First, Do No Harm
Even if the time hadn’t changed last weekend, there’s no hiding the fact that spring has sprung. Trees are budding out, daffodil shoots are poking up through the soil and the grassy lawns at UMMC are so lush and emerald green they cry out for an Easter egg hunt.
And then there’s the packed schedule of budget meetings, the home stretch of the legislative session and the leadup to one of the sentinel moments of medical school, Match Day, which will occur later this morning.
As the seasons change and rites of passage like UMMC’s Commencement come and go, it’s important that there are constants in the work we do every day at the Medical Center. For me, the most important of these is our commitment to clinical quality – keeping our patients safe from harm while they are under our care. Clinical quality improvement continues to be our No. 1 strategic priority at UMMC, but it’s more than that. It’s our ethical duty, one that we accept as clinical providers to “do no harm” to our patients.
That’s why I am “all in” on a new effort to keep patient safety at the forefront of our consciousness with the “Chasing Zero” campaign. Part of our overall clinical quality improvement program, Chasing Zero targets six of the most serious harm events – the so-called “never” events – and affirms that they should never happen on our watch. Never as in zero.
The six occurrences that make up the initial focus of the campaign are:
- The wrong patient, site or procedure
- An unintended retained foreign body
- A medication error resulting in death
- A patient fall resulting in serious injury or death
- An irretrievable loss of an irreplaceable tissue specimen
- Administration of the wrong blood product
Much like an industrial plant that prominently posts the number of days since its last safety breach, we will post the same information in a banner at the top of our Clinical Intranet and in units across the Medical Center.
We’ve borrowed the Chasing Zero concept from The Joint Commission Center for Transforming Healthcare, which is guiding the adoption of systems and techniques to transform health care into a high-reliability industry with a safety profile comparable to commercial aviation.
One of the ways we will make this transformation is by bringing our quality record out of the shadows and making it visible, not just to ourselves, but to our patients and the public at large. Sharing how we measure up on a number of quality indicators not only gives us information about areas where we need to improve, it increases our accountability to our current patients and those who are considering becoming our patients.
To take that commitment to transparency a step further, we have developed a new section of our public-facing website devoted to clinical quality. The site has information about our quality improvement efforts and includes the most recent data regarding our performance on five key publicly reported quality measures. This is useful in part because comparable data on national websites (Hospital Compare, Leapfrog) can be up to four years old.
Our Chasing Zero initiative is another step in the direction of a comprehensive approach to quality that is driving us toward high reliability. Zero harm is certainly the expectation that our patients and families have as they receive care from our excellent provider teams at UMMC. And causing zero harm, I have no doubt, is also the intention of every person who works here in support of our patient care activities.
What hard experience has shown us, though, is that good intentions are necessary but not enough. We have to operate within a framework of continuous quality improvement built around safety systems that have proven themselves over time. Only then will our sacred commitment to do no harm be fully realized, sustaining us on our journey toward A Healthier Mississippi.