Patient Safety: An Interview
with Dr. Tejal Gandhi

I think sometimes we get frustrated by the pace of change. When I look back to that time period [when the report first came out], there weren’t patient safety teams, or programs, or patient safety officers, or any of that. No one was talking about patient safety. It wasn’t in any nursing school or medical school curricula. There was a lot of denial that medical error even existed.  There was a culture that doctors need to be perfect. And, [back then] we certainly wouldn’t tell patients about errors.

Today a lot of that has really changed. The standard is disclosure to patients. The culture that we are trying to achieve is that we do talk about these things in order to learn from them and prevent harm in the future. We don’t punish but rather promote a just culture. We have teams and programs and initiatives and have seen, I think, major improvements in things like infections and medication errors. And, we’re seeing education and training [around patient safety]. We are seeing the ACGME as well as nursing schools and medical schools focusing on patient safety. So, I do think that we’ve made progress. And, when you think about it in that sense, 20 years is not that long compared with how long, let’s say, we have been battling cancer or other things. On balance, we have a good list of accomplishments so far. But we know we have a long way to go.

I think there was certainly attention from the media but those tend to be blips. I don’t know that it changed the trajectory of anything. I do think that many people in the field had some issues with the methodology behind that study, and I think most of us in the field feel like there ends up being too much debate: “Is it really the third leading cause of death? Is it the seventh?” I think many of us in the field are tired of that debate. The number is far too many regardless of where it stands in the rankings, and we need to get on with improvement as opposed to being fixated on the numbers. 

Insurance companies were already moving toward non-payment for hospital acquired conditions, serious reportable events, and hospital readmissions for a long time. CMS has very much led the way. Here in Massachusetts it’s been about ten years that Insurance companies would not pay for serious reportable events. So, I think they’ve all been thinking about the non-payment piece for a while.

I think that they understand the importance of patient safety. I don’t think that non-payment is necessarily the strongest lever that they have, though. I think we have a lot more that we can do around how we bill for services and paying more for prevention, better patient engagement, and those types of efforts—as opposed to just billing for time and procedures and RVUs (Relative Value Units). I think that the change we need to see is paying for quality and value as opposed to quantity. That’s the shift we need to see in the insurance industry. If I, for example, spend 30 minutes counselling a patient on depression or obesity, that has huge long-term preventative value. But the way performance is measured reimbursements are set up currently, physicians are not able to spend 30 minutes on something like that.

I do think the financial argument for patient safety has been challenging. And, I often have felt, why do we need to have a financial argument for patient safety? It’s actually about doing the right thing. “First do no harm.”

That being said, there are financial choices that organizations have to make. And, I think that because patient safety tends to be about a “cost averted,” it has been a hard argument to make sometimes. We’ve done a lot of work trying to engage CFOs in that conversation, and I do think that’s been a challenge. But I think the big challenge is that there have been so many competing priorities for the C-Suite’s attention.  They’re thinking about mergers and acquisitions, very tight margins, and all those types of things. Particularly in the last five years or so, there has been a lot of work in patient safety. So, I think now we are seeing a bit of complacency. The argument goes, “We’ve been working on this for a while. We’ve made some initial investments. We’re starting to see some progress. So, let’s move on to the next thing.” But we can’t get complacent. We need to keep a constant drum beat on safety.

Anesthesia has certainly been the leader. From the very beginning, Anesthesia has been the place that has led the way. I think about team training and simulation and those topics. Whether it’s the emergency department or operating rooms, I think there’s been a lot of progress using those types of tools in those high acuity settings. That’s where you can see the benefits a little more immediately. I think it’s harder when you get into primary care settings and ambulatory care settings where events happen over a long period of time and it’s a little harder to feel like you can make an impact on those.

The philosophy of risk managers is quite variable. I’ve met risk managers who have totally bought into patient safety and who understand [patient safety] concepts and philosophies. And, I’ve met risk managers who are all about protecting an organization from a legal standpoint and that’s their focus. And, so, that’s the whole spectrum.

To me, a critical piece, if you’re in safety, is to make sure that you are connected and not siloed from risk management, that you try to ensure that your risk management department really understands the principles of patient safety. In theory we’re all trying to do the same thing—mitigate risk and prevent harm. That’s the mutual goal. Where we’ve had challenges are around issues of transparency and disclosure and those kinds of things, but I think we’re making progress on that front.

