Safety tool stresses education and action
Tragedy transforms facility into industry model
Two tragic medication errors seven years ago prompted Dana-Farber Cancer Institute in Boston to undertake what CEO Jim Conway calls "a journey of change." That journey has led to industrywide praise and recognition, including the recent awarding to Conway of one of the two inaugural Individual Leadership in Patient Safety Awards from the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance.
Among Conway’s most notable accomplishments was the development of a patient safety self-assessment tool that encourages executives to initiate improvements proactively rather than to wait for the occurrence of adverse events to force action.
In early 1995, Dana-Farber discovered that two patients had received massive chemotherapy overdoses. As one of those patients was Betsy Lehman, a well-known health reporter for the Boston Globe, the events received extensive media coverage, including 28 front-page stories in the Globe. The question on everyone’s lips seemed to be, "How could such a bad thing happen at Dana-Farber, and to such an informed patient?"
This led to what Conway calls "a journey of change for our leadership and staff." Naturally, he says, Dana-Farber carried the burden of these events, but that was not enough. "It was also our responsibility to learn all we could about why our system failed," Conway says. The events, he says, took on significant power, driving health professionals across the country to learn about medical errors. "It’s mentioned in the first sentence of the executive summary of the [Institute of Medicine] report [To Err Is Human]," Conway notes. "It was not only a sentinel event, but a seminal event."
The development of the safety tool grew out of the ongoing process of change. "Myself, the chief of nursing, the staff, the directory of pharmacy, the director of risk management, and others have all spoken on the subject extensively," Conway notes. "We get two common questions from health care leaders. The first is, In the absence of high-profile events, how do you create the tension for change?’ The second issue we hear is something like this: You would never catch my boss standing in a public forum and talking about our stuff!’ We have talked a lot about the gap between excellence and perfection," he explains.
It was not surprising then that last November, the Joint Commission asked Conway to give a talk at its annual meeting on leadership and patient safety. "In preparation for that talk, we had conversations with our trustees and executive leadership, as well as with our staff," he says. "We asked ourselves, What are the things we do that work and seem to make sense, and that lead to success?’" Conway then put up a posting on the National Patient Safety Foundation listserv, asking if health care professionals believed their organizations’ leaders "got it" when it came to patient safety.
"We got a number of comments from people who said they did, and they told us what they do," Conway reports. "Then we went and looked in the literature. We spoke with people like [the Institute for Healthcare Improvement’s] Don Berwick and [Harvard University’s] Lucian Leape, and asked what they thought."
Dana-Farber also consulted two other groups: a state coalition of 20 organizations dedicated to improving patient safety, and their patients. The result was the patient safety tool, which has been given the title, "Strategies for Leadership — Hospital Executives and Their Role in Patient Safety." It is divided into four basic sections:
• Personal Education. How do you educate yourself? What books and articles have you read? Do you take courses? Do you understand the facts of your organization?
• Call to Action. What are you doing to establish a framework for safety in your facility? What policies and procedures have you put in place?
• Practicing a Culture of Safety. How do you do this every day?
• Advancing the Field. What do you do outside of your institution to support others?
The tool is presented in the form of a questionnaire, with "Y" and "N" boxes next to each of the 42 questions. The American Hospital Association in Chicago has put its imprimatur on the tool and has distributed it to hospital executives. In the cover letter, Conway notes: "To be sure, having a number of checks in the Yes’ column of the self-assessment is far more significant than having none. But identifying a plan to move some checks from No’ to Yes’ could be equally significant."
Clearly, he says, some "Y’s" are more important than others, but that can vary from institution to institution. "The question to ask is, How can I move in my organization from No to Yes?’ It is an opportunity to step back and reflect," Conway says. "We propose that you not only reflect with yourself, but with a group of other people before checking off the box."
The Dana-Farber program actively involves patients and family members at all levels of institutional planning; this is what helps keep safety at the forefront of all Dana-Farber activities, he adds. "We have patient and family advisory councils in both adult and pediatric care," he says. "They sit on most of our operational committees — at the board level on our quality committee. [They leave if the board goes into executive session.] We share error rates with patients, and slips and falls. When we go through the Joint Commission survey, they are involved."
By actively engaging patients and families in the process, Dana-Farber can get almost instant feedback. "We can implement a new system today, and the next day a patient can say, The infusion room is too crowded,’ or The construction project is making the staff uncomfortable,’ or When I was admitted they couldn’t find my records,’" he explains. "Our patients are experiencing care in ways that none of us do, and to the extent our processes are not working, they can tell us — and quickly. Sure, we do statistical surveys, but the results often come in two or three months later. We want our patients to pick up a phone and give us a call."
Out of a tragedy have come some very good things indeed. Today, Dana-Farber sees nearly three times as many patients as it did in 1995. "Not only has our volume grown, but our research has grown; the center is vibrant," Conway says. "Our story is the story of how an institution took a tragic situation and used what it learned to leverage the whole organization to a better place."
Need more information?
For more information, contact: James Conway, CEO, The Dana-Farber Cancer Institute, 44 Binney St., Boston, MA 02115. Telephone: (866) 408-3324. E-mail: [email protected].
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