Statementbeforethe

CommitteeonHealth,Education,LaborandPensions
SubcommitteeonPrimaryHealthandAging
UnitedStatesSenate

Hearingon:
MoreThan1,000PreventableDeathsaDay
IsTooMany:
TheNeedtoImprovePatientSafety.

By
JoanneDisch,PhD,RN,FAAN
ProfessoradHonorem
UniversityofMinnesotaSchoolofNursing
MinneapolisMN

July17,2014

ChairmanSandersandtheSubcommitteeonPrimaryHealthandAgingaretobecommended
forexaminingthecurrentcrisisofpreventabledeaths(PDs)thatoccureachyearintheUnited
Statesandfordevelopingthecompellingtitleofthishearing.TheestimatebyJames(2013)
thatpossibly400,000PDsoccureachyearismoreaccuratethanthepreviousInstituteof
Medicine(IOM)projectionof98,000/year(1999).However,Iwouldrespectfullysuggestthat
thetitleofthishearingunderstatestheproblemandthetitleofthehearingshouldbe
changedtoMorethan1000preventabledeathsand10,000preventableseriouscomplications
adayistoomanyWhilePDsarecertainlytobeavoided,Iwouldnotethatserious
preventablecomplications(SPCs)canresultinaqualityoflifethatmightbecomparableto
deathforsome,suchasthewomanfromMinnesotawho,approximately10yearsago,
underwentabilateralmastectomyforcancer,onlytofindoutshortlyaftersurgerythatthere
hadbeenamixupinthebiopsyreportsandshehadnothadcancer.

Mypointsarethree:(1)theimpactofpreventableeventsdeathandseriouspreventable
complicationsisevenmoreextensivethanthegrippingtitleofthishearingsuggests(James,
2013);(2)itispossiblythemostbipartisanissuethatexiststodaysincemany,ifnotmost,of
usherehavelikelyhadtheexperienceofbeingapatientorfamilymemberwhoexperienced
oneoftheseevents,orwillinthefuture;and(3)itisoneofthefewissuesthatmoneyalone

cannotsolve.AsIhaveoftensaidwhenlecturingonthistopic:EvenBillGatescannot
guaranteesafecareforhimselforhisfamily.

Thismorning,Iwillhighlightsomeofthekeyfactorsinfluencingpatientsafety,andmakethree
recommendationswhichIknow,frommy46yearsasanurse,makeadifference:(1)assuring
anadequateandappropriatelyeducatedsupplyofregisterednursesatthebedside;(2)actively
engagingpatientsandfamiliesaspartnersintheircare;and(3)movinghospitalsandother
healthcaresettingstoembraceasafetycultureandbecomehighreliabilityorganizations.My
commentsfocusonthehospitalsettingsincethatiswherewehavethemostdata,although
theprinciplesapplytoothersettings

Factorscompromisingpatientsafety
Thefactorsthatcontributetotheseeventshavebeenextensivelyoutlined,andrangefromthe
minortothemostcomprehensive.Theyincludethecomplexityofhealthcare,therapid
generationofnewknowledgeandinterventions,thepatchworknatureofourhealthcare
system,theincentivestodotoomanyinterventionsandnotenoughassessmentand
prevention,andtheuseoftechnology(bothtoomuchandtoolittle).

ECRI,anindependent,nonprofitorganizationthatresearchesthebestapproachestoimprovingthe
safety,quality,andcosteffectivenessofpatientcarehasbeguntocompileanannualTopTenlist
oftechnologyrelatedissuesthatjeopardizesafety.Table1includesthelistfor2013.

