PHMI and Beijing Novartis deliver first program of new professional development series in China

Tuesday, May 5, 2009

In April, 120 health care managers from across China gathered in Beijing for the first in a series of professional development programs developed by Partners Harvard Medical International in cooperation with Beijing Novartis Pharma and the International Health Exchange and Cooperation Center of the Ministry of Health.

Last year, PHMI entered into a multi-year agreement with Beijing Novartis to organize and deliver a total of 15 programs over the course of three years.

The inaugural two-day conference focused on patient safety and medication management. The PHMI faculty team included Dr. Kenneth Sands, Senior Vice President for Health Care Quality at Beth Israel Deaconess Medical Center, a major affiliate of Harvard Medical School. “The work of patient safety requires attention to both the clinical science of harm and its prevention, and the operational workings of the medical system itself,” said Sands. “We believe that the important common themes in efforts to improve patient safety are the following: a continuous effort to look for ways to create more reliable care delivery, and second: a continuous effort to learn from mistakes and mishaps.”

Dr. Sands was joined by Dr. Evan Benjamin, Vice President and Chief Quality Officer for Baystate Health in central Massachusetts, who spoke on the design of reliable health care delivery systems. Dr. Susan Abookire, Chair of the Department of Quality and Patient Safety at the Harvard-affiliated Mount Auburn Hospital, spoke about the concept of learning from adverse events as a critical component of systems improvement. PHMI Director Dr. Rick Van Pelt addressed how to communicate with patients when harm occurs, and how to support clinicians who are involved in such events.

Planning is underway for the second event of the series, which will focus on hypertension. The main program will be held in Beijing, with other Chinese cities hosting one-day programs on this important topic. Check back with PHMI World for the latest as program details are finalized.

 

An excerpt of the address given by Dr. Kenneth Sands:
Patient safety and medication management are key issues for all health care systems in all countries. In the United States, the subject of patient safety began to receive dramatically more attention after the publication of a report in 1999 by the Institute of Medicine, a group of distinguished physicians empanelled by the United States Government to provide opinions on important national issues. The conclusion of their report, which was titled “To Err is Human,” was that patient safety needed be a national priority for public health. They estimated that somewhere between 40,000 and 100,000 patients in the United States lose their lives because of harm caused by the health care system.

Those of us working on patient safety since 1999 have seen this subject receive an explosion of attention. We now have a greater sense of the types of things that cause patient harm. We know that even in the most respected, highest performing hospitals that patients are injured from complications of procedures, such as infection or bleeding complications. We know that mishaps with medications occur on a regular basis. We know that patients can suffer physical injury while receiving care from events such as falls or skin injury.

The exciting part is that we now also have evidence that it is possible to make a difference, and to decrease the occurrence of patient harm. Each of us coming to join you for this conference has stories from our own institutions about identifying sources of harm, taking steps to decrease the occurrence of those events, and being able to demonstrate a measurable improvement in patient safety. Our stories are all different, and this is what makes patient safety such a fascinating topic. The work of patient safety requires attention to both the clinical science of harm and its prevention, and the operational workings of the medical system itself.

In the short time we have with you, we don’t believe we can cover the vast variety of different initiatives that could or should be undertaken to improve safety. Instead, we are going to focus on what these initiatives have in common. We believe that the important common themes in efforts to improve patient safety are the following: a continuous effort to look for ways to create more reliable care delivery, and second: a continuous effort to learn from mistakes and mishaps.

With regard to creating reliable care, the 1999 Institute of Medicine report greatly emphasized the fact that patient harm is overwhelmingly the product of a flawed system. When systems are unreliable, unanticipated events occur and this is what leads to patient harm. As for a continuous effort to learn from mistakes, the 1999 report in its very title, “To Err is Human,” emphasized that medical care delivery relies on people, and no person is capable of never making a mistake. So, in our quest to create a reliable system, when mistakes occur we need to examine them, and use them as opportunities to make the system reliable enough to withstand human error, knowing that human errors will always occur.