We hear a lot in health care about patient safety and quality. While those terms would seem like a given, when it comes to patient care, they in fact are very strategic and measured. As Dr. Scott Allen, our chief medical officer, tells Dr. Anthony Alessi, much has to do with acknowledging the possibility of human error and establishing practices to mitigate its impacts, with practices such as daily safety huddles, checklists, empowerment to “stop the line,” and even use of artificial intelligence that can lead to an earlier diagnosis or assist with documentation in real time and enable physicians to focus more on the patient. It’s part of why UConn John Dempsey Hospital is in the running for an 11th consecutive “A” grade from Leapfrog for patient safety.
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Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up to date and timely information that’s brought to you by national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopedic Surgery, in addition to a grant from Coverys.
This podcast is not designed to direct your own personal medical care, and that should only be done by your physician. I’m your host, Dr. Anthony Alessi, and it gives me great pleasure to have as my guest today, Dr. Scott Allen. Dr. Allen is the Chief Medical Officer for the University of Connecticut here at UConn Health.
He’s also a specialist in internal medicine and specifically in primary care internal medicine. Scott, welcome to the show.
Dr. Allen: Thank you for having me.
Dr. Alessi: Scott, can you tell our listeners a little bit about your background and how you got here?
Dr. Allen: I’m a general internist by training. I actually trained at the University of Massachusetts Medical Center, came down here in 1994, mainly as a medical educator, also functioning as a primary care physician.
And over time, I took on responsibilities within residency programs, became a residency program director for eight years, and then really had the opportunity about 15 years ago to kind of morph into the quality world. Became a medical director for our quality department when it was first initiated, and then became the first chief quality officer, now as first chief medical officer.
Dr. Alessi: Now, we hear a lot of these terms as physicians here in practice. We hear about quality, we hear about risk management, we hear about patient safety. Can you address those terms and what they all mean to us? Especially patient safety. I find that to be an odd term, right?
Because it gives the impression - do you mean it’s not safe? So, can you talk a little bit about those programs and those terms and what they mean to the public as well as physicians?
Dr. Allen: So, when patients come to see a physician or a practitioner or come to the hospital, they really are looking for three things.
First, “be nice to me”, which really is the patient experience piece of health care.
Dr. Alessi: Sure.
Dr. Allen:, The second is “heal me”. Maintain my health or restore my health. And that’s really the quality component of health care. And then the last is, “don’t harm me in that process”. So that’s really sort of the patient’s safety.
So, all three are really connected to one another. So, the safety piece is really keeping people from harm. And so designing systems of care to allow that. Health care is a very complicated world. It’s high risk. And so, as humans, we’re always subject to making human mistakes, errors. And so, part of our job is to create systems that reduce making those human errors.
Dr. Alessi: Very interesting because back about 26 years ago, as I went back and got a master’s degree in medical management, and one of the things that struck me was much of what we were studying were industrial engineering principles, and back then it was all about Toyota and their industrial engineering and how we could take that and apply it to medicine.
And it was funny ’cause my father was an industrial engineer. And I never had any idea what he did until I went back to school. Can you talk a little bit about that movement of taking industrial engineering principles and how they kind of cover medical care?
Dr. Allen: So, the Toyota model was the ability to quote unquote, “stop the line.”
So, anybody on the production line could basically, in essence, push a button and stop production any time they had a concern. And that empowered those individuals to be invested in the quality and, if you will, the safety of their product. Carry forward to health care. We now empower everybody to be able to voice their concern.
So, if you have a concern about somebody’s safety or quality, you should be able to quote unquote, “stop the line” and be able to say, “I have a concern.” People stop, listen and address those concerns. So, what we’ve learned from Toyota is that empowerment piece to allow people to raise their voices of concern.
Dr. Alessi: Now, that works pretty well, I guess, in the operating room, right? Because now it’s pretty standard. We take a timeout and make sure everybody knows what we’re doing. But how does that work in clinic? I mean, how do you take that and apply it to something that’s so scattered? Is that what the huddle is for and things like that?
Can you explain that to me?
Dr. Allen: So, the timeout for those that are listening is when you go in the operating room, there’s a formal checklist that we will go down. You know, we’re doing the right procedure, the right side of the body, if you will. All those things, all the equipment is ready.
And that’s the checklist. And that’s just making sure that we are in fact prepared to do what we’re supposed to be doing. And so, what we’ve learned from, in this case, the airline industry, when the pilot goes into the cockpit, every single time they go down the checklist. Whether they just flew the plane and they knew it was flying safely, they’re going to go through the checklist.
And so, it’s the same mentality now in health care. We go down those checklists because we have to make sure everything is correct, every single time. So, no matter what’s really going on, you actually go through that checklist. That’s in sort of an OR, very sort of structured environment. In a clinic where it’s unstructured, it’s one of those sort of behaviors, safety behaviors that we promote called attention to detail. And it’s really stopping and taking that sort of mini mental timeout. So if I’m in the medical record and I can actually have four charts open, four different patients, and I’m going to put an order in, I have to sort of take that mini mental timeout to say, “am I in the right patient’s chart?” before I hit that send button. So, teaching people to take that, what we call STAR moment: stop, think, act, review. Mini mental timeout, and so that we’re not rushing. We’re all very busy in medicine, but it’s when we rush is when we create those errors.
