Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement

Carole A. Stockmeier; Eric Thomas; Sarah Mossburg; Merton Lee

Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement

Carole Stockmeier, MHA, BS, Eric Thomas, MD, MPH, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD | September 24, 2024

View more articles from the same authors.

The Hippocratic Oath, “First do no harm,” serves as the cornerstone of medical ethics and core value of healthcare: Patients should not be harmed by medical treatment. Yet, current estimates suggest that 10% to12% of hospitalized patients are harmed during their care and that half of this harm is preventable. While the causes of preventable harms and methods to prevent them continue to be identified and reported, some patient safety advocates have espoused a zero harm principle. Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare articulates the importance of establishing a goal of zero harm and shares principles, practices, and case studies in applying safety science and high reliability organizing to improve safety and advance toward zero harm. The editors argue that safety science research has shown that apparent barriers to zero harm, such as high cost, appear to be lowered as safety is achieved, and harms not traditionally associated with lapses in patient safety, such as worker stress, are also reduced.¹

Skeptics of setting zero harm goals have noted that the unattainable quality of zero harm, which its proponents acknowledge, risks lowering morale or may incentivize reduced reporting of errors, as articulated in a recent commentary. Even as patient safety experts debate zero harm as a stated goal and discuss its potential effects, they agree on the importance of a strong culture that supports safety and always seeks safer care.

Point

Zero Harm Goals Contribute to Improving Patient Safety

Zero harm goes beyond simply declaring a goal of zero preventable harm – it is an organizational commitment to safety as a core value combined with a systems-based approach to promoting culture and processes that support safe and reliable operations. A Canadian health system recently reported on their reduction in preventable harms after adopting a high-reliability organizing approach. They note that in an accreditation review they identified areas for improvement in patient safety, and there were anecdotal claims of underreporting.² They developed a “zero harm” initiative based on safety culture and found a 37% increase in reporting, and decreases in preventable harm: 39% decrease in injuries with falls, 37% fewer pressure injuries and a 34% reduction in central line-associated blood stream infections.² These reductions were achieved through a five-part strategy including engaging leadership and overhauling the system’s approach to patient safety.² Efforts were led from the top, with the chief executive officer of the hospital system communicating safety priorities and the importance or promoting safety in team meetings throughout the hospital system.² They also implemented dashboards to track harms and sought to define themselves as a learning health system by deploying an education program on patient safety throughout the hospital.² Prioritizing zero harm as a leadership initiative, as this Canadian group did, is a tenet of a strong safety culture and has been used by the South Carolina Hospital Association as described in their published blueprint which draws from a national safety culture initiative. Describing six domains across which safety culture should be directed, the South Carolina Hospital Association notes that, since the 2013 launch of their Certified Zero Harm Awards, member hospitals have achieved up to 88 month stretches of zero harm as validated by the state’s Department of Health and Environmental Control with two-thirds of member hospitals receiving Zero Harm Awards. In another case report, Community Health Systems in Tennessee reduced their rate of serious safety events by 89% through implementation of high-reliability and organizational learning principles.

In describing the achievements of the health systems above, their rate of preventable harm is not zero, or not zero forever. So why do safety culture proponents advocate the adoption of a seemingly unachievable goal? A commentator notes that evidence on safety in other fields suggests that ambitious goals can help create a movement, in which individuals feel like their efforts are part of a larger challenge, many with “zero” as their goals, such as “Vision Zero” to reduce deaths from road traffic, “Zero Suicide,” and “Built for Zero” to end homelessness for veterans. Indeed, these kinds of ambitious goals could be thought of as a type of “Big Hairy Audacious Goal,” a management principle espoused by Jim Collins and Jerry Porras, in which setting a lofty goal solves the problem of inspiring and recruiting colllaborators.³ Another aspect of setting a zero harm goal is that zero harm may enable a health system to remain consistent in its drive toward patient safety, not letting patient safety be a greater or lesser priority based on performance on benchmarks, which can shift.⁴ Arguably, benchmarks that focus on performing better than competitors eventually saturate, so further achievement becomes less strongly incentivized. Setting a goal of zero, may ensure better reliability long term in prioritizing safety goals.⁴ It may be argued that a zero harm goal is untenable due to expense. However, with the cost of preventable harm estimated to be as high as $19.5 billion per year in the United States, reducing harm is likely to lead to cost savings.³ Evidence, such as the Canadian hospital system and South Carolina’s and Tennessee’s successes, suggests that zero harm initiatives can jump start the transformation of a health system’s safety culture and that goals that seem impossible, actually achieving zero preventable harm over an increasing period of time, can be achieved with consistent leadership buy-in.

