March 2011
Hospital Process Improvements Necessary for the Future
One of the joys of this job is getting to meet and know some extraordinary people. One such person for me is Sorrel King.
I got to know Sorrel through the Tennessee Center for Patient Safety, specifically when she came to speak to a group of patient safety clinicians, along with Peter Pronovost, MD, who is our chief consultant from Johns Hopkins Medical Center and instrumental in getting the center’s patient safety efforts off the ground.
Sorrel, however, has a totally different background. We, in the medical field, killed her 18-month-old daughter.
As Sorrel tells it, Josie was admitted to Johns Hopkins after falling into a hot bath at home. She was in the pediatric intensive care unit, and everything was going along fine, with Josie responding to treatment. After being sent to a step-down unit, things began to go horribly wrong.
Orders were overlooked or changed; nurses were confused about treatment protocols; physicians didn’t listen to Sorrel, who pleaded that something was wrong with Josie and her care plan; and finally, a dose of methadone was administered that should have been held, snuffing out the life of an 18-month-old who had trusted, along with her mother, one of the country’s best rated hospitals to do the right thing.
This is the third time I have heard Sorrel speak, and I am always caught up in her passion. She speaks of wanting to “take Johns Hopkins down one brick at a time,” and not wanting to take any money for her loss. But eventually she did and created the Josie King Foundation, which is devoted to preventing these errors from happening again. It is because of Sorrel and Josie that I am so passionate about pushing all hospitals to go for zero preventable harm to their patients.
Listening to Sorrel this last time, I was struck by two things. One was the Tennessee Center for Patient Safety, along with our members, have made remarkable strides toward eliminating central-line infections, ventilator-associated pneumonias and even MRSA. However, even if we had zero hospital-acquired infections, Josie still would be dead.
Why? Because hospital processes and cultures are so convoluted.
My second thought was we must simplify hospital systems and processes to ensure the Josie’s of the world are safe while in our care. In addition, not only do our patients deserve this, but our caregivers do, as well.
I was struck by Sorrel’s compassion when she spoke of the devastating effects Josie’s death had on her caregivers. Sorrel feels so strongly about this, she has even dedicated a part of Josie’s foundation to providing care for the caregivers who find themselves caught up in patient errors.
I was with a group of clinicians last week and a nurse who works in a hospital setting in the operating room told me she was extremely frustrated. There were so many processes, steps and silos of getting a patient to the OR that they literally lost patients. She said they had a significant backlog of elective surgeries, but no one was willing to look at the processes of getting the patient to the OR and just wanted to talk about creating more ORs.
I believe she was making the point that the current processes endanger patients, cost the system significant dollars and frustrate caregivers to the point of wanting to quit. I believe we no longer can accept this as “business as usual” or “this is just the way health care is.” If this is the attitude that is taken, we will be facing even more scrutiny from the government and, worse yet, some of us won’t survive.
To that end, the THA board of directors will spend a portion of next month’s retreat discussing, starting and funding a Center for Innovation, which will focus on process improvement and getting away from complex processes that cause harm to patients and caregivers.
I have said many times that there are three things we must do in order to survive into the future. One is to get in alignment with the physician community. They must be made an integral part of the future of our hospitals. Second, we must make sure our quality and patient safety metrics are the best they can be. The payers, government and public no longer will tolerate “that is just the way health care is.” Finally, we must get costs under control, and process improvement is one major way of doing it. If we can get all three of these working together, we can take just about anything that is thrown at us.
These will be brave times for all of us, but Sorrel, Josie and all of those patients we take care of deserve our best efforts.