In Conversation With… Tejal K. Gandhi, MD, MPH
Approach to Improving Safety
Setting of Care
Editor's note: Tejal K. Gandhi, MD, MPH, CPPS, is an Associate Professor of Medicine at Harvard Medical School and President of the National Patient Safety Foundation. Her research has focused on patient safety and reducing errors using information systems and other system-based approaches. We spoke with her about NPSF and the organization's evolving role in enhancing health care safety at a national level.
Dr. Robert Wachter, Editor, AHRQ WebM&M: How do you see the role of the NPSF in today's patient safety world?
Dr. Tejal K. Gandhi: The way I see the National Patient Safety Foundation's role is to be a thought leader, to try to push the thinking about where we need to go in patient safety to new areas, to expand our thoughts on where the priorities need to be by influencing hospital leaders, CEOs, and policy makers. The other is to convene stakeholders from all disciplines—physicians, nursing, pharmacy—and also bring in patients and industry to try to develop better solutions for patient safety with multiple stakeholders at the table. And lastly, dissemination—so many best practices are out there right now, and we are constantly reinventing the wheel in each of our organizations to try to implement or create new best practices.
RW: How would you say the mission of the organization has evolved over the years? When it formed there really wasn't much of a patient safety field, very few other organizations were engaged, and most hospitals and professionals didn't know very much about patient safety. Now the environment is very different.
TG: I agree. When the organization started, the focus was very much on raising awareness of patient safety because it wasn't a field at the time. There wasn't a lot of understanding of what patient safety really was. Other organizations now do work on patient safety, which is great because it shows that the importance has grown over time. Now the focus is more on creation and spread of best practices but also creating a workforce that is competent in patient safety. So we have a lot of programs around training health care professionals to become expert in patient safety. I see the role going forward is how do we maintain the momentum on patient safety, especially as we have other priorities. In particular now with the priority on cost and value, an organization like NPSF really has to maintain the drumbeat of patient safety and make the case that working on patient safety will help efforts to reduce costs, because reducing errors and complications will take you in the right direction on the cost side. Keeping that constant message is really important, so there's not the kneejerk reaction to cut resources as opposed to thinking about patient safety enhancements that could hopefully have the same (or better) end result.
RW: Clearly there are times those goals are synergistic, where something that is safer will actually be less expensive. But it strikes me that there are times where these areas are competing for resources. As the former chief safety officer of Partners Healthcare System, you've been in the position to see that play out. How do you decide as the head of NPSF whether to argue that this is all synergistic or argue for an independent focus on safety?
TG: I really do believe that ultimately they are synergistic. I know that there's the initial competition of, do you invest in an MRI machine or do you invest in a CPOE system, for example. But if we're really talking about making sure that we are doing things like reducing readmissions, complications, and following test results and referrals, it is going to actually provide better outcomes for the population-based health that we're all trying to achieve. The question is: How do I get that message across effectively?
RW: Let's talk about two of the big trends in health care today. One is the Affordable Care Act (ACA) and what it's doing to and for health care, and the second is the wiring of the health care system. What do you think their implications are for NPSF specifically and then for patient safety more generally?
TG: The Affordable Care Act has drawn this focus on value and population health, especially with newer care models like Accountable Care Organizations. The result is that we are starting to pay for improved quality and safety as opposed to volume, which is a good thing for the NPSF because it does hopefully draw focus to improving quality and safety as opposed to just trying to churn more patients through. Improved access to care, which comes with the ACA, hopefully means that patients are getting seen by primary care and into the health care system at an earlier stage of their diseases to prevent future downstream complications.
RW: Are there areas in which it creates new problems or challenges for the field or for NPSF specifically?