Dr. Alessi: Is that the biggest fault? I mean, is it the rushing, like we’re trying like in the OR was it always “let’s rush ’cause we gotta turn over the room” and things such as that? Is that what we’ve found to be the biggest harm?
Dr. Allen: Rushing certainly contributes. And that’s why we actually promote not doing the rushing and actually taking the timeout so that again, we’re prepared every single time that we go in.
And so, we do have to sort of take that sort of momentary stop, that pause if you will, so that we are not rushing, and we’re keeping patients safe.
Dr. Alessi: Have we applied checklists? I mean, we talked a little bit before this interview about The Checklist Manifesto and Atul Gawande’s efforts in that regard.
Do we use checklists in other areas of medicine other than the OR now?
Dr. Allen: So anytime patients, let’s say, get admitted to the hospital, there will be checklists that nurses go through in terms of their initial assessment. You do a history and a physical on the part of the practitioners, there are certain elements of that template, if you will.
So, there’s a lot of elements of those checklists. We build templates into our electronic medical records so that we don’t forget to add a certain element, if you will. There are questionnaires that have, again, a checklist of items. You go in to have an MRI, that MRI tech is going to ask you a series of questions, probably 15 to 20, and they’re going to go through that checklist every single time to make sure that in this case, you don’t have, let’s say, a ferro metallic object that could be a risk for you when you go into the MRI.
Dr. Alessi: How about, let’s talk a little bit about, and you know, now that I’m removed and only in the clinic, I remember we used to have morning huddles, right? Is that still a practice?
Dr. Allen: Absolutely.
Dr. Alessi: Yeah, can you explain that to our listeners what the morning huddle is?
Dr. Allen: Yep. So, we have actually two huddles in the hospital. The first one, we do every morning at 8:30, and it’s about 100, 120 actual middle level, middle management, if you will, folks that are joining that, including senior leadership from the hospital. And we go through the previous 24 hours, all the new safety events that were submitted within our electronic system.
A brief review. We will spend time if we feel that there’s a critical need to, to understand why that happened, initiate some plans, if you will, to mitigate those things from happening again, or deciding when we need to do a deeper dive in terms of an analysis. All those events are reviewed, and then we also then follow up on previous events to make sure that those corrective action plans were in fact completed.
And we go through every single clinical area in the hospital, all our ancillaries, lab radiology, facilities. All those different aspects of care. Every part of the hospital is actually on our safety huddle. Nursing has its own separate huddle after that, which includes all of our nursing units. They go through more sort of the throughput issues.
Dr. Alessi: Sure.
Dr. Allen: And our outpatient clinics also have huddles, again, at the sort of middle management level.
Dr. Alessi: What’s the biggest challenge you think, in terms of your job, in terms of quality and safety? What do you find the hardest - what keeps you up at night? How’s that?
Dr. Allen: The hardest thing is establishing really a culture of safety.
I think we’ve made great strides. Establishing a culture starts really with leadership.
Dr. Alessi: Yep.
Dr. Allen: And we have great leadership even at our board of directors, which then carries down through Dr. Agwunobi, our CEO and hospital leaders to establish the accountability. The expectation is high quality and high, you know, safety.
So, starts with leadership, and then it’s that culture of reporting. We want people to report safety events. We want them to be able to speak their concerns, if you will. So, establishing reporting, so having an electronic system that makes it easy to report, you can report anonymously or you can have your name attached to it.
And then the last piece really from a culture perspective is what we call fair and just culture. And that’s sort of the middle ground between patient safety and sort of the safety culture. So, we do have accountability in health care, you have to be accountable for all of your actions. So, if you have somebody that is willfully not following policy and procedure, then they should be held accountable and appropriately disciplined.
But as we’ve said before, patient safety is also about human error. And if people create a mistake, they have a human error - they shouldn’t be disciplined for that, they should actually be more consoled. So, establishing this culture where people feel, what we call psychologically safe, to be able to report safety events and not be disciplined for those if it was truly just a human error.
So that’s what we continue to work on, is establishing this fair and just culture.
Dr. Alessi: You know, one of the other terms I guess we mentioned is risk management and Coverys gave us a grant to sponsor this program, and as a medical malpractice carrier, they are very forthright in requiring their insureds to do courses and things for risk management.
Is that the same here in terms of, does this all come under the umbrella of risk management?
Dr. Allen: So, quality and safety, interdigitates with risk management. It interdigitates with regulatory. We all work very closely together. So, if we have a patient safety event, somebody was harmed. Risk will be involved. Is this going to be a malpractice issue or not?
But if it’s a patient safety event, we think it was preventable, we want to be actually upfront and transparent. Days of old, we would sort of circle the wagons. We wouldn’t say anything we would sort of defend, right. Now it’s be transparent, be open. Those lines of communication, that trust, if you will, that you build with your patients, really goes a long way in terms of preventing malpractice and litigation.
