Open Letter to The Senate Subcommittee on Primary Health and Aging re: 7/14 Hearing on Patient Safety: “More than 1,000 Preventable Deaths a Day is Too Many”!

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Dear Senator Sanders and Members of the Subcommittee on Primary Health and Aging,

sandersI am writing to you and the esteemed panel of experts who testified on July 17th, 2014 at the hearing:  More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety as a nurse with over 25 years of experience in home health, occupational health, long-term care and as an organizational development consultant with almost 10 years experience specializing in communication and collaboration in healthcare.  It may also help to know that I am an author with a self-published a book in 2009 Confident Voices: The Nurses’ Guide to Improving Communication & Creating Positive Workplaces, am currently writing a core textbook for nurses with F.A. Davis Publishing Co., have produced several youtubes that speak to the issue at hand as well as many blogposts (Links at the bottom of this post.)

I’m writing because I  believe that the “Science of Safety” must be balanced with what I call the “Art of Safety” and although several testimonials touched on elements of this, my sense was that the push for more data and matrices and research overshadowed some extremely important and interrelated points that I would like to elaborate on.

First, healthcare is provided by humans and as such is a complex adaptive system.    Command and control, although has it’s place in healthcare, is not the only answer, yet the temptation especially within the medical world that is traditionally hierarchal and evidence-based is to pursue data. This, by itself will never solve the problems we have.  Human beings adapt and change and learn.  Complexity science tells us that the relationships we have as professionals and with patients and families will impact all outcomes.When we nurture these natural tendencies we get great ideas,  collaborative teamwork, patient-centered care which is safer and more rewarding to work in.  When we ignore or repress them we get resistance, alignments, poor communication, burnout, and unsafe care.  As Joanne Disch, PhD, RN, FAAN pointed out in her testimony, the underlying leading root causes of serious medical errors according to tracking and investigation by the Joint Commission of ‘sentinel events’ are human factors, communication, and leadership. These are true year after year after year!  If you look at the subcategories of these root causes you will see they are filled with examples of people skills that involve communication and collaboration.  Understanding this relationship between people skills aka soft skills and sentinel events, is absolutely essential for long-term meaningful changes that will make care safer!

We must set the stage for optimal collaboration to emerge in the moment.  We do this by building respectful workplaces and providing in-depth and interactive communication training that includes facilitated coaching with real world scenarios.  TeamSTEPPS and Crew Resource Management are both helpful processes  as well as a new technique entering the field, Medical Improv which has an exciting focus on building emotional intelligence, critical thinking, and positive relationships. (see youtube link below.) Checklists have their place and I commend Dr. Pronovost and colleagues for his work here, yet we must look deeper to understand why they work while realizing that having a checklist for everything we do will dilute their effectiveness whereas being able to rely on each other’s expertise and the relationships that support that ideal will enhance every intervention.

Second, when we apply the ‘science of safety’ without considering human behavior or the ‘art of safety’ we spend resources on treating a symptom rather than the cause of a safety-related problem. What happens, and I believe this is a primary reason for overall lack of progress in patient safety, is that the symptom improves but the underlying problem, unchecked simply creates another symptom. For instance, consider the ‘handwashing’ conundrum and Hospital Acquired Infections HAIs. Let’s say a medical-surgical unit brought down their spread of HAIs following focused training on handwashing and increased organizational pressure to wash hands per protocol and the infection rate goes down.  “We” walk away feeling like we have fixed the problem. But, what if the underlying problem has to do with understaffing and/or workplace bullying and these issues are not addressed? This might result in a shift in priorities leading to less HAIs, but are we asking what is not getting done, what new cracks exist in the system,  or what other shortcuts staff might be taking?  Are there more falls?  More back injuries for workers?  More nurse turnover?  In my per diem role in long term care, I can not do everything the way I am supposed to. I do not have the resources to support nursing interventions the way I have learned to provide them.  So, when organizational mandates force me to follow one set of guidelines more closely, or I have 100 urgent things to do but only time to do 60 of them according to protocols something has to give.   It is an exhausting and stressful erosion of professional standards that compromise safe, quality care and rewards of providing it.  I believe many doctors, nurses, physical therapists, occupational therapists, clinical social workers, and para professionals can relate.

