Aaron Gerds, MD, is the deputy director for clinical research at Cleveland Clinic Taussig Cancer Institute and associate professor at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.
Faster than a speeding IV pole, more predictable than Haley’s comet, able to induce somnolence in a post-call fellow with a single PowerPoint slide. What used to be a nascent administrative agenda item is now the main attraction: the quality meeting. Although providing the best and safest care for our patients with blood diseases is paramount, viewing dashboards that contain endless metrics during these meetings is like kryptonite subduing my soul. And from that point on, critical questions spring up.
First off, why are we doing this? The answer seems obvious enough. Quality care is safer care, and safer care is better care. Makes sense. But where is this coming from? Is it truly a push from within to be better, or are external forces at play? Rarely does the conversation about a new goal or target start with, “We have been looking at our patient care over the past year and have identified a way to be better,” but rather, “The enterprise wants us to do this.” When the conversation begins with the latter, I wonder where the initiative is coming from, especially with the constant specter of accreditation authorities floating overhead. More important, external dictums on safety seem to sow the seeds of doubt as to whether the efforts will translate to better outcomes for our patients.
When discussing individual quality metrics, the reasons for looking at them are often straightforward. For example, when patients are admitted to our leukemia service, they receive a central line to deliver chemotherapy, transfusions, and supportive care. Because central lines are direct conduits from the bloodstream to the dangerous outside world, they carry an inherent risk of infection. At every meeting we look at the number of central line–associated bloodstream infections (CLABSIs) that occur on our floor and compare it to past trends and targets set for the future. That’s when the clinical researcher in me comes to life. I begin to wonder about the parameters of this measurement: Is a change from one CLABSI last month to three this month really a 200% increase or just sampling error? What is variance in the observed measurements? Was this simply the result of a change in the denominator, and what is the denominator? What is the 95% confidence interval here?
In one faculty meeting, as my internal dialogue slowly spooled up like the turbo in my old 1985 Dodge Daytona, I wondered if I should ask these questions. On one hand, I could get some clarification. However, there were only five minutes left in the meeting and at least 15 minutes’ worth of material left, according to the slide deck. The meeting continued: “We need to get our CLABSI rate under 1.2 per month per our goal.”
I could no longer keep quiet. “Where did that number come from? Is it based on a national standard and data from comparable hospitals?” I asked.
The response: “Well, this is the standard that the enterprise has set.”
“Okay,” I said, “based on our historical data … wait, this is the enterprise standard? So we expect patients with leukemia with little-functioning immune systems and general medicine patients to have similar rates of CLABSIs? That doesn’t seem like an achievable goal. Do any of the proposed interventions have data suggesting that they can lower the rates of CLABSIs?” Suddenly, I realized that I was on the defensive, justifying the care we give our patients against what I perceived as a somewhat arbitrary metric.
Upon reflection after the faculty meeting, I began to wonder about my quick flip to the defensive. Quality encompasses a large range of topics and methods of interaction, but we often associate it with the investigation into individual safety events after they are reported to the safety officer. Therefore, when quality topics come up, we may react subconsciously with the recall of past root cause analysis or morbidity and mortality reports, like an episode of anticipatory nausea prior to chemotherapy.
Although the intent of these exercises is to learn from mistakes and develop processes to deliver better care, too often in these meetings the finger is pointed rather than the hand extended. Even if the case in question is presented by a third party for anonymity, it can still be a very stressful and intimidating event for those in the audience. It can feel like an acute conclusion was made, and we get only 30 degrees of a comprehensive 360-degree analysis. It’s hard not to take that personally.
Maybe this is indicative of a bigger problem that medicine has struggled with for some time. The hierarchical nature of medicine fosters intimidation, harassment, or undermining behaviors, affecting trainees and seasoned practitioners alike. On a personal level, this behavior erodes confidence and mental well-being. On a larger scale, it compromises collaboration and open communication, which are critical to having meaningful discussions that enact positive change around quality and safety events. By establishing psychological safety in the context of everyday work and creating a culture where individuals feel secure to voice concerns, seek guidance, and admit mistakes without fear of reprisal, we can then take on the introspective job of looking at the care we deliver. When we have a culture of empathy and respect, and then put our patients and coworkers at the center, we can finally make deeper inroads on quality care.
Although I may disagree with some of the quality measures emphasized in faculty meetings, I could not be more supportive of what we are trying to do with quality work. We are here to care for patients, and anything that can improve the care we provide is welcome. However, psychological safety serves as the linchpin for fostering a culture of quality care. Until we improve the quality of how we care for each other in medicine, we will be limited in our ability to improve the quality of care for our patients with blood diseases.
Aaron Gerds, MD
The content of the Editor’s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated.
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