Discussion
DR. FINEBERG: You have heard a very compact summary, and I hope you will take the time to read the report. I think you will find it really outstanding in its depth and documentation, and it is readable. It really is, but our closing messages to you are ones that I think you will resonate to.
One is that we cannot afford to wait to act. You look back, and it has been four years since the To Err Is Human report. Progress has been made but not as much progress as needed. This is a clear blueprint for healthcare organizations.
While we were talking in the past hour I did the back-of-the-envelope calculations, and if you take the rates at which individuals are dying because of errors that the To Err Is Human report said in the last hour 5 to 11 people died in this country because of errors. What this report tells you, and what Bill showed you in his own experience, is that those numbers could be substantially reduced through building systems and processes that take the potential for error out of patient care.
It is clear, too, that organizations, and Bill could have talked about this, are going to have to invest different amounts of resources to move ahead because each organization is going to have areas in which they have some strengths and some serious weaknesses, but I think there is a very positive message here that when you look at what you need to do to improve patient safety you are also addressing those issues that reduce nursing turnover. Turnover is expensive. The estimates in our report are anywhere from $10,000 to $45,000 per nurse. That is a huge amount of
resources if you are talking about 21 percent of registered nurses (RNs) each year or you are talking about in nursing homes about half of the RNs each year.
These recommendations also produce greater patient satisfaction, along with a sense of well-being and a sense of feeling that the care system has actually cared for them and they have received better outcomes.
In our report we also tried to document using case studies of specific organizations, and some research supports the evidence that we had that there are actually some potential financial advantages. In general, when errors occur it costs resources, and if you look at the payment system for hospitals, overwhelmingly those resources that relate to complications and to more intensive interventions for individuals who have suffered adverse effects cost the hospital resources, and so society, the hospital, and the patient pay for these errors.
I think they chose me to do this, but the very final slide shows that you need an academic up here to know that an important purpose for every report is to lay out a research agenda. I think as you go through the report, even though it is impressive, the amount of evidence we have now, the gaps in that evidence are also of great concern. When we talked about staffing guidelines for acute inpatient hospitals, we only had the data sufficient to talk about a guideline related to intensive care units and not for all the other units. In nursing homes we are in a much better position because the research has been done.
So, let me just point to a couple of these and not take you through all of them. One is a very clear sense that we need to move ahead on research that measures patient acuity in ways that are useful in staffing and to use it in standardized ways across the organizations to be able to produce and share staffing data. This report suggests having staffing data available and hospital report cards and nursing report cards in ways that are useful as well to hospital managers, to nurses, and others who have to use that information.
Issues around fatigue—some of these don’t go away. Shift workers who are working a graveyard shift and a swing shift pay a price for doing that, and we need to have ways to help workers and help organizations handle that in the best way possible. So, additional research that goes beyond what we have already is needed, and especially research into this concept of collaboratives: bringing together the hospital, nurses, academics, and others who are involved in evaluation to learn together how to build continually the information base about how to improve safety and then to take those next steps forward. In the best of worlds, we would have a fail-safe operation and be able to guarantee patients that we can do them no harm.
Let me close with that. I assume that we have time for questions and
would welcome those and your comments about what this committee has done and where we need to move from here.
The floor is open, and we are eager to open up for wide discussion at this time.
PARTICIPANT: You pointed out yourself that 10 of the recommendations are for health-care organizations, and I think most of the folks in this audience, I would guess, are from the nursing community. So, my question is what are your plans to bring this report to the CEO communities and what would you recommend for all of us? How do we get the message? You are very enlightened, but how do we get the message to the unenlightened ones?
DR. FINEBERG: Not the term some of my staff have used. Why don’t you start? Really I am happy you raised this question because, truthfully, if all that happens is a report that is talked about in a room like this, it is not going to have its purpose fulfilled. So, Don, why don’t you start?
DR. STEINWACHS: I will be happy to start off, and then I was going to turn to Bill very quickly, who probably has the real answer, but it seems to me that the translation process to get this from a report into action is not only that we need to create a sense of public demand, if not public outrage, about the continuing problems we have in the health-care system, but we have to be able to provide the kind of technical assistance, the ways in which CEOs and boards will feel comfortable, for moving into what they see as a major change.
I think what Bill described to us is a huge transformation in an organization. Well, there are very few people who will take that on unless they feel they can be successful and it will lead them to the right end point. So, having an example like Bill and some of the other examples in this country are critical and being able to provide the kind of guidance through collaboratives and working together so it is a joint effort; it can’t just be an instruction, but it has to be a joint effort.
