BY: SR. PATRICIA A. TALONE, RSM, Ph.D.
Sr. Patricia is vice president, mission services, Catholic Health Association,
St. Louis.
The adage, "Above all, do no harm," from the Hippocratic oath, is
the primary mandate that every physician pledges at the outset of his or her
medical career. Hospitals, long-term care facilities, and other caregiving organizations
similarly share in the physicians' commitment to nonmaleficence. For those
committed to serving within the Catholic healing ministry, the Old and New Testament
injunction to "love your neighbor as yourself" (Lv 19:18 and Lk 10:27)
offers an even more essential exhortation. We are called to treat the sick with
the same devotion and tenderness that we would hope for ourselves. It is not
sufficient to minimally avoid harm — we must do good for and to our neighbor.
The Institute of Medicine (IOM) report, To Err Is Human: Building a Safer
Health System, published five years ago this month, issued an alarming clarion
call to physicians, systems, and institutions across the country.1
Subsequent to the publication of the IOM reports, the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) in 2002 issued The Physician's Promise:
Protecting Patients from Harm, and in 2004, Meeting JCAHO's National
Patient Safety Goals, among others. JCAHO now evaluates and ranks health
care facilities according to patient safety benchmarks. CHA's Physician Committee,
after reading and reflecting upon the IOM's 1999 report; its subsequent 2001
report, Crossing the Quality Chasm: a New Health System for the 21st Century2,
and JCAHO's 2002 text, determined to dedicate its energies to confronting this
issue.
The Physician Committee realistically recognized that even broad-based programs
to ensure patient safety will not prosper unless everyone involved in patient
care recognizes that this avoidance of medical mistakes is necessary not merely
to avoid litigation, not merely to conform to JCAHO standards, but because it
is the right thing to do. Such recognition arises from the very nature of Catholic
health care's identity. It makes tangible Catholic health care's covenant
with the sick. Commitment to and excellence in patient safety must arise from
the very culture of health care. And so, the Physician Committee determined
to dedicate its 2002 Physician Leader Forum to patient safety, inviting David
B. Pryor, MD, senior vice president, clinical excellence, Ascension Health,
St. Louis, to lead the group in a discussion about fostering a culture of safety,
rather than a culture of blame. Pryor's keynote address, "We Have
No Choice," led to the brief patient safety survey that CHA sent to its
members in November 2003.
Leading by Example
As physician leaders in Catholic health care analyzed and addressed issues of
quality and safety in our health care delivery system, a separate but complementary
CHA task force, Envisioning a Future Health Care Delivery System, devoted itself
to asking, "Is our health care delivery system as competent and beneficial
as it could be, and, if not, what can we, as a ministry engaged, do to ensure
that the future health care delivery system is improved?" The task force,
made up of clinical, public policy, and administrative leaders, concluded that
while our current system is often breathtaking in its accomplishments, rich
in technological advances, and practiced by the world's most highly trained
and skilled professionals, it fails to meet its potential. The task force advocated
concrete steps to contribute to the social movement toward transformed health
care delivery. Among these, and relevant to the IOM's studies, is the recommendation
that "all Catholic health care facilities lead by example and strengthen
the credibility of Catholic health care" by improving and reporting quality
indicators in acute and long-term care.
This issue of Health Progress arises from these two corresponding groups,
providing a critical resource to boards, sponsors, and administrative and clinical
leaders as they work concretely to transform our health care delivery system.
Physicians and nurses, as well as theologians and administrators, delve deeper
than the "what" of patient safety, analyzing the "why" and
the "how" of the challenge before us.
Fr. Michael D. Place, STD, CHA's president and CEO, in "Quality
and the 'Efficacious Work of God,'" situates patient safety
and quality within both the "how" and the "why" of the Catholic health ministry.
To build a sense of trust in our fractured health care system, Fr. Place maintains,
we must build on the virtues of beneficence and nonmaleficence, while, at the
same time, rooting both in the Catholic notion of the common good. To follow
the IOM's summons to "cross the quality chasm," we must likewise ground commitment
to excellence and quality in the covenantal human relationship between patient
and caregiver.
Embracing the Paschal Mystery leads the faithful person to live a virtuous
life. Sr. Juliana Casey, IHM, STD, PhD, executive vice president, mission integration
and sponsorship; and Richard Afable, MD, executive vice president and chief
medical officer, both of Catholic Health East, Newtown Square, PA, in their
"Contract or Covenant," contemplate the profound patient-physician relationship as primary
to an organization's response to a medical error. Describing this relationship
as more fundamentally covenantal than contractual, they utilize the metaphor
of a gift to illustrate the health caregiver's responsibility regarding his
or her healing power. The true healer, they argue, is one who recognizes vulnerability
(in both the patient and the self) and is therefore compelled to humility and
truthfulness.
