JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 65, NO. 15, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2015.03.001
FELLOWS-IN-TRAINING & EARLY CAREER PAGE
Building Trust for the Safety of the Patient From Internship to Fellowship Prashant Vaishnava, MD
I
recently accepted a new role to serve as a quality
continued to be less-than-pleasant interactions with
officer at my institution. In this role, I have been
some consultants. As a fellow—often overwhelmed—I
charged with a range of responsibilities, from
found myself sometimes fractious when accepting
oversight of our performance on quality indicators,
consults.
such as medication errors, to patient satisfaction. I
When considering quality and safety in health
have been struggling to understand why we, as a pro-
care, I cannot help but recall these formative experi-
fession, fall short on such common and simple met-
ences. We are sometimes forced to accept a culture of
rics as hand hygiene compliance—which is routinely
intimidation from some consultants, and as a partici-
in the range of 40% (1). In trying to understand why
pant of this culture, we need to acknowledge our
we are not doing better with such simple compliance
short-temperedness when responding to clinical re-
issues as hand washing, I think back several years.
quests. My interaction on my first day of internship
I vividly remember my first day of internship. I
is especially memorable, because it was discordant
recall the camaraderie of the time, the fear and
with what I expected as an eager, unjaded intern. Were
elation of carrying a pager, and the shallow white coat
we not all thrilled to be providers and eager to help
pockets overflowing with papers and handbooks.
each other? I entered internship with high expecta-
From this time, there is an incident that has stayed
tions that I ultimately had to dilute. I had to establish
with me. I called a fellow to request a consult. In my
lower expectations, accepting a different culture in
naïveté, I did not think it would matter that I was
which such interactions were part of the norm.
calling “late” in the evening. I fully expected a friend
But how can health care achieve near-zero patient
at the other end, a colleague excited to lend a helping
harm and cultivate a culture of safety when we
hand. Instead, I had awakened a hibernating bear,
lower our expectations from our first days of care-
grumpy and vocal about the lateness of the consult
taking? Shades of unprofessionalism stymie our
and my inadequacies as a physician who could not
ability to achieve near-perfect safety and near-zero
manage the issue by himself. Left in tears, I was not
harm. Health care stands in sharp contrast to other
even capable of a response as he flatly refused to see
industries, like commercial aviation or nuclear power,
my patient. My supervising resident at the time was
which are able to operate under dangerous condi-
very sympathetic, but not surprised. I was encour-
tions but achieve an exceptional margin of safety (2).
aged to move on and not be affected by such in-
Health care is sapped by such iatrogenic difficulties
teractions that were not rare and actually part of an
as health care–associated infections, preventable
intern’s life. One sage resident told me that I had
medication errors, flawed handoffs, imperfect tran-
something to learn from every colleague and consul-
sitions of care, inadequate hand hygiene, and alarm
tant; sometimes that something was how not to act.
fatigue. The list goes on. My view on why health care
For weeks following this incident, I was nervous
may differ from other industries that achieve high
when calling in consults. As months passed, my skin
reliability and superior performance is that we are
grew thicker and the fear subsided, although there
standing in our own way. In the current landscape, where many of us are victims to intimidating behavior, it is not sur-
From the Zena and Michael A. Wiener Cardiovascular Institute, The
prising that we have difficulty in attaining “collective
Mount Sinai Medical Center, New York, New York.
mindfulness,” which has been described as a culture
Vaishnava
JACC VOL. 65, NO. 15, 2015 APRIL 21, 2015:1592–4
Fellows-in-Training & Early Career Page
in which all workers or participants report small
diminishes the expectation out of a select group and
problems or unsafe conditions before they escalate
shifts the emphasis to a team that is “collectively
into larger risks (2). In describing the attributes of a
mindful.”
culture of safety, Reason and Hobbs (3) draw atten-
The path to health care quality—getting the right
tion to the centrality of trust in an organization. The
care to the right patient at the right time (6)—begins
elimination of intimidating behavior is 1 prerequisite
with a cultural shift away from accepting low expec-
to building trust, where workers trust each other and
tations from each other. It is not acceptable to
their organization to recognize, report, and respond
intimidate each other; intimidation is a significant
to errors. Consider modern aviation as an enterprise
barrier to building and sustaining a culture of safety
that displays remarkable safety, with 1 passenger’s
in health care.
life lost per 10 million flights, compared with the
The achievement of patient safety and quality
health care industry, where 13.5% of hospitalized
starts with us; let us challenge ourselves to be pro-
Medicare beneficiaries experience an adverse event
fessional, kind, and collegial in all interactions. Such
(4). Counter-heroism is a key tenet of safety in public
a demeanor is a prerequisite to nurturing a culture of
transport aviation (5). The principle of counter-
safety for our patients. Maybe we would wash our
heroism shifts the onus away from individual pilots
hands more than 40% of the time if we felt empow-
and emphasizes team dynamics. If a problem is en-
ered to tell each other when we did not.
