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Re-Engineering Health Care to Keep Patients Safe

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Can you imagine that most doctors learn little about the third leading cause of death in medical school?

Most medical students receive little or no formal training on how to prevent medical errors and reduce preventable complications, which cause more than 250,000 U.S. deaths each year -- a number topped only by heart disease and cancer.

While not all of these deaths and complications are avoidable, studies have shown that nearly 70 percent of common patient harms like infections and blood clots can be prevented. The potential cost savings of interventions, both in terms of lives and avoided treatment costs, is staggering.

Nobody wants these harms to occur -- not patients, not clinicians, not employers, not the private sector. Yet they continue, seemingly unabated. To adequately protect patients, health care organizations should rely less on the heroism of individual clinicians and more on teamwork and automated technology and integrated systems that optimize care and reduce cost.

In other industries, as information and technology evolved, operators worked with engineers to develop decision support tools. For example, a pilot's cockpit is much simpler today than 30 years ago; it is far more error-proof, and built-in defenses enhance safety. On the other hand, hospital ICUs, which contain anywhere from 50 to 100 pieces of separate electronic equipment, appear unchanged. A patient in the ICU is at risk for over a dozen types of preventable harm, and should receive more than 200 therapies a day to prevent these. Yet no information system has automated this list of therapies. Health care is grossly under-engineered: devices don't talk to each other, treatments are not specified and ensured and outcomes are largely assumed rather than measured.

While these challenges may seem daunting, health care workers, administrators and policy makers can overcome failed systems by working together on focused efforts. After an 18-month-old girl, Josie King, died more than a decade ago from a catheter infection -- a type of infection that kills nearly as many people each year as breast or prostate cancer -- a team from Johns Hopkins virtually eliminated these infections at Hopkins by using a checklist and other technologies, improving teamwork and measuring results.

With funding from the Agency for Healthcare Research and Quality (AHRQ), Johns Hopkins replicated that success, first in hospital ICUs in Michigan. Johns Hopkins then partnered with the American Hospital Association, state hospital associations and others, spreading the program across the country and reducing infections by more than 40 percent. More than 1,200 hospitals, large and small, now have infection rates previously believed impossible.

Though this success is laudable, it falls far short because these efforts focused on only one kind of preventable harm. And by relying on individual performance instead of safely designed systems, and on paper-based checklists rather than automated ones, hospitals have only been able to work on a few types of harm while patients continue to be at risk for a dozen.

Health care providers, along with the public and private sectors, must work to change this. At Johns Hopkins, we are trying to eliminate preventable harm by using a systems engineering approach to health care, leveraging technologies and creating better processes to ensure patients always receive the therapies and treatments they need and that clinicians work as effectively and efficiently as possible.

By a systems engineering approach, we mean a set of parts that are integrated and working interdependently to achieve a goal that no one can do alone. That's why we've invited patients and their loved ones, engineers, doctors, nurses, epidemiologists, bioethicists and numerous private-sector partners to help us develop the technologies and tools needed to deliver care that's safe and treats patients with dignity and respect.

Our project is made possible through a $9.4 million grant from the Betty and Gordon Moore Foundation, and is being led in parallel with a team at the University of California at San Francisco.

This is our vision: to work with patients, their loved ones and others, to eliminate preventable harm, optimize patient outcomes and experience, and reduce waste.

Imagine that your loved one is admitted to the ICU after cancer surgery and you are actively involved in his or her care. You provide information about their symptoms and raise concerns, knowing what is going on and are actively participating in decisions.

Clinicians are using technology to predict what complications your loved one is at risk of suffering. Using technology, you and the clinician have a checklist of the 200 therapies that your loved ones need to receive every today to prevent harm. You can see when they are due and when they have been done. And most are automated because the devices are connected.

You sleep well knowing that if the medication delivered by the infusion pump started to slow your loved one's breathing, the machine would shut off. You attend rounds daily, sometimes by video conference, sometimes in person. You are provided with a daily score card on how well your loved one's symptoms were managed, how well the team performed those 200 things and the results it achieved for other patients. You feel the staff care about your loved one and have time to talk to you, rather than squandering their time answering false alarms on bedside monitors. You sense a high morale and teamwork, and you feel you and your loved one are treated with respect and dignity.

Unfortunately, this scenario is not a reality in most hospitals.

To address the magnitude of preventable harms that patients suffer, many more initiatives of this kind will be needed. Health care organizations must abandon their siloed approaches to quality improvement to make the kind of drastic improvements that patients and their loved ones need and deserve.

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