The Daily Briefing's Josh Zeitlin spoke with Joe Kiani, founder and chairman of the Patient Safety Movement Foundation and also founder, chair, and CEO of Masimo Corporation, about the biggest impediments to further progress on patient safety, as well as his organization's goal of achieving zero preventable patient deaths across the U.S. health system by 2020.
Question: Joe, you've been involved in patient safety efforts for more than two decades. Why has the health care industry—which in theory is about keeping patients healthy—not been more focused on patient safety, or why hasn't it achieved the degree of patient safety improvements we might have hoped for?
Kiani: I think the biggest enemies are apathy and ignorance.
I say "apathy" because if it's not your family, it's not yourself, maybe you're not as motivated. There are those heroic people in hospitals, from administrators to nurses and doctors, but in general, this third-party mentality doesn't make the best environment for doing what's best for patient care.
A lot of people like to use the analogy of pilots and airplanes and patient safety. With airplanes, the pilot are in the same plane with you, so there's a lot of interest to make sure that plane doesn't crash, not just to save the passengers, but to save the pilots themselves. That's not the case in health care.
And then there's ignorance—which I don't use in a pejorative way; I'm just saying that ignorance is a fact. I think a lot of hospital leaders are not aware there are things they aren't doing to protect their patients, things that if implemented would also save them money. So because they have their quality committees and they have their patient safety officers, they just assume everything is being done that could be done. But I have not met a hospital that was doing all the processes that would reduce dramatically the likelihood of patient harm or preventable deaths.
What I've found when I sit down with them and I explain to them that, and I say "OK, have you done this, are you doing that," they quickly say, "Hmm, you're right, we're not."
Q: Have you seen those conversations you've had with hospital leaders pay off?
Kiani: Absolutely. I sit on the board of Children's Hospital of Orange County (CHOC), and it's really been fantastic to see them make the transition. They now have made zero preventable deaths part of their plan for the year, and they have tied it to their bonuses for their staff. And now, what's great is that they're not just hoping for it, they're planning for it, and they're putting processes in place to do their best to make sure that zero really happens.
As part of those efforts, they've taken our Actionable Patient Safety Solutions (APSS), which are processes or easy to follow "recipes" that hospitals can implement to reduce preventable death. CHOC prints off each of the APSS executive summary checklists as it's released, and literally, using red, yellow, or green, indicates which parts of the recipes they're following and those they're not following yet that they plan to implement later.
When I first went on the board of the hospital, tracking quality was basically tracking the stuff that the government had mandated through value-based payments, yet there is a whole set of other things that harm patients that the government didn't mandate that now they track.
Q: Your organization, the Patient Safety Movement Foundation, has really been pushing for hospitals to publicly commit to that goal of zero preventable patient deaths. Can you talk about why that is?
Kiani: Someone said a long time ago that that which is measured improves. And that which is measured publicly improves faster. At that moment when you publicly say, "We're going to get to zero preventable deaths," you're more likely to track it—and you're more likely to go make plans for it instead of just hoping for it.
That goal forces you to get out of your comfort zone, forces you to no longer stay ignorant. If you are having one or two or three preventable deaths a year, you're going to have to say, well, what could I have done to eliminate them? It forces you to do root-cause analysis, and that's critical.
I'm not naïve enough to think we're going to in 2020 wake up and we're all at zero preventable deaths and it's never going to go up again. But I do believe we can hover around that number if we implement the processes that can help prevent medical errors from turning fatal, because that IOM report title, "To Err is Human," is kind of true, but it's inhumane not to put processes in place to make sure those human errors don't become fatal.
Q: Other than setting that goal, what are other important steps hospital leaders can take to reduce patient harm?
Kiani: I think the best thing that can help patient safety would be if each individual who reads this article decides she or he is going to be the leader in their hospital to make sure that patients are safe. I think the biggest problem we've had is that too many of us abdicate the role we each play to the guy on our right or the guy on our left or someone who has a big role in patient safety.
With patient safety, it's like eating and sleeping: It's something we all have to do every day. And whoever is reading this article, whether they're the janitor or the CEO of the hospital, I hope they will decide that they are going to be the patient safety leader in their hospital.
Q: What are some examples of progress that the Patient Safety Movement Foundation has made since you founded it in 2012?
Kiani: One of them is getting the ecosystem together, un-siloing our ecosystem. You know, there's just always been this attitude of "medtech industry vs. hospital industry," "doctors and nurses vs. engineers and CEOs." So I think getting everyone together, getting patient advocates together, the government, and having everyone say "we've got to go fix this," that's been a very important accomplishment.
But more measurable has been that, as of January 2016, we had 45 healthcare technology companies who had signed the Open Data Pledge to share their data, including giants like Philips, GE, and Cerner. And by the January summit, over 1,600 hospitals had committed to zero preventable deaths, had implemented processes to avoid preventable deaths, and reported 24,643 lives saved annually. And we hope by the next summit in February 2017, we'll have doubled all of these numbers.
So I think we've made some really good progress, and I think we've got enough momentum that people are feeling that maybe we can really pull this off.
One of the other things we've created that's really beneficial and I've seen hospitals use are the APSS, which stand for Actionable Patient Safety Solutions. If you go to our website, you'll see there are 12 of them now. These are taking the best medicine out there to deal with patient safety based on evidence, and bringing it down to the smallest essence that people can easily follow, and people are doing it. It's a really useful tool.
Q: So if anyone reading this wants to get involved with the Patient Safety Movement, what should they do?
Take action by going to our website and making a commitment to zero preventable deaths by 2020.
It's easy; there is a quick form to complete, detailing your action plan to reduce preventable deaths. Create an account as a health care professional, at patientsafetymovement.org/login-register, and then fill out the form.
I also recommend reviewing and downloading our APSS. We will highlight three new ones at our 5th Annual World Patient Safety, Science & Technology Summit on February 3-4, 2017. The panel and presentation videos of this Summit and past Summits are all on our website free of charge.
Eight steps for successful change initiatives
Performance improvement seems simple at first: identify a problem, then take steps to solve it. But in practice, many organizations struggle to get change initiatives off the ground, often due to four pitfalls: lack of leadership attention, poor work planning, rocky rollout, and insufficient follow-up.
Our overview synthesizes years of Advisory Board research and experience into a single road map for performance improvement and defines eight steps crucial to avoiding these major pitfalls in any change initiative.