Physicians Need to Rely on Good Systems to Ensure Quality and Safety

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When Rahul K. Shah, MD, MBA, is in the operating room, and particularly when he’s performing standard procedures, he’s often preoccupied by what could go wrong. “Those are healthy kids that come to us, and they need to be sent out that way,” he said. “It’s a lot easier to do a trauma or a multi-vehicular accident victim. It’s really difficult when you take simple, easy stuff and make sure it happens safely over and over.”

Dr. Shah, who is vice president of medical affairs and chief quality and safety officer at Children’s National Medical Center in Washington, D.C., gave the Cotton-Fitton Endowed Lecture in Pediatric Otolaryngology at this years’ American Academy of Otolaryngology-Head and Neck Surgery Annual Meeting. His talk, “Quality and Safety: The Next Iteration,” addressed how physicians need to rely on systems to mitigate risk rather than trying to be superheroes operating alone.

“As otolaryngologists, I firmly believe we’re one of the most vulnerable specialties out there,” he said. “From newborns to geriatric, from outpatient to inpatient to nursing homes, we touch the breadth of everything, and we manage the head and neck. It’s very complicated and, rather than simplifying it, we need to embrace that complexity and build systems to sustain it.”

Dr. Shah pointed to high reliability organizations, such as utility companies and the military, and asked how these organizations consistently get it right. “It’s because highly reliable organizations have two tenets: They anticipate, and they contain.” According to Dr. Shah, the other things these high reliability organizations have in common is a preoccupation with failure, a reluctance to simplify their observations and interpretations, a sensitivity to operations, a commitment to resilience, and a deference to expertise.

About 15 years ago, Dr. Shah and his colleagues at Children’s National asked otolaryngologists about what had happened in their practices in the previous six months to identify high risk areas. Based on the information they gathered, in 2007, Children’s National put in place structures and processes to improve safety and saw a 95% reduction in their serious event rate, a win for physicians and patients, and one with a financial payoff as well. “Whatever you’re paying for your malpractice, if you are able to put in place structures and processes that drive improvement,” Dr. Shah said, “you’re going to see that money come back.” Children’s National, he said, has also used the same methodology of structure, process, and outcomes to bring about a marked improvement in hospital-acquired conditions.

“Your job is to go out there and deliver great care to the community. Your organizations, through medical staff and administration leadership, have to build those systems for you,” Dr. Shah told the audience. “I hope at the end of this, you feel more educated to go back and implore them to build those systems and hold them accountable.”