Kiame Mahaniah, M.D., was appointed to serve as Undersecretary for Health in the Massachusetts Executive Office of Health and Human Services in April. He has practiced addiction and primary care medicine for more than 20 years and most recently served as CEO of Lynn Community Health Center, where he continues to see patients. Dr. Mahaniah is also an Assistant Professor in the Department of Family Medicine at Tufts University School of Medicine and holds an M.B.A. from UMass Amherst, a medical degree from Thomas Jefferson University, and a B.A. from Haverford College. He helped launch the Roadmap to Health Care Safety at a forum in April and recently talked with Patient Safety Beat about his new role and ways to improve the safety of care.

Patient Safety Beat: Which experiences from your time as CEO of the Lynn Community Health Center have special relevance to your new role?

Dr. Mahaniah: As a provider in the community, I have seen the work of the Office of Health and Human Services from the consumer’s point of view, which gives me an appreciation of just how complex our systems are. Massachusetts offers an incredibly generous safety net of services, but because those programs organically grow over time, the system can be very difficult to use. It has evolved over time and mandates; It’s not like someone sat down one day to design a perfect system.

I've always been astounded by the number of services that are offered to people who may not know what their rights are and what is available to them. I have patients, for example, who are in both Medicare and Medicaid. Many don’t know they can call on a case manager for help. It's not a coincidence that the less literate you are, the harder it is to understand and access the system. Our systems, unfortunately, are built as if we'd all received a small liberal arts college education.

I remember talking to a patient who had just moved here from the Dominican Republic. I said, “You have dangerously high blood pressure, so I need to give you medication to bring it down.” When he asked how long he would have to stay on it, I realized that he came from a place where health care was only available for acute issues, like fractures and infections. When I told him he would need to take this medicine every day, every week of every month of every year for the rest of his life, he just thought I was a bad doctor. Like, I didn't know how to solve the problem. I always try to think about what things look like to someone who doesn’t have the hyper-educated framework in which our policies and our products are nested.

Patient Safety Beat: How can we best engage patients around the safety and quality of care?

Dr. Mahaniah: In my experience, most people don’t use safety data when choosing providers. If a clinician speaks their language, they almost don't care how they perform on safety or outcome metrics. It’s more likely that people say, “I don't want to go to that clinic because nobody speaks my language or because the first time I went there, people yelled at me. I don't want to go there anymore.”

In the policy realm, I think medicine is in a place where economists were 20 years ago, when they assumed everybody made rational economic decisions. Now we know that’s not the case. In medicine, we would like to assume that people know they're the agents of their own health care, but there are many reasons why most patients don’t feel that way.

I can understand why, if an error or even a near miss occurs in the care I provide, a patient might not say anything. Many would feel it’s not their place to complain. I’d rather protect patients by building safety into systems than ask them to speak up. Safety has to be embedded at a system level to have maximal impact.

Patient Safety Beat: A key tenet of the Roadmap to Health Care Safety is that a systematic focus on solving problems will also help address other challenges, such as workforce burnout and racial disparities. How might organizations reframe their work so that these are not seen as competing priorities?

Dr. Mahaniah: There are different ways to approach this problem of prioritization. I recognize that it's very human for people to take comfort in doing the things they know how to do and avoid the hard problems. There are very few experts who can say, for example, “I know exactly what’s needed to move this institution so that in five years, it's a totally equitable institution.”

To address equity, burnout and safety, it’s more effective to think about improving processes than having big ideas. Also, these problems are interrelated. Take burnout, for example. Moral injury — where clinicians either have to do things they know are not optimal or can't do the thing that they think is ideal — is known to contribute to staff burnout and also can lead to patient harm. On paper, these are separate problems that require big systemic changes. But when you start untangling one thread, you may begin to see improvement elsewhere. These things all tie together. Promoting safe culture and outcomes may also lead to a more satisfied workforce and allow you to address problems like health inequities.

Patient Safety Beat: Now that COVID-19 is more manageable, many aspects of health care face an inflection point. How are you thinking about patient safety, especially at the leadership level, at this time?

Dr. Mahaniah: Obvious and important safety risks, like wrong patient surgery or serious medication errors, pop into our consciousness sporadically. But much of the time, issues of patient safety disappear unexamined in daily practice. Lean training uses “rocks in the riverbed” as a metaphor for these hidden problems. By lowering the water level, we can reveal submerged rocks and begin to remove them.

Everyone working in health care, especially those in leadership positions, must work to lower the water level and make our rocks — our patient safety threats — explicit and visible.

Eating vegetables or flossing your teeth are other metaphors for this. What really matters is the daily discipline of doing things consistently for years and years. I think patient safety falls into that category. There's no secret sauce. You have to pay attention on a daily basis and gradually work to lower the water level and find the rocks. You go from addressing one thing to the next, to the next, to the next, putting in place systemic processes that will lead to your institution being safer for everyone.