Reflections from Salzburg: From Exploration to Forcible Action

Karen Wolk Feinstein (second from left) with Mary-anne D’Arpino, Doris Grinspun, and Gina De Souza of the forum’s Canadian contingent. Photo courtesy of Herman Seidel.

A Note from Karen Wolk Feinstein, PhD

As a participant at the Salzburg Global Forum's session on patient safety last month, I was in the company of true luminaries in our field. Forty-four participants hailed from 16 countries including Canada, the U.K., Ghana, Uganda, Japan and Australia. The World Health Organization and the Institute for Healthcare Improvement organized the five-day session, and both sent strong contingents. Participants were selected based on their knowledge of the topic and potential role in driving reforms.

Titled Moving Measurement into Action: Designing Global Principles for Measuring Patient Safety, the five-day seminar concluded just a week before the first-ever World Patient Safety Day. That calls attention to the problem of medical error, which causes an estimated 250,000 preventable deaths in the United States each year and an estimated 100 million deaths worldwide over the past two decades.

Despite 20 years of research, experimentation and advocacy, we have little to show in the way of progress — in the U.S. and globally. At the Jewish Healthcare Foundation alone, we trained more than 10,000 people in Lean safety and quality improvement techniques through our Perfecting Patient Care model, after realizing that basic safety science principles are not routinely taught in the schools of health professions. RAND researchers studied us. They found that our participants leave with an enthusiasm to drive change, but their hopes are often dashed when they encounter a perverse safety culture upon returning to work.

In Salzburg, Don Berwick put out a call for urgency, to which all participants agreed. However, I fear that the revolution won't come from small-scale changes or better measures.Our international health systems need a jolt of forcible activism.

Creating safe environments is not a mystery. There are playbooks and a rigorous curriculum in safety science. High-performing, complex and high-risk industries build continuous improvement into their work processes, achieving nearly defect-free environments.

What Could Force Change

1. Value-Based Purchasing

This would reward the safest, most efficient providers, but it requires real transparency of meaningful data on cost, quality, and safety that is not gamed. It requires payers and purchasers who will not be denied or deceived.

2. A Consumer Movement with Vigorous Advocacy

Health systems leaders — boards and executives — could be held accountable for the safety of patients and employees. When design errors caused two Boeing 737 MAX 8s to crash in the past year, killing 346 people, nobody blamed the pilots, engineers or trainers. The accountability rested with the Boeing board of directors and its executives. Pilots refused to fly, purchasers refused to buy, and passengers refused to ride. Boeing's corporate leadership accepted responsibility.

3. Competition from New Players

Our health systems are ripe for disruption. Consolidation and mergers among legacy providers and payers have created giant health systems that have neither lowered costs nor improved safety. However, powerful customer-centric companies that have dramatically disrupted transportation, communications, and retailers are now pouring millions of dollars into developing health care services to meet consumer needs and preferences. These disrupters will engage patients in their own diagnostic and treatment decisions that might provide simpler, faster, cheaper and more reliable care. Perhaps they will provide the jolt that legacy systems need.

4. Creation of a National Patient Safety Authority

Systems achieve what they are designed to achieve, but a strong regulatory fabric offers a critical safety net. Most organizations lack the infrastructure to monitor and ensure that our health systems are wired for safety. An airline or car manufacturer that doesn't observe basic safety precautions and meet high standards can pay stiff penalties — even be denied the sale of their products. Health care needs an overarching authority with teeth to enforce rigorous safety science practices. In the U.S., models exist in the form of the Federal Aviation Administration, the National Highway Traffic Safety Administration, and the Food and Drug Administration, to name a few.

What Will Speed Progress

These are secondary considerations, but nevertheless useful if there is to be real progress in patient safety. We need:

  • Informed, activated board members held accountable for the safety of patients and employees.
  • Consumers who demand and receive accurate information on safety records.
  • Culture change where frontline staff can safely report on safety problems and where an atmosphere of curiosity and discovery cause staff to pull for information and solutions.
  • Useful measures for safety to ensure real transparency that isn't gamed.
  • Application of Lean principles for building safety improvements into the workflow at all levels of care.
  • Improved EHRs, a critical element basic to workflow redesign and progress, and that allow for credible prediction and prevention of error.

In short, patient safety improvement requires a jolt, not incremental progress. Acceptable safety conditions will not result from doing the same things we've done for 20 years. It will come from significant new pressures that direct patients to systems and sites and innovations that guarantee safety. And, above all, from health systems leadership that accepts accountability for creating the safest environment possible.

Participants at the Salzburg Global Forum. Photo courtesy of Herman Seidel.
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