Leading the leaders

Dr Ronald Wyatt is a leader in the world of patient safety and in his new role as patient safety officer for The Joint Commission he aims to help leaders within healthcare organizations drive progress towards high reliability. He outlined his mission to HRMR.

The appointment of Dr Ronald Wyatt to the newly created position of patient safety officer is a clear statement of The Joint Commission’s intent to be not only an accreditation organization but also a healthcare improvement organization.

There’s no doubting the timeliness or importance of the appointment. Some 16 years after the Institute of Medicine’s To Err is Human report, Wyatt says that the actual number of deaths caused by adverse events in healthcare per year is far more than the 100,000 posited by the report.

“When you look back on the report, you see that it is focused on hospitals. Since that time, further research has been published that put the number of preventable deaths in hospitals in the US at over 440,000 per year—and that is just in hospitals,” Wyatt says.

“If you consider the fact that The Joint Commission accredits health organizations across the continuum—not just hospitals, but also clinics, ambulatory surgery centers, outpatient surgery centers, long-term care facilities, behavioral health organizations, community health centers and federal prisons­—and you start to think about the possibility of preventable adverse events, deaths and injuries, then you start to see that there is a huge issue.

“If you believe most current research, then preventable deaths in hospitals would be the third leading cause of deaths in the country behind heart disease and cancer. That really focuses The Joint Commission’s efforts around how organizations can become more reliable in terms of patient safety.”

Wyatt will continue to serve as The Joint Commission’s medical director in the Division of Healthcare Improvement, a position he has held since joining the organization in 2012. In his added role, effective immediately, he will focus on healthcare quality and patient safety at both the organizational level—including patients, practitioners, staff and leadership—and the healthcare system level. In addition, he will promote quality improvement and patient safety to internal and external stakeholders, and expand The Joint Commission’s role as an influencer in public policy and legislation.

Discussing his appointment, Dr Ana Pujols-McKee, executive vice president and chief medical officer, The Joint Commission, said: “Patient safety is a core value at The Joint Commission and central to our goal of zero patient harm. The creation of this new position and the appointment of a recognized patient safety expert like Dr Wyatt exemplifies our commitment and ensures we will continue to make great progress in the areas of quality and patient safety.”

A career in patient safety

Wyatt, a board-certified internist licensed in Alabama, came to The Joint Commission with a wealth of patient safety experience.
He served on the Food and Drug Administration Drug Safety Oversight Board and as a mentor to the Center for Medicare & Medicaid Innovation Advisors program at the Centers for Medicare & Medicaid Services. He also served as director of the Patient Safety Analysis Center for the Department of Defense Military Health System.

He continues to serve as The Joint Commission representative on the National Coordinating Council for Medication Error Reporting and Prevention, and was named one of Becker’s Top 50 Patient Safety Experts in the US in 2013 and 2014.

“Rather than minimizing what contributed to the event once it has already happened there needs to be a shift to telling your leadership where your risks are." Dr Ronald Wyatt

Wyatt earned his medical degree at the University of Alabama Birmingham and completed residency at St. Louis University Hospital, where he served as chief resident in the Department of Internal Medicine. He earned the Executive Master of Science in Health Administration (MSHA) from the University of Alabama at Birmingham, and in 2000, the Morehouse School of Medicine conferred him with an honorary Doctor of Medical Sciences degree. He was a George W. Merck Fellow with the Institute for Healthcare Improvement 2009/2010 and also completed a Harvard School of Public Health program in Clinical Effectiveness.

During his time at The Joint Commission, Wyatt has led several important patient-safety initiatives. He was instrumental in renaming the former Office of Quality Monitoring to the Office of Quality and Patient Safety to better reflect the primary focus on patient safety. He has collaborated in the development of national patient safety goals, Sentinel Event Alerts, and Quick Safety publications, and oversees data management and analyses in his division. He is leading an effort at The Joint Commission that focuses on health equity as a patient safety priority as well as the role of professionalism in healthcare as an issue that undermines safety culture.

Shifting the focus

One of the most important lessons Wyatt has learnt about patient safety during his long career in the field is that leadership in healthcare is often more focused on revenue margins than on preventing harm.

“That’s the biggest thing we continue to see,” he says. “You see leadership people who in an active way have decided, for instance, that it’s better to take a penalty for admission rate than to reduce readmissions.

“You have to recognize that a readmission is a defect in your system—one that creates waste and creates expense, but you have CEOs who have done financial analyses and say they make more money on readmissions than working on decreasing readmissions. In any organization whose leadership has that way of thinking, what you have in place is a nominal leader.”