Counterpoint

Zero Harm Goals May Have Unintended Negative Safety Consequences

The rationale for setting zero harm as an organizational goal is drawn from safety science, specifically high reliability theory which suggests that with greater effort accidents can be reduced potentially to zero.¹ Critics of zero harm have noted an alternative conception of error and complex systems in safety science, a competing theory called Normal Accident Theory, which posits that some level of accident is intrinsic to highly complex systems, regardless of effort. Indeed, the amount of effort expended in the resource scarce environment of hospital administration suggests one problem with a zero harm goal uncritically adopted, that hospital administration may divert resources that could improve clinical outcomes for an unattainable safety goal of zero.⁵ This tension between allocating resources for zero harm initiatives and other areas of healthcare, could be a significant downside to pursuing zero harm, argues surgeon Thomas Aloia when considering zero harm goals in surgery.⁶ Based on surveys, younger surgeons are preoccupied by error and dread reporting avoidable negative outcomes, and this preoccupation may contribute to the high rates of burnout that correspond temporally with an increased emphasis on safety in surgery that dates from the past ten years.⁶

Aside from the question of resource allocation, commentators have also questioned how zero avoidable harm can be reliably measured, and the consequences of unreliable metrics. Statistically, patient harm is rare enough that reliably assessing whether a harm is preventable or not is hampered by insufficient data.⁵ For patient mortality, where the most data would be available, a systematic review found that 8-17 reviews of a single death would be necessary to reliably determine if it were preventable or not, and preventability is even harder to determine for non-fatal harms like healthcare associated infection.⁵ Unreliable metrics on preventable harm make it difficult to accurately measure these harms and thus difficult to assess whether initiatives such as zero harm goals are working, and the subjective dimension in determining whether a harm is avoidable or not makes reporting harms vulnerable to unconscious or conscious misclassification. The temptation to under-report or misreport harm increases, argues critics, if the goal is unrealistic.^5,7

Commentators also point out that in practice, zero harm initiatives may target harms that are preventable by consensus, and overlook more difficult to assess possible harms. For instance, a hospital may focus on eliminating severe pressure injuries as a preventable harm, but not direct attention to other preventable but more difficult to assess harms, such as over-sedation, which can result in respiratory arrest or stroke.⁷ Whether a healthcare organization focuses on bed sores, oversedation, or both may be thought of in terms of that health system’s overall approach to safety and harm reduction. It may be that health systems following a “Safety I” approach in which harm is thought to arise from linear, repeated processes that can be reliably improved, can result in focusing on reducing harms like bed sores, without addressing more complex harms like over-sedation. Alternatively, a “Safety II” approach sees healthcare delivery as non-linear, and complex, so repeatable interventions alone will not necessarily result in safe, high quality care. Instead, with “Safety II,” risk reduction can motivate improvements in patient safety by focusing on risks more than harm, in fact, even unanticipated harm might be reduced by careful attention to risk.⁸

Zero harm initiatives assume that preventable harm is measurable and that staff working together can find and implement what has eluded researchers in patient safety: consistent, widely applicable strategies to eliminate harm. Skeptics of zero harm suggest that it is impossible to measure preventable harm reliably and that the causes of harm are too complex to altogether eliminate.

Areas of Agreement About Zero Harm

Proponents and critics disagree on the likely effect of setting zero harm as a goal. Does a zero harm goal contribute to reducing preventable harm, or does it exploit unreliable metrics? Will health systems save money, or will pursuing zero harm put strain on limited health system resources? Will health systems free up resources as harms become less frequent, or will efforts to reach zero harm draw resources away from areas that could better improve clinical outcomes? Ultimately those who espouse zero harm as a goal and those who are skeptical agree that a patient should not be harmed while undergoing medical treatment and that striving for safer care delivery is an on-going journey.

