NATIONAL HARBOR, Md.—"We're on the cusp of rapid acceleration of improvement in patient safety," Lucian Leape predicted at yesterday's opening plenary of the Patient Safety Congress outside Washington, D.C. "The forces are aligning."

Leape is an adjunct professor of health policy at Harvard and chair of the National Patient Safety Foundation institute bearing his name. Recent reports indicate that too many errors still occur in health care, but he said those findings don't jibe with the experiences of nearly everyone in the audience. "You've seen improvement. Maybe not as much as you'd like, but there's been real improvement in patient safety."

One indication: Three to four years ago, hospital CEOs and trustees were asking, "What should we do?" Now they're asking, "How can we do it?" Still, Leape lamented, too many leaders "still haven't gotten it."

They better. Medicare is implementing payment incentives and penalties based largely on quality and safety. Leaders might squawk at certain details of value-based purchasing and other payment reforms, Leape said, but "the vise is tightening."

Another powerful motivating force is the HHS-led Partnership for Patients to help providers reduce hospital-acquired conditions 40 percent and readmissions 20 percent by 2013 compared with 2010. HHS has committed $1 billion to the effort, "by far the biggest investment in patient safety in history," Leape said.

An audience member complained the reports indicating that too many errors still occur in health care also showed a significant proportion were not preventable, a point most media coverage failed to mention.

Leape's response was blunt: "There's a word we must get rid of—'preventable.' The notion that some incidents are not preventable. They're all preventable. Figure it out. As long as you say some are not preventable, you won't prevent them."


Creating 'the Safest Children's Hospital in America'


Also yesterday, NPSF awarded its 2011 Chairman's Medal to Robert Connors, M.D., president of Helen DeVos Children's Hospital in Grand Rapids, Mich.
The medal recognizes emerging leaders in the patient safety field, chosen, said NPSF President Diane C. Pinakiewicz, "for their ability to inspire and lead the change necessary to successfully implement patient safety improvements while creating a culture of respect, openness, learning and a positive team dynamic." Here's how NPSF described DeVos Children's' journey:

Beginning with the stated goal of creating "the safest children's hospital in America," Connors spearheaded a patient safety program in 2007 that empowered staff by removing traditional hierarchies and barriers to communication. After completing an intensive training program in safety sciences and armed with error reduction tools and techniques to guide their practice, employees directly involved in patient care gained the authority to raise safety concerns with anyone at any time. The program has now been adopted by the entire Spectrum Health System, the DeVos Children's parent organization, which includes nine hospitals and 180 care sites.

Among the outcomes:

  • Between 2008 and 2010 safety events declined by 68 percent.
  • Ventilator associated pneumonias in the pediatric critical care unit have been eliminated for 19 consecutive months.
  • Hand hygiene has improved from 56 to 96 percent for more than a year, helping to reduce hospital-acquired infections by 50 percent.
  • Catheter-associated blood stream infections in the newborn intensive care unit were reduced by almost 50 percent.
  • Asthma core measures at discharge achieved 100 percent compliance.
  • Spinal surgery infections were eliminated.

"Safety is now an integral part of our strategic planning and daily operations," Connors said. "We have appointed an executive director of quality and safety, created unit-based safety champions and forged partnerships with other leading children's hospitals engaged in safety work best practices."