The key, he says, is to have truly accountable leadership. Patient safety efforts have to start with committed engaged and activate leaders from the board level to the C-suite. They need to recognize that there is money in decreasing waste and improving outcomes and making sure that patients and their families truly have the best experience possible.

Wyatt believes that four key aims when managing population health should be to improve your patients’ experiences, know your community, know how well you’re doing in your community, and know how you are doing compared to other communities.

“Again, that benchmarking requires leadership. The leadership need to understand those numbers and commit to being highly reliable and safe—so it has to start with them. The old mantra was ‘no money, no mission’ but what I say to that is ‘if you don’t have a mission you’re not going to have any money’.
“If you look at where CMS is in terms of reimbursement based on value and patient experience versus volume, the days of paying for volume are gone, as are the days of lengthening hospital stays because you have a medication error or some other patient safety event. It is almost ridiculous to say you get paid more for hurting people—but that’s how it’s been for so many years.

“Now you will be paid based on the best outcomes—and what better outcome is there than making sure that when a patient comes into your organization you don’t hurt him, and you don’t make him wait.”

Smoother transitions

The emphasis, Wyatt says, should be on treating patients with dignity, respect and compassion and making sure that when patients move on—whether to their home, rehab or long term care—the transition of care is handled in a highly reliable manner.

“We see too many errors and too much patient harm done when the patient is transitioned from the hospital to home.”

Key points to check are: is the medication correct? Does the patient understand how to take her/his medication? Does the patient know when her/his follow up is? Does the primary care physician have the discharge summary by the time the patient comes in? Is there a method to check that the patient can get back to her/his appointment; and, is there a system in place to get patients back within a decent timescale for follow-up appointments?

“Too often we see people who are transitioning out of the hospital only to be lost to follow-up because there is no system in place to get that person back, or they end up back in the ED because they didn’t understand what took place when they were transitioned out of the hospital.”

Reading the signs
Another hallmark of a successful approach to patient safety is recognizing that when something goes wrong, this is an important indicator of a system that needs changing.

“In patient safety you learn to recognize signals of safety failures as true signals and not an anomaly. Saying, ‘that’s rare but it will never happen again’ is no good.

“The truth is when we look at these events we find that there have been signals of failure all along the way until finally it touches a patient and kills them—and then it’s written off as rare. Well, it’s not. It’s common, and you’ll often find there have been care team members who knew they had been working around some issue.

“It could be on the staffing, it could be an unprofessional manager, it could be faulty equipment or some other environmental condition that puts the care team and patient family at risk—but the care team knows about it and they do their best every day to work around it.”

Wyatt says one of the most common safety events is the unintended retention of a foreign object—commonly surgical instruments or sponges. Sometimes staff in the OR spot the problem but fail to speak up because of fear of punishment or admonishment by the surgeon. In these types of situations, a nurse who fails to speak up can become a second victim of the error as he or she struggles with a sense of responsibility for the harm caused to the patient.
The third victim of such a situation is the organization itself due to the damage to its reputation.

Other safety areas The Joint Commission is highlighting this year include fires in healthcare settings—of which there are around 600 a year in the US; wrong site surgery; and falls with injury, which were the third leading sentinel event last year.

Severe maternal morbidity is another area of focus.

“We know that even with massive transfusion protocols and other methods in place to decrease severe maternal morbidity, when you look at the numbers, the rate of severe maternal morbidity really hasn’t decreased,” says Wyatt.

“There isn’t a week that goes by when we’re not talking to some organization that has had severe maternal morbidity that rose to the level of a sentinel event or at least to the level of an adverse patient event.”

Becoming resilient

Very often what’s needed is a shift change away from a culture where staff are afraid to report problems towards one where they are encouraged to speak up. As Wyatt puts it, it’s about returning joy and celebration to the workplace so that when someone reports a safety lapse, it is celebrated for being pointed out as opposed to being punished.

“You need to value each person on the team for the contributions they make to keeping the system safe—which means reporting to leadership when they have a faulty piece of equipment or are struggling for equipment.

“One of the questions we ask when people get in touch with us is, why are you contacting The Joint Commission? All too often we hear from care team members that they have been trying to tell leadership about an issue for months and years and they’ve done nothing.”

An important key to improving patient safety, says Wyatt, is to recognize signals of system failure rather than seeing them as anomalies. Building a resilient system also means not just waiting again until a bad event happens before addressing a problem, but putting in place systems and barriers that will prevent the event from happening in the first place.

“Part of resilience is working out how to avoid getting in the situation and building a system that decreases the chance of care team members doing the wrong thing,” says Wyatt.

