10 Takeaways for Healthcare Providers from PSMF’s Unite for Safe Care Virtual Event
Every year, September 17, 2020 is the World Health Organization’s World Patient Safety Day — a day to raise awareness of and reiterate the importance of healthcare safety. This day calls for global solidarity and concerted action by all countries and international stakeholders to improve patient safety.
This year, the Patient Safety Movement Foundation’s campaign for World Patient Safety Day was #uniteforsafecare, with the theme, “Health worker safety is patient safety.” PSMF hosted a nearly four-hour live YouTube event, with a lineup of speakers including survivors of preventable errors, family of those who have been lost to medical errors, healthcare providers, advocates, lawmakers, and others seeking to raise awareness of healthcare safety. Keynote speakers included the Director-General of the WHO, Tedros Adhanom Ghebreyesus, as well as former President Bill Clinton.
HealthySimulation.com congratulates the Patient Safety Movement Foundation, the International Society for Quality in Health Care (ISQua), The Leapfrog group and the American Society of Anesiothiologists on putting together an amazing event which was enlightening, powerfully moving, and inspirational!
Here are 10 takeaways for healthcare providers from PSMF’s “Unite for Safe Care” virtual event:
1. Safe health workers and safe patients are two sides of the same coin. Health worker safety is a priority for patient safety. As WHO Director-General, Dr. Adhanom, stated, “The COVID-19 pandemic has unveiled huge challenges and risks for health care workers — health care associated infections, burnout and stress, violence and stigma … [that] can lead to illness and even death.” Working in difficult conditions can have negative consequences for patients, because health workers can make more errors in such an environment.
As Dr. Adhanom stated in his keynote speech, safe health workers and safe patients are two sides of the same coin. Around the world, millions of patients die each year as a result of adverse events. “When errors do occur, it’s important that we learn from them so we can prevent them from happening again.”
2. COVID-19 is exacerbating existing problems, but the system can be fixed if we work together to help protect us from future pandemics. PSMF Chairman, Michael Ramsay, is President of Baylor Scott & White Research Institute in Dallas, TX. As Dr. Ramsay noted, more than 200,000 people die in U.S. hospitals of preventable errors alone, and many others are harmed. Now, in the COVID-19 pandemic, healthcare workers are getting sick and dying, too. However, the system can be fixed if we work together. Together, we can beat COVID-19, so that we are much better prepared for future pandemics.
As Former President Bill Clinton stated at the virtual event: “Keep coming to the table together to save lives and fulfill that promise of zero preventable deaths.”
3. Hospitals must take into account human factors and work towards becoming High-Reliability Organizations. Nuclear submarines and aircraft carriers are two examples of High-Reliability Organizations (HROs). In HROs, there are procedures and redundancy in safety precautions (for example, checklists, or an auditing function) that can ensure safety. Everyone knows their roles, and has practiced them many times.
Health care systems must be safe. Safety is a result of doing the correct things — following the correct protocols — and correcting errors as soon as they come up. The APSS on the PSMF website come from the safest hospitals around the world. “If every hospital followed APSS, we would have a very safe healthcare system,” Ramsay said at the virtual event.
4. Advise patients and their loved ones to speak up and take control of their own health care. An essential element in ensuring patient safety is reminding patients and families that they have a role to play in their own care. Encourage patients to ask questions and stay engaged.
5. We can learn a thing or two from Florence Nightingale. Danielle Ofri, an internist at Bellevue Hospital in New York City, talked about the first patient safety expert and first biostatistician, Florence Nightingale. Nightingale measured where the problems with patient care were, devised interventions, developed simple rules, and measured outcomes. “If you don’t measure where the problems are, you’ll never figure out what’s going on and how to fix it,” Ofri said in the #UniteForSafeCare virtual event. “Checklists can help.”
2020 is the 100th anniversary of Florence Nightingale’s birth, so WHO has made 2020 the year of the nurse.
6. Combat the culture of silence. As President and CEO of the Leapfrog Group, Leah Binder works towards improved safety and quality in hospitals. As she stated in the virtual #uniteforsafecare event, “too often, patient safety is treated with silence — people don’t talk about the problem, or we may think it’s a secondary priority — but it’s a major priority.” Instead of a silence culture, hospitals should work towards a communication and safety culture — when something goes wrong or could go wrong, communication is essential to avoid the unthinkable.
