Designing the Executive Fellowship in Patient Safety

The publication of the 1999 Institute of Medicine's report, "To Err is Human" generated much discussion and debate about the dangerous conditions within our health care system. The statistics published which mentioned that more people die every year in a hospital the result of various medical mistakes made, than die from car accidents, breast cancer, AIDS, and airplane crashes combined. The estimate that as many as 100,000 patients dying each year the result of healthcare accidents (that number may be as high as 200,000 per year according to more recent studies) was analogized with the deaths resulting in the crash of one jumbo airplane every day!

In reality, these statistics came as no surprise to anyone working in the healthcare industry. Indeed the dangerousness of our hospitals has been published since 1974 in a variety of academic medical and legal journals. Despite this knowledge, most mistakes made on patients, if they were handled at all, were handled retroactively through the legal tort system. Commonly referred to as the medical malpractice crisis, injuries to patients, which resulted from apparent negligence were seldom reported within the hospital system, certainly not reported to the patients themselves, and it was left to the patient to seek legal counsel who would initiate a malpractice claim to determine if a "breach in the standard of care" had resulted in injury to the patient. If so, damages were sought. Most physicians, hospitals, and others working in the healthcare system carried commercial liability insurance, and such policies discouraged the proactive investigation of how accidents happen and how they might be avoided in the future. On a periodic basis, about every 25 years or so, malpractice insurance would become outrageously expensive or even unavailable to those in need and another wave of healthcare tort reform would go through various state legislatures.

For at least the last 50 years, patient safety (although not called by that specific name) has been taught in medical, health administration, and law schools, using a retroactive punitive approach. It is interesting that in all three types of schools, the concepts of medical malpractice have been approached using the "blame" technique. Identify who did it and punish them. This philosophy of blaming individuals and punishing them is evident throughout the various factions of our healthcare system. For example if a nurse or physician made a medicine error he/she would be fired and reported to their respective disciplinary board which would take the license of the professional away. Hospitals making too many errors risked loosing their accreditation and/or Medicare provider status. Elaborate techniques were developed by healthcare professional to hide the discovery of such mistakes, particularly if such mistakes did not result in any measurable harm to patients. Often called the practice of "defensive medicine" researchers tried to measure the cost of physicians ordering tests or doing unnecessary procedures solely for the purpose of protecting themselves against any unknown but future litigation. It seems as though all professionals were taught the tactics of "the blame game", approaching patient safety through the philosophy of the tort system, retroactive investigations, and punishments for mistakes made.

A proactive approach to patient safety dramatically changed the underlying assumptions everyone was making about how mistakes happen and what should be done about them Rather than placing blame on the last individual to make a mistake, the IOM study emphasized a systems approach to identifying, correcting, and mitigating the consequences of such mistakes. This approach focuses not on the end result (for example a nurse who gave the incorrect medication to the incorrect patient) but rather on the various "systems" that allowed the unfortunate nurse to be placed in that situation in the first place. Instead of presuming that it was a "bad" nurse who made a mistake, the focus is on a "bad" system that allowed a good nurse to participate in such an error.

The consequences of a shift in philosophy from bad people to inefficient and faulty systems have been felt throughout the entire healthcare system. The science of systematic error is actually well developed in other complex industries such as the airline industry. In just a few short years, major changes have been made regarding how we identify and handle potential patient safety problems. The Joint Commission has significantly changed its regulatory approach to identifying and handling sentinel events. New methods for investigating "root cause analysis" have been designed and implemented. Non-punitive reporting mechanisms have been designed and implemented, and finally, new areas of analysis particularly human factors engineering have been designed and adapted for the healthcare industry.

All of this has had a fundamental impact on how we learn and how we teach concepts of patient safety to physicians, hospital administrators, and healthcare lawyers. While the procedures for changing academic standards for students is routine, the challenge is to provide intensive, rigorous, and applied standard for those already seasoned and practicing in the field. The major concepts of a systematic approach to patient safety cannot be at all adequately dealt with during a continuing education conference, but it appeared unnecessary to address these issues by developing another advanced academic degree program. Something was needed that was in-between continuing education credits and a degree program. In addition, something was needed immediately for fulltime working professionals who needed not just a theoretical orientation to patient safety, but needed skill development in application technique. So was born the concept of an Executive Fellowship in Patient Safety.

Positioning Patient Safety into Health Administration

For years, the Department of Health Administration at Virginia Commonwealth University has been the leader in graduate education, particularly executive education in health administration. The Department created in and accredited in 1949 more recently has identified these trends in healthcare education:

1. The development of "executive" training through the implementation of our professional MSHA program using on-line distance learning adapted for fulltime working professionals who are typically mid-career.
2. The resistance of adapting specialization tracks for students, but instead maintaining a generalists approach which gives students flexibility in career planning, but with a focus on teaching a "systems" approach to health care administration
3. A continued focus on the use of information technology, the Internet and system designs to help students gain a competitive advantage in the marketplace, through the use of these tools.
4. The development of a global approach to healthcare and healthcare education.
5. The need for more "cross" training of students and professionals through the use of joint degree programs such as our MHA/JD, MD/MHA, and others
6. The need for more "cross" teaching among schools within VCU and among other universities in the United States to give students a more balanced understanding of the complexities of administering health care in the United States
7. Incorporation of standards of ethics in health administration.
8. Intensive use of our own graduates, alumni, and healthcare business partners to provide affiliate and adjunct teaching to our current students. This further integrates practice experience and training with academic theory to develop well rounded professional students.

For these and other reasons, it was natural that the faculty of the Department along with the leadership of its current Chairman, Dr. Stephen Mick would unanimously vote to support the implementation of the Executive Fellowship in Patient Safety as part of the Department’s Williamson Institute for Leadership Studies.

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