High Reliability Healthcare

Observations and Lessons Learned on the Journey to High Reliability Health Care.

To Err is Human: The Next 20 Years

11/18/2019

By Mark Chassin, MD, FACP, MPP, MPH, president and CEO, The Joint Commission

I was a member of the Institute of Medicine’s Committee on Quality of Health Care in America, which wrote To Err is Human: Building a Safer Health System in 1999.  The report was very successful in raising awareness of the serious scope and magnitude of our nation’s healthcare quality and safety problems. 

However, it’s been 20 years, and we haven’t moved the quality and safety needle as much as we had hoped.  The health care industry has directed a substantial amount of time, effort, and resources at solving the problems, and we have seen some progress.  That progress has typically occurred one project at a time, with hard-working quality professionals applying a “one-size-fits-all” best practice to address each problem.  The resulting improvements have been pretty modest, difficult to sustain, and even more difficult to spread. 

Over the next 20 years, I do believe we can achieve far higher levels of safety and quality, but only if we shift the improvement paradigm in three important ways: 

  1. Commit to zero harm. Conservative estimates report that invasive procedures on the wrong patient or body part occur about 45 times every week in the United States. The ultimate goal for any health care endeavor HAS to be zero harm, meaning: 
  • Zero complications for patients
  • Zero injuries to caregivers 
  • Zero episodes of overuse 
  • Zero missed opportunities to provide effective care 

That’s not an easy lift, and it may take longer than 20 years. Other industries have done it. US commercial aviation and nuclear power industries are now recognized worldwide for their exemplary safety records, because they’ve accepted nothing less than zero harm.  That achievement would not have been possible without the full commitment of industry leaders to the goal.  The same should be true for health care. We can no longer debate how much harm is acceptable. No amount of harm is acceptable. 

  1. Overhaul organizational culture. It falls on health care leaders to reverse the trend of staff being subjected to disrespectful and demeaning behavior when they raise concerns about safety and quality. Such behaviors, which are all too common, drive critical information about unsafe conditions underground, not to be discovered until patient harm results. 

The second part of the equation calls for leadership to institute programs that hold every caregiver—regardless of seniority or professional affiliation—accountable for consistent adherence to safety protocols and agreed-upon safe practices. Getting this equation right will go a long way toward removing the health care organization’s vulnerability to a myriad of risks. 

  1. Adopt the most highly effective process improvement methods. Health care safety processes very often fail at rates of 50% or higher. The improvements we have achieved over the past 20 years have largely resulted from health care organizations undertaking a series of focused projects, each one aiming to reduce a specific type of harm, for example: 
  • central line infections 
  • pressure ulcers  
  • medication errors 

We’ve made some significant progress, but the next major gains will arise only from the efforts of healthcare leadership and organizations, not government, business, market forces, nor patient advocacy groups. These interested parties cannot deliver zero harm. 

After the past 20 years of efforts to improve, who is satisfied with the current state?  If we’re not satisfied, we need to change the way we have been going about improvement.We cannot continue to use the same methods and expect different results.

There’s a better way.  With a process improvement methodology that combines lean, Six Sigma and change management, improvements of 50-70% are common across health care’s most persistent quality and safety challenges such as reducing: 

  • falls with injury 
  • risks of wrong-site surgery 
  • hand hygiene non-compliance 

This process improvement methodology has the capacity to pinpoint and measure the frequency of the critical few key causes of persistent quality problems. Interventions targeted to eliminate the key causes lead to major improvements. Key causes differ from place to place, however, which necessitates the identification of key causes before deploying interventions. That is why applying the same best practice everywhere has yielded disappointing results over the last two decades. Most importantly, some health care organizations utilizing this methodology are starting to show that zero is possible. 

Together, let’s answer the call to systematically apply these improvement methods and know that we’ve done our part to contribute to making zero harm a reality during the next 20 years. Leadership commitment to the goal, strong action to improve organizational culture, and the enthusiastic adoption of new, highly effective improvement methods will propel health care down the road to zero harm.  

Mark R. Chassin, MD, FACP, MPP, MPH, is president and chief executive officer of The Joint Commission.  Dr. Chassin is also president of the Joint Commission Center for Transforming Healthcare. Established in 2009 under Dr. Chassin’s leadership, the Center works with the nation’s leading hospitals and health systems to address health care’s most critical safety and quality problems. Dr. Chassin is a member of the Institute of Medicine of the National Academy of Sciences and was selected in the first group of honorees as a lifetime member of the National Associates of the National Academies. In addition, Dr. Chassin was a member of the IOM committee that authored “To Err is Human” and “Crossing the Quality Chasm.” He is a recipient of the Founders’ Award of the American College of Medical Quality and the Ellwood Individual Award of the Foundation for Accountability.