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Mayo Clinic

Health Care

Mayo Quality Conference Recap: We Can Do Better

About 90 percent of patient harm is due to system failures

Published: Thursday, May 26, 2011 - 05:00

“We can do better” was the underlying takeaway message from the 15th annual Mayo Clinic Quality Conference. This year’s theme was “Creating and Paying for Value in Health Care.”

The conference, held May 3–4, 2011, in Rochester, Minnesota, drew about 1,000 people to hear national leaders in health care quality as well as dozens of local, regional, and international presenters who showcased quality improvement efforts.

“We’ve got great doctors and nurses,” said Dr. Charles Denham, a keynote speaker and chairman of the Texas Medical Institute of Technology (TMIT), a medical research organization dedicated to finding patient-centered solutions to create value, save lives, and save dollars in health care. “But we don’t have the systems to support them.”

He noted that almost 90 percent of patient harm is due to system failures. And that can make being a patient a dangerous proposition. Health-care harm remains the third leading cause of death in this country.

(Movie) star power

Actor Dennis Quaid, a vocal proponent of zero medical errors, participated in the conference via video. His passion comes from personal experience. In 2007, his infant twins were admitted to the hospital for treatment of routine staph infections. In error, they were given 1,000 times the prescribed dose of the blood thinner heparin—twice during an 8-hour period. “They came very, very close to dying,” said Quaid.

As Quaid delved into the reasons for the error—similar bottle sizes and labels contributed—he was shocked that medical errors don’t garner more public attention. He says the number of deaths from medical errors each week is the equivalent of ten 747 aircraft crashing with no survivors. (See one result of his work, Chasing Zero: Winning the War on Health Care Harm, co-produced by the Discovery Channel and TMIT.)

Keynote speaker Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement, said improved quality is happening at the frontlines of patient care here and around the globe. She cited numerous examples, including structured huddles, where staff routinely come together to assess strengths and risks of procedures, evaluate what might go wrong, and prepare.

Aligning performance with value

Another keynote speaker, Dr. Patricia Simmons, medical director of the Division of Government Relations at Mayo Clinic, covered how health care organizations are responding to new health care reform laws. “We have to change,” she said. “We know we have to align performance with value.”

Attendees had many opportunities to seek out ideas for quality improvements to take back to their workplaces. Speakers shared ways to improve clinical outcomes, cost management, patient safety, and service. Some examples: Attendees learned methods to increase childhood immunization rates, decrease patient falls, and provide faster lab results for the sickest patients.

Participants were able to offer their quality improvement ideas after in-depth panel discussions around the topics of cost, outcomes safety, and service. Ideas ranged from better teamwork and communication to taking more safety cues from the airline industry.

The recurring theme was taking responsibility for quality. “The country is depending on people like you,” Denham told those assembled at the conference.

That’s exactly the message that Mayo Clinic physicians and conference co-chairs Dr. Douglas Wood and Dr. Stephen Swensen worked to convey throughout the event. “We all have two jobs at Mayo,” said Dr. Swensen. “Doing our work and improving it.”

The 2012 conference will be May 8–9 in Rochester, New York. Proposals for oral presentations will be due in September 2011. E-mail qualityacademy@mayo.edu for more information.

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Mayo Clinic

Mayo Clinic is a nonprofit worldwide leader in medical care, research, and education. Doctors from every medical specialty work together to care for patients, joined by common systems and a philosophy of “the needs of the patient come first.” More than a half million people are treated each year at Mayo Clinic’s campuses in Rochester, Minnesota; Jacksonville, Florida.; and Scottsdale/Phoenix, Arizona; and its community-based providers. See Mayo Clinic at the Mall of America—exploring new ways of serving people, where and when it is most convenient for them.