countered in flight, a pilot’s response is to follow a standardized set of procedures; in contrast, the
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
response in medicine is often not so homogenous or
Prashant Vaishnava, The Zena and Michael A. Wiener
predictable. Improvised reactions, though ingenuous
Cardiovascular Institute, The Mount Sinai Medical
and often successful, may perpetuate a culture of
Center, 1468 Madison Avenue, Box 1030, New York,
heroism and discourage others from being vocal
New
about perceived errors. An ethos of counter-heroism
mountsinai.org.
York
10029.
E-mail:
Prashant.Vaishnava@
REFERENCES 1. Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283–94. 2. Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Quarterly 2013;91:459–90.
3. Reason J, Hobbs A. Managing Maintenance Error: A Practical Guide. Burlington, VT: Ashgate, 2003. 4. Levinson DR. Adverse Events in Hospitals: National Incidence among Medicare beneficiaries. 2010. Available at: http://oig.hhs.gov/oei/reports/ oei-06-09-00090.pdf. Accessed February 28, 2015.
5. Lewis GH, Vaithianathan R, Hockey PM, Hirst G, Bagian JP. Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improvepatientsafety.MilbankQuarterly2011;89:4–38. 6. Clancy CM. What Is Health Care Quality and Who Decides? Statement to Committee on Finance Subcommittee on Health Care. United States Senate. March 18, 2009.
RESPONSE: Safety and Trust, Above All Else Laurence S. Sperling, MD Emory University School of Medicine, Atlanta, Georgia E-mail: [email protected] Dr. Vaishnava discusses the importance of building trust
as well as stewards of supportive, interdisciplinary care in
in the delivery of safe and quality care. Trust remains an
the midst of complex health care systems. Patient safety
essential element in medicine and is the core of our pro-
needs to be a critical focus of excellent patient-centered
fessionalism as physicians. As health care rapidly trans-
care. We are taught early in our careers the Latin phrase
forms from volume- to value-based metrics, we will be
primum non nocere, “first do no harm.” In cardiology,
challenged, measured, and judged in ways that may feel
we should continue to reduce radiation doses delivered
uncomfortable. Appropriate use, readmission rates, and
during imaging, preventable drug interactions, and
performance score cards will not only be commonplace,
procedure-related complications.
but likely will be tied to reimbursement and efforts
Dr. Vaishnava mentions barriers to patient safety,
focused on cost savings. Importantly, we need to remind
including the lack of effective teamwork and a culture of
ourselves of our role as physicians to be patient advocates,
heroism. Since 2007, I have had the privilege of serving as
1593
1594
Vaishnava
JACC VOL. 65, NO. 15, 2015 APRIL 21, 2015:1592–4
Fellows-in-Training & Early Career Page
a society mentor for medical students in Emory’s small
them. As in the commercial aviation and nuclear power
group-based curriculum. This past week, in a gathering of
industries, we must shift our focus away from individuals
our group to both congratulate the M2’s on completing
to teams, in addition to the development of effectively
Step I of their boards and to provide them with a “pep
implemented processes and systems. Registries and
talk” as they embark upon their clinical journey in medi-
performance measures will inform us. Moreover, imple-
cine, I shared with them the same message I have shared
mentation scientists, systems engineers, and technology-
with students past: “Being a good doctor is not about
supported information ecosystems will be required to
you.” Being a good doctor is about caring for your patients
improve quality, safety, and ultimately, trust (1).
and your colleagues. A culture of safety and trust is
Expectations for safety and quality have never been
imperative. However, to deliver safe, cost-effective care,
more rigorous. Our patients, communities, and payers
more will be needed. In cardiology, we have appropriately
are demanding new approaches to the delivery of health
focused on exploring the biology of vulnerable plaques in
care for both individual and economic reasons. It is
addition to identifying and treating vulnerable patients.
critical that we acknowledge and address our challenges.
We must, though, recognize that there are vulnerable
We should embrace the importance of safety for our
circumstances in health care delivery, such as care tran-
patients and provide leadership in this transformative
sitions that increase the likelihood for predictable
time. Although medicine is swiftly changing, we must
and preventable safety issues. We must first identify
not lose sight of the importance of safety and trust,
safety concerns and then create strategies to eliminate
above all else.
REFERENCE 1. Pronovost PJ. Enhancing physicians’ use of clinical guidelines. JAMA 2013;310:2501–2.