[One area that patient safety has really pioneered is a systems and human factors approach, which I think really wasn’t as much of a focus of the risk field until recently.] [So, as I said, I think the attitudes you will find among risk management are quite variable. Trying to remove some of that variability by patient safety and risk management working together is really important.]

We always talk about data and stories, and you need to have both in hand when you talk to the C-Suite. And, I think as much as you can make a business case that’s always helpful. I also believe it’s really important that the Board be engaged in patient safety, because the C-suite gets direction from the Board. My organization just recently released a white paper and related resources to help leaders and Board members assess their understanding and move forward with appropriate oversight of quality and safety. When Board members understand patient safety issues, measures, and approaches, they are more likely to make patient safety a priority. Ultimately, though, you need to have a CEO who is committed to this. You have to get their time. You have to be convincing. But ultimately you have to have the right person in that role of CEO. And, that actually is the responsibility of the Board—to make sure the right person is there who will actually make patient safety a priority.

I have a good one, and it involves simulation. Twenty years ago I was working at a large academic medical center. When we would have a code in the hospital, there was an overhead page “Code Blue.”  Whoever was nearby responded to the code and you’d have 20 people in the room trying to figure out who is in charge and who’s going to do what. It was chaos.

The team that oversaw the resuscitation service said, “Okay, we’re going to have to change this. We’re going to have a code team. They’ll rotate every two weeks. They’ll carry a dedicated pager. So, no more relying on the overhead pages where everybody shows up. The team will arrive, and we will follow a prescribed approach.”

The code team received team training in our simulation center before they started so everyone knew what their roles were before they started, how they needed to respond, how they needed to communicate. Things shifted from that original model to a dedicated model that received team training through simulation before they started, and it became much more streamlined in terms of the quality of the code responses. Then they started doing mock codes in situ in the actual hospital as opposed to the simulation center to emulate the environment more accurately. That shift to really focusing on the team and the communication and using simulation to do that really made a big difference in the quality and safety of code events.

[It’s] the statistics about maternal mortality internationally but particularly [here] in the U.S. [It’s] the high mortality rates that we are seeing, particularly the disparities and rates of complication which are certainly higher in women of color and underserved populations. I think that really just resonates with us. It’s an area that we need to focus on, both from the harm standpoint and the equity standpoint. We have been doing work on maternal and newborn mortality internationally for some time and have started to do work in the U.S. We’ve been urged by others to do more, and it seems like the timing is right to make a dent in this particular issue because we’re seeing statistics right now that are very troubling. Just in terms of preparedness and responding to emergencies, there are huge gaps to fill.

The training is quite different for physicians, nurses, and pharmacists, and tends to be pretty siloed. So you have these siloed educational streams that have to come together and actually work together. I think there are ways that we could restructure how we approach education. There are certainly schools out there that are much more interdisciplinary in their approach in bringing the med students, the nursing students, and pharmacy students together during training times.

But even without that I do think having those opportunities for everyone to come together and do training together on things like teamwork and communications can have huge value. Even things like walking in others’ shoes for a day help. When I was at Brigham and Women’s we would do this. It made a big difference for people to see all these steps that other people have to go through to do their job and why. Just understanding that and building relationships can help in many ways. We’ve seen this in the OR, particularly around team training, where bringing the surgeons together with the nurses and the techs can really make a difference.

The best thing to do is to have discussion. It’s important for people to know that we have made progress. It’s important to talk about some of the things that we’ve done and some of the directions that we need to go. I wouldn’t want people to walk [away from the movie] thinking we’re never going to solve this, because I do think we’ve made [advances]. And, so, I think it’s a great way to get a conversation going about how we accelerate things from here.

I think in patient safety we really have to be cognizant of the fact that clinicians out there are trying really hard to do well by their patients, and it is useful to look at how we learn from the positive deviations as well as the negatives. If we are going to try to take on issues like burn out, for example, which we’re seeing as a major factor which can hurt patient safety, we need to not sugar coat it but balance it with some of the positives as well. We’ve started talking about the positive things that have happened in the last 20 years. Now it’s time to accelerate.

We have amazing people in hospitals who are dedicating their lives to helping people, taking care of people, and making a huge difference in the lives of people. I think we need to make sure those people are working in an environment that lets them do their jobs to the best of their abilities. That’s really what we should be aspiring to. We have huge appreciation for everyone working in hospitals and all the incredible work they do. Happy Hospital Week!