Bill?
DR. RUPP: I don’t have the answer, but I would hope that we first start some controversy with this report and get some discussion going. We actually probably haven’t spent enough time saying what our plan is for getting this out to multiple sites, but there are a number of other areas that we can bring in as we begin to publicize this, the 80 different hospitals that are magnet hospitals, for example, that also have low turnover rates. Mine isn’t the only one. There are a number of examples around the
country that we ought to be publicizing significantly to get this kind of information out.
I come back to the research. For so many hospital CEOs, the data is still not there. We haven’t done the research to show the dollars and cents outcome from this, and we absolutely have to get it over time.
DR. FINEBERG: Do you want to comment on this? It is such an important point.
DR. HINSHAW: Yes, particularly from the viewpoint of being a member of the Governing Council for the Institute of Medicine (IOM), because the IOM has been very concerned about dissemination and getting the information into the field and actually beginning to track what kind of impact we may have had with these different kinds of reports. Already I know some of us on the committee have been asked by Janet Corrigan and by Ann Page which groups do we need to get to first; how do we prioritize these groups; how do we get into their conference agendas; how do we get into their literature, etc., and really begin to get the information out. That is very consistent with the usual way that the IOM is really concerned about not just sitting on reports. It is really concerned with the translation piece.
MS. LUBIK: My name is Ruth Lubik, and I am a member of the IOM. I am a nurse midwife. I feel that there is a team member missing in the way that the report is presented, and that team member who should be very important is the public or the client. If you are going to reduce errors, it looks to me as though the client him- or herself plays as important a role as does the nurse or the doctor. Until we give and acknowledge the role that people’s involvement in their own care decisions, until we acknowledge that they deserve that and have that it is very difficult.
I was in London just last week, and in the London Times there was a supplement about orthopedic errors and deaths and so forth, and page after page was published for the use of the public to look at and read. I know that the whole mention of the National Health Service in England turns a lot of people not only off but on fire. So, I mention that with hesitancy, but as a nurse midwife I learned very early that if I did not have the pregnant mother and her family sharing in their care that it just wouldn’t happen. You wouldn’t find the improvement we hoped that we would like to see. So, I guess my question is to Dr. Rupp and to the committee members and I do congratulate them on a very difficult task well done, is how involved were clients, consumers, the people who suffered, let us say, in the look at what is going on?
DR. FINEBERG: Thank you very much for the comment. Would anyone like to react to it?
DR. STEINWACHS: I think she took it to you, Bill, and I will be happy to reply.
DR. RUPP: The question is how involved were the consumers in the look and not as much as they should be. Our natural tendency isn’t to always go there. The specific example I am thinking of is in my current organization. We put up signs in every hospital room saying, “We promise to wash our hands before touching you.” The hospital, nursing, and medical staff went berserk. By the way, the data that we now have shows that hand washing has increased exponentially after doing that, but I think the point is that our natural tendency, no, we didn’t have consumers on this panel. Should we? Probably, but didn’t yet at this point. That is not a natural way that we go every time.
DR. FINEBERG: Any other comments?
DR. STEINWACHS: I was just going to add my support to the view that Crossing the Quality Chasm I think talks eloquently to the fact that it is not the system that provides care, and you are a passive recipient if you are going to have good care, and that it is the interaction just as you are talking about, and what we failed to do is to provide the tools and the information for consumers and families. This report does talk about report cards, though the research we have today sort of suggests that report cards sometimes influence the providers a lot more than they influence the consumer saying, “How can I use this to make a better choice? How do I know that that nursing home will be a place I really don’t want to go?”
DR. FINEBERG: Thank you for raising a critical point.
PARTICIPANT: Yes, I’m with the National Center for Patient Safety. I practiced cardiovascular surgery for 20 years, and a couple of years ago I worked for Senator Kennedy as a Robert Woods Johnson fellow. The nursing shortage was one of my issues, and as I traveled around the country and spoke to a lot of nurses, I was concerned that at the time—if you think back a couple of years ago, Congress’ focus on this issue was primarily about increasing recruitment, getting more students to go to nursing school, giving the scholarships and loan repayments, and so forth—I really thought talking to the nurses I knew from the work place and the nursing groups I spoke to around the country would uncover the real
issue. And I congratulate you for focusing on the real issue, which is the conditions under which they work, and a couple of questions in that regard. Number one, why is that only 10 percent of the work force in nursing in this country is male? If you compare the private sector with the Department of Defense, 30 percent of military nurses are male. I asked them the question, and they said that it was about career track and opportunities to advance in their profession that are just not there in the private sector nearly as much. That was why a lot of males told me they were in the nursing profession. So, I think that is an intriguing question when you think about the work force, especially the alarming figure that 20 percent of nurses who are training and educated don’t even do nursing right now.