Carole Stockmeier, MHA, BS
Senior Vice President of Safety and Reliability
Press Ganey
South Bend, IN

Eric Thomas, MD, MPH
Director of the University of Texas Houston Memorial Hermann Center for Healthcare Quality and Safety
Associate Dean for Healthcare Quality
McGovern Medical School at University of Texas Health
Houston, TX

Merton Lee, PharmD, PhD
Researcher
American Institutes for Research (AIR)
Columbia, MD

Sarah E. Mossburg, RN, PhD
Senior Researcher
AIR
Arlington, VA

References

Clapper C, Merlino J, Stockmeier C. Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare. McGraw-Hill; 2019.
Wilson MA, Sinno M, Hacker Teper M, et al. Toward zero harm: Mackenzie Health’s journey toward becoming a high reliability organization and eliminating avoidable harm. J Patient Saf. 2022;18(7):680-685. [Available at]
Gandhi TK, Feeley D, Schummers D. Zero harm in health care. NEJM Catalyst. 2020;1(2). [Available at]
Davis DJ. Going beyond benchmarks: zero harm for every patient, every time. J Nurs Adm. 2015;45(4):183-184. [Available at]
Meddings J, Saint S, Lilford R, et al. Targeting zero harm: a stretch goal that risks breaking the spring. NEJM Catalyst. 2020;1(4). [Available at]
Aloia TA. Should zero harm be our goal? Ann Surg. 2020;271(1):33-36. [Free full text]
Stockwell DC, Kayes DC, Thomas EJ. Patient safety: where to aim when zero harm is not the target-a case for learning and resilience. J Patient Saf. 2022;18(5):e877-e882. [Available at]
Thomas EJ. The harms of promoting “Zero Harm.” BMJ Qual Saf. 2020;29(1):4-6. [Free ful text]

In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement

September 24, 2024

Editor’s note: Carole Stockmeier, MHA, BS, is the Senior Vice President of Safety and Reliability Solutions at Press Ganey, with over 20 years of experience in safety science and high reliability organizations. We spoke to her about zero harm and patient safety.

Sarah Mossburg: Please tell us a bit about yourself and describe your current role.

Carole Stockmeier: For over 20 years, I’ve had the pleasure of helping healthcare organizations learn safety science, practice high reliability organizing, and most importantly, improve outcomes and experience for patients and workforce. I currently serve as the Senior Vice President of Safety & Reliability at Press Ganey. Prior to joining Press Ganey, I had the honor of being part of the founding team and Chief Operating Officer of HPI (Healthcare Performance Improvement). I live in the eastern part of Virginia, where I began my career with Sentara Healthcare and served as the Director of Safety and Performance Excellence. As a healthcare professional as well as a cancer survivor, I have safety (and harm) experience from both a professional and patient perspective.

Sarah Mossburg: Could you start the conversation by explaining the concept of zero harm? What is zero harm?

Carole Stockmeier: Patients come to us with faith, hope, and trust that we will restore health and heal wounds. When errors and mistakes result in harm, we fail in our mission and fail those we serve. Safety is a commitment we make to the patients we serve, and the goal of that commitment is zero harm.

We have the same obligation to our workforce: to keep each other safe while carrying out our mission so our workforce can be their best, both for the patients we serve and their families.

In the early 2000s, preventing harm was focused primarily on physical harm to patients and slips, trips, and needle sticks for the workforce. That has evolved. Our commitment to zero harm applies to physical as well as emotional harm, to patients as well as workforce, and to acute care as well as ambulatory, home care, hospital at home, and telehealth.

Sarah Mossburg: Could you speak to why you think zero harm is an important goal?

Carole Stockmeier: Safety as an uncompromisable value and zero harm as the goal are important and powerful alignment tools that enable three things. First, they set our direction both corporately and individually. They align team members, regardless of role or rank, around our purpose of healing without harm. Second, they guide our path in moment-to-moment decisionmaking—whether in the boardroom, the bedside or the boiler room—among what could seem to be endless competing priorities of supplies, staffing, satisfaction, finances, and efficiency. And third, the aspirational goal of zero harm inspires improvement, even in areas that today may be perceived as issues that are not preventable. Many known complications of yesterday are preventable conditions today. In a learning organization, an event of harm creates a zero harm gap that we yearn to close. It causes us to ask, “What were the contributing factors that led to this event, and how can we prevent them from occurring in the future.”

