Five Questions with Tejal Gandhi, MD, MPH

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Dr. Gandhi

Tejal K. Gandhi, MD, MPH, CPPS, is chief clinical and safety officer at the Institute for Healthcare Improvement (IHI), following a May 1 merger with the National Patient Safety Foundation (NPSF), where she served as president and CEO since 2013. She is also president of the Certification Board for Professionals in Patient Safety. She is a board-certified internist, an associate professor of medicine at Harvard Medical School, and former executive director of Quality and Safety at Brigham and Women’s Hospital. Dr. Gandhi has spent much of her career leading efforts to standardize and implement patient-safety best practices across hospital and health systems.

We spoke with Dr. Gandhi after the 19th annual NPSF Patient Safety Congress, held in Orlando last month. (The 20th Congress is scheduled for May 23-25, 2018, in Boston.) She discussed ways to promote provider teamwork, prevent burnout and restore joy to jobs in health care settings; the merger with IHI; and the importance of treating patient safety as a unique professional discipline. (See “Just One Thing” for more information on safety certification.) 

1. Betsy Lehman Center: What are some of the barriers to creating a culture of teamwork?

Dr. Tejal Gandhi: Some of the impediments are simple logistics. People aren’t working with the same people all the time. A surgeon may have a different nurse or a different scrub tech for every case they do in a day or a week. So just not having continuity of staffing can be very challenging.

And there are physical barriers. You might have 10 patients on 10 floors and you’re not going to spend a lot of time on every floor, so a lot of teamwork comes from just being physically together and chatting and getting to know each other and all that kind of stuff. So that’s one piece.

Then there’s the dynamics of the team — the hierarchy piece. Does somebody think they know it all — do they think they are in charge and don’t necessarily want to listen to other members of the team or respect their opinions? It may not necessarily be the physician. It could be other members of the team that they are having those kinds of problems with.

2. Betsy Lehman Center: So what do you do to overcome that and promote change?

Dr. Gandhi: It’s very challenging. For example, when a surgical team is getting ready to start a procedure, as part of their routine checklist, they can start by introducing each team member. It sounds silly, but that isn’t happening. So even just that — breaking down barriers and making sure everyone knows who the others are — can really help.

Simulation training is a big thing being used in a lot of places to model scenarios and get honest feedback. For example, a surgeon might discover he or she cuts off open communication in the OR. “Hey, at that point you really shut her down when she was trying to say something.” I think simulation has real potential to help with creating some of the team behaviors we are looking for.

 A lot of it comes down to culture and to leadership setting expectations. As a leader you have to say, “Look, this is how our teams are going to work, and if you are disruptive or are not going to be a good team member there are going to be consequences.” There needs to be some accountability so it’s not like “well so-and-so is the chief of the department so it’s ok if they were obnoxious.”

3. Betsy Lehman Center: How do you engage primary care physicians in this effort?

Dr. Gandhi: We know that PCPs are being asked to do too much, so we need to establish teams that can aid them in getting all the work done, and we need to help providers function in those kinds of teams.

Many primary care doctors are used to doing everything themselves and having full control, and they are micromanaging everything. So giving that up to somebody and trusting them to, say, do all your test results or similar things, takes a lot.

Teaching primary care doctors how to trust and set expectations and define roles and ensure competencies, all those kinds of things, will be very important. But I do think the team approach is going to solve some of the primary care problems going on right now with burnout.

4. Betsy Lehman Center: What are your thoughts on the numbers of medical professionals leaving the field because they are ‘burnt out’?

Dr. Gandhi: It’s true there’s a lot of talk and work going on right now about burnout nationally and locally — CRICO and the AMA (American Medical Association) and the National Academy of Medicine are very involved. We tell leaders at the hospital or clinic level that there are good instruments now to measure burnout. Because you cannot improve what you cannot measure. So we are really encouraging people to start measuring.

The way I like to think about it is that there are individual factors and system factors. Personally, I think it’s far more critical to work on the systems factors. Because individually you can have a very resilient person but you put them in a terrible working environment and it’s pretty hard to stay resilient — and most people who go into health care are pretty resilient to start with.

So for burnout, we really need to work on system solutions such as work volume and peer support. Say you are having a really rough day, are there supports there to help you?

That being said, the absence of burnout does not necessarily mean the presence of joy in doing their jobs. To me the first step is that we absolutely need to get better at burnout. And there’s a lot more that needs to happen to build in the joy piece as well. We need to think of ways to make the work more meaningful, to give people more control over the work they do, to make sure they have good, productive interactions with colleagues.

5. Betsy Lehman Center: What should we know about the NPSF merger with IHI and the certification in patient safety program?

Dr. Gandhi: With IHI, I think we are going to have a single stronger voice to advocate for patient safety. Before, we were both in the safety space but not necessarily joined at the hip with our respective messages. Now we’ll have a broader impact. Our strengths are very synergistic. NPSF has done a lot of work on best-practice creation and thought leadership. IHI has been very focused on implementation. It’s a strong combination of theory and practice that dovetails really nicely. In fact, over the summer we’ll be releasing a framework of what the components are of a system that helps to achieve joy and meaning in the medical workplace.

With certification, we have credentialed almost 1,700 people as Certified Professionals in Patient Safety and have established clear, core competencies. It’s a growth field. We see that organizations are starting to put certification into job descriptions. This credential sets a standard for expertise in the underlying principles of patient safety, which apply regardless of the care setting. We hope to see more professionals working in ambulatory care pursue this credential because that is where most care is delivered.

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