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Baltimore, MD
Dr. Wu is Professor, Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health. Dr. Sexton is Assistant Professor, Department of Anesthesiology and Critical Care Medicine, and Dr. Pronovost is Professor, Department of Anesthesiology & Critical Care Medicine, School of Medicine, Johns Hopkins University.
Correspondence to: Albert W. Wu, MD, MPH, 624 North Broadway, Baltimore, MD 21205; e-mail: awu{at}jhsph.edu email
ICUs are dangerous places.1 One widely quoted study2 suggested an incidence of two errors per patient per day, and virtually all patients are exposed to risk for serious harm. If it were not for the potential of the ICU to prolong and occasionally save the lives of critically ill patients, no sane person would place themselves so squarely in harm’s way.
One reason why is that so many things are done to the patient by so many different people. Much of the problem stems from problems in communication and teamwork.34 Too often, people are operating in their "own silos," ignorant of crucial information known by other caregivers just feet away. Although teamwork has received a good deal of lip service, much of the care occurs without real partnership between physicians and other members of the care team. Some of these physicians, in fact, define good teamwork as "they do what I tell them." In this issue of CHEST (see page 1571), by joining forces in a single article on making the ICU safer, the past presidents of the American Association of Critical Care Nurses and the American College of Chest Physicians practice what their organizations have begun to preach.5
The initiatives are certainly stronger when considered together. The standards of the American Association of Critical Care Nurses focus on fostering a healthier ICU work environment that includes true nurse/physician collaboration. The American College of Chest Physicians road map focus is on "patient focused care," which Dr. Irwin describes as "compassionate, ... sensitive to the everyday and special needs of patients and their families, and ... based on the best available evidence. It is interdisciplinary, safe, and monitored." The article is unusual in that it contains useful and specific suggestions, such as educational programs using instructors from at least two disciplines, inviting multidisciplinary audiences, planning social events to allow team members to know each other as people, and evaluating providers on their communication and teamwork skills.
The article begins by citing the first two of the Institute of Medicine "chasm" reports,67 which emphasized that medical errors are a problem, and that we cannot do better simply by working harder: we need to change the way that we work. The most recent chasm report, Preventing Medication Errors,8 is also relevant; the new report sets out a comprehensive set of strategies to reduce errors for stakeholders at all levels of the health-care system.
Preventing Medication Errors goes beyond previous Institute of Medicine reports by seeking to strengthen the provider/patient partnership. It emphasizes that consumers who are more informed and engaged may decrease their chances of experiencing a medication error. The report recommends that patients become more active members of the health-care team, speak up when unsure, and be certain that all caregivers know the important information that they have about their own health. Other suggestions for hospital inpatients include "Ask the doctor or nurse what drugs you are being given ... do not take a drug without being told the purpose of doing so." This echoes the aspiration expressed by McCauley and Irwin5 and ourselves9 that all team members feel comfortable and supported in challenging care processes.
It is only natural that the concept of teamwork be extended to include patients and family members. But we do not make it easy for patients to speak up, and our medical and nursing schools have not historically focused on producing clinicians who will be good at collaborating with others. On hearing these recommendations, a research colleague expressed incredulity at the suggestion that patients should be more assertive. "Ask the doctors to wash their hands before examining me? I couldn’t do it" she admitted. Even this highly educated and otherwise empowered colleague was too intimidated, or at least too deferential, to follow the recommendation. Sadly, the unfortunate consequence is that physicians and others on the team are deprived of information that could help them deliver better care.
How can we change these dynamics? All members of the care team, particularly physicians, should appreciate the value of different kinds of information, regardless of the source, whether it be physician, nurse or clerk, patient or family member. This kind of cultural and behavioral shift is difficult and can only be accomplished gradually.
This article represents an important step in the change process. However, it is a relatively early step, since it is still easy to discern which voice is the nurse’s, and which is the physician’s. The message would have been more profound if the call for collaboration had originated from the doctors rather than the nurses. We are not persuaded that physicians take teamwork as seriously as is needed. It is important that "teamwork" be more than window dressing.
We offer some suggestions for realizing the vision set forth in this article. First, we should develop and implement tools to improve communication. Experience from other high-reliability industries suggests that health care will need to develop its own tools that fit our culture. Current tools available in the literature include daily goals, morning briefings, and the Comprehensive Unit-based Safety Program.10 We would warn against proscriptively incorporating tools from other industries, such as Situation-Background-Assessment-Recommendation, into health care without rigorous validation in health care. We have observed that physicians too often react with skepticism to the assessment or recommendation when instead they should focus on the alarm being raised.
Second, we should integrate communication modules into our medical and nursing school curriculums, so that clinicians are given better foundations on which to build collaborative practices. It seems intuitive that some of this instruction should be done combining members of the disciplines that need to communicate. At our own institution, patient safety classes for medical students are cotaught by nurses, physicians, and social scientists. We have also combined audiences of, for example, physicians and nurses, or surgeons and anesthesiologists.
Third, efforts at improving the underlying culture and teamwork should be evaluated. The methods to accomplish this are still evolving. However, an assessment of the culture of safety is recommended by the National Quality Forum and Joint Commission on Accreditation of Healthcare Organizations and is a great first step. Tools to evaluate behavior, through direct observation, are being validated for use in health care.11
Fourth, further research is needed to develop, implement, and evaluate interventions to improve safety and quality, with an emphasis on methodologic rigor. Our own Chair in Anesthesia and Critical Care Medicine personally orients new residents to the department by encouraging them to pursue quality and safety research as publishable science that will advance their careers and provide a needed service. This builds capacity for patient safety and quality as a respected science.
Medicine is gradually becoming more patient centered, and the concept of evidence-based medicine is now widely accepted. It is unclear whether the term patient-focused care, used in this article, adds sufficient explanatory power to make a permanent addition to the health-care lexicon. Regardless of what we call it, this is the kind of care we would all want. In addition to the recommendations of McCauley and Irwin,5 perhaps a good way to start would be to borrow the sentiment expressed to one of us recently: "I have only three patients," the physician said, "One is my parent, one is my spouse, and one is my child." Whenever you see a patient and consider a course of action, act as if you were treating one of these three people.
Footnotes
Drs. Wu and Sexton have no conflicts of interest to declare. Dr. Pronovost is a stockholder in VISICU, Inc.
References
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