TG: Developing new models of care, like the primary care medical home or ACOs, and making sure it's done in an effective way with the right resources is a huge challenge. If you suddenly have to invest in a large number of case managers to care for patients across the population, how do you incorporate this new resource into the workflow safely and effectively? And for NPSF, as I mentioned, the ACA has created a focus on value and cost reduction. So taken in a vacuum with just the focus on cost, not thinking about quality and safety, could be a detriment to the NPSF's mission.
RW: Another trend in the safety field was we began with a huge focus on the hospital and the acute care environment. Does this accelerate the pressure to think about safety more broadly in the ambulatory environment and think about safety and its relationship to population health?
TG: That's a great point. The ACA does start to push attention to settings outside the hospital, which is really important because there is evidence that many safety and quality issues occur there. Ambulatory care or care across the continuum is a very complicated space, and includes a real diversity of setting such as primary care, specialty care, nursing homes, rehabilitation centers, dialysis centers, etc.
RW: You've been one of the leading experts in the role of information technology (IT) in patient safety. We've gone from 10% IT in American hospitals and clinics to probably 60% to 70% in a few years because of Meaningful Use incentives. How has that changed the environment for safety generally and then NPSF specifically?
TG: I'm a firm believer that health information technology can improve the safety of the care we deliver. This rapid transition is a good thing. We're getting over that adoption hump and getting into these new systems, which have great potential to improve care. The challenge is that often the systems are not necessarily implemented to optimize safety and quality for a variety of reasons, whether it's workflow or poor design. But there are many reasons why I don't think we're maximizing the benefits of health IT. Another big issue—it often feels like every implementation is standalone, where every hospital or clinic is trying to decide which way is the best way to do things. Best practices around how to implement are starting to come out but are still quite rudimentary.
Many decisions are made in implementation that have big impacts on quality and safety, but they are decided in one-off situations instead of having a standard for how we should be implementing to optimize quality and safety. A concrete example is around drug interactions. Which ones should we show or not show to optimize the benefits while minimizing over-alerting? It's a decision that every place makes on its own. It strikes me that there should be a standard for something like that, but also there's all this work happening at each site that could be avoided if there was a best practice around this. Another example is around medication lists: who can touch them, how should they be kept accurate, what should a specialist do versus a primary care doctor? I know places are spending days, weeks, months, and years trying to figure this out. Is there a way to get some best practice standards out there to help people optimize these things? Because having an accurate medication list is such a fundamental component to delivering safe care, yet we really struggle with it. I feel like the role of the National Patient Safety Foundation is to use our convening function to create some of these best practices around health IT implementation, for example.
RW: Another emerging trend in the field is patient and family engagement, and NPSF has been a leader in that area. What do you think are the lessons of the last few years? What are we now coming to understand that we didn't get 5 years ago?
TG: We've made progress in patient and family engagement over the last decade in terms of starting to see more partnerships with patients, more patient-family advisory councils, patients involved with quality improvement efforts, better tools for shared decision making, better tools for disclosure around medical error, etc. But I think a lot more work needs to be done. What needs to happen now is to say that it doesn't matter where you go, there's always going to be immediate disclosure, and after an error patients will be involved in root cause analyses and quality improvement efforts. This needs to become a standard and an expectation that it will be this way in every institution. Another thing is that we're trying to do so much more to engage and empower patients and make sure they know what questions to ask and how decisions should be made with them at the center. I think there's a real issue with how providers are trained to be accepting of the new empowered patients. Because there's concern that the more you empower patients the more providers might think that they're difficult patients as opposed to being engaged patients. So on the training side, we need to reinforce to our providers that we want patients who are engaged in their care as opposed to being passive participants.
RW: It seems like a very tricky area. The electronic medical record has given patients at least the possibility of ubiquitous access to their record. The 23andMe controversy raises the issue of whether patients should be given all the information and be allowed to make very complex decisions without the intervention of expert intermediaries. Negotiating this new terrain is something we haven't fully thought through. Do you have any thoughts about that?