So, we have a model here called candor and that that’s basically C-A-N-D-O-R. Communication and optimal resolution. Be upfront, be transparent, and that actually helps resolve things on the back end.
Dr. Alessi: Scott, what do you think has been the biggest success? I mean, you’ve been doing, you’ve been at this for 15 years.
What do you think the biggest success has been in terms of managing patient safety and quality?
Dr. Allen: One of the things that people will look at are external scorecards. Things like the Leapfrog Hospital Safety Grade.
Dr. Alessi: Sure.
Dr. Allen: We’re pretty proud that, you know, we have a letter grade A for 10 times in a row, and that’s one of the longest running in the state of Connecticut.
So, you can look at those external scorecards, you can look at other awards like Health Grades being in the top 15% in the nation for patient experience. So, as I’ve said before, patient experience is one aspect of quality. You have quality and sort of the outcomes of care and then patient safety, and they all kind of interdigitate.
So, I look at the Leapfrog Hospital Safety Grade as just one marker of that success. I think establishing high reliability training is really a marker of success. So, we train everybody, and this was initially through a collaborative with the Connecticut Hospital Association back in about 2011, where we train every staff member in techniques of high reliability.
And that really then carries forward to preventing errors. And so, training everybody, establishing that safety culture really is what I look at in terms of whether we’re successful or not. And yes, we’ve been very successful in improving our safety culture, but it’s one of those things that it’s a never ending journey.
Dr. Alessi: My next question, I guess, is it working? And I don’t mean this to be facetious, but if we look back 50 years ago, right? Do we have these programs now because it’s become so complex? Because there are so many other avenues for error as opposed to the way medicine was practiced before?
Dr. Allen: Yes, health care, I think, has become more complex.
Dr. Alessi: Right.
Dr. Allen: Especially with the electronic medical record, the need to document because of all the regulatory requirements. And so, we spend a lot more time documenting and sort of checking the boxes now. But I think yes, health care has become more complicated.
There’s more sophisticated techniques, tools, people are living longer, so their, if you will, their comorbidities are more complex. So, when people come into the hospital, they are technically sicker than they were in the past.
Dr. Alessi: Thus the risk?
Dr. Allen: Hence the risk.
Dr. Alessi: Okay. Very important. Well, tell us about the future.
Take out your crystal ball for me. What do future programs look like in quality and safety?
Dr. Allen: Well, obviously the buzz term is “artificial intelligence”, and so we are using artificial intelligence now. And then I’ll give you a couple of examples and maybe this will speak to patient safety. So, in our ambulatory clinics, you can just pull out your cell phone and turn it on and it will record the entire encounter. We’ll actually create the encounter note for you. It’s designed to be able to recognize who the patient is, who the physician is, and so that allows more time for the physician or the practitioner to spend time with the patient as opposed to spending time on the computer, typing in notes, if you will.
So, the focus is in now, on the patient interaction as opposed to the documentation. So it allows the physician or practitioner, again, to spend more time focused on what’s important to the patient. Patient experience improves. Again, the focus on health care improves. Second example is, we use artificial intelligence in radiology.
So, we have the ability to pull out all of the reports that have what are called pulmonary nodules, so things that are growing, if you will, in the lungs and shouldn’t be there, and all those reports then get pulled into a database. And the specific software associated with this AI then can actually look at each individual chest x-ray or CAT scan and grade the likelihood of malignancy of that nodule.
What does that do? It actually catches lung cancer earlier. So, if we need to, because of the higher risk, get somebody in for a lung biopsy sooner than somebody who’s low risk, let’s repeat a CAT scan in three or six months, the artificial intelligence is helping us actually catch lung cancers earlier.
Dr. Alessi: Wow. I find that fascinating. I guess one other question is, are patients generally receptive when a doctor goes in the room and explains they’re using the DAC system or the AI system as we know it, are patients generally receptive?
Dr. Allen: They are, I think they’re also in tune to AI and what’s coming down the road.
Everybody knows what cell phones are, so it’s sort of a comfortable environment for them. It’s on the cloud, it’s not something that’s kept in the computer. So, in terms of the risk of a HIPAA breach seems pretty darn low in that sense. So, I think patients are quite comfortable with it.
Dr. Alessi: Scott, thank you.
Thank you for your time today and especially thank you for all you do for keeping quality at the highest here at the University of Connecticut. Thanks again for your time.
Dr. Allen: Thank you for having me.
Dr. Alessi: Many thanks to our guest today, Dr. Scott Allen. If you have questions or ideas for future programs, you could reach out to me at healthyrounds@uchc.edu.
Jennifer Walker is executive producer for the Healthy Rounds podcast. Chris DeFrancesco is our studio producer here at the Healthy Rounds Podcast, and Tessa Rickart is in charge of social media for our podcast. Until next time, this is Dr. Anthony Alessi. Please stay healthy.