If covenant, humility, and truthfulness form the foundation of the patient-caregiver
relationship, then one's action must flow from this relationship. The virtuous
or ethical individual must act out of the best of his or her identity, beliefs,
and commitments; the virtuous or ethical organization must do the same. Fr.
Kevin O'Rourke, OP, JCD, professor of bioethics at Loyola University Chicago,
and no stranger to the readers of Health Progress, brings his keen ethical
analysis to bear on this topic in his article, "Medical
Error: Some Ethical Concerns." Arguing that medicine is both a science
and an art, Fr. O'Rourke focuses on the intrinsic motivation of the physician
(and by association, other caregivers). Even with its tremendous scientific
advances, medicine is still not an exact science; nor can it eradicate death
from the human experience. "No matter how excellent and error-free the medical
care patients receive, some of them will still die," Fr. O'Rourke reminds us.
Echoing the assertion of Sr. Juliana and Afable, he maintains that the "professional's
personal responsibility should be presented as a sacred trust." While programs
of continuing education should remain mandatory for caregivers, an overreliance
on external environmental activities will not sufficiently address the internal
attitude necessary for each professional to embrace a culture of safety.
It is precisely the actions of institutions regarding "sentinel events" that
the CHA Physician Committee sought to explore through the 2003 survey on the
topic. When a medical mistake occurs, committee members wondered, do we, as
individuals and organizations, respond from the very core of who we are? Or
do we hastily attempt to rectify the situation by changing policies or casting
blame? While many systems have made a strong start in this regard, survey results
demonstrate there is much that remains to be done. Thomas Hooyman, PhD, and
Nancy Hooyman, MD, have examined and analyzed the results of the survey I mentioned
earlier. In "The 'Sentinel
Events' Study," they note that although every facility that responded
to the survey does have a sentinel-event policy, relatively few of them situate
their response to these errors squarely within the context of their stated values.
The Hooymans propose guidelines for building a safety of culture, basing their
guidelines on the principles arising from a culture of safety. Such guidelines
can form a foundation for those institutions and systems that seek to improve
the quality and effect of their policies and procedures.
Even as CHA's Physician Committee and its Envisioning task force directed their
efforts to safety issues, many Catholic health systems simultaneously launched
extensive initiatives in this regard. There are far too many such programs to
list in this special section of Health Progress. But one such program,
at Sisters of Mercy Health System, St. Louis, is described in "'Mercy
Meds' Boosts Safety," by Kelly Turner, PharmD; Barbara Meyer; and Michele
Stewart, BSN, of that organization. Devised by clinical caregivers,
Mercy Meds is proactive rather than reactive in nature. It employs multidisciplinary
teams to develop procedures that concretely illustrate the fact that safety
is, as the IOM noted, a system property, demanding buy-in from multiple stakeholders,
not the least of whom are those persons closest to the bedside.
Toward a Culture of Safety
If one agrees with the IOM's assertion that establishing a health care
delivery system that both prevents errors and learns from them when they occur,
then all stakeholders must commit themselves to a culture of safety.
Where do we go from here? First, this special section of Health Progress
may be used as a resource for those organizations that, in a spirit of performance
improvement, seek to root their sentinel-event and patient safety policies in
the stated theological and ethical values of Catholic health care. Since patient
safety is a systemic issue, leaders in the health care community — trustees,
administrators, and managers — would certainly benefit from reflection upon
and discussion of this vital topic. Second, the editors of Catholic Health
World, recognizing the creativity and resourcefulness of those in the ministry,
will periodically highlight leading practices from systems. We actively welcome
your suggestions and submissions in this regard. Suggested readings on patient
safety will be listed on CHA's website.
These are only small steps in an enormous task. Still, to quote Pryor, "we
have no choice." The IOM, in Crossing the Quality Chasm, avowed that
"achieving a higher level of safety is an essential first step in improving
the quality of care overall."3 Involvement
of all stakeholders — trustees, leaders, and clinicians — can bring about
a transformed system. Such a culture will ensure that errors are "tracked, analyzed
and interpreted for improvement rather than blame." It will devote extensive
research to those factors that lead to injury and institute new systems of care
designed to prevent error and minimize harm. In such a way, Catholic health
care can indeed demonstrate that it takes seriously the biblical call to "love
your neighbor as yourself."
NOTES
- Institute of Medicine, To Err Is Human: Building a Safer Health Care
System, National Academies Press, Washington DC, 2000.
- Institute of Medicine, Crossing the Quality Chasm: A New Health System
for the 21st Century, National Academies Press, Washington DC, 2001.
- Institute of Medicine, Crossing the Quality Chasm, p. 46.