Sarah Mossburg: Are there situations where a zero harm approach to goal setting has been successful?

Carole Stockmeier: One example likely familiar to everyone is ventilator-associated pneumonia or VAP. VAP used to be considered a known complication of being on a ventilator. Then we learned that there are specific things you can do to prevent it: elevate the head of the bed, daily sedation vacation and assessment of readiness to extubate, secretion drainage, and oral hygiene. With knowledge of this evidence-based process bundle, units and organizations began tracking “days since last VAP” and setting goals of zero VAP. Setting the aspirational goal of zero harm rather than incremental goals makes you think differently about strategies and interventions for improvement.

The evidence-based approach is true when it comes to preventing errors and mistakes that can lead to other types of patient and workforce harm. Human performance in complex systems is not random. We know how humans experience error, we know the conditions that make error more likely, and we know the individual, team, and leadership behaviors and processes that reduce the probability of experiencing errors and catching errors that occur before they lead to an event. Combine this prevention strategy with a spirit of continuous learning from successes and failures, and progress toward zero harm is possible. Does it mean that you won't ever have an event? No. Yet, similar to VAP, organizations with advanced safety and organizational learning systems go for lengths of time without experiencing a serious safety event. And when an event does occur, they focus on understanding the root causes and identifying corrective actions to prevent recurrence.

Sarah Mossburg: You’ve probably heard the concern that zero harm can be unattainable or unrealistic. You just spoke to the fact that harm does happen even in organizations that have a zero-harm goal. And so, folks who have that view tend to say we shouldn't set zero harm as a goal if it's unrealistic or unattainable. Do you think that's a misunderstanding of your viewpoint?

Carole Stockmeier: I would say that zero harm is both aspirational and attainable. Progress doesn’t result from not setting a goal because we might not achieve it. We have a goal of zero harm because we should aspire to nothing less and patients and team members should not experience preventable harm. The role of leadership goes beyond saying, “Have a safe day today,” to creating the culture, structure, processes, protocols, and environment that enable having a safe day. And, when we do have an event of harm, the role of the leader is to help the organization pick itself up, learn from that event, and manage forward to make today a safe and exceptional experience for patients and workforce. Critics often argue that setting a zero harm goal and then having an event can be demoralizing to staff. We have observed and have data that demonstrates the opposite. Organizations that prioritize safety and demonstrate that commitment in word and deed actually have a more engaged workforce.

Sarah Mossburg: Could you speak more about how organizational context is an important part of setting a zero harm goal?

Carole Stockmeier: In a punitive environment, where there's fear of punishment for making an error or a mistake and where organizational learning does not thrive, the hammer of a zero harm goal can drive reporting down. Yet in the context of a leadership-driven organizational commitment to safety as a core value with culture, processes, and technology that support a safe, high quality, and exceptional experience, a zero harm goal emanates as a natural fit. What other acceptable goal is there when it comes to harm? That's what makes the difference. Zero harm needs to be positioned in the context of an organizational commitment to safety as a core value. Safety as the core value means that the commitment to zero harm is not just some of the time, but all the time, and it needs to be reflected in the vision, mission, strategy, goals, and most importantly, the day-to-day words and actions of the organization. Zero harm and safety culture go hand-in-hand, an uncompromising commitment to safety as a core value with zero harm as the goal.

Sarah Mossburg: So having that safety culture and leader’s support of safety culture in what they say and do is critical to ensuring that a zero harm goal doesn't potentially lead to decreased reporting?

Carole Stockmeier: More than leader support, safety culture requires the personal commitment of leaders. And that has to start at the top. Organizations where safety culture is an intentional focus and responsibility of the board and the CEO are the most successful in achieving and sustaining results in patient and workforce safety. Why is board involvement so important? Many organizations have made great strides in safety culture improvement under the leadership of a CEO who personally and passionately led the way. And when that CEO left, those organizations lost those gains in a matter of months when the new CEO didn’t lead the way as personally and passionately. The Board plays a critical role in hiring a leader who will provide continuity of commitment and purpose when it comes to safety culture.