Table1:TheTop10listoftechnologyrelatedissuesthatcompromisepatientcare
1,Alarmhazardsthatresultinfatigueandinadequateresponsebycareproviders
2.Medicationadministrationerrorsusinginfusionpumps
3.Unnecessaryexposuresandradiationburnsfromdiagnosticradiologyprocedures
4.Patient/datamismatchesinEHRsandotherhealthITsystems
5.InteroperabilityfailureswithmedicaldevicesandhealthITsystems
6.Airembolismhazards
7.Inattentiontotheneedsofpediatricpatientswhenusingadulttechnologies
8.Inadequatereprocessingofendoscopicdevicesandsurgicalinstruments
9.Caregiverdistractionsfromsmartphonesandothermobiledevices
10.Surgicalfires

Somefactorsrelatetohealthcareproviders(HCPs)themselves,suchasfatigue,disruptive
behavior(Rosenstein&ODaniel,2008),lackofadequatepreparation,andeitherfailureto
keepupwithcurrentpracticeorpersistenceinfollowingoutdatedpractices(Disch,2012).
Amalbertiandcolleagues(2005)identifiedfivesystembarriersthatwouldpreventunsafe
professionalbehavior,amongthem,the(1)theneedtoabandonstatusandselfimagein
exchangeforinclusionandrespectforthecontributionsofallproviders;and(2)theneedto
reduceproviderautonomy,i.e.,doingwhatonechoosestodooverevidencebasedpractices.
Makary(2012)describedinadequatelevelsoftransparencyandoutrightconcealmentofcertain
resultsinhisrivetingbookUnaccountable:Whathospitalswonttellyouandhowtransparency
canrevolutionizehealthcare.


Withallofthesefactorscontributingtopreventabledeathsandcomplications,itcanbeover
whelmingtoknowwheretofocusfirstandwiththegreatestimpact.TheJointCommissionhas
createdalisteachyearofthemostfrequentlyidentifiedrootcausesofsentineleventsderived
fromRootCauseAnalysesoftheseriouseventsthatmustbereportedwhenevertheyoccur.
Thereare28oftheseevents,andincludeseriousmedicationerrors,fallsthatresultin
significantharmordeath,hospitalacquiredinfections,decubitusulcers(bedsores).Overthe
years,theanalyseshavefoundthatthemajorityofeventshaveseveralrootcauses.In2013,
themostfrequentlyidentifiedrootcausesof887sentineleventsarelistedinTable2:

Table2:Mostfrequentlyidentifiedcausesofsentineleventsreviewedin2013
Humanfactors(635)
Communication(563)
Leadership(547)
Assessment(505)
Informationmanagement(155)
Physicalenvironment(138)
Careplanning(103)
Continuumofcare(97)
Medicationuse(77)
Operativecare(76)

Itisimportanttonotethatthefirstthreefactorsrelatetopeople:
Humanfactorsstaffinglevels,staffingskillmix,stafforientation,inserviceeducation,
competencyassessment,staffsupervision,residentsupervision,medicalstaff
credentialingandprivileging,rushing,fatigue,distraction,complacency,bias
Communicationoral/written/electronic,amongstaff,with/amongphysicians,with
administration,withpatientorfamily
Leadershiporganizationalplanningandculture,communityrelations,service
availability,prioritysetting,resourceallocation,complaintresolution,collaboration,
standardizationandbestpractices,inadequatepoliciesandprocedures,noncompliance
withpoliciesandprocedures.

Thisisnottosuggestthatthecauseofpreventabledeathsarethepeopleinvolved.The
challengesfacingHCPsarecomplex;systembarriersmakedoingtherightthinghard;time
pressuresreinforcedoingthingsquicklywithoutfixingunderlyingproblems;longstanding
traditionsthatdemanderrorlessperformanceanddiscourageexaminationofsystems
fallibilitycreateachillingenvironment;andthewholefieldofsafetyscienceisunknownto
mostHCPswhograduatedmorethan10yearsago.Thepointhereisthatthechangesthatare
neededwillrequirechangesinbehaviorandmindsetandthesearethemostdifficultto
achieve.Itwouldbeeasierifwecouldjustallocatemoremoney.Commonwisdomusedtobe
thatthoseofusinhealthcarejustneededtobevigilanttopreventmistakes.Thereisstilla
roleforvigilancebutthatiswoefullyinadequateintodayshealthcareenvironment.Thereare
certainlyresponsibilitiesthatweascareprovidershave,butsafetysciencesuggeststhatwe

mustalsofixtheunderlyingsystemissuesforsustainablechangewhichrequiressignificant
changefromallofus.

