PRESS RELEASE

For Immediate Release
Date: May 30, 2002
Contact: Carl Armstrong, M.D., VHHA (804) 965-1208
Dick Hamrick, III, M.D., MSV (804) 643-6631
Jane Olsen, Trigon (804) 354-3926

2nd Annual Conference Retrospective

On May 29th, five hundred doctors, nurses, health plan executives, legislators and regulators filled the Richmond Marriott ballroom eager to discuss a topic that used to be taboo: medical mistakes and close calls. The event was the second annual conference of Virginians Improving Patient Care and Safety (VIPC&S), a statewide patient safety organization. What made the participants so willing to dive into the troubled waters of medical error was the fact that through VIPC&S Virginia is becoming a national leader in efforts to minimize patient harm through system-wide solutions. Participants came to the conference with a year’s worth of research and results to share.The atmosphere was vibrantly interdisciplinary, as several speakers observed. Suzanne Delbanco, executive director of the Leapfrog Group, a coalition of 106 national corporations, noted that Virginia was unlike other states in its collaborative approach to health care safety. “Here I’m seeing equal interest from providers and purchasers,” she said. “In most other states it’s only the purchasers.” 

VIPC&S Vice-President Dick Hamrick, MD opened the afternoon session by  outlining VIPC&S’ progress since last year’s conference, citing as high points the addition of a dozen new member organizations and the passage of a bill to promote reporting of errors by strengthening confidentiality. These initiatives represent the diverse, public-private approach to safety that VIPC&S’ founders dreamed of fostering when the organization was born three years ago. At that time, the federal Institute of Medicine had just released a groundbreaking report, To Err Is Human, which claimed that up to 98,000 Americans were dying every year from medical mistakes. It detailed how our healthcare system was fraught with opportunities for mistakes, and only concerted efforts to redesign the system would solve the problem. In Virginia, six statewide institutions formed a coalition to promote “collaborative efforts between consumers and other purchasers, providers, health plans, regulators, accrediting bodies, and others; the dissemination and implementation of best practices; and education and training guided by appropriate data collection and analysis.”

VIPC&S’ first conference in June 2001 was marked by efforts to define the problem in its many dimensions. Participants became familiar with broad themes of the patient safety movement, such as creating a “culture of safety” and analyzing “systems of care.” Most importantly, as Centra Health’s chief medical officer Chalmers Nunn remarked this year, the 2001 meeting “crystalized our sense of the need to do something.” 

Last month’s conference was different. Having grappled with the safety problem in practical ways, participants spoke from experience about how to produce lasting change in cultures and systems. They concluded that the key was to focus on the “human factor” in patient care. “Change people’s behavior first, and their hearts and minds will follow,” advised Dr. Lucian L. Leape of Harvard University. Dr. James P. Bagian, director of the Veterans’ Administration’s National Center for Patient Safety, told administrators they should rely on the “innate altruism of caregivers” but must first create an environment where workers can feel safe communicating problems.

The presenters agreed that the prerequisite for safety is openness, both within the organization and with the public—extending even to patients who have suffered or nearly suffered from mishaps. The common objection that acknowledging lapses would lead to lawsuits was disputed. Dr. Leape told of a Minneapolis children’s hospital that moved to a policy of full disclosure and saw a decrease in malpractice suits. Airline safety expert John Nance said that at least 65 percent of malpractice suits would never have been filed if those responsible had offered the victims an explanation or an apology.

The afternoon session was devoted to caregiver-oriented efforts launched during the preceding year. Representatives of nine clinical and academic institutions shared success stories. For example, after Danville Regional Medical Center removed punitive features from the safety reporting process, nurses reported drug variances at twice the previous rate and staff satisfaction improved. In one of the most dynamic presentations, a team from the University of Virginia demonstrated a “black box” system for operating rooms. Entire operations are unobtrusively recorded from several angles, allowing staff to see how they function as a team. Initial findings were striking: communication before the procedure was adequate only 15 percent of the time, and support personnel knew only half of what they should know about each case. The remedy was obvious—train all surgery personnel in “crew resource management”—but would not have been clear at all without the black box system.

Founded by the Medical Society of Virginia, Trigon Blue Cross Blue Shield, the Virginia Hospital and Healthcare Association, the Virginia Association of Health Plans, the Virginia Pharmacists Association and the Virginia Department of Health, VIPC&S represents 42 health care associations.