Medical Training Magazine Interviews:

Joe Kiani

MTM: The goal set for the Patient Safety Movement of zero avoidable deaths in healthcare by 2020 is one which we very much support. So far you have had four summit meetings with incredible speakers. How do they help you reach your goal? A)  for patients

B)  for healthcare providers

C)  for technology companies

D)  for policymakers

Joe Kiani: Well, in two ways: one, by having these incredible leaders, who are in and out of patient safety and medicine around the world, attend and speak at the Summit; it makes the Summit something that more people want to come to. And, given that our Summit and our movement is a commitment-based model, you can't just show up to the Summit unless you are going to take action. If you want to be invited, you’ve got to make a commitment to improve patient safety. Therefore, having these leaders attend our Summit increases people’s likelihood of making a commitment, a public pledge, to improve patient safety.

The second way it helps is that the people speaking have to internalize the topic, which is patient safety. And the process of doing that, to come up with what they want to say, how they want to help, makes them understand the problem even more. Every time they attend, these world leaders, as well as experts in medicine and even patients’ families, become even more committed to do something to get us to the goal of zero preventable deaths.

One of the wonderful things I’ve seen as a result of the Summit is that these amazing people, like former President Bill Clinton, Vice President Joe Biden, Senator Barbara Boxer, and Senator Tom Harkin, attend the Summit and then share the message on a broad scale. Look at what they’ve done and what they say. President Barack Obama, Vice President Biden, and President Clinton all talk about how important data sharing is. They talk about how important it is to un-silo our healthcare eco system. These are our messages and now they are reaching the global stage. You see Senator Boxer implore California hospitals to take action. You saw Senator Harkin, who at the time was Chairman of the Senate Health Committee, hold a Patient Safety Senate Hearing. So it’s a really amazing virtuous circle being able to have these incredible people come to our Summit and speak. When people hear about what we’re doing, they get intrigued, but they think it’s just another meeting. I remember some did not want to commit prior to the Summit. For example, some of the healthcare technology companies wouldn’t commit to share their data. But when they attended the meeting, within the first break, the CEO of Zoll and CTO of Cerner were saying, we’re in, we’re going to commit. What I hear people telling me about the Summit is that it’s an experience like no other, and it drives them to want to do something.

And I think we owe much of the success to the world-recognized leaders and the patient advocates the family members who have lost someone. I think their storytelling humanizes the tragedy like numbers can’t ever do. So whether it’s healthcare providers that made a commitment or healthcare technology companies that made a pledge, attending the meeting made them want to commit to patient safety.

MTM: The patient safety movement has issued 12 challenges for hospitals and healthcare providers, from creating a culture of safety to optimizing obstetric care. What progress has been made on each of these initiatives, from checklist to executive reviews? Are there committees or groups that have oversight for each challenge and how do they function?

JK: The challenges we go after to make Actionable Patient Safety Solutions (APSS) are voted on by the attendees of the mid-year meeting. For the first mid-year meeting, it was me and a couple of other people. Our last mid-year meeting had over 100 people attend. We brainstorm the challenges that are killing people at hospitals, and then we take a simple vote, and everyone gets to vote, including me. And then once we’ve identicied them as challenges we are going to address, we assemble the best people in the healthcare industry who know the most about how to x those problems that we can, and they come up with Actionable Patient Safety Solutions (APSS) to deal with them.

We of course edit them; we make sure they’re simple, easy to follow, and that’s done typically by some of the doctors who have been around the movement for a while, like Dr. Michael Ramsey and Dr. Steven Barker. But then I also take a look at them to make sure they’re consistent with the vision we have for these APSS, which is to make them like a recipe in that the ingredients are called out clearly and there are no secrets, and the process to put them together is not only thorough, but simple and easy to follow, so they are not overbearing. If I can understand them as a non-clinician, then I hope clinicians will have no problem following them.

The APSS are available for download on our website: http://patientsafetymovement.org/challengessolutions/actionable-patient-safety-solutions-apss/ The current 12 APSS address: 1. Creating a Culture of Safety 2. Healthcare Associated Infections (HAI) 3. Medication Errors 4. Failure to Rescue: Monitoring for Opioid-Induced Respiratory Depression 5. Anemia and Transfusion: A Patient Safety Concern 6. Hand-off Communications 7. Suboptimal Neonatal Oxygen Targeting 8. Failure to Detect Critical Congenital Heart Disease (CCHD) 9. Airway Safety 10. Early Detection of Sepsis 11. Optimal Resuscitation 12. Optimizing Obstetric Safety

This year, the 5th Annual World Patient Safety, Science & Technology Summit will focus on APSS for the following challenges: • Venous Thromboembolism (VTE) • Mental Health • Pediatric Adverse Drug Events

MTM: How many hospitals are now signed up to meet the challenge, and how are they sharing/communicating with each other and the movement?

