At Mercy Hospital in Iowa City, Iowa, the implementation of safety and quality systems is “stirring up the pot,” says Mercy hospitalist and medical director Martin Izakovic, MD.
He has been recruited to supervise Mercy’s latest safety initiatives, including electronic medical records, pay-for-performance measures, development of treatment protocols, standardization of care, and deep-vein thrombosis prophylaxis.
Hospitalists at Mercy face the challenges their peers around the country face in their quest to improve quality and safeguard patients. The leader in these areas needs to be a role model and respected peer for the physicians he or she must lead day after day, says Dr. Izakovic.
How do hospitalists, who are so well-positioned to become leaders in patient safety, develop in that direction?
“The biggest challenge I see is the spectrum of polarization between clinicians and administrators,” he says. “One of the most important qualities that a patient safety officer needs is the ability to overbridge the doctors on one hand and the administrators on the other.”
What They Need
A patient safety officer (PSO) requires a critical mix of clinical and administrative skills, says Peter B. Angood, MD, vice president and chief patient safety officer for The Joint Commission, in Oakbrook, Ill.
On the clinical side, the hospitalist who wishes to be a PSO needs more than awareness of safety and quality improvement processes. He or she must be knowledgeable about and conversant in safety science in industries beyond healthcare. That expertise needs to encompass leadership, behaviors and cultures, human factors, and process redesign or systems engineering. Important, too, is training in how to corral the pieces of an organization and ensure they operate well together.
An understanding of organizational behavior is of great value. The potential PSO should understand how the key players interact: the board of directors with chief executives, chief executives with senior management, senior management with all staff (including the allied professionals), and medical staff with the organization as a whole.
“Because safety is a systemwide process, the patient safety [person] is pivotal in forming a hub from which much of the quality, safety, and process improvement occurs,” says Dr. Angood.
Jason Adelman, MD, MS, former hospitalist and current PSO at Montefiore Medical Center in New York City, says developing patient safety leaders should embrace technology. “Pay attention to the latest and greatest ideas, products, and services,” he urges. “Come up with strategic plans to implement in healthcare, get the information quickly into the hands of physicians, have physicians report, and include forcing functions [whereby computers will not process to completion when key data are missing].”
Above all, the patient safety officer must train to be a change agent. “Influencing patient safety means you have to be there in the capital-allocation process,” says David Shulkin, MD, chief executive officer at Beth Israel Medical Center in New York City. “You have to be there when they’re designing facilities. You have to understand your human resource policies and the skill sets and aptitudes of the people that the hospital is hiring. To be a good patient safety officer, the training needs to involve broad exposure with a slant toward operations.”
Build a Bridge
As a young physician who wanted to develop as a leader in the field of quality and safety, Dr. Shulkin had to forge his own path. In 1992, after he became chief medical officer (CMO) at the Hospital of the University of Pennsylvania in Philadelphia, he fielded several inquiries a month from young physicians who wanted to pursue a similar career. In response to that need, he designed a quality improvement/patient safety fellowship at his school.
David Bernard, MD, now chief medical officer at Beth Israel, had been practicing medicine for 30 years when at age 50 he took a year’s leave of absence from Boston University and enrolled as Dr. Shulkin’s first fellow in 1994. Dr. Bernard, a nephrologist, was a vice dean in the school of medicine at Boston University Medical Center, a hospital vice president for clinical affairs, and a senior clinician in his specialty group.
Drs. Shulkin and Bernard left the University of Pennsylvania in 1999 to take the concepts of quality transparency to a higher level and formed DoctorQuality Inc. in Conshohocken, Pa. To continue their work, DoctorQuality funded the fellowship. In 2005 when Dr. Shulkin went to Beth Israel in New York, the fellowship was restarted as the Don Hoskins Quality Improvement/Patient Safety program and funded for five years with private philanthropy.
Modeled after graduate medical education, the fellowship is predominantly hands-on. Fellows work on real projects alongside professionals in management, quality, and safety.
Under the Hood
Giving trainees the inside view into the intricacies of how to change physician behavior and cultural issues in hospitals is the backbone of Beth Israel’s program. Fellows see what clinicians rarely see: the real-world complexity of hospitals, why there is so much inertia, and the reasons changing systems can be so difficult. Fellows learn how almost every hospital issue involves financial, personnel, facility, policy and political considerations. By allowing entrée into the executive offices, the fellow gets to hear the many different perspectives when people react to an issue.
“After a quality-improvement meeting, for instance, where people are positioning and requesting different things rather than taking action,” says Dr. Shulkin, “the fellow gets to hear the behind-the-scenes analysis—how executives sometimes label people and develop strategies to overcome some of these barriers.”
Understanding how administrators, directors of social work, or nurses, for instance, view situations and understand their culture helps the leader be more effective.
“To get both leadership and clinician buy-in, and to get leadership to motivate clinicians to participate in system changes, you also need to be politically savvy,” says Dr. Adelman. “Plenty of people resist change. The PSO needs to come off as sincere, passionate, and smart, and has to be able to answer people’s tough questions.”
