their organizations. Too many caregivers are too often subjected to disrespectful and demeaning behavior when they raise concerns about safety and quality. Such behaviors drive critical information about unsafe conditions underground, not to be discovered until patient harm results. Leaders cannot delegate this responsibility. They must personally move to the forefront of efforts to celebrate the reporting and mitigating of quality problems. In addition, leaders must establish programs that hold every caregiver—regardless of seniority or professional affiliation—accountable for consistent adherence to safety protocols and agreed-upon safe practices. Failing to address these problems leaves healthcare organizations vulnerable to myriad risks.
Third, leaders must face the reality that healthcare safety processes very often fail at rates of 50% or more. Hand-hygiene compliance and hand-off communication are two of the more conspicuous examples. Major gains will develop only from the work done by healthcare leaders and their organizations. Other interested stakeholders—government, business and patient advocacy groups—cannot deliver the results we all want. Nor will market forces. Realizing those gains requires sober consideration of the magnitude and nature of the progress we have made, which has been significant if not sufficient, and an understanding of the limitations of the methods we have used to achieve that progress.
The improvements we have achieved over the past 20 years have largely resulted from healthcare organizations undertaking a series of focused projects: to reduce central-line infections or pressure ulcers or medication errors, etc. Broadly speaking, the method we have employed is the “one-size-fits-all” best practice. Experts review evidence and come to a consensus about how to solve a problem. Then we produce a variety of guidelines, toolkits, checklists and protocols that every healthcare organization is expected to use in the same way. The result, with very few exceptions, has been modest and inconsistent improvement that is difficult to sustain and even more difficult to spread. We cannot continue to use the same methods and expect different results.
Evidence is accumulating that process improvement methods long used successfully in industry—Lean, Six Sigma, and change management, taken together—are far more effective than the “one-size-fits-all” best-practice approach. What’s different about them is their capacity to pinpoint and measure the frequency of the critical few key causes of persistent quality problems. Interventions targeted to eliminate the key causes lead to major improvements. The key causes differ from place to place, however, which necessitates the identification of those key causes before deploying interventions.
That is why applying the same best practice everywhere yields such disappointing results. Published reports document that hospitals and health systems using these methods have achieved improvements of 50% to 70% in reducing falls with injury, risks of wrong-site surgery, and hand-hygiene noncompliance, among others. Leaders should apply these improvement methods systematically and broadly to facilitate the transformation of their organizations from low to high reliability.
Achieving zero harm is a daunting challenge. Satisfaction with the status quo in quality and safety is untenable. We need to break new ground. Meanwhile, some healthcare organizations are starting to show us that zero is possible. Leadership commitment to the goal, strong action to improve organizational culture, and the enthusiastic adoption of new, highly effective improvement methods will advance healthcare on its journey to zero harm.