JK: We have 1,850 hospitals that have formally committed to zero preventable deaths. Their commitments are all posted on our website. They not only meet each other at the Summit annually, but a lot of them stay in touch with each other regularly. Some of them end up working together. Some of them come up with innovative solutions together. I was just on a conference call between the University of Vermont and Children’s Hospital in Orange County, which I represented. We were there to learn what the University of Vermont was doing that’s consistently keeping their central line associated bloodstream infection at zero. So there is much camaraderie, sharing and caring. I have noticed the people who are having great success are proud to talk about their work; they’re proud to share it. They want to go beyond their own hospital and make every hospital as good as theirs.

MTM: How many technology companies are now onboard, and how are they working together to achieve PSM goals?

JK: We have 64 technology companies that have signed the Open Data Pledge to share data. They agreed to share their data, which is valuable to these companies. They all can monetize it selfishly, but they decided to be true leaders and accept their responsibility in improving patient safety and share it for the sake of patients.

The second thing that many of them did was approach me at the last Summit and say, “Hey, we want to help more. What else can we do?” So we had about 20 companies begin training their sales people and clinical specialists in talking about patient safety to their customers, so that more hospitals are aware of what we’re doing and join our movement. In addition, many of them are also working with the Center for Medical Interoperability, which is one of our partners, to help create the standards for interoperability, which will make it easier for users, researchers, and companies who are trying to do something about patient safety to get access to all of the data.

MTM: What exactly is the technology patient data highway, and what are its functions in preventable deaths?

JK: Well, I think of the “patient data superhighway” as a stream of data that follows patients wherever they go. It has data from the past, like the patient’s phenotype, or any test or bloodwork that’s ever been done on them as much specific information about the patient that’s available and not just the general knowledge we have about people. This data is added to the data that’s being collected on them in real time in the hospital, from the vital signs, radiology, and bloodwork data to the therapeutic data that shows what’s being given to them that stream of data. That’s the superhighway for every patient that we want to create through the data sharing work we have started.

This will enable powerful predicative expert system algorithms to tap into that data and look for patterns, both short-term as well as long-term, and discover long before something bad happens to the patient that something’s emerging with some level of probability that clinicians and family need to be aware of. I doubt that it will always be 100 percent correct, but at least it will provide a warning for what may be occurring so that ultimately a care provider can consider the problem so that there’s no act of omission. If something is decided not to be done, it’s from an act of commission.

MTM: What policy changes must take place to achieve the PSM goals, and how does the Patient Safety Improvement Act help achieve these goals?

JK: Yes. Number one, the simulation industry shares blame in the fact that some of those tools are being left in boxes. Many of the simulators today are too simple to be a useful training tool. They need to be more complicated, matching the patient more closely. Think about the simulation tool for pilots. When you’re inside the simulator for pilots, you feel like you’re flying an airplane. That’s how good they are. If you really want to simulate, and you want people to use a simulator, then my challenge to the stimulation industry is to start making simulators that are as good as the ones that are made for the airline industry and pilots.

JK: Well, we don’t have an act like that yet. ACA went a nice distance in creating some incentives and disincentives to help patient safety with never events. But there are many more things that are killing people. So what we’d like to see is policymakers around the world make laws that brings forward transparency and incentivize hospitals and care providers to put processes in place so that medical errors are less likely to occur and human errors won’t become fatal.

So unlike ACA which says, “we’re not going to pay for certain never events,” we’d like the law to change to say, “we don’t want anyone dying from a preventable cause, and if you put a process in place to avoid that and a patient still dies from it, we’ll pay for it. But if you haven’t put a process in place, then all bets are off, and we’re not even paying for the initial care that was given.” That way, it’s not punitive because every hospital has a chance to put the process in place, because indeed, to err is human, and sometimes despite all the wonderful processes you’ve put in place, bad things occur, but that should happen very infrequently, not as frequently as they hap pen now. And the reason they happen frequently now is because the processes are not put in place. People are hoping for zero preventable deaths but they’re not planning for it.

MTM: It would seem that the only power big enough to change the healthcare sector is government. Do you agree or can you see another force/s coalescing or emerging to bring about these changes?

JK: I agree that the government could move things very fast if it came up with the aligned incentives law I just discussed. And they can also create the transparency law to have every hospital report every medical error-related harm, every preventable death, so that patients can see which hospitals have fewer of them (adjusted for complexity of patients’ conditions) and choose and create competition between hospitals based on safety.

Unfortunately, I don’t expect the government to do it because of all the special interests that get in the way of best ideas turning into law. That’s why we’re hoping government will do something for it, but we’re not planning for it. Our plan is to get every hospital in the US, every hospital in the world, to implement processes to get them to zero. If each hospital individually achieves zero, all hospitals together will achieve zero.

And the good news is I don’t know a nurse or a doctor or a hospital executive who doesn’t want to do that. They unfortunately sometimes think they’re already doing everything. And then you have to challenge them by asking, “Well, are you doing this? Are you doing that?” I haven’t heard one hospital say yes to all of them. And, I only know of one hospital that has implemented the majority of them since joining the Patient Safety Movement.