Please understand that I am not against research, but rather for balancing the science of safety with the art of safety.  This means:

  • Creating workplace cultures where open and honest communication and respectful relationships are the norms.
  • Ensuring enough staff with the skill mix necessary.
  • Insisting on leadership which empowers frontline staff with problem solving responsibility
  • Providing resources that support the work that nurses, doctors, and others trying so hard to do.

If you’ll spend some time on this blog, in particular with these blogposts and youtubes you’ll gain a deeper understanding of problems we face in fixing healthcare and why 15 years later we are still limping along.

*Links to Resources & Expert Testimony on # of Deaths, Medical Errors, & Patient Safety in U.S.

Blogposts:

Youtubes:

BB closer Headshot 1-13 CherationsThank you for your work and attention. I am happy to answer questions and/or be a resource in leadership efforts to create safe, quality, affordable, and compassionate care for all.

Beth Boynton, RN, MS

  • Beth@bethboynton.com
  • 603-319-8293

 

 

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24 Responses to Open Letter to The Senate Subcommittee on Primary Health and Aging re: 7/14 Hearing on Patient Safety: “More than 1,000 Preventable Deaths a Day is Too Many”!

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  13. whisperingsage1 says:

    the Three Signs of a Miserable Job is a great and simple start. We must
    care about each other and we must get to know each other- it is our job
    as human beings- for more look up free lectures by Leo Buscaglia- he was
    the beginning of the journey for me.
    This bonding will help us work
    as a team. I have been lucky enough to have seen this work in action,
    and have these types of folks as mentors. It is connected to what he
    calls relevance- so we know how our job affects others on the team. This
    is a part of causing us to care. The most unfamiliar part of his work
    to me is measurement. But I’m looking at that. Another Patrick Lencioni
    book is the 5 Dysfunctions of a team, and finally, the 7 Habits of
    Highly Effective people By Steve Covey. Carney, but basic and brings
    meaning to our job and our workplace.

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  16. Barbara Duffy says:

    Beth –
    You beautifully sum up the challenges in providing safe care
    and the frustrations so many of us feel. Nurses want to be provided the
    opportunity to do their jobs well! Unfortunately, so much of the
    current situation has only the potential to make things worse. I support
    your efforts to improve this intolerable and sad course of events that
    has derailed the mission of healthcare to provide compassionate, safe
    care to all. I admit, there are times I have been ashamed of the career I
    so love.

    • Beth_Boynton_RN_MS says:

      Thanks, Barbara. It is frightening to think of things getting worse, but I agree. I also have been ashamed and angry and tired! I do believe that nurses have a lot of potential power and if we can become more collaborative with each other and consumers and other well-intentioned healthcare professionals we’ll have a chance. I hope so anyways.

  17. Jim Murphy says:

    Beth,
    You are quite on target and what you say is crucially important. We are seeing healthcare in acute form a “disease” all too common in organizations. Something is recognized as important and a campaign is launched to do something.
    But for change management to work, there has to be a good organizational culture. If there isn’t, then a campaign to reduce errors, make employees smile more, improve hand washing, or anything else is not going to work. First, the organizational culture has to be fixed and only after that can problem of the day or the campaign of the moment be attended to.
    Safety is crucial, and there is a large body of research on what causes failure in this area: flaws in the organizational culture. The Challenger launch decision is probably the most famous safety failure and has been analyzed in a famous book and in a compelling video.
    Why did it happen? Because people feared speaking up. The culture did not support open communication and concerns were suppressed.
    If people don’t feel able to express their concerns on safety or any other organizational issue, how can problems be correctly identified and progress be made? So programs to accomplish any change or goal, no matter how laudable, will not be successful.
    Open and honest communication among all members of the organization has to be the starting place of any change effort. Otherwise it is as if the organization is providing only superficial and palliative care instead of dealing with the fundamental organizational health issues.

    • Beth_Boynton_RN_MS says:

      Jim, thank you for making such a clear and strong statement about the importance of organizational culture. The very same campaign that thrives in one facility can be a dismal failure in another. Many of your/our/my posts at CV blog speak to the how, what, and why re: culture change in healthcare. I think you are referring to “Failure to Launch” and it is a compelling book. Yes, the “O-rings” failed, (the science) but people didn’t speak up, (the art). In addition to being afraid to speak up in nursing, there is also a ‘giving up’ mindset that arises from speaking up over and over again and not being listened to. We can also add scarcity of resources to the list of contributing factors which was also part of the culture in the Shuttle disaster. Always rushing, never enough resources, easy targets for blame when something goes wrong are creating a perfect storm for the safety problems we have. Instead of setting up systems where ‘we’ can’t do it wrong, we have systems where ‘we’ can’t do it right. (There are definitely success stories in safety too, but not nearly enough).