TG: I agree. There are so many concerns about patient portals and patients having full access to their record. If a patient receives a test result or a radiology report with something concerning and they see that before the provider, how do you manage that so you don't cause undue stress to a patient? I think we're just starting to get experience with this. With the OpenNotes project, there was concern that patients might not understand some information in the record and it would cause stress or harm, which actually did not end up happening. So I do think we're moving in this direction, and it makes absolute sense that what's happening to patients should be transparent. The key is learning the lessons of how to do it well. And we'll have plenty of places where we don't do it well, and we'll have to learn from it.
RW: Thinking about the world of safety today as compared to maybe 10 or 15 years ago, the federal government is far more involved than it was. How does that change the nature of your work?
TG: It's always good when the federal government is interested in the topic because that means there is funding to try to move the field. AHRQ has had attention on patient safety for a long time, but having the attention from CMS is great because there's an additional source of funding. The Hospital Engagement Network is building collaborations to help drive reduced complications and readmissions. I see the role of NPSF in this new arena as taking what's being learned from the Hospital Engagement Network and trying to share that learning in a more broad way, especially for folks that aren't engaged in the network.
RW: Much of what NPSF does is education and convening. Is the new technological world that we find ourselves in—the world of MOOCs and videos—changing the nature of how you think about getting people together and working collaboratively across time and space?
TG: This is an area that we're just starting to explore. We, and I think other organizations, have found that it's harder to get people to travel to meetings. Even though the one-on-one networking at meetings is really valuable, given financial and time constraints, this is a challenge for many organizations. I think we are going to be much more engaged in other forms of convening technology and best practice sharing technologies. We've done webinars, but in the next year or two we will be exploring other ways to try to convene folks that doesn't involve face-to-face interaction.
RW: You've also created a certification program in safety. How do you think about this question of whether there should be certified experts in safety, or this should be a generic skill that every doctor and nurse and pharmacist should have?
TG: I don't think those two concepts are mutually exclusive. There absolutely needs to be fundamental patient safety knowledge in everyone caring for patients. Yet there are times when that knowledge won't be enough, and you need to bring in an expert. I think about it like primary care: a primary care provider knows about cardiology or gastroenterology, but when things get complicated they bring in a specialist. So you need a generalist who understands patient safety and can be in the trenches doing continuous improvement, identifying problems, reporting problems, and even working to fix problems. But when it gets too complicated, when things span across multiple departments, divisions, the continuum of care, where it's going to be difficult for that local person to solve it, you need some of these specialists who can do the more complex problems as well as do the more complex analyses of why an error happened. That being said, the NPSF programs have targeted both. We've had curriculum that's more of a Patient Safety 101 for generalist education, and then we've also created the certification for that extra level of specialty and to create an awareness that patient safety is an actual field.
RW: I want to talk about workforce for a second. Recently we called Brian Sexton who had done pioneering work on safety culture. We had spoken with him 6 or 7 years ago about what we're learning about teamwork training and culture. We contacted him for an update on that, and Brian said, "I don't really work that much in that area anymore because I've changed my focus to resiliency and burnout among clinicians. I've come to believe that until we get the workforce reenergized, teamwork is almost too high on the Maslow scale to work on; the clinicians' basic needs are not attended to." It was a sobering discussion. In the work you're doing now you have to pay a lot of attention to where the workforce is, are they ready and do they have the capacity to do some of the safety work. How do you think about that issue of burnout and improvement fatigue versus the imperative of making a lot of changes?
TG: That's a great question. This issue has been at the forefront of NPSF as well because of work that came out of NPSF's Lucian Leape Institute on joy and meaning in the workforce. That report called out the fact that many physical injuries are happening in the workforce, as well as psychological injury due to lack of respect, bullying, fear, stress, and productivity pressures.
