Year: 2010
Type: article
Abstract: IT is an extraordinary honor to be here today to deliver the 48th Annual Rovenstine Lecture. I am reminded of the tremendous journey that anesthesiologists have traveled over the last half century: a journey that started when anesthesia was in its infancy, and patients died needlessly; a journey that required great vision and determination, that reduced preventable harm, and that made patient safety in anesthesiology a model for all of medicine.Today, this journey continues. The healthcare industry faces daunting challenges. Physicians must play a significant role in evolving health care to ensure that all patients receive the best and safest care possible, while at the same time controlling healthcare costs. This is a heavyweight responsibility on anesthesiologists, whose job has traditionally been to keep patients safe in the operating room (OR) and whose concerns with healthcare costs ended at those doors. In the days to come, our responsibilities will only intensify.Dr. Rovenstine started this journey of vision and excellence with his scholarly work and great leadership. Today, there is an even greater need for leadership. We use the word leadership slackly, often without clearly defining its meaning. Some describe leadership as being in charge or providing protection. Others describe leadership as a position of power. Yet, neither description is accurate. Leadership is helping people address problems that will make the world better. It means focusing on a goal and inviting everyone to help achieve it. It means serving others more than ourselves. It is inherent in each of us; something anesthesiology, health care, and the world need desperately.You do not have to be the smartest or the strongest or the most powerful or the most influential. You also do not need to be the department chair to show leadership. You simply need to have courage to think of what could be, clarity about the task at hand, and commitment to convert these thoughts into a reality.I remember being on a camping trip. I was in one of the three groups of eight campers; each group had a lead counselor. We set out early in the morning to hike a local mountain, but we had to choose, from among a number of peaks, which one to climb. One counselor took an autocratic approach. He decided which peak to climb and provided excruciating detail about what we would do every step of the way. Needless to say, there was little enthusiasm from the group. The second counselor took a noncommittal approach. He said, “There are a lot of great hills. I do not care where we go. Which one do you want to climb?” This vague directive also garnered little enthusiasm. The third counselor took a collaborative approach. He said, “You see that peak over there, I think that is the one we should climb; it has an amazing view from the top. I am not sure we will make it. It is going to be difficult, and I will need your help. However, if we all work together I am pretty confident we can reach the summit.” As expected, everyone wanted to be a part of his group.You do not need to have all the answers to be a great leader. You will never, but you must actively lead. You must take a stand, set a course, and inspire people to lift themselves and others to new heights and make the world a better place. It is not about individualism; it is about teamwork. It is not about judging and blaming. It is about accepting responsibility for what can be accomplished. For every great achievement, there is an army of leaders helping to make it happen. Leaders must see beyond the barriers, and they must focus on the goal and inspire others to do the same. It is the power of that collective vision—when the team and the leader see the same future—the one that enables the group to make the world a better place.Anesthesiology has had many visionary leaders. Beecher and Todd1first unveiled the problems of patient safety and preventable harm with their groundbreaking work on anesthesia-related deaths in 1954. Never before had anyone questioned our methods, encouraged us to study ourselves, and inspired us to do better. Then, in 1959, Phillip et al .2showed that anesthesia was a principal cause of mortality in 6% of surgery-related deaths. This shocking revelation led Phillip et al .3to declare that anesthesia-related mortality was a major public health problem. Similarly, in the work by Beecher and Todd,1this information was not welcomed. These studies met tremendous resistance and were challenged by many prominent members of the field, yet these brave leaders persevered.It is understandable that these findings would meet opposition. An anesthesiologist's job is to protect and heal patients not harm them. However, patient safety is one of the biggest problems that health care faces today. It is our duty as physicians to reduce preventable harm and improve patient outcomes. To achieve this, we need to learn from each other and develop strong teamwork. As long as preventable harm is common, and it is, we must address the problem together with surgeons and nurses, with regulators and insurers, and with hospital leaders and consumers. We cannot simply hide our heads in the sand. We must be leaders.This pioneering work continued in 1978 when Cooper et al .4conducted the first critical incident analysis in anesthesiology. They identified that technical mistakes (things anesthesiologists do) were the most common contributor to adverse events. They recommended that we train and educate, use appropriate monitors and protocols, and organize our workspace. In 1984, Cooper et al .,5took us even further when they hosted the first international symposium on preventable anesthesia morbidity and mortality and created the Anesthesia Patient Safety Foundation.All of this great work seems to have paid off. The American Society of Anesthesiologists' Web site states that over the past 25 yr, the number of deaths attributable to anesthesia has dropped 25-fold, from 1 in 10,000 to 1 in 250,000. Indeed, anesthesiology is widely heralded by the Institute of