So we have to have the army of the unassuming and the willing. If they know that they’re not doing everything, then they’ll do everything. So that’s what we’re planning for, but we’re still working toward our hope that the government will do something. And not just the government of the United States, but Britain, Japan, Mexico, Australia, Spain ... We’re reaching out to get these governments to take action.

MTM: The healthcare business has a reputation for high and rapidly increasing cost. How far do you think that financial “weapons” could be used to rein in cost and reduce error?

JK: I think the question should be “How could people implementing processes to avoid preventable deaths help free up resources and reduce costs?” because every one of these processes that we’re aware of not only saves lives but saves money. And we think in the U.S., for example, if all of the hospitals implemented all of the APSS, we could save our economy as much as a trillion dollars. Imagine a trillion dollars freed up—what it could do for improving healthcare, improving education, and then the other things that we could do with it. So this is one of those wonderful ANDs: implementing APSS will not just save money or save patients. It will save money and save patients.

MTM: The GAO recently published a report on attitudes toward patient safety within six hospitals. Despite the tiny number of institutions involved, the output was of real interest. The conclusions seemed to be that they do not know what to do to put things right. When they have tried to do so in some areas, their MDs have been uncooperative. And when things have been successful, they tend to drop off again in about three months. Do you have any comment? How could the results being achieved in your movement change these views and outcomes?

JK: Well, first of all, when you make a plan to do something, you make progress toward it. But when you make a public pledge to do something, you not only end up really doing it, but your speed of getting there increases. That’s why we are so interested in hospitals making a public pledge, and then tracking it, because we understand the power of making public commitments. Secondly, hospitals have to understand that medicine is in a state of evolution, and there are many more good things to come in terms of treating cancer, treating heart disease, treating diabetes, and so forth. But, unlike the hard problems that still require evolution and innovation, the solution to preventable deaths are here now. There are best practices, and they need to be implemented as a standard operating procedure to avoid preventable deaths.

Every clinician has to be trained on how to follow these simple processes. It’s no different from the production of any technology, whether it’s pulse oximetry or smartphones: while these inventions are incredible and unique, the people who make them every day follow the same pattern every day how to make them. They don’t get to decide how they’re going to put one together on their own every day.

And if one day something new is invented, like a non-invasive blood glucose monitor, a way to detect cancer, or a way to treat heart disease, once those technologies are available, again, they’ll be produced under standard operating procedures; very meticulous instructions for how to manufacture them will be followed by anyone building them. So when it comes to some of the mundane things in hospitals, like preventing hospital-acquired infection or looking for onset of sepsis, they need to become standard operating procedures, and, until a better way for doing these things is invented, the procedures need to be followed to a T by everyone who works in the hospital, to make sure we have big and sustainable gains in reducing preventable deaths. MTM: “Training decay” is a well-known phenomenon within the professional training industry; pilots are assessed as to capability twice a year as a result of this, and if they do not pass the check ride, they are retrained. Teams are trained and retrained in communication and team training exercises. Does PSM support that kind of regime in healthcare?

JK: Absolutely. Simulation and training is the only way to not only learn how to do the mundane repeatedly, but to learn how to deal with the unusual with expertise.

MTM: How does the industry ensure that new protocols, procedures, and training are delivered more uniformly? Currently much is expected of individuals and their dedication to CMEs gained via peer reviewed journals and conferences. Do you feel that is sufficient, and what more could be done?

JK: It’s not sufficient. We don’t have our arms around it yet. We’re trying to work with educators and those who create curriculums to dramatically improve them, while also taking the training down many levels, even to junior high school kids to teach them what they need to know about patient safety and to increase their healthcare literacy. That’s one area where we have aspirations but have not yet gained much traction.

MTM: Finally, much money has been spent in developing and deploying simulation devices for training and assessment over the past 10 years or so. Stories abound of devices being left in boxes or not being maintained. Do you have a view on the value of simulation to the sector? How could the simulation industry help itself and the sector improve training, care, and results?

JK: Yes. Number one, the simulation industry shares blame in the fact that some of those tools are being left in boxes. Many of the simulators today are too simple to be a useful training tool. They need to be more complicated, matching the patient more closely. Think about the simulation tool for pilots. When you’re inside the simulator for pilots, you feel like you’re flying an airplane. That’s how good they are. If you really want to simulate, and you want people to use a simulator, then my challenge to the stimulation industry is to start making simulators that are as good as the ones that are made for the airline industry and pilots.

Biography As the founder, Chairman, and CEO of Masimo Corporation Mr. Kiani has been a beacon for patient safety and innovation in healthcare for more than 20 years. In 2010, he created the Masimo Foundation for Ethics, Innovation and Competition in Healthcare to encourage and promote activities, programs, and research opportunities that improve patient safety and deliver advanced healthcare worldwide. And in 2011 he founded the Masimo Political Action Committee to spotlight the important issues that will shape healthcare policy