When tragedy happens in a hospital, very often, someone dies, and a defensive culture kicks in which makes it impossible for health care professionals to speak openly and honestly about what went wrong so that lessons can be learned. The CANDOR Process can be useful to fight the culture of silence. This way, lessons can be learned from what went wrong and make sure it never happens again.
7. Recognize mental health and burnout of health personnel. The safety concerns in the healthcare setting are not unique to healthcare. As one doctor stated at the virtual event, “We are all human beings and we have the same reactions, but doctors are caring for life, and they know that if they don’t go to work, so much is at stake…we blame ourselves for not working hard enough. Physicians have a burnout rate of almost 50%, but it’s often swept under the rug. The problem starts in medical training. Better regulations are needed to push for change.”
8. Help us align incentives to ensure that healthcare organizations get paid for safe care. Zubin Damania, more commonly known as renowned medical vlogger ZDoggMD, shared his thoughts on the patient safety crisis in health care: “Hospitals are the most dangerous places on earth. They are dangerous for staff and patients…there’s violence against health care providers, and violence against patients in the form of medical errors that are preventable. The main reason for these errors is that we don’t get paid for quality. Safety should be the absolute highest priority like it is in the airline industry — not just “another thing” we have to do. That’s tearing us apart — which is not good for patients.”
Never let a crisis go to waste, advised ZDoggMD. “Step up and say we’re going to do better for patients and each other, lobbying policy makers for different payment models.”
9. Advocate for smart health care reforms that can support a better health care system. Another speaker at the #uniteforsafecare event was Jeremy Hunt, former Secretary of Health of the UK who brought greater transparency to the National Health Service. During the virtual event, Hunt challenged participants with a few questions: “Why is it after 20 years of campaigning on [patient safety] that we still have terrible statistics? The truth is that we need to change the law.”
“Adjust our laws so there is absolute clarity … between ordinary human errors that we all make in our lives, and gross negligence … which should not be acceptable. This line is currently blurred in medicine, and healthcare providers are scared that if they speak openly about a mistake, they could lose their job.”
It’s important to remember that a toxic culture negatively impacts quality of care. Robyn Symon is the filmmaker behind the movie Do No Harm which looks at physician burnout and suicide. Symon says that reforms such as independent investigation and oversight can help healthcare providers both get help they need and reduce medical mistakes.
10. Address disparities in care. Ronald Wyatt, MD, grew up in rural Alabama, and at the time, did not know that there was any health care disparity. However, throughout his life, he has noticed “significant less-than-optimal and poor outcomes for Black, Indigenous, and other” minority populations due to “structural and institutional bias and racism that is part and parcel of health care delivery and clinical decision making.” This disparity also includes language and cultural barriers. According to Dr. Wyatt, frank and honest discussions are needed “about what are the structures, what are the policies in place, and how we can work towards eliminating disparities in health care.”
Becoming a safer organization is a journey. This journey involves reporting things that could be better, learning, Health care providers must work towards a new way to deliver care with greater safety, transparency, and accountability focused on advancing tried-and-true best practices (such as the PSMF APSS). Cultural change is essential, and it serves as a foundation to build process improvements. Transparency, teamwork, and communication are essential here to drive results, with a shift from “patient-centered” care to “person-focused care.”
Becoming a safer organization is a journey that requires us to change the way we think about care delivery and performance improvement. Lasting change will not occur until a solid foundation for reliable care is established that includes three critical components:
- A person-centered culture of safety, where transparency, honesty, and a
- A holistic, continuous improvement framework
- An effective model for sustainment
This journey involves reporting things that could be better, learning, Health care providers must work towards a new way to deliver care with greater safety, transparency, and accountability focused on advancing tried-and-true best practices (such as the PSMF APSS). Cultural change is essential, and it serves as a foundation to build process improvements. Transparency, teamwork, and communication are essential here to drive results, with a shift from “patient-centered” care to “person-focused care.”
Lance Baily, BA, EMT-B, is the Founder & CEO of HealthySimulation.com, which he started while serving as the Director of the Nevada System of Higher Education’s Clinical Simulation Center of Las Vegas back in 2010. Lance is also the Founder and acting Advisor to the Board of SimGHOSTS.org, the world’s only non-profit organization dedicated to supporting professionals operating healthcare simulation technologies. His new co-edited Book: “Comprehensive Healthcare Simulation: Operations, Technology, and Innovative Practice” is available now. Lance’s background also includes serving as a Simulation Technology Specialist for the LA Community College District, EMS fire fighting, Hollywood movie production, rescue diving, and global travel. He lives with his wife Abigail in Las Vegas, Nevada.