Thecriticalroleofthenurseinpatientsafety
NursesarethecornerstoneoftheAmericanhealthcaresystem.Registerednursesformthe
largestelement(2.6million),withmorethanhalf(58%)workinginmedicalandsurgical
hospitals(BLS,2013).Theyprovidecare24/7andareonthegroundfloorofcaredelivery.
Theyaretheeyesandearsofpatientsandtheirfamilies,aswellasphysiciansandotherHCPs
whoareinteractingwiththepatientintermittently.Thenursesroleistoassessthepatients
conditionandresponsetotreatment;performindicatedtreatments;preventcomplications;
assistthepatientandfamilyinadjustingtothetreatmentorimpactofchronicillness;and
createasafeenvironmentwithinwhichhealth,healingorapeacefuldeathcanoccur.Itisthe
nursewhoseesaskinbreakdownthatwillleadtoabedsore;itisthenursewhonoticesthe
olderwomansunsteadygaitandputsinplacestrategiestopreventafall;itisthenursewho
noticesthatthedoseofthedrugorderedisnotrelievingthepainandwhoinitiatesa
conversationwiththephysiciantogettheorderchanged.Individualswhohavebeen
hospitalized,orhavehadafamilymemberhospitalized,understandtheessentialroleofthe
nurse.Actually,nursingcareisthereasonforhospitalizationanditisthenursewhoisthe
lastlineofdefenseagainsterror.

Whocouldarguewiththispointofview?Ourcurrenthealthcaresystemisbuiltonthebelief
thatthephysicianisthecaptainoftheshipandneedstobeinchargeineverysettingand
situation.However,giventhecomplexityofhealthcaretoday,thatisimpossible,maybe
dangerousandisactuallyunnecessary.Rather,todayweneedinterprofessionalteamsof
caregiverswhocaneachcontributetheirownexpertiseandperspectives.Sometimesthe
physicianwouldbeincharge,atothertimesthenurseorsocialworkerorpharmacist,
dependingonthepatientsneeds.

Theelderlyareparticularlyvulnerabletocomplicationsandtheconsequencescanbemore
seriouswhenerrorsoccur.Olderindividualsareoftenlessphysicallystable,havechronic
conditionsforwhichmultipledrugsandtreatmentsareordered,canhavesensorydeficits,and
memoryimpairment.Iftheyareunsteadyontheirfeet,theyaremorepronetofalls;iftheyare
notactive,theyarepronetobedsoresandothercomplications.InadequatelevelsofRN
staffinginhospitalsandnursinghomesdecreasethenursesabilitytopreventcomplications.
ItisvitalthatnursesandreallyanyHCPberespectedfortheirknowledgeandskills,andbe
encouragedtoactivelyspeakupwhentheythinkthatsomethingcanbeimprovedoraproblem
prevented.Butthatisnotcommonpracticeineverysettingtoday.

TheInstituteofMedicine(2011)hasrecommendedthatNursesshouldbefullpartners,with
physiciansandotherhealthprofessionals,inredesigninghealthcareintheUnitedStates.In
mostinstances,physiciansareactivelyinvolvedindecisionmaking.Andthefocusinimproving
healthcarehasoftenbeentoassureenoughphysiciansareeducated.However,thiscrisiswill
notbesolvedbyfocusingonlyonanadequatesupplyofphysicians,bothinthepipelineandin

practice.RegisterednursesandotherHCPsareequallyessentialandneedtobeactively
fundedandincluded.Thisissueofnursesbeinginvolvedandengagedinindividualpatientand
systemwidedecisionmakingisnotsimplyamatterofparity,i.e.,thatnursesshouldbe
includedbecausephysiciansare.Ratheritsamatterofperspective,i.e.,thatnursesbringa
vitalviewpointtosafetyconcernsthatisoftenabsentyetessentialifworkablesolutionsfor
safecarearetobeputinplace.