The other question I wanted to ask, actually two other questions. What is it about magnet hospitals that have a much better retention rate? It has a lot to do with empowerment, at least that is what I heard, but what in specific terms could you speak to? My other question I forgot.
DR. FINEBERG: You might have a chance to think of it as you get the answer to the first two, but those are two very important points.
Ada Sue, do you want to take on the first question to start with, which is related to why don’t we have men taking up nursing, and what is it about career paths, etc., at this point?
DR. HINSHAW: I think part of it is career paths and people not understanding the multitude of opportunities that are open out there for nurses. Many people still see only the stereotypical kind of response to nursing, and what they don’t understand is you can be a nurse in many locations, many sites. You can go through many different kinds of educational programs. You can advance in administration, education, and in clinical specialty and staffing roles and stay at the bedside in those roles, but I think many people don’t see that kind of array of opportunities. There is also the issue that it has been difficult to be able to get the salary and the pay of nurses to continue to increase over time. We have gotten the initial salary up more, but it is still true that you top out earlier than you do in other professions, and this affects both men’s and women’s selection.
The other issue is image. I think we have to talk about that being predominantly female at this point. It is very difficult to convince particularly young 18-year-old men that this is a profession that really provides a number of opportunities.
What we see is there are many more men entering the second career programs than in the initial generic program. These are individuals with a baccalaureate in another field who may have some experience in work life who then come back into nursing. Image is no longer the same issue as it
is for the 18 year old, and so how we begin to deal with some of those kinds of factors is very difficult. I mean I don’t have these answers for any of that except to know that I think we really do have to become much more explicit about beginning to look at strategies for that.
PARTICIPANT: Advancement means leaving the staff level nursing position and going on to advance practice nursing, or perhaps industry where the skills of a nurse are much needed and much valued.
DR. HINSHAW: Except some of the CEOs now are really beginning to look at clinical ladders at the bedside and not the old concept of a clinical ladder but new kinds of skills that will be required that will take new knowledge capability. You can advance, but you can advance in the expertise of caring for patients, groups of patients within a unit and staying close to the bedside, but that has always been a problem. I agree with you. That is a tough one for us.
DR. FINEBERG: Thanks, Ada Sue.
Bill, would you want to comment on what makes magnet hospitals magnetic?
DR. RUPP: No, I will let Ada Sue do that.
DR. HINSHAW: I seem to be the resident expert on these particular hospitals. These have been very exciting institutions that do both recruit easily, in fact usually have waiting lists and do retain nurses, and there are several characteristics that come through in the research literature, both Aiken and her colleagues’ work and Marlene Kramer and Schmallenberg’s work.
Those characteristics primarily have to do with adequate staffing, autonomy, and control of their own nursing practice, very visible leadership that has a trust for the staff workers and uses decentralized decision making, increased educational opportunities both formal and informal in the area, and a culture of very strong interprofessional relationships, particularly the physician-nurse relationship. This is very important for individuals, but this is also what you will find in the literature that makes these places magnetic and in fact they have better patient outcomes. That has been studied in Aiken’s work.
DR. FINEBERG: Thank you very much.
PARTICIPANT: If you will allow me, I remembered my third question. It is very quick. I ask this of Bill Rupp. What, if any, strategies have you employed to either reduce or eliminate mandatory overtime, which is a real sticking point for the staff nurse, especially one who tries to have some other life and has kids to pick up after school and so forth?
DR. RUPP: The question is, how do you reduce mandatory overtime? We don’t have mandatory overtime, though there clearly is a pressure to do that. It comes down to if we are doing that, if we are asking people to stay late, then units need to be red and we have got to stop taking admissions, and we can’t keep piling onto that. There are times when you have a patient population. We have them now. We have to take care of them. That is the facts of life, but there is no sense then in adding onto that burden as we go along. We have the opportunity to hold up on electives and to move patients elsewhere.