I agree—how are we going to expect people to spend time and energy improving the system when they are burned out, feeling disrespected, and generally not happy with their current environment? The patient safety discussion almost 15 years ago started with this topic of culture—trying to change the culture of punishment and blame. It seems like 15 years later, we're still in that cultural discussion. But the thinking on it has broadened, so it's not just about that fear of punishment or blame; it's really the concept of respect and dignity. We're going to have to think of different ways to move forward on that, one of which is measuring how staff are feeling in this regard, which we've started to make progress on with some culture surveys, but probably have much more to do. Having better programs to measure is important but also having real intervention tools to try to get at disruptive behavior and not have it be an accepted part of your day to get yelled at. That's going to require leadership to really make a commitment to change the status quo. I don't think that it means that we stop working on the other safety things that we've talked about, but it is a big piece of how we're going to make a more quantum leap towards the system that we want.
RW: I'm finding that even in environments where the culture seems pretty good, there's a reasonable amount of respect among the caregivers and the organization wants to do the right thing, people are beginning to cry uncle and say, I just can't do another project. I'm drinking through the fire hose—it's bigger and bigger and more interventions, more change. We've said to them, there's a light at the end of the tunnel, eventually all of this improvement work will clean up so much wasted time and energy that the payoff will come. I think people are beginning to wonder where that light is. Are you feeling that?
TG: Absolutely. Even just with all the measures that need to get measured and the mandates, whether it's from your state, your local system, CMS, or The Joint Commission, people are inundated with improvement projects and then you really struggle with how to prioritize because they all seem important. I think it's a very real issue. Hopefully there's also some alignment where if you're working on one project, it can also fulfill other requirements. But that's still more the exception than the rule. I've gone to clinical leadership groups with projects that I've wanted to move forward, and they've said, yes, absolutely, this makes total sense but we can't do it because we have five other things that are higher priority right now, all of which are also really important. So many things are broken, unfortunately, that trying to fix them all can be quite overwhelming. So that prioritization piece is really challenging.
RW: Does NPSF have a role in advocacy and working with all of these organizations to try to create a set of policies that work better?
TG: It is an area where we want to have influence. For example, we are connected with The Joint Commission, we have a member from Joint Commission on our board, and I sit on a safety advisory group at The Joint Commission. We also try to be involved in NQF activities, CMS activities, AHRQ activities, etc. So at least on the safety side, we're trying to have a more prominent role in making sure that things are connecting. We're very early in that piece right now, so that's an area in terms of our longer term vision where we would like to see NPSF play a stronger role.
RW: When this job opened up, you were in a very prominent role in patient safety at a world-renowned institution and you made this very big change. What were the things about it that most excited you?
TG: I was really excited to move to the National Patient Safety Foundation because my passion in my entire career has been patient safety. I've had an impact on patient safety at a local institution, at a hospital level, and at a health system level. So I was really excited about taking the next step trying to have impact on a more national scale, and I felt that in my prior roles I had seen how patient safety could potentially be challenged by some of the other priorities out there. I wanted to make sure that NPSF keeps the banner of patient safety going among all of these other priorities and demonstrates that there is huge value to continuing to focus on patient safety.
RW: Fast forward to the 10-year anniversary of your tenure at NPSF, and you've been wildly successful even beyond your dreams. What does NPSF look like and how is it different than it is today?
TG: I would envision that NPSF has actually not just a national impact but also a global impact, because patient safety is a global issue. We would have an international branch that is thriving and advocating for patient safety at an international level, with sharing of best practices and education and other activities. We would have a very strong presence in Washington to impact policy in the US. Then we would have all sorts of new and innovative technologies, which I don't even know what they will be in 10 years, to ensure that if an institution one place in the country learns something from an error, it is instantaneously disseminated to everybody else in the country who could learn from it.
My big aspirational vision is that we also see an environment of care where patients are really at the center of any decision that's made about them and that is the expectation, culture, and assumption as opposed to the unusual occurrence as it sometimes feels today. NPSF's new vision is to create a world where patients and those who care for them are free from harm.
Previous interviews can be heard by subscribing to the Podcast