Patient Safety as an Academic Discipline
Article Outline
ACGME, Accreditation Council for Graduate Medical Education
Significant improvement in the delivery of safe and effective care of children will not occur until fundamental gaps in the organization of care are understood and resolved. Most errors and failures in healthcare are the product of poorly designed, poorly engineered, and poorly coordinated care that does not recognize the complexity and tight coupling of contemporary healthcare across many sites and services and in the home.
Although there has been success in developing specific interventions to prevent error and improve outcomes (eg, central line and ventilator-associated pneumonia bundles, bar-coding, provider order entry, crew resource management), most error results from fragmented and unnecessarily complex processes, poor communication, lack of team work, and failure to understand technical work in a detailed and coherent manner. Uncertainty and confusion are common and contribute to the inability of patients, families, and providers to find their way through the labyrinth that is today's healthcare: incomplete information, un-reconciled medications, and production pressures. These examples are but a few of the many barriers to safe and reliable care that require study.
Doctors, nurses, and other professionals struggle to improve the conditions in which they work, but they often lack the knowledge and skills to make a significant difference. The need exists to comprehensively address the problems and challenges of today's healthcare in a practical and highly disciplined way. This need can be met, for example, with the creation of “test-beds” to engineer and study quality and safety improvements for children and families. There is, however, argument about what constitutes legitimate methods to study and build evidence for reliable patient safety practices and care models. The release of the Institute of Medicine's report, “To Err is Human: Building a Safer Health System,” mobilized attention, but the work of safer health care has proven more difficult, time consuming, and expensive than expected.1 Cook articulates that most efforts have been in applications rather than explorations into patient safety itself, and that applications alone cannot provide insights into basic mechanisms of why an intervention works or fails, so there is limited new knowledge to substantially improve patient safety.2We believe it is time to get on with the work at hand and correct the perception that the large, randomized clinical trial is the only valid research. Although there is comparatively little published in medical journals about patient safety improvement, there are countless experiments occurring in hospitals throughout the nation and the world. Each hospital is striving for improvement, creating new and often inventive ways to deliver care, but failing to record and report their experiences. This lack of knowledge transfer results in the “reinvention of the wheel,” failed projects being repeated in different locations, and failure to accelerate exploration in pediatric patient safety.
The causes for the lack of scholarly investigation and publication of these experiences are protean and include a lack of time to publish, demands of urgent issues that crowd out scholarly activity, and lack of recognition and academic rewards for this type of work. Davidoff and Batalden have published a framework that may help advance the academic discipline for improvement. 3 We believe it is critical to create academic systems that reward and support improvement exploration and study. The quality and safety literature is slowly evolving to produce scholarly work publishable in peer-reviewed journals. For example, Wall et al conducted a study of blood stream infections associated with central lines and demonstrated a near elimination of infections.4 In another study focused on reducing ventilator-associated pneumonia, Wall et al reported on a system-wide collaborative across 63 hospitals.5 Hunt and coauthors improved patient safety and studied the impact of an intervention on prevention of respiratory arrest and cardiopulmonary arrest, demonstrating a significant decrease in the incidence of inpatient respiratory arrests.6 These publications are among the few appearing in peer-reviewed journals. In the publication period of March 2008 to March 2009, there were only 15 articles with “patient safety” or “quality” in the title or abstract of the 1272 articles published in Pediatrics.7 Similar results were found in the Journal of the American Medical Association and the New England Journal of Medicine.