DR. MARX: I am Eric Marx. I am the Associate Dean for Faculty at the Uniformed Services University which is the federal medical school, and we have a graduate school of nursing. I am struck by the importance of this work because of something which I think most of the people in the room are aware of, the recent imposition by the Accreditation Council for Graduate Education (ACGME) of the 80-hour work week for house staff. What I wish from a medical educator’s standpoint is that this kind of basic research was done prior to the institution of that.
You are talking about 60 hours. We are dealing with 80 hours, the issue about transitions, the dependence now that we are looking to on nurses to cover it when we have really kind of shift work and I would suggest to you that, when you are talking about areas of distribution for this particular study, it is very clear for those of us who are trying to deal with this that without a true reorganization of the infrastructure of the facilities in which we deliver the care, simply playing with the hours is not going to be it. Because if you look to see how most teaching facilities have dealt with the 80-hour work week, all they have done is changed around the schedules. You know, they haven’t looked at why a house officer really only spends 2.5 hours doing direct patient care and like the data you got spends 4.5 hours looking up things and another 2.5 hours where we are not really quite clear what it is. It is usually waiting for a staff person or moving a patient around or finding things.
So, I would suggest that the importance of this work clearly transcends the issue of nursing and really is the first clear-cut environmental study that I have seen that deals with the entire structure. So, I would tell you the one place that I would start distributing this to is I would make this mandatory through the Association of American Medical Colleges.
So, it would go to every single dean of every single medical school in the United States and be a topic of conversation for every board of regents because this clearly provides information that we desperately need in order to compensate for what is really a system in some trouble.
DR. FINEBERG: Thank you for that comment. In light of the hour and the number of people at the microphone I think we will have time to take a comment or question from each of those who are now standing, and then I think we will have to wrap up.
DR. SCHMIDT: I am Maddie Schmidt from the University of Rochester, and I would like to expand on the comments that Ruth Lubik made and advocate for the idea that there is another set of missing partners in this discussion and that is families, particularly for our most vulnerable hospitalized patients. I have become very sensitized to this by a recently completed study by one of our young colleagues where she has instituted an intervention for families of hospitalized elders where she has nurses working with families to contract to work with the nurses to prevent certain kinds of high-risk complications in hospitalized elders, for example, decubiti and acute delirium. The work that she has completed in a pilot study shows a direct impact of that kind of collaborative work between nurses and families in reducing those kinds of complications. She is now funded for an RO1 to continue that work, but I think we have got the potential there of folks who are sitting in the hospital environment who care very much about what is happening to patients, and more active engagement of them as partners in this patient safety initiative I think would generate a lot of positive things.
DR. FINEBERG: Thank you very much for the comment.
DR. GIBSON: I am Rosemary Gibson with the Robert Wood Johnson Foundation, and in some spare time wrote a book on medical errors from the experience of patients and families.
Two quick questions for you. One is in some of the more successful reports on making change. I think of To Err Is Human. There were numbers that rose above the din of all the dialogue we have in our public life and also the 3,000 kids a day that start smoking. Is there a succinct message that you have for this report that will similarly rise above the din that is catchy? Because I think that is the thing that really makes the work that you do so successful.
Secondly, have you ever considered with all the wonderful work you have done in To Err Is Human and Crossing the Quality Chasm (that you might) develop a lay version for the ordinary educated public and maybe
put some of these together so that we can create awareness? There are certainly great CEOs like yourself, but what about all the others, the ones who are the laggards? I don’t think you folks can fix it. I think it is pressure from the public, as the National Roundtable on Quality report noted. So, would you consider doing a lay version that could help stimulate that?
DR.FINEBERG: An excellent suggestion. That first succinctly stated but rather complex initial question, does anybody want to have a comment on that? Don?
DR. STEINWACHS: We have it down to a long paragraph. We have a ways to go.
DR. FINEBERG: Fair enough but an important point. The lay version I think is a well-taken point and is something we should do. We will follow up with you and with others on that because I agree with you. So much of what we do has to be interpreted and conveyed in a way that is relevant to the reader or audience, and this is a very well taken point.
DR.TOWERS: I am Jan Towers with the American Academy of Nurse Practitioners. I have two brief questions. I want to commend you on this. This is really wonderful, although you always do good work. So, I don’t know why we would expect anything different. But one of the things in looking at this that I am wondering, did you look at or was there any thought to looking at the levels of nursing that are used in terms of preparation within these frameworks to see what kind of impact that has on patient care? Of course, I am particularly interested in advance practice nurses. Also is there any talk, and there probably is and I am just not aware of it, of expanding some of this kind of work to the primary care setting? I know we are meeting with physician groups in relation to trying to think this through, and it is very hard to get a handle on that.
