Patient Safety Leadership Congress

Friday, November 01, 2013 12:28 PM

Attendees discuss burnout in health care, patient safety

Kate Alfano, CMS contributing writer

It all began with one report, published by the Institute of Medicine in November 1999; “To Err is Human: Building a Safer Health System” launched the entire patient safety movement, said Robert Wachter, MD, professor and associate chair of the Department of Medicine at the University of California San Francisco. He kicked off the 2013 Patient Safety Leadership Congress on Oct. 22, which was jointly sponsored by the Colorado Hospital Association, the Colorado Medical Society and COPIC.

When the study’s authors quantified the number of lives lost to medical mistakes as a jumbo jet a day, “it opened the public’s eyes,” he said. “All of a sudden, we realized for everything we’re spending on health care, we’re not getting the products we want.”

The event brought together physicians, hospital executives, patient safety advocates and other professionals to discuss what is happening in patient safety, why it’s happening and what’s likely to happen in the next few years. “It’s easy to lose sight that we’re in the middle of something historic in health care where our system is being forced to transform itself into something wholly different,” Wachter said.

He introduced his session with a quick history lesson on the evolution of the movements toward improved quality, safety and value. In the late ’90s, most people believed that quality and safety in health care were pretty good, he said. There was no reason to think otherwise until the IOM report came out. Suddenly there was a growing case for safety and quality, though it started with a focus on blame and shame of individual providers. “No one spoke about systems thinking; those were not things that any clinician understood circa 2000. We thought about errors as individual.”

Fast-forward to present thought that increasing quality and getting rid of waste is mostly about systems, not individual perfection. “We’ll only have great systems when we have great people,” Wachter said. “The system is a living, breathing thing and the only way the system gets better is if the humans make it better.”

He stressed that this is a bipartisan movement; most of the key events in his timeline happened under the Bush administration and are independent of the Affordable Care Act. He illustrated this point with the “two Pauls,” U.S. Congressman Paul Ryan and economist Paul Krugman. While they are as far apart on the political spectrum as they can get, they agree that the country needs to get a handle on health care costs.

“What’s happening is the end of health care exceptionalism,” Wachter said. “The world has looked at us and said you’re not providing a product that is high enough quality and the cost of it is bankrupting our country. In the U.S. we have a fundamental belief that companies succeed when they deliver value. We want health care to do the same thing.”

“We’re being asked to cut costs and increase quality,” he continued. “I believe they’re the same thing.”

Brian Sexton, PhD, associate professor of psychiatry at Duke University School of Medicine and director of the Patient Safety Center at Duke University Health System, spoke about the importance of physician resiliency in increasing quality and patient safety.

“I want you to come away from this with a need to redefine what we mean as quality. Quality has traditionally meant patient-centered care,” Sexton said. “I’d argue that the way this has evolved is that now, in 2013, we have to do a better job at taking care of ourselves. That’s what the data show very strongly. First, are you taking care of yourself? Second, how are we taking care of each other?”

The health care industry has the highest rate of burnout. With countless studies, he demonstrated the “science of self-care,” paying particular attention to the importance of sleep in memory consolidation and emotional regulation and giving practical exercises to refresh and replenish mental capacity. His point was that there are many great tools in medicine that can increase quality, but until the workers are less burned out they won’t have the ability to implement them.

He presented five categories of resilience: Self-awareness, or understanding strengths and weaknesses to play up one’s strengths; mindfulness, noticing patterns without judging; sense of purpose, knowing how to frame things in a purpose-ridden way; self-care, or fatigue management; and relationships, how to work with others. Good practice of each category can lead to improved wellness.

“Once you’re taking care of yourself and each other, then you can take meaningful care of your patients in a sustainable way,” Sexton said. “But if you just jump into patient-centered care, show up early, stay late, work through lunches, your patients are not receiving patient-centered care. Even though you might think that you are, that’s not what the data bare out if we don’t have resilience where it needs to be.

“I’d argue that it’s the job of the health care worker to show up at work ready to do their job. Leaders have a responsibility to protect the work-life balance of their employees and when they put this balance at risk, that threatens safety and the patient-centered nature of care we’re trying to deliver.”

Eric Coleman, MD, MPH, director of the Care Transitions Program at the University of Colorado Anschutz Medical Campus, talked about the challenge of ensuring patient safety during transitions out of the hospital. These transitions are a time of great vulnerability for lapses in safety and quality, plus the amount of resources dedicated to this area is proportionately small, he said.

Coleman presented seven strategies to ensure safety and quality during care transitions. First, foster greater patient engagement. By default, patients and family caregivers perform a significant amount of their own care coordination but they do this without skills, tools or confidence. Training the patient and the caregiver in their post-hospital care can make a difference. This leads to the second strategy, fostering family caregiver engagement instead of ignoring this important partner. Coleman suggested scheduling discharge instructions at a time when family caregivers can participate.

The third strategy is to foster greater physician engagement and accountability. Readmission penalties are refocusing the discussion on transitions and a new care coordination benefit under fee-for-service Medicare is designed to promote support and pay providers for post-hospital discharge care coordination.

The fourth strategy is building professional competency, training health care professionals on the strategies to promote effective care coordination across multiple settings. This is closely related to the fifth strategy, forging cross-continuum care teams. This team could include the hospital, outpatient physician practices and home health agencies, and also adult day health centers, mental health providers and quality improvement organizations.

The sixth strategy is improving communication so the transfer summary is concise, contains essential elements and gives perspective on objectives for future care. Finally, the seventh is re-conceptualizing risk identification, considering factors outside of the diagnosis that might cause readmission like health literacy.

“Patient safety is a collective effort, not a competition,” Coleman said, encouraging teamwork. Many of the conference speakers noted that collaboration is key to progress in patient safety, and encouraged physicians to learn from each other and work together. Wachter said, “One of the most exciting things happening in medicine today is it’s forcing us to speak with each other and learn to collaborate in new ways. We realize we must collaborate in ways we’ve never done before.”