Creative and critical study in patient safety constitutes academic activities that are beyond traditional research and clinical trials. Universities and their clinical academic departments should encourage such activities that affect patient care and safety by incorporating them into the criteria for recognition and promotion. Once patient safety and systems improvement becomes an academically recognized activity, we anticipate that many students and residents will enter this realm with great enthusiasm, ingenuity, and results. In 2008, Don Berwick, MD, MPH, posed this question at the International Quality Improvement Conference in Paris, France: “What type of evidence is needed that will help us make change happen?”8 The question is central to whether we can effectively understand and introduce better practices in the absence of randomized clinical trials. It is time that we take the lessons of Shewhart and Deming to heart and recognize that solid, statistically valid research can be conducted in an uncontrolled environment.9
We believe that we must move past the traditional notion of research hierarchy to advance the work of pediatric patient safety. The domain of patient safety is inherently complex, because it is grounded in anthropology, sociology, psychology, engineering, human factors science, and medical science. When results are not quantifiable, we must use the rigorous assembly of evidence from experiential and practice knowledge. As the complexity and risks of providing pediatric care in high hazard environments are becoming widely recognized, physician scientists must study and develop knowledge in healthcare-specific practices. Moreover, we must provide the physicians with the science and the tools to study those practices: Statistical Process Control, Six Sigma, System Dynamics, and others.
We are challenged to improve our performance in a socio-technical system with interdependencies and tightly coupled elements. Standard medical research methods, although valued and necessary, are insufficient to pursue breakthroughs in creating safer care delivery for children. Imagine if each pediatrician and pediatric specialist would complete residency as a healer, caregiver, and system improver. Yet, to do so, knowledge, experience, and research of system dynamics are required. Most new physicians are ill-prepared to contribute, and even fewer to lead, in pediatric patient safety.
If we accept harm as a diagnostic category—an epidemic claiming more lives than many illnesses or injuries—we are obligated to support this emergent need through training and education. If this phenomenon were a new disease state, we would assign intellect, talent, and resources to solving this problem, not excuse it away. Our next generation needs to be prepared to understand and transform the care delivery system, not be victims of it. Both the Accreditation Council for Graduate Medical Education (ACGME) and the medical certifying boards have recognized this lack of patient safety science and improvement knowledge in physicians. The ACGME has made improvement a supporting pillar in 2 of the 6 core competencies that must be taught to residents (practice-based learning and improvement, and systems-based practice). Maintenance of certification programs are beginning to add such improvement to their requirements for re-certification. As an example, pediatricians who will re-certify after 2009 will need to demonstrate their ability to systemically assess and improve quality of care. It is incumbent on academic medical centers to provide improvement training during medical education and residency and provide venues for lifelong improvement learning for residency graduates and faculty.
The leadership of academic departments and clinical practices is critical. As we develop new knowledge and solutions to prevent illness, treat complex congenital and childhood illnesses, and introduce life-saving protocols, there is an equally important need to transform practice, communication, and systems on the basis of well-designed investigation into better delivery models. Bringing legitimacy and support to patient safety research is required to distinguish effective evidence for widespread improvement and sustainability from ideological arguments. Responsibility for safe, high-quality care cannot be delegated to other personnel. Active partnership is required.
If we fail to prepare physicians to explore system dynamics—the setting, habits, processes, patterns, and peculiarities—we will fail to embrace analytic capabilities and simply maintain the apprenticeship model. This places our new professionals at similar risk to earlier generations in which uncertainty and complexity are not well recognized. Can we really afford to continue to design systems with only a thought of, “Well, that's how they did it when I trained”?
References
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- . Lessons from the war on cancer: the need for basic research on safety. Arlington, VA: Testimony submitted for the AHRQ-sponsored second National Summit on Patient Safety Research; 2003;p. 2
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- . Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children's center. Arch Pediatr Adolesc Med. 2008;162:117–122
- Spielman A Review of titles and abstracts. National Patient Safety Foundation. March 2009.
- . International Forum on Quality and Safety in Health Care. Institute for Healthcare Improvement. France Paris: Le Palais des Congres de Paris; 2008;April 22-25
- . The economic control of quality of manufactured product. New York: D. Van Nostrand Company, 1931, Rreprinted by the American Society of Quality Control; 1980;
PII: S0022-3476(09)00545-9
doi:10.1016/j.jpeds.2009.05.032
© 2009 Mosby, Inc. All rights reserved.