VOL. 65, NO. 15, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2015.03.001
FELLOWS-IN-TRAINING & EARLY CAREER PAGE
Building Trust for the Safety of the Patient From Internship to Fellowship Prashant Vaishnava, MD
I
recently accepted a new role to serve as a quality
continued to be less-than-pleasant interactions with
officer at my institution. In this role, I have been
some consultants. As a fellow—often overwhelmed—I
charged with a range of responsibilities, from
found myself sometimes fractious when accepting
oversight of our performance on quality indicators,
consults.
such as medication errors, to patient satisfaction. I
When considering quality and safety in health
have been struggling to understand why we, as a pro-
care, I cannot help but recall these formative experi-
fession, fall short on such common and simple met-
ences. We are sometimes forced to accept a culture of
rics as hand hygiene compliance—which is routinely
intimidation from some consultants, and as a partici-
in the range of 40% (1). In trying to understand why
pant of this culture, we need to acknowledge our
we are not doing better with such simple compliance
short-temperedness when responding to clinical re-
issues as hand washing, I think back several years.
quests. My interaction on my first day of internship
I vividly remember my first day of internship. I
is especially memorable, because it was discordant
recall the camaraderie of the time, the fear and
with what I expected as an eager, unjaded intern. Were
elation of carrying a pager, and the shallow white coat
we not all thrilled to be providers and eager to help
pockets overflowing with papers and handbooks.
each other? I entered internship with high expecta-
From this time, there is an incident that has stayed
tions that I ultimately had to dilute. I had to establish
with me. I called a fellow to request a consult. In my
lower expectations, accepting a different culture in
naïveté, I did not think it would matter that I was
which such interactions were part of the norm.
calling “late” in the evening. I fully expected a friend
But how can health care achieve near-zero patient
at the other end, a colleague excited to lend a helping
harm and cultivate a culture of safety when we
hand. Instead, I had awakened a hibernating bear,
lower our expectations from our first days of care-
grumpy and vocal about the lateness of the consult
taking? Shades of unprofessionalism stymie our
and my inadequacies as a physician who could not
ability to achieve near-perfect safety and near-zero
manage the issue by himself. Left in tears, I was not
harm. Health care stands in sharp contrast to other
even capable of a response as he flatly refused to see
industries, like commercial aviation or nuclear power,
my patient. My supervising resident at the time was
which are able to operate under dangerous condi-
very sympathetic, but not surprised. I was encour-
tions but achieve an exceptional margin of safety (2).
aged to move on and not be affected by such in-
Health care is sapped by such iatrogenic difficulties
teractions that were not rare and actually part of an
as health care–associated infections, preventable
intern’s life. One sage resident told me that I had
medication errors, flawed handoffs, imperfect tran-
something to learn from every colleague and consul-
sitions of care, inadequate hand hygiene, and alarm
tant; sometimes that something was how not to act.
fatigue. The list goes on. My view on why health care
For weeks following this incident, I was nervous
may differ from other industries that achieve high
when calling in consults. As months passed, my skin
reliability and superior performance is that we are
grew thicker and the fear subsided, although there
standing in our own way. In the current landscape, where many of us are victims to intimidating behavior, it is not sur-
From the Zena and Michael A. Wiener Cardiovascular Institute, The
prising that we have difficulty in attaining “collective
Mount Sinai Medical Center, New York, New York.
mindfulness,” which has been described as a culture
Vaishnava
JACC VOL. 65, NO. 15, 2015 APRIL 21, 2015:1592–4
Fellows-in-Training & Early Career Page
in which all workers or participants report small
diminishes the expectation out of a select group and
problems or unsafe conditions before they escalate
shifts the emphasis to a team that is “collectively
into larger risks (2). In describing the attributes of a
mindful.”
culture of safety, Reason and Hobbs (3) draw atten-
The path to health care quality—getting the right
tion to the centrality of trust in an organization. The
care to the right patient at the right time (6)—begins
elimination of intimidating behavior is 1 prerequisite
with a cultural shift away from accepting low expec-
to building trust, where workers trust each other and
tations from each other. It is not acceptable to
their organization to recognize, report, and respond
intimidate each other; intimidation is a significant
to errors. Consider modern aviation as an enterprise
barrier to building and sustaining a culture of safety
that displays remarkable safety, with 1 passenger’s
in health care.
life lost per 10 million flights, compared with the
The achievement of patient safety and quality
health care industry, where 13.5% of hospitalized
starts with us; let us challenge ourselves to be pro-
Medicare beneficiaries experience an adverse event
fessional, kind, and collegial in all interactions. Such
(4). Counter-heroism is a key tenet of safety in public
a demeanor is a prerequisite to nurturing a culture of
transport aviation (5). The principle of counter-
safety for our patients. Maybe we would wash our
heroism shifts the onus away from individual pilots
hands more than 40% of the time if we felt empow-
and emphasizes team dynamics. If a problem is en-
ered to tell each other when we did not.
