Stories are powerful forces for change. They pin us to current performance or propel us to new pinnacles. Stories are so powerful because they influence how we act in the world; change the story and you change everything. Stories like John F. Kennedy describing his vision of putting a man on the moon and having him return safely.
Health care is also influenced by stories, and we are telling several stories that are stifling improvements in patient-centered care, safety and quality, and costs. One prominent story is that "harm is inevitable rather than preventable." Although reductions in catheter-related infections contradict this story, we still passively accept that complications and disrespectful care are inevitable. Another stifling story is that "quality and safety are projects, working on one harm at a time and having a defined start and finish, rather than an integrated and enduring performance system." A system similar to the safety management systems is in high-reliability industries, which focus on eliminating all harms through an integrated governance, leadership, management, hiring, training, and accountability system.
A third stifling story is that "quality improves through coercion rather than inspiration." Most efforts by policy makers to improve health care use coercion: you perform better and we pay you a nickel; you perform poorly and we take away a nickel. These types of efforts work through extrinsic motivation and repress intrinsic motivation. Although extrinsic motivation is sometimes needed, it pales in potency compared with intrinsic motivation. Indeed, it is likely that a coercive approach, which limits clinician control, is contributing to burnout.
The final story holding us back is that "safety depends on the heroism of clinicians rather than the design of reliable systems." We force clinicians to use clunky and clumsy technology with poor usability and absent interoperability. Such technologies often hurt productivity and have little or even a negative impact on safety. In safe industries, technologies support workers and help them do their job. When Boeing builds a plane, they subcontract to over 1000 vendors who each build a part. Imagine if the landing gear manufacturer were to say, "I decided not to have a signal sent to the pilot telling if the landing gear is up or down because it's my data. The pilot will just have to look out the window or guess." Boeing would get a new vendor. In health care, we would accept the landing gear manufacturer's reasoning, saying, "no problem, people will die, planes will crash, and it will be very expensive, but we will still contract with you."
Over the last 15 years, we have learned a lot about how to improve safety. One great example is the 80% reduction in central line-associated bloodstream infections across intensive care units in the United States.1 This success offers hope that we can change these stories, telling new and inspiring stories, ones that did enable us to decrease bloodstream infections. Yet bloodstream infection is just one harm and patients are at risk for dozens of harms, including harm from disrespectful care and wasted resources.
We learned that it takes more than a checklist intervention to significantly reduce harm. It takes an organization aligned by a common goal and measures. Senior leaders must declare and communicate a goal of zero harm. Health system quality leaders must create an enabling infrastructure to support the improvement work, providing project management, improvement science, analytics, and training. Quality leaders must engage local clinicians to lead the work and connect them in peer learning and clinical communities. Finally, senior leaders and quality leaders must transparently report performance and create accountability systems. Gather these together and clinicians can tell a new story of preventable harm and improvement can move forward.
To move forward, Johns Hopkins Medicine created the Armstrong Institute for Patient Safety and Quality.2 The purpose is to partner with patients, their loved ones, and all interested parties to end all preventable harm, to continuously improve patient outcomes and experience, and to eliminate waste in health care. The Institute integrates research, training, and operations for patient safety and quality care, drawing upon 18 disciplines from all schools of the Johns Hopkins University. To achieve its purpose, the Institute created a safety management system. This includes a governance system with a quality board committee to oversee the safety and quality of care anywhere it is delivered under the JHM brand, and an accountability plan that has escalating oversight for steadily declining quality performance and a mechanism to transparently report progress.
The safety management system also has shared leadership accountability. Leaders first hold themselves accountable for ensuring that staff know the goals and roles and have the skills, resources, and time for the work. Then, staff are accountable for performance. Management is structured like a fractal model, in which each higher level in the organization creates a structure that brings together each lower level unit to share learning and co-create interventions. For example, at the JHM level, all the hospital and entity presidents meet regularly; and the hospital presidents have a forum for all the department chairs. This structure builds trust allowing interventions to be developed with stakeholders rather than for them.
To achieve alignment, all the work done throughout JHM is organized into 6 domains: internal patient safety risks (evaluated by risky providers, risky units, and risky systems); performance on externally reported quality measures; patient experience; value (improving or maintaining quality while reducing costs); health care equity (ensuring we provide similar care to various subgroups of patients); and population health. To support leadership accountability, the Institute developed a robust training and analytic infrastructure to ensure staff can develop the skills and have the resources to improve. Finally, we are creating a process to hire and orient staff to ensure they are aligned with our purpose and values.
The patient safety movement has made great progress in the last 15 years, but several stories are stifling improvements. We look forward to a better tomorrow when health care tells stories of inspiring workers to achieve safety, to envision harm as preventable, and to help design safer systems in which to deliver care.
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