January 22, 2010

Quality, safety Morath’s chief concerns

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Julie Morath, R.N., M.S., and colleagues are advocating for patient safety improvements. (photo by Anne Rayner)

Quality, safety Morath’s chief concerns

Recently, a group of 12 of the nation's most prominent health care experts and consumer advocates issued an emphatic appeal for system-wide improvement of patient safety.

Among the authors of the appeal, which appeared last month in the journal Quality and Safety in Healthcare, is Julie Morath, R.N., M.S., chief quality and patient safety officer at Vanderbilt University Medical Center.

The authors constitute the current membership of the Lucian Leape Institute, a patient safety think tank attached to the National Patient Safety Foundation.

Under the title “Transforming healthcare: a safety imperative,” Morath and colleagues state that progress has been slow and that culture change is needed “to radically change [how people] think about care and how it is provided. Health care needs not just to be improved but to be transformed.”

They devote the bulk of their paper to five signposts for transformation: transparency; care integration; patient/con-sumer engagement; restoration of joy and meaning in work; and medical education reform.

“We went through a process of examining all the important work that's taking place, or should be taking place, then distilled it to these five areas that we felt would have the greatest impact for change,” Morath said.

In the wake of the paper's publication, the Lucian Leape Institute has launched a series of roundtables that will issue concrete recommendations.

An initial set of recommendations, on medical education reform, is set for release later this winter.

In an interview in her office in Medical Center North, Morath expanded on various points from the article.

On transparency

“Transparency is essential for learning and accountability with our patients and families, between caregivers, within and across our organizations and to the public. You cannot improve what you do not know, and until we expose and make visible errors and accidents in health care, we will be unable to understand the systems and conditions that are operating.

“Transparency makes visible the processes of care that are often implicit, making them explicit so the whole team is aware and performance feedback is immediate in the conduct of work. We have not had the reliable cross-disciplinary communication this requires; we have not consistently made visible our thought and care processes so that we understand them and therefore can stabilize and measure them to evaluate whether or not they're appropriately working.

“We think the shift required is moving from an episode or a moment in care to looking at care from the patient's perspective, that is, as an entire process across the continuum. How does it all fit together? How does it work for them? This requires moving from a discipline- and site-centric view to understanding a whole process for a population. That is a major change.”

On restoring meaning in work

“Unless people feel respected, have the knowledge, tools and support to do the work they're here to do, and are recognized and thanked for doing the work, you don't have an engaged workforce based on trust and the ability to communicate across disciplines, departments and the hierarchy of power structure. And transparency requires that.”

On reforming medical education

“There is a call for the science of safety and the science of improvement to complement medical science, so that we have healers, caregivers and scientists who are also system improvers. We need to better prepare our students on teamwork and communication; I think Vanderbilt is very forward-thinking in this area, but there is room to continue to improve and we will lead the way.”

On patient/family engagement

“We believe strongly that patients are no longer passive recipients of medical expertise, but rather essential partners to the decision-making and planning and the delivery of care, and that patients themselves and their families are a vital line of defense to prevent things from going wrong.”

On the science and practice of safety

“I think if there's any specific window into the science of safety it would be from the perspective of high-reliability engineering and resilience. There are two main dimensions to safety. One is prevention — we prevent by understanding the details of technical work and the experience of care, the data and the lessons learned from simulation, failure and tools like failure mode and effects analysis.

“Another dimension of safety is resilience, the ability to recognize emerging risk, immediately recover, and have multiple concurrent scenarios so that we know how to act under different conditions to reduce the probability of something catastrophic happening.

“To me, the most important thing in safety is candid, courageous conversations among people who care about what they're doing, using a systems approach. The cultural context is far more important than any checklist or regulation that would be imposed on an organization.

“One of the greatest risks to safer care is that we turn patient safety into strict compliance. That approach alone provides an illusion of being safer because the boxes are checked off. But safety is a dynamic non-event requiring constant vigilance and having the best possible design in the systems and processes of care. The use of evidence-based medicine and practice is part of that care design. You can never take safety for granted, because the conditions continually change.”

On her work at VUMC, and collaborating with Owen Graduate School of Management and the School of Engineering

“I think I've got one of the greatest jobs at Vanderbilt, because I get to work with all of Vanderbilt. This includes contributing to the design and stewardship of the pillar goals for quality and working with stakeholders across the entire Medical Center.

“We are collectively building alignment for a comprehensive system of improvement, from shaping students to the delivery of care by all clinicians and those who support frontline work. This includes working with many disciplines and scientists across Vanderbilt, and the alignment and active involvement of department chairmen, faculty, leadership and the Medical Center Board.”

In addition to Morath, the paper’s authors are:

• Lucian Leape, M.D., adjunct professor of health policy, Harvard School of Public Health. Leape's research helped usher in the now decade-old patient safety movement;
• Donald Berwick, M.D., M.P.P., president and CEO, Institute for Healthcare Improvement;
• Carolyn Clancy, M.D., director, Agency for Healthcare Research and Quality;
• James Conway, M.A.M., C.H.E., senior vice president, Institute for Health Care Improvement;
• James Guest, J.D., president, Consumer Union;
• David Lawrence, M.D., chairman and CEO (retired), Kaiser Foundation Health Plan and Kaiser Foundation Hospitals;
• Dennis O'Leary, M.D., president emeritus, the Joint Commission;
• Paul O'Neill, former secretary of the U.S. Treasury, chairman and CEO (retired), ALCOA
• Diane Pinakiewicz, MBA, president, National Patient Safety Foundation;
• Paul Gluck, M.D., immediate past chair, National Patient Safety Foundation board of directors; and
• Thomas Isaac, M.D., institute fellow, Dana-Farber Cancer Institute.