Health Care Needs a New Kind of Hero to improve #ptsafety

Dr. Peter Pronovost posted a blog regarding the patient safety education in medical school. That is fascinating.   Recently, I had a chance to talk few friend’s high school kids. They want to study medicine and than want choose biology as pre-med for colleague. When I suggest them to learn more about engineering (systems thinking), IT (technology driven innovation), management ,etc. beyond biology. It seems foreign to them. Apperently their teacher didn’t catch up what is happening in the frontier of medicine (like Armstrong institue). Maybe the patient safety education need to extent to high school? There is a long way to go to create critical mass (of providers) to understand the limitation of “craftsmanship” medicine and willing to embrace a new kind of hero. ( Let us work together to move this forward.

“In Praise of Fresh Air” and Medical Simulation 2.0

Finished the #IMSH2012  this Wednesday Feb 1. On my way home, ads inside newspaper did got my attention and inspiration.  That was the new brand and logo promotion from J.C. Penney by Ron Johnson (previous Apple executive) (Disclosure,  I don’t have  personal financial conflict of interest).  The key message is ” In praise of fresh air”.  The IMSH2012 draw near 3000 people around the world.   Beyond the fresh air we had at San Diego, I had chance to talk old and new friends.  Their insights made me thinking: What is the next 10 years for medical simulation community?

#WHO Report on the Burden of HAI and its impact on patient safety #yam #ptsafety

WHO published Report the Burden of Endemic Health Care-Associated Infection Worldwide. 


From the report: 

” • The estimated HAI incidence rate in theUnited Stateswas 4.5% in 2002, affecting 1.7 million patients and corresponding to 9.3 infections per 1,000 patient days.

• The European Centre for Disease Prevention and Control (ECDC) estimated that more than 4.1 million patients are affected by approximately 4.5 million HAIs every year inEurope.

• In the United States approximately 99,000 deaths are attributed to HAIs each year, and the annual economic impact was estimated at approximately $6.5 billion. ” 




Modeling for the Decision Process to Implement an Educational Intervention: An Example of a Central Venous Catheter Insertion Course

Just read a paper regarding “decision analytic model of the theoretical impact of an educational intervention to improve the safety” .  This paper demonstrate a system approach (computer modeling and simulation) for health care institutions to estimate the costs and benefits of  proposed interventions (medical simulation training or others).   There is another paper also found even minimal improvement in hand hygiene compliance could lead to substantial savings for hospital.

How about technology solutions (RFID or other RTLS based solutions) to improve hand hygiene compliance ? Joint Commission Resources just published four leading hospitals using RFID solutions to fight HAIs (healthcare assoicated infections) .  Does HIT solutions more cost effective ?  Researchers  start to evaluate technology solutions for the century-old challenge.   Future Study is need to study how to deliver effective and efficient interventions to improve healthcare delivery.  Peter Pronovost’s paper suggests education might not be the strongest risk-reduction intervention in anesthesia.  Multidisciplinary systems approach to modify the latent risk factors  can enable a  design of  more robust system to reduce human errors and improve patient outcome.

Structure, process or outcome: which contributes most to patients’ overall assessment of #healthcare #quality #ptsafety

Structure, process or outcome: which contributes most to patients’ overall assessment of healthcare quality?  This a very interesting paper from patient perspective.   Professor Donabedian already published related papers in Science in 1978 and JAMA in 1988 and milbank in 1966.  Why it takes so long for healthcare industry to appreciate the importance of structure and process ?

N.Y. may ban germy doctor ties, lab coats to improve #ptsafety

N.Y. may ban germy doctor ties, lab coats.  You can find details of Deadly Ties and the Rise of Multi-Drug Resistant Infections: A Case For a New Health Care Practitioner Hygienic Dress Code. from NY State Senator Klein website.



Nuclear expert: After Japan, examine plants’ safety systems, not reactor design

From WSJ, The accident at the Fukushima Daiichi nuclear-power plant involved multiple system failures that cast doubt on the guiding principle of the nuclear power industry: that engineers can build enough redundancy into safety systems to overcome any threat.”

Aristotle’s words — “Probable impossibilities are to be preferred to improbable possibilities.” — should serve as a motto for engineers, reminding them to plan not just for rare events but also for contingencies that seem impossible.

Healthcare is in the process to transform the healthcare delivery, systems thinking is critical to deliver safety and quality care to patient every time and every day.

This is the key point from white paper Unmet Needs: Teaching Physicians to Provide Safe Patient Care published by Lucian Leape Institute at the National Patient Safety Foundation.

Nuclear expert: After Japan, examine plants’ safety systems, not reactor design

What is the north star of medical simulation? Transforming healthcare: a safety imperative — Leape et al. 18 (6): 424 — BMJ Quality and Safety

What is the north star of medical simulation?

Read what patient safety leaders perspective about patient safety:

“The principal conclusion of the To Err Is Human report is  that the major cause of adverse events is poorly designed systems, not negligent individual performance. The implication is that physicians, managers, nurses and others should work together in teams to redesign flawed processes to prevent harm. One reason this has not happened faster is that physicians have not been educated to carry out this critically important work.”

This is one of five transforming concepts from The Lucian Leape Institute, established by the US NationalPatient Safety Foundation to provide vision and strategicdirection for the patient safety work.

  • Transparency
  • Integrated care platform
  • Consumer engagement
  • Joy and meaning in work
  • Medical education reform

Transforming healthcare: a safety imperative — Leape et al. 18 (6): 424 — BMJ Quality and Safety

Great program by National Patient Safety Agency (NPSA)

“If you can’t measure it, you can’t improve it” – Lord Kelvin

From WSJ,  The Doctor Will See You Eventually

Providers are starting to look what can improve the process in order to make the whole office visit experience better for patient and also for providers. Here are waiting time mentioned at WSJ this week.

  • Hospital emergency room: 4 hours, 7 minutes
  • California Department of Motor Vehicles: 42 minutes, 32 seconds
  • Main security line at Hartsfield-Jackson Atlanta International Airport during Monday morning rush: 25 minutes
  • McDonald’s drive-through window: 2 minutes, 54 seconds

It is not easy to make people agree that quality of care (multidimensional metrics) have three types of measures “ structure, process and outcomes” purposed by Avedis Donabedian first in 1966.  Same day WSJ also mentioned Medicare Faulted on Surgery EvaluationAlthough the Archives of Surgery paper mentioned in the article didn’t showing the link between process compliance and patient outcome, but both outcome and processes are important quality metrics to measure healthcare care delivery and quality.  This concept has been published in the same journal back to 2004. Systems Approaches to Surgical Quality and Safety. More research studies need to be done to understand what the relationship between patient outcome and care process beyond patient risk factors.  

Health Care Tips and Advice: Practicing Patience at the Doctors’ Office –

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