ThequestionthatnursesoftenaskisDoesthisworkat2am?Wehaveaverypragmatic
appreciationforwhatworksroundtheclock,andonweekends.Weoftenhavesolutionsfor
seeminglyintractablesystemissues,orpersonalsituations.Onerecentexample:Anurseand
physicianweretalkingwithapatientwithcongestiveheartfailurewhowasneedinghis
medicationsadjusted.Thedoctorprovideddetailedinstructionsandaskedthepatientto
weighhimselfdaily,andtocallbackifhegainedmorethan3pounds.Afterthephysicianleft,
thenurseaskedthepatientifhehadascaleonwhichtoweighhimself,recallinghishousing
situationandthathewashomeless.Toadaptthedirectionstohissituation,sheaskedhimto
carefullynotewhetherhisshoesbecametighterandtocallbackifthathappened.Thatisan
exampleofanursepersonalizingcaretopreventacomplicationandneedlesshospitalization.

Inconsideringwhatcanbedonetoreducepreventabledeaths,wemustredirectourefforts.
First,ratherthancontinuingtoworkatthemarginwemustnowturntowardfundamental
changeinourhealthcareorganizations;andsecondwehavetofocusonthreecrucial
strategiesthatareoftenoverlookedbecausetheyseemsosimpleandapparentandyetthey
areessentialifwearetomakeprogress.

1.Assureanadequatenumberofappropriatelypreparedregisterednurses
Fornursestomaketheiroptimalcontributiontoimprovingthesafetyofhealthcare,therehave
tobeenoughnursesandtheyhavetobeequippedwiththerighteducationalpreparation.
AccordingtotheBLS(2013),theRegisteredNurseislistedamongthetopoccupationsfor
jobgrowththrough2022,withanexpectedincreasefrom2.71millionin2012to3.24
millionin2022(19%increase).TheBLSalsoprojectstheneedfor525,000replacement
nurses,sothatthetotalnumberofjobopeningsfornursesfrombothcauseswouldbe
1.05millionby2022.Thegoodnewsisthatmorepeopleareenteringnursingin2013,
therewasareported2.6%enrollmentincreaseinentrylevelbaccalaureateprogramsin
nursing(AACN,2013),yetthisincreaseisinsufficienttomeetprojecteddemandsfor
nursingservicesinallsettings.Morethan32millionAmericansaregainingaccessto
healthcareservicesprovidedbyregisterednursesandadvancedpracticeregistered
nurses(APRNs).OfgreatconcernisthatU.S.nursingschoolsturnedaway79,659
qualifiedapplicantsfrombaccalaureateandgraduatenursingprogramsin2012dueto
insufficientnumberoffaculty,clinicalsites,classroomspace,clinicalpreceptors,and
budgetconstraints(AACN,2013).Alsothemostrecentinformationindicatesthatthe
averageageoftodaysnurseis47years(HHS,2010).

Thereisasignificantbodyofresearch,bothhereandabroad,thatshowsthatregisterednurses
withaminimumofabaccalaureatedegree,andatadequatestaffinglevelsinhospitals,havea

positiveimpactonpatientsafety,includingmortalityrates(Needlemanetal,2006;Aikenetal,
2014).Keyimplicationsarethatnursingstaffingcutstosavemoneyjeopardizepatientsafety
andhiringmorenurseswithbaccalaureatedegreescoulddecreasethenumberofpreventable
deaths.However,themostrecentdataindicatethatonly50%ofnurseshavebaccalaureateor
higherdegrees(HRSA,2010);andifwelookatthepercentageofnursesinbaccalaureate
programsastheirfirsteducationalprogram,itisonly35%(IOM,2011).TheIOMhas
recommendedthatitbe80%by2020.[ThereiscurrentlyabillbeingproposedinCongress
calledtheRegisteredNurseSafeStaffingActtoassureanadequatenumberofnurseswith
baccalaureatedegreesbehired.Thiswouldhavesignificantimpactonpatientsafety]

Inadditiontoformaleducation,however,nursesandallHCPsneedtobeknowledgeable
andcompetentintheIOMsrequiredcompetenciesforachievingsafepatientcare:
patientcenteredcare,teamworkandcollaboration,informatics,safety,evidencebased
practiceandqualityimprovement.Manynurses,physiciansandotherHCPsreceived
theireducationalpreparationmorethan10yearsagowhenhealthprofessionscurricula
didnotcontainthiscontentsothatbothhealthprofessionalsstudentsandpracticing
HCPsneedtobeeducatedinthesecompetencies.

