Editor's note: Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based system that includes Massachusetts General and Brigham and Women's Hospitals. He was previously the Director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. He has also served on The Joint Commission's Board of Commissioners, Institute of Medicine panels, and the National Patient Safety Foundation's Board of Directors. We spoke with him about training and certification in patient safety.
Dr. Robert M. Wachter: You've been in the middle of the movement to create certification in patient safety. Why is that important?
Dr. Gregg S. Meyer: It is important to think about how we can establish standards in patient safety. There are ways to start to define the core characteristics of people who have expertise in this area. As for certification in patient safety, I think we're ready for it. It's time.
I look at the value in it from three different perspectives. The first is one as an employee. The certification says, I have these skills; I've demonstrated that I know the science of patient safety; I know how to apply it appropriately; and I understand why it's important in health care today. A different perspective is that of an employer. As we try to build up our capabilities in patient safety, we need to have a qualified workforce. In the past, we've largely built our patient safety workforce from people who had an interest in care improvement from the quality world, and many from the clinical world. But we need folks who can draw on a variety of experiences, like human factors engineering and organizational behavior. From an employer perspective, the notion that I have some mechanism to look at a variety of people potentially applying for a role in patient safety to see that a certain group has demonstrated that they have this broad range of capabilities, it makes my life much easier.
Then the final perspective is the patient perspective. When we look at the arc of the history of patient safety, it's fair to say now that it is becoming more professionalized. A cadre of professionals has identified themselves as leaders in the field. For an organization like ours that employs people, certification says something about the importance that it puts on patient safety. So those are all the reasons certification is important.
RW: I guess the argument comes up, and this is fairly typical for other fields as well, shouldn't everybody be certified in patient safety?
GM: That's a terrific notion—to say we all should. And there are two problems with that. The first is that in some ways if everyone said yes, I'm an expert in patient safety—the reality is that no one really is. And that's true for most things in life. You really need to have a small group of people who take this on in a very serious way; otherwise the real work will never get done. The second argument is that it does require a certain dedication to learn the science. Looking at the evolution of patient safety science over the last 20–25 years, we have really started to define the field. We have pulled in the expertise from other areas like engineering, human factors, and psychology and applied them to this discipline, and we can't expect everyone to know that in great depth. At the end of the day, yes, I want everyone who works in the health care system to have some baseline understanding of patient safety. But in addition, I do need a small but really important cadre of folks who understand the depth of the science and can also apply it. That's where certification comes in. So it does provide that differentiation; it is that step up from what we expect everyone to have at baseline.
RW: As you thought about what certification, and I guess by extension, what training would look like in patient safety?there is foundational science, and there's a very pragmatic part: how do you run a meeting, how do you move an organization, how do you do the diplomacy part, and how do you do the handholding? How have you thought about teaching that and how have you thought about testing that as part of the certification process?
GM: That's a terrific question, and it's important to realize that any competency requires a certain amount of content knowledge. That's necessary but it's never really sufficient. You also need that process knowledge. One real advantage of patient safety as a field is that from the very beginning we've recognized how important culture is. We need to understand the science of safety, and the work of James Reason, Charles Vincent, and Karl Weick who have laid out the science of safety. But the application of that is where we need expertise. So what we try to do in certification is to not only assess your content knowledge but also to demonstrate how to apply this to real-world scenarios. How would you approach this? How would you organize a way to understand this issue? How do you decide who is sitting at the table? That type of information, which I would say broadly writ is taking content knowledge and using change management to make a difference. The sweet spot of patient safety certification is testing that. Having gone through that process myself, I was pleasantly surprised that the important pieces on content were there, but the majority of the examples were how to apply these in the real world.
RW: When you and the other leaders began thinking about patient safety, the American health care system was largely paper based. Today it's largely digital. How does that change the thinking about the content and the methods of both training and certification?
