Five Questions

Dr. Jacobson on what a systems approach to safety at Dana-Farber really means

Joseph jacobson
Joseph Jacobson, M.D.

Joseph Jacobson, M.D., has served as the Chief Quality Officer at Dana-Farber Cancer Institute since 2011. Before joining Dana-Farber, Dr. Jacobson was chairman of medicine at North Shore Medical Center. As part of the Partners Healthcare system, he co-developed the Partners Clinical Process Improvement Leadership Program. He has an extensive track record in quality measurement and quality improvement, serving as a founding member of the American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative (QOPI), as co-developer of the ASCO/ONS Chemotherapy Safety Standards and as recent past Chair of the ASCO Quality of Care Committee. He is the 2019 recipient of ASCO’s Joseph V. Simone Award and Lecture for Excellence in Quality and Safety in the Care of Patients With Cancer. In speaking with the Betsy Lehman Center about his work, Dr. Jacobson credited Dr. Simone, numerous individuals at ASCO, and others in the patient safety field who influence his thinking and work in safety systems improvement.

Betsy Lehman Center: As you know, Betsy Lehman’s death 25 years ago was a catalyst for the ‘patient safety movement.’ In what ways has the field of patient safety improvement work progressed in that time frame and in what ways do you think it has yet to reach its full potential?

Dr. Jacobson: Attention to patient safety has grown incrementally over the last 25 years. Thinking back to that time, our focus was clearly on taking care of patients and doing it meticulously, but we were greatly limited in the tools needed to assure patient safety. Supervision of trainees was less than today and many of the structural components of patient safety that we take for granted today were not in place. It was a very different time and patients were vulnerable in a way that they are not today. Certainly, Betsy’s death was a difficult and important moment. Many staff remain at Dana-Farber who took care of Betsy and all of them remain deeply affected by her loss.

Care is not getting less complex and the time has come for us to admit that we need a different approach.

In oncology, it took a number of years to understand gaps in routine care. In 2005, ASCO introduced QOPI, which enabled oncology practices to track their quality performance on a number of process measures and to benchmark themselves against their peers. At Partners Healthcare, we created a training program that engaged teams to tackle projects together to improve the quality and safety of patient care. Other examples of progress include more robust hospital leadership and board engagement in patient safety and the routine use of root cause analysis and other tools to better understand what happened when something went wrong. Today, our focus is shifting to being more proactive, rather than reactive. At Dana-Farber we work side-by-side with systems engineers and that has been hugely transformative for us. It isn’t easy because the engineers often challenge the way we think and do things. But care is not getting less complex and the time has come for us to admit that we need a different approach.

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Betsy Lehman Center: For years, many experts believed that safety improvement needed to be viewed and approached as a separate discipline, distinct from quality improvement work. As Dana-Farber Cancer Institute’s first Chief Quality Officer, talk a little bit about how you see the synergies and distinctions between safety and quality?

Dr. Jacobson: Patient safety is inseparable from the quality of care. It is partly why I resisted changing my job title to Chief Quality and Patient Safety Officer as many of my colleagues have done across the country. You cannot have safe but low-quality care. If you think about it, safety is inseparable from so the other domains in health care quality: efficiency, effectiveness, equitability, patient-centeredness and timeliness.

Betsy Lehman Center: You and others in the field cite aviation, nuclear and other high-risk industries as models for medicine when it comes to safety improvement. What does that look like day-to-day in the work you do at Dana-Farber?

Dr. Jacobson: We have worked very hard at Dana-Farber to move the focus on safety beyond responding to a patient event. This began as a conscious decision to elevate near misses to the same level of importance of a ‘completed’ safety event. We now routinely perform root cause analyses on near misses and we recognize those who interrupted an error before it reached the patient. Some characterize this approach as an effort to understand ‘what went right.’ In November of 2016 we hired both a systems engineer and a human factors expert. With their expertise in place, we have been able to tackle large scale projects with the goal of building safer systems.

There are certainly challenges to adopting a full-scale systems-based proactive approach to patient safety. When an event occurs, there is still tremendous pressure to aggressively investigate the event, and then put it behind us. In addition, getting staff to truly believe that our goal should be to achieve zero preventable is a slow process. Some don’t think it is achievable. Changing the paradigm requires transformation that must engage the entire organization, from the CEO to frontline staff. We’re making progress, but we still have a long way to go.

Changing the paradigm requires transformation that must engage the entire organization, from the CEO to frontline staff. We’re making progress, but we still have a long way to go.

Betsy Lehman Center: It’s one thing for something like “safety systems thinking” to make it into the lexicon. It’s another to articulate just what it means to a broader group of individuals not immersed in patient safety improvement work every day, including many frontline clinicians and staff. What are some helpful ways to talk about systems thinking and how it applies to patient safety?

Dr. Jacobson: What I believe that we all do in health care is to be heroically thorough, borrowing a term from Don Berwick. We put the burden on ourselves to ensure that our patients are safe. We depend on ourselves to be sure that the i’s are dotted and t’s crossed and that loops are always closed. Quality improvement interventions helps to an extent because they streamline operations and makes processes a bit better. But when you bring in systems thinking and systems engineering, problems can be viewed holistically, which allows the organization to adopt broad, sweeping interventions that are much more likely to sustainably improve patient safety.

Betsy Lehman Center: You’ve spoken eloquently about your motivation to specialize in oncology because of your mother’s experience and early death from cancer. What motivates you now as you try to tackle larger, systemic challenges that contribute to care that is not as safe and effective as it could be?

Dr. Jacobson: In 1969, when I was a teenager, my mother required emergency surgery for peritonitis complicating the recurrence of ovarian cancer from the year before. She lived another year, but never recovered from the operation. She was left bedridden, with draining abdominal wounds. This was a time before hospice and before visiting nurses were routinely available. I had no idea that she was dying until the day she died, and I am not sure that she did either. There were no good-byes and there was no opportunity to prepare for her death. In my mind that was unnecessary suffering for the patient — my mother — and for her family, including a vulnerable teenage son. I am happy to say that 50 years later, patients and families can be spared that particular brand of unnecessary suffering. The widespread availability of palliative care and hospice has really changed the landscape. In my 40 years of medical practice, I have seen many patients experience severe suffering from their medical condition and I have seen patients experience suffering as a consequence of our treatments. Our opportunity is to prevent the avoidable suffering due to systems failure and that is extremely important and motivating to me.

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