2.Engagethepatientandfamilyaspartnersincare
Anothervitalpartnerinassuringsafepatientcareisthepatientandhis/herfamily.
Whereashealthcarehastraditionallybeenofferedinawellintentioned,yetpatriarchal
fashion,withthephysicianknowingbest,todayshealthcaredeliveryrequiresthatthe
patientandhis/herfamilybecomethesourceofcontrolandfullpartner(Cronenwettet
al,2007).Thisisdistinctlydifferentfromthewayhealthcarehastraditionallybeen
provided,andinmostsettings,iscurrentlyprovidedtoday.AstheIOMreportTheFuture
ofNursing:LeadingChange,AdvancingHealthnoted:Practicestillisusuallyorganized
aroundwhatismostconvenientfortheprovider,thepayer,orthehealthcare
organizationandnotthepatient(2011,p.51).

Patientcenterednessisactuallynotanewconcept.Barnsteiner(2014)notesthatHippocrates
taughtthefirstmedicalstudentstoprovidebylisteningtothepatientandpriortothe
establishmentofhospitals,individualswereroutinelycaredforintheirhomesbyfamily
members.However,manycontemporaryfactorshavealteredthisrelationship:professional
autonomy,themedicalmodelofhealthcare,theeducationofhealthprofessionals,technology,
thepressuresoftime,thecomplexityoftheoptionsavailable,andtheperverseincentivesfor
financingofhealthcare.

Increasingly,theconsumermovement(Disch,2014)andthepatientmovementbeliefof
Nothingaboutmewithoutmearecreatingpressuresforactiveengagementbyindividuals
andtheirfamilymembersinhealthcaredecisions.Thisisagoodthing:Ithasbecome
increasinglyapparentthatbetterqualityoutcomesareachievedwhenpatientspartnerwith
theircareprovidersandassumeresponsibilityformanagingtheirownhealth(Balik,Conway,
Zipperer&Watson,2011).WhileHCPsknowthesciencebest,thepatientand/orfamilyknow

theindividualbest.AppendixAincludesatruestoryofthepowerfulimpactandpositive
changethatcanoccurwhenincludingapatientspreferencesinmanaginghermedications.

3.InstituteasafetyculturewithHighReliabilityOrganizations(HROs)
Overthepast15years,thequalityandsafety(Q/S)literaturehasincludedfindingsfrom
hundredsofstudiesexaminingstrategiesforimprovingQ/S,suchasrapidresponseteams;
rounds;patientsafetyaudits;checklists;andpatientsafetyofficers.Howeverithasbecome
increasinglyclearthatwhiletheseeffortscanimprovesafetyatthemargin,amoresystemic,
upstreamapproachisneededanentireculturededicatedtosafety.

AccordingtotheAgencyforHealthcareResearchandQuality(2010),asafetycultureofan
organizationis
theproductofindividualandgroupvalues,attitudes,perceptions,competencies,and
patternsofbehaviorthatdeterminethecommitmentto,andthestyleandproficiency
of,anorganizationshealthandsafetymanagement.Organizationswithapositive
safetyculturearecharacterizedbycommunicationsfoundedonmutualtrust,byshared
perceptionsoftheimportanceofsafety,andbyconfidenceintheefficacyofpreventive
measures.[fromOrganisingforSafety:ThirdReportoftheACSNI(AdvisoryCommittee
ontheSafetyofNuclearInstallations)StudyGrouponHumanFactors.HealthandSafety
Commission(ofGreatBritain).Sudbury,England:HSEBooks,1993]

Sammerandcolleagues(2010)conductedacomprehensivereviewofsafetyliteraturewithin
UShospitalsandidentifiedsevensubculturesessentialforasafetyculture:leadership;
teamwork;evidencebased;communication;learning;acommitmenttojustice;andpatient
centered.Highreliabilityorganizations(HROs)orsettingswithconsistentperformanceat
highlevelsofsafetyoverlongperiodsoftimeshareseveralkeycharacteristicsbutmost
importantlytheyprovideacollectivemindfulnesswhichisembodiedbyeveryonethroughout
theorganization(Chassin&Loeb,2011,2013).