GM: In terms of content, it's incredibly important to constantly keep up with all of the digital transformation going on in health care. For example, in the past we used to worry about handwriting errors. The good news is that for many health care organizations, handwriting errors are now a thing of the past. That said, health IT has introduced a whole new set of patient safety challenges. Keeping the curriculum current with that transformation is extraordinarily important. In terms of the certification process, it's also had a major impact. The first is recognizing that most of us are best able to learn in an experiential fashion. We're going to learn on our schedule rather than sitting in a classroom, and we're going to learn by getting some content and having a chance to rapidly apply it. We're moving from a classroom-based training environment to doing this largely through online training. It's the right way to go forward, and also the best way to fit into the busy schedules of the clinicians, administrators, and health care executives. In terms of the exam itself, we were able to design it to do over the Internet. It's done locally at a certified test site, and one of the powerful aspects of testing digitally is that the individuals get the results right away.
RW: You were very involved in the early years of safety in lots of roles, including at AHRQ. As you reflect back over 15 or 20 years of experience, has anything surprised you in terms of content areas that have become more important than you would have expected, or those that are less important or changed in fundamental ways?
GM: I often reflect back on the honor and privilege I had to be there at the beginning of the federal response to the patient safety challenge. Some of our early approaches we thought, "This is a good idea. It's going to take some time, and we believe over time it really can make a difference." I would put as Exhibit A, WebM&M. That's something where early on I always thought this is a powerful vehicle; this is going to work. It was going to take time to get there, but this was something that we ought to invest in.
One thing we underappreciated was the importance of culture. It wasn't just the notion that culture has an impact on safety, but that it could be quantified or measured. We've made great strides in measuring culture through surveys and demonstrating conclusively that those results are highly associated with meaningful outcomes for our patients. That has been a big surprise.
The other big surprise is how quickly the field transformed from one dominated by people pushing the envelope to one where we now have very disciplined programs. Five years ago, there really was only one fellowship opportunity, through the National Patient Safety Foundation and the American Hospital Association. Now we have fellowship programs through the Harvard system and similar programs across the country. Schools of public health have started to put in the curriculum. I don't think we appreciated how quickly patient safety would become a much more mature and defined discipline.
The final thing is that we were very impatient. Everyone wanted to be able to "fix the problem." That's what physicians like you and I do. The reality is that patient safety is a commitment, a journey. Given my background in the Air Force, I constantly remind myself of aviation safety and how safety changed over time. For any given 2-year, 5-year, or even 10-year slice of time, you could worry that we were not moving fast enough. We've stagnated. We're going nowhere. Yet we have the ability to look over that arc of 5 decades, and you can see something incredibly stunning. I'm very optimistic?as I always am?that this is what we're going to find in patient safety.
RW: About 10 years ago, I interviewed Brian Sexton about safety culture, one of the world's experts. A few years ago for the series, I called him back to do an update on safety culture. And he said something like, "I don't really want to talk about it because I've come to recognize that safety culture is higher on Maslow's scale than satisfied and joyful clinicians or other workers in this area. I've come to believe that until we restore the joy and the resiliency and deal with the burnout, we can't even begin to address safety culture." How do you react to that?
GM: That is a terrific insight, and I know from our own experience with our workforce. We've done burnout surveys of our clinicians, so we know where we stand. Frankly, we're no better, and not a whole lot worse, than anybody else in health care, where health care is in general is not good. We've incorporated Paul O'Neill's questions about workforce and about joy and meaning into our safety culture surveys. "Are you treated with dignity and respect? Are you given resources and support to do work that adds meaning to your life? And does anybody really notice and give you recognition for that?"
Brian is right that this is absolutely of fundamental importance. The notion that this is a building block you have to create as a foundation to build a safe culture on top of is important. We ought to be able to look at both. And change our safety surveys to incorporate those types of questions and deliberately consider burnout programs to be patient safety programs. The other way to pull these worlds together is to recognize what the Lucian Leape Institute says about joy and meaning in work making a huge difference for our patients.
Working on culture without focusing on burnout and joy and meaning will not give us the results we need. Just focusing on joy and meaning without really looking at culture and leadership is also going to be a bit of a dead end. So we have to pull the pieces together.
RW: What are you seeing as new generations of folks enter the safety field? They've grown up in a world where we were paying far more attention to safety than was being paid when you and I were in school. How is that changing the way you think about training and certification and what you need to do with this generation to have them be effective and be leaders?