It can take an ambassador’s touch to make headway in the traditional physician culture.
“The patient safety officers, the chief medical officers, often have to function as diplomats,” says Dr. Angood. “This physician engagement piece is one of the most complicated issues out there, and it arises because physicians historically are trained to be autonomous, to be independent, and to expect that institutions are there to serve them.”
—Latha Sivaprasad, MD, Don Hoskins Quality Improvement/Patient Safety fellow, Beth Israel Medical Center, New York City
One Hospitalist’s View
When Latha Sivaprasad, MD, current Don Hoskins fellow at Beth Israel, started her fellowship six months ago, she was astonished how little she knew about patient safety and quality. Although she felt she knew the day-to-day deficiencies in the hospital and on the front line—and despite having practiced in three other hospitals—she wasn’t prepared to learn what she hadn’t known she didn’t know.
“In my five years as a hospitalist, I knew very little about patient safety and quality—to my shock now,” she says. “Since I’ve been a fellow here, I realize how much I had been underutilized and how much more I could have contributed to making my respective hospitals run more safely.”
Understanding people’s motivations and meeting their needs to make a hospital safer is an intricate process.
“I think it is important for hospitalists to understand how complicated and time-consuming system changes are,” she says. “You do not have that perspective as a clinician. You think that change can occur from a memo or from good intentions to do the right thing.”
She has learned to think about the bigger world outside the clinical portion of running a hospital.
“To be a change agent you really need to appreciate the hospital from the penthouse view, which is what this fellowship provides,” she says. “You need to have access to every meeting, every record, every clinician, and every senior executive to put the pieces of the puzzle together to understand how things change.”
The hospital is working to apply the Toyota method of employee involvement to the issue of how an obstetric patient progresses from triage in the emergency department (ED) to labor and delivery, and how much time passes before the triage the patient is discharged or admitted. Their focus first targeted convening the right group to discuss the issue and identify the details of the problem, then put a plan in place to track ED triage. They looked for ways to make that process more efficient, met again to determine how to implement a new version of that process, then tracked the difference. “All of this was a multihour ordeal,” she says.
It’s exhilarating, frustrating, and intriguing—and sometimes discouraging. “It’s very tedious making change, and I didn’t appreciate that before the fellowship,” she says.
Dr. Sivaprasad advises hospitalists that to be effective in patient safety efforts means being a problem solver, highly empathetic, sensitive to others, and above all, extremely patient. But results often emerge slowly.
“You must have several things brewing at once because if certain programs’ changes are taking time, you need to complete the loop on something else,” she advises.
The Ideal Candidate
Of the 20 fellows Dr. Shulkin has mentored, about half were older and more experienced than he was. Reflecting on the successful fellows and those who benefited less makes him think the distinction of experience and age is less important than the individual’s personality.
“What is important is the personality and motivation and self-directedness of the fellow,” says Dr. Shulkin. “This is a very autonomous fellowship. One of the pluses and minuses of working with senior executives is that they are very busy; they don’t have time the way traditional academic program directors or residency directors do to think, ‘Where are my fellows and what are they doing?’”
Those who will get the most out of this type of experience know how to be delicately assertive yet drive their own agendas.
To Drs. Shulkin and Bernard, a good patient safety leader is naturally curious about what makes healthcare organizations tick. The ideal candidate has an appreciation for hospital financing and the science behind physician behavior change, and the capacity to be a good listener. The trainee also needs to put aside his or her ego while transitioning from a physician in charge to stepping back into the student role to learn the new language and environment.
—David Shulkin, MD, chief executive officer, Beth Israel Medical Center, New York City
Where to Begin
The institution sponsoring the development of the patient safety officer is just as important as who that candidate is.
“The administration has to have a visionary leadership that recognizes that healthcare quality and safety is the way you do business,” says Dr. Bernard. “You have to be in an institution that is not just paying lip service to moving quality and safety. It has to be part of the fabric of the institution.”
The institution also has to be able to offer a variety of experiences, making this kind of training difficult in a nonacademic setting.
For those interested in pursuing this area of leadership, the natural first step is to meet with the CMO or CEO to explore whether the individual’s and hospital’s interests can be aligned.
“But you can’t force it,” warns Dr. Shulkin. “If that is not a natural fit, if the CMO or CEO doesn’t see their role as, or have an interest in, training faculty people; or if they don’t have the expertise to do it, it’s not going to be a good experience. In those cases, the hospitalist should look elsewhere. An increasing number of centers can offer this kind of experience for a year,” he says. “Then the hospitalist might return to their institution to take on a leadership role there.”
Creating a costly infrastructure to train a patient safety officer is not required. What is necessary is chemistry in the mentor-trainee relationship.
“This is the first time in my postgraduate career that I actually have consistently committed mentors who care about how I am molded as a physician and what my ultimate contribution to the medical field will be,” says Dr. Sivaprasad. TH
Andrea Sattinger is a medical writer based in North Carolina.