Intheseorganizations,everyoneisclearthatevensmallfailuresinprocessorsystemscan
resultincatastrophicoutcomes,andthateveryonehasaroletoplayinidentifyingerrorsand
nearmisses.Everyoneisactivelyencouragedtobepartoftheproblemfindingandsolution
generating;modelsofsharedgovernanceandpatientengagementarethriving.Everyone
includespatientsandtheirfamilies.OfparticularimportanceinHROsistheneedfora
greaterrelianceon[interprofessional]teamsandincreasedcomplexityintermsofteam
composition,skillsrequired,anddegreeofriskinvolved(Baker,Day&Salas,2006)Alsoin
HROs,theleadersarepassionateadvocatesforpreventingharmandaltertheirrolesfromthe
traditionaloneoffocusingonthefinancialbottomlinetooneofbeingequallyconcernedabout
theQ/Sbottomline.

Atthecoreofhighreliabilityorganizationsarefivekeyconcepts,whichareessentialforany
improvementinitiativetosucceed(AHRQ,2008):

 Sensitivitytooperations.Preservingconstantawarenessbyleadersandstaffofthe
stateofthesystemsandprocessesthataffectpatientcare.Thisawarenessiskeytonotingrisks
andpreventingthem.
Reluctancetosimplify.Simpleprocessesaregood,butsimplisticexplanationsforwhy
thingsworkorfailarerisky.Avoidingoverlysimpleexplanationsoffailure(unqualifiedstaff,
inadequatetraining,communicationfailure,etc.)isessentialinordertounderstandthetrue
reasonspatientsareplacedatrisk.
Preoccupationwithfailure.Whennearmissesoccur,theseareviewedasevidenceof
systemsthatshouldbeimprovedtoreducepotentialharmtopatients.Ratherthanviewing
nearmissesasproofthatthesystemhaseffectivesafeguards,theyareviewedassymptomatic
ofareasinneedofmoreattention.
Deferencetoexpertise.Ifleadersandsupervisorsarenotwillingtolistenandrespond
totheinsightsofstaffwhoknowhowprocessesreallyworkandtheriskspatientsreallyface,
youwillnothaveacultureinwhichhighreliabilityispossible.
Resilience.Leadersandstaffneedtobetrainedandpreparedtoknowhowtorespond
whensystemfailuresdooccur.

Conclusion
Agreatdealofworkhasbeendoneoverthe15yearssinceToerrishumanwaspublished
(IOM,1999),andprogressisbeingmade.Aphenomenalamountofresourceshavebeenmade
availablethroughAHRQ,theDepartmentofDefense,DepartmentofVeteransAffairs,and
organizationssuchastheInstituteforHealthImprovement.Patientsafetynetworksand
consumergroupshavebeenformed;surveyshavebeendeveloped;incentiveprogramshave
beencreated.Alotofpeoplearedoinggoodwork.

However,toincreasetherateofimprovementandreducepreventabledeathsandserious
implications,wemustmoveupstreamandimplementsomeofthemorechallenging,yet
fundamentalstrategiesforasafehealthcaresystem.Wemustchangethesystemsofcareand
howwefundamentallythinkaboutandworktogethertoreducepreventabledeathsand
seriouscomplications.

Ihavehighlightedherethreestrategiesthat,frommyperspectiveasanurseformorethan45
years,yieldthegreatestbenefit:
1.Assuringanadequatenumberofappropriatelyeducatedregisterednurses
2.Engagingpatientsandtheirfamiliesinthecareprocess
3.EstablishingasafetyculturewhereeveryhospitalisaHighReliabilityOrganization

Thankyouforthisopportunitytocommentonthisvitaltopic.

 References

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OperationalAdviceforHospitalLeaders.RockvilleMD:AHRQ.