GM: First of all, in general I am incredibly bullish on the direction things are going. From the clinician viewpoint, I can honestly tell you that when I was working at AHRQ in the late 1990s, if I stood up in front of a group of residents, fellows, junior physicians, or young nurse executives and said, "Hey listen, we have this great opportunity for you to work in something called patient safety," I would have seen blank stares. When I first came back to the provider organization side as a medical director in a large hospital, about 14 years ago, I would get visits from maybe one resident a year. I always thought it was terrific when they walked through my door and they said, "I'm interested in the safety and quality thing. How do I get into that?" That was in 2002. By the time it was about 2005 and 2007, there were three or four of them coming through my door every year. By about 2010, we could fill a room with about 15 residents and fellows who showed up to a voluntary lecture series every month. And by 2012 we said, we ought to build a fellowship in this; I wonder if people are going to apply. We actually recognized quite quickly that there was huge interest in it. And that was a pretty rapid transformation.
On the clinical side, the difference between now and a decade ago is that people are seeing it as a career path and as a way to explore their own interests and to be able to contribute to improving health care. And that's not just physicians; the same is true of nursing. You're starting to see a nursing curriculum, a medical school curriculum that patient safety is moving from "this is an interesting elective" to "this is a core piece of our curriculum."
On the nonclinician side, what's recently really exciting is the people who are being pulled into health care who have long been at the sidelines. In particular, I've experienced being part of a university system where there was this one world of clinical care and health care delivery, and then this other world of the undergraduate science campus and the engineering faculty, and never the twain would meet. The truth is that today we're getting more cross-fertilization, not just at the university level but getting individuals with backgrounds in engineering, human factors, or organizational psychology that are now looking at health care and realizing they can make a difference. We now are creating multidisciplinary teams. When I think back to my days at AHRQ, we had a fantasy that something like this would begin to happen. But I get to experience it every day. Sitting around the table with folks who come from a very different world asking, "Did you really analyze how this works? Do you really understand the contributing factors? Don't you think you could build this process a little bit differently? Don't you think there's harmful waste over here? Is it fair to expect our patients to put up with this?" Bringing those disparate viewpoints together has been a huge advantage.
RW: Where do you see things going and what do you think might be the next big things in this field?
GM: The whole notion of the continued professionalization of safety right now is on an inexorable upward trajectory. And I think that certification is a start to this. Just like we see in other fields, we're going to have individuals who are working in the area who are very focused in one area and not capable of rising up to that more general competency that we would say is worthy of certification. We're going to see a number of folks get certified. We're going to see folks who want to dig in deeper. I predict in the not too distant future that we're going to see an increase in schools of public health offering a focus in patient safety. We're going to see it become part of an essential part of nursing curricula; we're going to see it become more professionalized in terms of the type of jobs that hospitals and health care organizations are offering. On that front, the future is very bright and the evolution that we've seen will continue.
One thing I've tried to do through the National Patient Safety Foundation is to ensure that this certification has meaning. Keeping up with this rapidly changing field is both an opportunity for us to incorporate new knowledge and new competencies into the certification process, but it's also a big challenge to keep this up to date. So that continued commitment to the constant evolution is something that I want to see us focus on.
Finally, I'd invite those who have been working in safety to take the challenge. The challenge is one I personally took and that was to sit down and to put my money where my mouth is and say, yes, I've been working in patient safety for a number of years and maybe even have had the privilege of developing expertise in a few areas. But the reality is I wanted to put myself to the test and learn those areas where I needed to do more work. I needed to increase my understanding. I can tell you that the certification process for me allowed me not only to test myself, but also to identify areas where I could improve and provided me with enough information to say here's how I ought to be doing that. I've used it as the learning opportunity that I think it is.
RW: Great. Anything else you wanted to talk about?
GM: You asked me about things that surprised me over time with patient safety. One thing I found incredibly gratifying and extraordinarily useful to me personally, but to some extent a little bit surprising, is the incredible transformative power of transparency. If I had to think back on a few major changes that I tried to make in health care organizations that I've been associated with over the last several years and say, what really moved that forward? What allowed us to make progress? The notion that transparency is one of the most powerful allies was very much underappreciated early in the patient safety movement. It's now being baked into the general approach. The recent work of the Lucian Leape Institute in defining that has been very helpful. As we share our stories with patients and with colleagues, as we share our data more openly, as we challenge ourselves to get better and hold ourselves accountable in a public forum, we are going to accelerate in a way that none of us anticipated early on.