“How do we make doing the right thing easier and doing the wrong thing more difficult? That’s a leadership challenge and leadership has to own that.”
The Joint Commission believes that the vast majority of patient safety events go unreported, often due to a culture that does not allow this kind of openness. By making it psychologically safe for staff to report issues, it is possible to pick up on key signals that the system is unsafe before you have a sentinel event.
Engagement of patients and families, ideally including a patient and family advisory council that is actively engaged with leadership—can further help an organization identify risk and look for ways to proactively decrease harm.

The risk manager’s role

As far as an organization’s risk managers are concerned, Wyatt is supportive of the current shift in the industry away from firefighting and towards proactively addressing risk so that problems are less likely to occur.

“In a traditional sense risk management has focused on how not to get sued. Instead, risk management should involve applying some form of risk assessment to your system, testing the system whether through simulation or culture surveys, and trying in a predictive, proactive way identify the risk.
“Rather than minimizing what contributed to the event once it has already happened there needs to be a shift to telling your leadership where your risks are. It’s not complicated: you can start simply and look at where you paid out most of your losses last year. You can look at claims paid, at your adjusted mortality rate and which service line has the highest adjusted mortality rate and why; you can look at your medication errors and what they are costing you.”

By shifting to a more proactive, enterprise-wide approach, risk management becomes a vital function for creating resilience and culture change.

A blueprint for safety

In order to help organizations address the complex issues surrounding patient safety, The Joint Commission issued a new Patient Safety Systems chapter in the 2015 Comprehensive Accreditation Manual for Hospitals. It provides a blueprint for leaders seeking to build an integrated approach to patient safety, focusing on the role of leadership, the role of safety culture and the role of patient and family activation.

In an unprecedented move, The Joint Commission has made the chapter freely available to the public as a download.

“We are now working on what we are calling a patient safety systems tracer. Using the Patient Safety Systems chapter as a framework, it will be part of an organization’s accreditation survey process and will focus more on patient safety aspects of healthcare organizations,” says Wyatt.

“When I talk to healthcare organization leaders about the things that keep them awake at night—medication errors, falls, wrong site surgery, retained foreign objects—a big part of my work, through The Joint Commission and The Joint Commission Center for Transforming Healthcare, is to teach those organizations how to approach patient safety in a more reliable manner, as what we call high reliability organizations.”

There is a growing demand for The Joint Commission to help organizations begin the journey to high reliability, and to that end The Joint Commission Center for Transforming Healthcare has created a set of assessments and resources called ORO 2.0 which aims to transform healthcare into a high reliability industry.
“It starts with organizations doing what is in essence an internal risk assessment to see where they are in terms of high reliability—are they beginning or are they advanced? I can tell you there are very few healthcare organizations in this country that we would consider advanced in terms of high reliability, and a big part of improving on this is making sure organizations understand the role of leadership.”

Improving the data
The Joint Commission is also looking at ways encourage organizations to report their patient safety-related issues and to move beyond the limited reported data it currently possesses.

“We cannot say at present that the data we have is truly epidemiological data—it’s self-reported, so both at The Joint Commission and externally we would like to see more research that is based in epidemiology.

“The truth of the matter is that research in patient safety has taken a back seat to the traditional randomized control trial research, so that research doesn’t get into the top journals. We are pushing the fact that there is an ongoing critical issue around patient safety so we need to research to better understand these components and help us create better solutions.”

With this in mind, The Joint Commission is working through its Center for Transforming Healthcare to develop its Targeted Solutions Tool® (TST®), an innovative application that guides healthcare organizations through a step-by-step process to accurately measure their organization’s actual performance, identify their barriers to excellent performance, and direct them to proven solutions that are customized to address their particular barriers.

Projects currently addressed by the TST are fall prevention, hand hygiene, hand-off communications and safe surgery.

“Resilience engineering is a big part of high reliability, and another area that we will continue to focus on is helping organizations understand the importance of administering a safety culture survey every couple of years. We will continue to talk to organizations about making sure they do some sort of proactive risk assessment at least every 10 months to help them identify where the risks are in their organization so that they can then focus their limited resources in areas where it’s going to matter the most.”

Most healthcare organizations tell The Joint Commission they want to know how to become more reliable.

“The starting point is committing to being a deeply safe organization, with an emphasis being on prevention, predictability and using your data to understand your system’s safety,” says Wyatt. He adds that you also need some kind of quality improvement method, such as Lean, Six Sigma and Change Management, which is what The Joint Commission refers to as robust process improvement.

“The most challenging component of improvement is how you change a culture, how leadership thinks about things differently, how healthcare improvement is taking place in real time. Becoming more reliable, becoming safer is not a project—it is a daily way of doing things that has to become part of who you are down to the microsystems and up to the macrosystem.

“Everyone has to understand this is how you do things in your organization, because patient safety is your top priority and core value.”