countered in flight, a pilot’s response is to follow a standardized set of procedures; in contrast, the
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
response in medicine is often not so homogenous or
Prashant Vaishnava, The Zena and Michael A. Wiener
predictable. Improvised reactions, though ingenuous
Cardiovascular Institute, The Mount Sinai Medical
and often successful, may perpetuate a culture of
Center, 1468 Madison Avenue, Box 1030, New York,
heroism and discourage others from being vocal
New
about perceived errors. An ethos of counter-heroism
mountsinai.org.
York
10029.
E-mail:
Prashant.Vaishnava@
REFERENCES 1. Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283–94. 2. Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Quarterly 2013;91:459–90.
3. Reason J, Hobbs A. Managing Maintenance Error: A Practical Guide. Burlington, VT: Ashgate, 2003. 4. Levinson DR. Adverse Events in Hospitals: National Incidence among Medicare beneficiaries. 2010. Available at: http://oig.hhs.gov/oei/reports/ oei-06-09-00090.pdf. Accessed February 28, 2015.
5. Lewis GH, Vaithianathan R, Hockey PM, Hirst G, Bagian JP. Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improvepatientsafety.MilbankQuarterly2011;89:4–38. 6. Clancy CM. What Is Health Care Quality and Who Decides? Statement to Committee on Finance Subcommittee on Health Care. United States Senate. March 18, 2009.
RESPONSE: Safety and Trust, Above All Else Laurence S. Sperling, MD Emory University School of Medicine, Atlanta, Georgia E-mail: [email protected] Dr. Vaishnava discusses the importance of building trust
as well as stewards of supportive, interdisciplinary care in
in the delivery of safe and quality care. Trust remains an
the midst of complex health care systems. Patient safety
essential element in medicine and is the core of our pro-
needs to be a critical focus of excellent patient-centered
fessionalism as physicians. As health care rapidly trans-
care. We are taught early in our careers the Latin phrase
forms from volume- to value-based metrics, we will be
primum non nocere, “first do no harm.” In cardiology,
challenged, measured, and judged in ways that may feel
we should continue to reduce radiation doses delivered
uncomfortable. Appropriate use, readmission rates, and
during imaging, preventable drug interactions, and
performance score cards will not only be commonplace,
procedure-related complications.
but likely will be tied to reimbursement and efforts
Dr. Vaishnava mentions barriers to patient safety,
focused on cost savings. Importantly, we need to remind
including the lack of effective teamwork and a culture of
ourselves of our role as physicians to be patient advocates,
heroism. Since 2007, I have had the privilege of serving as
1593
1594
Vaishnava
JACC VOL. 65, NO. 15, 2015 APRIL 21, 2015:1592–4
Fellows-in-Training & Early Career Page
a society mentor for medical students in Emory’s small
them. As in the commercial aviation and nuclear power
group-based curriculum. This past week, in a gathering of
industries, we must shift our focus away from individuals
our group to both congratulate the M2’s on completing
to teams, in addition to the development of effectively
Step I of their boards and to provide them with a “pep
implemented processes and systems. Registries and
talk” as they embark upon their clinical journey in medi-
performance measures will inform us. Moreover, imple-
cine, I shared with them the same message I have shared
mentation scientists, systems engineers, and technology-
with students past: “Being a good doctor is not about
supported information ecosystems will be required to
you.” Being a good doctor is about caring for your patients
improve quality, safety, and ultimately, trust (1).
and your colleagues. A culture of safety and trust is
Expectations for safety and quality have never been
imperative. However, to deliver safe, cost-effective care,
more rigorous. Our patients, communities, and payers
more will be needed. In cardiology, we have appropriately
are demanding new approaches to the delivery of health
focused on exploring the biology of vulnerable plaques in
care for both individual and economic reasons. It is
addition to identifying and treating vulnerable patients.
critical that we acknowledge and address our challenges.
We must, though, recognize that there are vulnerable
We should embrace the importance of safety for our
circumstances in health care delivery, such as care tran-
patients and provide leadership in this transformative
sitions that increase the likelihood for predictable
time. Although medicine is swiftly changing, we must
and preventable safety issues. We must first identify
not lose sight of the importance of safety and trust,
safety concerns and then create strategies to eliminate
above all else.
REFERENCE 1. Pronovost PJ. Enhancing physicians’ use of clinical guidelines. JAMA 2013;310:2501–2.