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SafetyCulture.RetrievedJuly14,2014from
http://www.ahrq.gov/professionals/qualitypatient
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staffingandeducationandhospitalmortalityinnineEuropeancountries:A
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10,2014fromhttp://www.aacn.nche.edu/mediarelations/factsheets/nursingshortage

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10

AppendixA

NewsStory:PatientCenteredCareRedistributesResponsibility
BettyA.Marton,April2012,HealthLeaders

In2008,a23yearoldwomanwithseverecysticfibrosis(CF)successfullycarriedanddelivereda
healthy,fulltermbabygirlatLongIslandJewish(LIJ)MedicalCenter,inNewHydePark,NY.Despitethat
majorachievement,thecomplexregimenofdailymedicationsthatChristinaMarieMcDonaldneededto
manageherdiseasecreatedchallenges."Onthematernityward,nooneunderstoodanythingabout
CF,"saysRubenCohen,MD,directoroftheadultCFprogramandcodirectoroftheasthmacenterfor
the888bedtertiaryteachinghospital."Shedidn'treceivehermedicationswhensheneededthem."

"Afterthatexperience,thepatient'sfatherwrotealetterasking,Whydoesthehospitaltieourhands
andputtheseroutinemeasuresinthehandsofbusymedicalpersonnelwhenthepatientsandtheir
familiesknowtheillnessverywellandareexpertsintheirowncare?'"explainsFatimaJaffrey,MD,
directorofoutcomesresearchatLIJMedicalCenter.Thehospitalrealizedtheyneededanewwayof
doingthings.LIJMedicalCenterembarkedonaprocesstoexplorehowtoimprovetheinhospital
deliveryofdailymedicationstoCFpatients.

InFebruary2009,Jaffreybegancoachinganinterdisciplinaryteamofallthefrontlinecaregivers,
includingCohen,andarespiratorytherapist,dietician,nurse,pharmacist,CFsocialworker,and
Christina'sfather,inhowtoapplythemethodsofimprovementsciencetoimprovingCFcare.Theteam
focusedonhowitcouldsupportandempowerthepatientwhilestillmeetingregulatoryrequirements.
"Thegoal,"saysJaffrey,wastogofrom"asystemofcarethatwasn'tdeeplyconnectedtopatients'
experiencestoonethatisincrediblyconnected."Sixmonthsafteritwasestablished,theteammetits
firsttwogoalsofreducingthelengthoftimepatientshadtowaitforthedeliveryofthemedicationsfor
whichtheywereadmittedtotwohours(from15ormore)forthefirstbreathingtreatmentandfour
hours(from18)forIVantibiotics.

TheprogramwentliveinMarch2010,withpatientswhoopttoselfadministerreceivingspeciallocked
boxescontainingalloftheirmedications.Patientskeepalogofwhattheytakeandwhenandnurses
reviewthelogtodetermineifmedicationsarebeingtakencorrectly.Thenursesalsoworkwiththe
hospital'spharmaciststokeeptheboxreplenished."Theprocessgivesthenursesoversightsowecan
stillmanagethedocumentation,"saysMargaretMurphy,RN,senioradministrativedirectorofpatient
careservices."Itallseemssosimpleinretrospect,butatthetimeitrequiredalotofcoordinationand
education.Itoffersatremendousamountofefficiencywhileensuringthatthepatientswhoknowtheir
medicationsareadministeringthemcorrectly."Havingdramaticallyreducedthetimeittakestoprovide
thecareCFpatientsneedhasreducedtheaveragelengthofstayinthehospitalforCFpatientstoseven
daysfrom11.Thesuccessofselfadministrationisalsoreflectedinpatientandprofessionalsatisfaction
surveys:Satisfactionratesforbothgroupsrosefromlessthan20%beforetheinterventiontoabove
95%."What'sremarkableisthatthissophisticatedworkcanonlybedoneatgroundlevel,"explains
Jaffrey."Peoplewhodothedaytodayworkcangetthroughtheseissueswithsomuchvelocity.When
weempowerthemtobethechangeagents,we'releveragingthelargestuntappedresourcewehavein
healthcare."

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