Patient Safety Stories of Success - The Partnership Symposium 2001

Patient safety must be measured and strengthened through greater, yet non-punitive, accountability program national safety conference.

The conference, the Partnership Symposium 2001- Patient Safety: Stories of Success, was attended by non-frontline workers. The symposium was hosted in Dallas, TX running from Wednesday, October 10 through Friday October 12.

Hearing October 10 comments from the leadership of the Partnership for Patient Safety (p4ps), Premier Inc. and VHA Inc., participants were encouraged to view patient safety improvement as an important and just mission.

"While the world is a war on terrorism, we urge you to see this (patient safety) as a war on 'errorism' said C. Thomas Smith, President and CEO of VHA, Inc.

"Safety is an issue on which even competitors should find common ground," affirmed Rick Norling, Chairman and CEO of Premier, Inc. "Just as airlines have worked to rebuild trust among Americans, hospitals still have much work to instill patient confidence. We can do that together."

The conference was launched with a dinner event featuring comments of the Agency for Healthcare Research and Quality Director, John Eisenberg, M.D. and aviation consultant and news commentator, John J. Nance, Esq. A multimedia discussion allowed the audience to hear from supporters and critics alike who expressed concerns and opinions on the ethics of appropriate and immediate disclosure. A common thread was how and why the profession - one provider at a time-should build non-punitive environments.

"Whether it be mandatory or voluntary, reporting because you know you're going to learn from your reporting and your colleagues are going to learn from your reporting, is the real key, " Eisenberg said in pre-videotaped comments. "One of the tragedies in American medicine is that we are not as willing to be as critical of ourselves as we need to be," he concluded.

Responding to Eisenberg's (and others) comments were Jack Cox, M.D., M.M.M., Senior Vice President and Wilson, M.D., M.P.H., Vice President, Clinical Affairs of VHA Inc.

"The knee-jerk reaction to remediate healthcare workers is inherently flawed," challenged Jack Cox, M.D., Senior Vice President, Premier Clinical Innovations. "If you have a worker who's caused an error because a system lets it happen, how does removing the worker help the problem? A bad system is still going to harm patients."

"This year's conference has been rich with ideas and plans on how to keep patient safety top-of-mind," commented Martin Hatlie, JD, president of p4ps. "The tremendous turnout, even in light of the September 11th tragedy, just tells me that healthcare professionals care deeply about this problem. And they want to know how to make error-free environments a reality."

Making Leaps

Arnie Milstein, M.D., a leader of the Leapfrog Group, kicked off day two of the conference, recounting some of the lessons learned from the coalition's yearlong effort. "The majority of his comments revolved around who can present the business case for patient safety, and how incentivizing providers can make a difference in care. Purchasing and (healthcare) delivery are clearly dysfunctional. Over the course of our work, we hope to get healthcare up to three Sigma by making customers more value sensitive," said Milstein, referring to the Six Sigma quality scale in gaining momentum in the business performance improvement arena.

Hospitals, while waiting for results, have shown that they want tangibility. Rather than looking for abstract concepts to inspire quality, they want to know how Leapfrog will ultimately benefit their bottom-line. Milstein Suggested that hospitals may find those results shortly, as data collection and measurements among participating institutions are high; and he clearly said that Leapfrog has much more work to do.

"Our first three leaps are just a subset. Safety is much more than the ICU, CPOE (computerized physician order entry), and clinical improvements," Milstein commented, alluding to the initiatives Leapfrog launched in November 2000.

Breakthroughs showcased in breakouts

Hospitals took center stage as breakout sessions highlighted selected safety programs. In spring 2001, hospitals were solicited to submit abstracts for possible presentation at this year's event. NPSF chose nearly 40 programs, as well as honorees for innovation awards for patient safety, to present at The Partnership Symposium.

Disclosure, technology-based medical error reporting, accountability, processes, and public health were hot topics of day one. Day three will center on collaborations and measurements.