DR. FINEBERG: Good questions. Comment or reaction?
DR. STEINWACHS: Let me take the second one. I have already forgotten the first question. I can only do one at a time, and I was thinking Ada Sue would need to answer the first one. In the primary care setting, it seems to me it is one of the areas where research needs to move. Sometimes, at least for the patient, there is a lot of ambiguity about is it a nurse, who is the nurse, and what kind of support occurs in those environments. Since doctor’s offices have all sorts of staff but as you move into the outpatient arena, as the Crossing the Quality Chasm talks to, really the potential for errors rises tremendously and you are much more reliant on the
patient and the family to be able to carry this out, and it is a different sort of system that needs to be there, but it is crucial.
DR. FINEBERG: Ada Sue, do you want to comment?
DR. HINSHAW: On the first one that you had raised, the different types of nurses and then the accompanying education that goes with that, we did not try to get into that question because it is quite frankly a huge issue in itself and so did not try to go there.
We really were looking with staff nurses and nursing homes and in hospitals particularly because that is where we had the data. What can we do with the work environments that will really help keep patients safe?
DR. TOWERS: So, are we dealing with a lack of data still in relation to that, or is it that this is another issue that probably needs to be looked at sometime?
DR. HINSHAW: It is a lack of data in terms of education, and it is also a lack of data in terms of different settings. In home care we had almost all data. It is an excellent testimony, but no actual data that we could work with, and that was also true in ambulatory care sites and in primary care, as Don suggests. So, we have some work to do.
DR. TOWERS: Okay, thank you. I would also comment that primary care is carried out by more than physicians and nurses. It is also nurse practitioners and other advanced practice groups, and I think there could be some real teamwork in working on some of those things.
DR. HINSHAW: As a dean who supports two nurse-sponsored clinics and three school clinics, I understand that concept.
Thank you.
DR. FINEBERG: Thank you very much.
MR. BAGIAN: I am Jim Bagian and I am the Director of the Virginia National Center for Patient Safety. One of the things I wanted to ask a question or comment on is the third from the bottom here about methods to help night shift workers compensate for fatigue, and I wonder if that is a bit too restrictive. The point is we heard comments before about using hours as a metric, and I think most of the industries that have really dealt with this find that it is a very ineffective and blunt tool.
In fact, many of us that were asked to comment on the ACGME working for eight hours said that it is foolish and shouldn’t be done because
you can make yourself feel good about bookkeeping hours. But in fact we feel that with the ACGME guidelines it is very easy to comply with the spirit of the rule and yet not—I mean with the letter of the law and not the spirit of the law—and the fact is when you go to why aviation really feels this is a failed strategy although they are always the ones that are looked at, there is quite a bit of research done on this and the move now for instance in aviation is looking at fatigue countermeasures. The fact is there are ways to monitor fatigue, and one size doesn’t fit all. For example, certainly as you pointed out here very nicely, cognitive capabilities, visual, and things like that are the first to go. However, some things, such as can you start an IV or something like that, don’t. You can also monitor by strategically managing a person that stays over or is forced into that and say, “You know what, you don’t set up the IV pumps. You don’t calculate drips, but you know what you can take vitals,” instead of just saying that you can’t do it because that is unreasonable and not really founded on fact. You can look at things like napping, strategic napping, using caffeine, and things like that. I think nobody has really done this in a coherent way thus far, and it probably is something that should be considered because it is really more effective at getting the end result you want rather than this blunt instrument because one of the reasons it has failed is 80 hours from when, from when you got up in the morning? You are coming on at night shift. So, you are up all day. You painted the house. You go shopping and now you show up at 12 o’clock. I don’t think you just start the clock at twelve. There is 15 hours before that that you are not counting and yet you are in compliance with the rules and really haven’t done much to help the patient.
So, I think the reinforcement of the third one to really talk about strategies and methods is probably more beneficial because the hour thing has been looked at for decades, and there are no good answers to that, I don’t think.
DR. FINEBERG: An excellent point and thank you all for a whole series of wonderful comments, very thoughtful and very valuable to us.
I want to conclude by thanking our panelists and all the members of our committee and staff who helped make this possible.
DR. FINEBERG: Thank you all very much for being here.