  18. Bravo, Beth! And thank you for such a well-articulated comment, Susan! Today I read yet another blogpost by a hospital marketing person that emphasized the #1 way to patient satisfaction is for staff to smile more(!). I’m weary trying to respond to folks who are oblivious to why medical errors are the #3 cause of death in the U.S. I appreciate the Beryl Institute’s definition of the Patient Experience….”the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care”. If administration, leadership, HR, direct care staff, support services….EVERYONE was operating from the same mindset of what is involved in TRUE communication and collaboration, there might be hope for the major healthcare cultural shift that has yet to happen.

    • Beth_Boynton_RN_MS says:

      Thanks, Stephanie! I read that same ‘smile’ blogpost I think. AHHHHHHHHH! And I totally understand your weariness, I feel that way at times too. I have to wonder how the lack of awareness about the persistence and severity of our patient safety problem is an inconvenient truth. People are still shocked to hear that statistic about medical errors being the 3rd leading cause of death in the USA. How can this be? Peter Pronovost made some interesting comments about consumers reaction to a plane crash where many people die, but how in healthcare it is one by one. I don’t recall his exact comment, but it makes me wonder if this is part of the phenomenon.
      Thanks for pointing out the Beryl Institute’s definition of Patient Experience. It is a great example, once again, about how important open and honest communication and respectful relationships are in our efforts to provide safe, quality care for everyone! We do have a long way to go. Thanks for commenting!!

  19. Susan Cooke says:

    Beth

    I cannot agree with you more! Safety is an art as is the practice of nursing. We must as a profession come together and collaborate with not only the medical and support disciplines but with high level administrators to do the right thing to assure patient safety.

    This is my last week as an ICU Nurse Manager. I have been a Nurse Manager for over 15 years and I can’t do it any longer. I have believed since the beginning of my career as a clinical bedside ICU nurse that the proper amount of staff and access to needed equipment would be the difference in outcomes. I still believe that today. Every single nurse manager I have worked with fights the staffing battle every day. We provide excellent care in an institution that is extremely financially solid. While we are very good at what we do being great is what saves lives. I have fought my last battle trying to convince finance not to cut essential personnel like a charge nurse without an assignment or a much needed Tech to support over worked staff. It gets worse every year and for me it is not about working smarter anymore. It is a moral and ethical dilemma.

    We have embarked on the TEAMSTEPPS journey as an institution. It’s a wonderful concept and I believe if used as it’s meant to be it would have a powerful impact on communication and ultimately patient safety. But like you said it has just become one more thing we don’t have time to hardwire. It is on the list with 25 other priorities that are just as if not more important

    Value Based Purchasing, HCAHPS , readmission penalties , throughput, etc. are all wicked problems. We can study data and create all the checklists we want but until healthcare institutions adopt a Green Bay Packers mindset whereby we all work together or die separately more lives will be lost needlessly.

    As a nurse and moral human being I would love to become involved in making the plight of nursing and healthcare workers in general heard. Please let me know how I can help. Giving up my role as a NM I’m pretty certain Ill have some time to dedicate to the greater good.

    Respectfully,

    Susan Cooke MSN,RN NEA-BC

    • Beth_Boynton_RN_MS says:

      Hi Susan,

      Thanks for your dynamic and validating message. Your football metaphor is perfect! There are parts of teamwork that must by nature unfold in the moment. There is plenty of science in the practice, and protective equipment, even getting psyched up, but when the game starts, the action emerges.

      And thank you also for trying and trying to advocate for staff. No doubt you can see first hand what your staff need to provide safe care and instead of support, more and more is asked of them. I hope that your last days in this role you are able to hold your head up high and be honored for your commitment, skills, knowledge, and hard work. I have a lot of respect for those who fight for safe staffing. (I understand those who don’t too…sigh)

      When you have a chance to exhale, write to me at beth@bethboynton.com. I’d love to have you be a guest blogger and maybe over time share your perspective here if you are interested. Andrew Lopez does a lot of nurse advocacy too and you can find him at Nurseup.com or i’m happy to connect you.

What are your thoughts?