Hospital leaders seeking to improve patient safety and quality have a couple of in-house resources that could be used more effectively: their own patient safety and quality data and their own patients, according to two leading quality experts.
Don Berwick, M.D., president emeritus and senior fellow at the Institute for Healthcare Improvement, and Kaveh Shojania, M.D., who is the director of the Centre for Quality Improvement and Patient Safety at the University of Toronto, and editor-in-chief, BMJ Quality & Safety, urged health care leaders to step away from the data and do something with it, speaking at a webinar. The webinar was held by the National Patient Safety Foundation, and was centered on an NPSF report released in December, Free from Harm: Accelerating Patient Safety Fifteen Years after To Err Is Human.
Responding to a question about the possible creation of a national clearinghouse of quality statistics, both indicated that enough data has been collected. “We already know a ton,” Berwick says, continuing a theme he promoted at last month's IHI conference. “Reporting’s good in moderation, action is better.”
Shojania went a step further. “Incident reporting has been one of the bigger disappointments of the last 15 years,” he says. “It sorted of ended up that there’s such an emphasis on just reporting and reporting and reporting, and not actually learning from these events. I would rather see us move on some of the events we know about, rather than just recording more and more, and aggregating them and not being clear what the benefit of it is."
And while the hospital field has been moving closer to broad use of patient advisers, Berwick described them as being almost a foundational element to managing or acting as a board member to a hospital or health system.
He urged the quality-focused webinar attendees to invite patients who have been harmed to meet directly with executives and board members to bring attention to the issue of patient safety. “It’s very, very hard to turn away when they’re in the room,” he says.
The beneficiaries will be the hospital field representatives, Berwick says. “Any board of trustees and any executive would be well advised to spend a lot of time having patients talk in both public and private ways about their experiences in care in really authentic ways,” Berwick says. “We’re not talking about focus groups or hearings or testimony, but inviting people in to really talk.”
The American Hospital Association and other groups offer tools that can assist in that task.