To mark the anniversary of the Institute of Medicine’s watershed report To Err Is Human: Building a Safer Health System, West Health is running a series of interviews with IOM committee members who helped produce the report, as well as other national health experts to examine what progress has been made in reducing medical errors in the US.
This week’s Q&A is with, Tejal Gandhi, MD, MPH, CPPS, president and chief executive officer of the National Patient Safety Foundation, an independent, not-for-profit 501(c)(3) organization that partners with patients and families, the healthcare community and key stakeholders to advance patient safety and healthcare workforce safety, as well as disseminate strategies to prevent harm.
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Joe Smith: What initially spurred your interest in patient safety? What impact did the IOM report have on your work to increase patient safety?
Tejal Gandhi: My interest in patient safety began when I was a medical resident at the Durham VA Medical Center in North Carolina (part of the Duke University residency program). They had just implemented a computerized physician order entry system (CPOE) and I did a project to try to understand whether this new system was improving care or possibly making care worse. That work ultimately led me to Brigham and Women’s Hospital in Boston, where I did a general medicine fellowship with David Bates, MD, MSc, looking at how information technology (IT) can impact quality and safety, which was ultimately the focus of my research career.
As for the IOM report, when it came out in 1999, I was advocating for the hospital to create a patient safety program. The IOM report certainly was a help in getting that program initiated at Brigham and Women’s. We were one of the first hospitals to create a patient safety team and program, and having that report support the case helped us get that set up.
JS: In your opinion, what are the largest challenges and greatest opportunities to improve patient safety?
TG: One of the biggest challenges is the competing priorities in healthcare. With the focus on cost reduction and changing payment models, having leadership keep a focus on patient safety is daunting. Another challenge is workforce burnout issues— the production pressures the frontline teams are under—and also not having a true culture of safety in the organization. Fear of reprisals and the reluctance to talk about errors is still a bigger problem than it should be. So the current environment and organizational culture are two of the broadest issues.
Among the opportunities, our organization has been trying to raise awareness and interest in a number of important, yet also broad areas, such as patient engagement, workforce safety, transparency, health IT and ambulatory safety. Earlier this year, the NPSF Lucian Leape Institute released a report on patient engagement that outlines a number of recommendations for clinicians, health leaders and policy makers to try to drive progress in this area. We’ve also done substantial work around workforce safety, both from a physical and psychological standpoint, and we recently developed a checklist for organizations seeking to improve their workforce safety culture.
Health IT continues to evolve, and now that we have so many systems using electronic health records, the opportunity is there to make sure these systems are implemented well and optimized for patient safety. Ambulatory safety is really an area that I think will be getting a lot of attention in future. Most of the patient safety work thus far has been centered in hospitals, but most of the care that is provided in the U.S. is in the outpatient setting, so there is a lot of research and improvement work to be done there.
JS: In your testimony before the U.S. Senate Committee on Health, Labor, Education and Pensions Subcommittee on Primary Health and Aging hearing this summer, you talked about the need to design better Health IT systems to maximize patient safety benefits and minimize risk. Can you elaborate on the role interoperability plays in this equation?
TG: Clearly transitions of care are serious, high-risk situations for patients, and not only transitions in and out of hospitals, but also across all care settings. Improving interoperability would really help ensure that information is moving across these settings in a way that clinicians can use it to optimize care. Care across the continuum is a key area we need to focus on. Information needs to move across the continuum, and interoperability is essential to that.
JS: Some point to a ‘data flood’ overwhelming the bedside clinician. Do we need to think about more automated, connected and coordinated systems to automate where we can to decrease some of the cognitive burden on clinical caregivers?
TG: Yes. Cognitive error is a newly emerging area in patient safety, and we definitely need better tools to help minimize cognitive overload and associated errors. Electronic health records contain huge amounts of information, and we need much better ways of displaying the most relevant and important information to the clinician so he or she can make better critical decisions. Decision support tools such as alerts, reminders and guidelines can also be very helpful but need to be created in ways that optimize their value (and minimize over-alerting).
JS: What can Congress and/or the Administration do to directly impact and reduce the number of medical errors in hospitals?
TG: One area that many of us in healthcare recognize as a problem is measurement. We need additional focus on developing the right patient safety measures across the continuum of care to really get a firm and accurate picture of how our health systems are performing. Once we have that, it will also be important to have the right incentives in place so leadership across healthcare will make safety a priority. Once we measure adequately we can incentivize. For example, patient experience and quality data is being used in Medicare’s value-based purchasing program. There could be important safety measures, such as safety culture data, that could be added to these programs in order to drive improvements in culture.
Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation. Dr. Gandhi is a board certified internist, associate professor of medicine at Harvard Medical School, and a certified professional in patient safety. Dr. Gandhi’s research interests focus on patient safety and reducing medical errors using information systems. She won the 2009 John M. Eisenberg Patient Safety Award for her contributions to understanding the epidemiology of and possible prevention strategies for medical errors in the outpatient setting.
Previously, she served as chief quality and safety officer at Partners HealthCare, where she helped lead the efforts to standardize and implement patient safety best practices across the system. Before that, as executive director of quality and safety at Brigham and Women’s Hospital for 10 years, she worked to redesign systems to reduce medical errors and improve quality.