Medicine in its influential report, To Err is Human , for its marked reduction in anesthesia mortality.6We have undoubtedly made progress. However, how much is uncertain; we still have much work to do. The reported numbers likely overestimate how much we have improved because it is difficult to measure safety. It takes science, which is prone to bias. As an example, we can examine the numbers cited on the American Society of Anesthesiologists Web site. The 1 in 250,000 number was based largely on deaths from malpractice claims, but only approximately 1 in 7 preventable adverse events (and likely fewer deaths) leads to claims. In fact, in 1989, Lagasse7concluded that the mortality rate is more similar to 1 in 13,000. These studies did measure different things and use different data sources. However, such a wide discrepancy suggests that what you measure and how you measure it makes a significant difference. It highlights the dangers of not having a standardized and transparent measurement system. Twenty years later, we are still uncertain about how safe we are.The same is true about regional anesthesia complications.8We say that the risks are small, even negligible, but the risks are likely substantially underestimated. Risk assessments stem largely from physician self-reports or liability claims, and neither is very accurate or complete. A more accurate approach would be to conduct direct follow-up with all or a sample of patients. However, this is seldom if ever done. We liked what the available data revealed and looked no further.The concern with measuring progress in improving patient safety is perhaps best demonstrated by our inability to prevent wrong-site surgeries, something you have all worked hard to prevent. The number of wrong-site surgery reports has increased annually since we started counting them. Now, the scientists among us may conclude that our efforts have effectively increased wrong-site surgery events. I do not think that is the case. However, we established a national policy with a superficial understanding of these events, with no pilot testing to discover whether the interventions actually worked, and no system to measure whether patients were actually safer. Thus, the increase in these events likely represents reporting bias; but we do not really know. We need to know. Patients deserve better.To reduce patient harm and improve care, we must establish clear goals and valid measures to determine where we stand and what we need to do to improve.9The patient should be the focus not the clinician. We need to move away from labeling deaths as anesthesia related or surgery related. When a patient dies from a hemorrhage, it is easy to ascribe this to the surgeon. However, in most cases, good teamwork would have saved the patient's life. Patients certainly do not care how we categorize death.This call for leadership is not limited to the OR. The entire healthcare system is in disarray. The United States spends more than 2 trillion dollars on health care; approximately $8,000 per person to buy care that is often of poor quality. We have an expensive health system that denies health insurance to 47 million people and too often harms rather than helps them. Mothers face the dilemma of taking their child to the doctor or paying the rent and the elderly of buying food or medicine. Rising health insurance premiums are forcing consumers, small business owners, and large corporations into bankruptcy.We need leadership to increase research funding and expand the science of healthcare delivery. For too long, science has been obsessed with finding new genes and new drugs. It is not surprising that our understanding of patient outcomes is limited. We barely spend a penny on researching healthcare delivery for every dollar we spend on basic and clinical research.Einstein said that the problems we face today cannot be solved with the same level of thinking we had when we created them. The science of medicine is expanding exponentially, and we need creative and courageous leaders to tackle complex, interconnected, and perilous problems born from this growth. It will take mass collaboration among clinicians and administrators, consumers and employers, policy makers and regulators with a common goal to solve the new healthcare problems that we face today.Several years ago in my small corner of the universe, a group of doctors and nurses in the surgical intensive care unit (ICU) at the Johns Hopkins Hospital decided to be leaders. We chose one small problem that kills between 30,000 and 62,000 people each year (central line-associated bloodstream infections). For decades, medicine accepted these deaths as inevitable, as the cost of being in a hospital, as the norm rather than the exception.We questioned that mindset. We knew that most patients were not receiving the interventions recommended to prevent these infections. We had a hunch that most were preventable. Hence, we set out to prove it and used the Johns Hopkins Hospital as our learning laboratory. 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You will have to inspire and your role in health will on those have before us and our and from at the Rovenstine it be said that you were leaders with a vision that did not those health for increased and the it be said that you worked and made the world a better health to be and our must be you have much more to I to the you are on this us what great work you have inspired and great work that has anesthesiology into the our collective my a from that a small group of can the Indeed, it is the only that ever You are that group and may you the you and the for their on this and The Johns Hopkins of Johns Hopkins and of and The Johns Hopkins of and The Johns Hopkins of and The Johns Hopkins and The Johns Hopkins of and of and The Johns Hopkins and of and Johns Hopkins for in this
Source: Anesthesiology
Author: Peter J. Pronovost
Institution: Johns Hopkins University
Language: English
Subfield: Strategy and Management
Domain: Social Sciences
Open Access status: bronze
OpenAlex ID: W2023485496