Sarah Mossburg: You mentioned the importance of a culture of safety and organizational context, which is likely an area of common ground with someone who might have an opposing view on zero harm as a goal. Are there other areas where you probably agree with someone who holds an opposing view?

Carole Stockmeier: When considered in the context of a culture of safety and high reliability organizing, I’m sure most healthcare leaders would be closely aligned that the safety goal should be zero harm. Who would want to receive care where there is a preventable harm goal other than zero?

Sarah Mossburg: I would love to hear your thoughts on regulatory incentives for zero harm. The proposed CMS Patient Safety Structural Measure includes a specification that an organization's strategic plan publicly shares a commitment to zero preventable harm. What is your reaction to CMS putting that into a proposed quality measure?

Carole Stockmeier: There's been a lot of dialogue lately about whether the proposed CMS Patient Safety Structural Measure is a step in the right direction or a step too far. It is a step in the right direction. Ideally, an industry would mobilize itself to take a stand on safety and harm prevention issues. While many efforts have advanced the cause, so far, none have resulted in a unified culture of safety across the healthcare industry. The Patient Safety Structural Measure is an attestation-based measure that encourages hospitals to assess and work toward a culture, structures, and processes that drive a safe, high-quality experience. These kinds of leading and real-time indicators are the right focal point in the effort to change outcomes in patient and workforce safety.

Sarah Mossburg: If zero harm is part of a regulatory call, what are your thoughts on the risk for organizations that don't have a strong safety culture espousing this type of zero harm goal?

Carole Stockmeier: As we have talked about, it is important for a zero harm goal to be grounded in an organizational commitment to patient and workforce safety. While the CMS Patient Safety Structural Measure includes the goal of zero preventable harm, it frames that goal well within the five domains of governing board and leadership commitment, strategic planning and organizational priority, safety culture and organizational learning, accountability and transparency, and patient and family engagement. The practices of organizations leading the way will hopefully become the tipping point for making the best practices of some the common practices of all. The CMS structural measure is a push in the right direction and in the right way.

Sarah Mossburg: Well, thank you so much for this conversation. It's been really interesting, and I appreciate hearing all your thoughts on these issues.

Carole Stockmeier: You're welcome.

In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement

September 24, 2024

Editor’s note: Eric Thomas, MD, MPH, is the Director of the University of Texas Houston Memorial Hermann Center for Healthcare Quality and Safety and is Associate Dean for Healthcare Quality. We spoke to him about zero harm and patient safety.

Sarah Mossburg: Could you tell us a little bit about yourself and your current role.

Eric Thomas: I am a Professor of Medicine at the McGovern Medical School at the University of Texas Health Science Center in Houston. I am a general internist and do adult primary care about 20% of my time. I do research on patient safety about half of my time, and the rest of my time is in teaching and leadership of our outpatient quality and safety programs. Most of my professional time has been spent doing patient safety research for about 30 years now, and I have studied a wide variety of topics in the area of patient safety. I am also the Co-Editor-in-Chief of BMJ Quality and Safety.

Sarah Mossburg: Please start our conversation today by explaining the concept of zero harm. What is zero harm when it is used in literature?

Eric Thomas: That is a great question because I think it's not well-defined. There are two definitions of zero harm generally used. Some people use zero harm as a goal, as in, “Our goal as a healthcare organization is to have zero preventable harm.” Other people use it more as an abstract concept, something that we aspire to—zero harm, but not necessarily using it as a measurable, quantifiable goal. Or to be more precise, some people use zero harm as a value, and others use it as a goal. For example, “Do no harm” has been a professional value in the medical profession forever. But a goal is something that is specific, measurable, actionable, and tends to be time-bound. People, including me, sometimes conflate those two ways of thinking about or defining zero harm. This is an important distinction; I personally believe it's not helpful to have zero harm as a goal. Whereas it is, of course, desirable and mandatory to affirm a value not to harm patients.

Sarah Mossburg: What types of harm does “zero harm” apply to, either as a value or a goal?

Eric Thomas: Most people would agree that either as a value or a goal, we're talking about harms that are thought to be preventable. There are certainly harms in a very literal sense that are an intentional part of healthcare. It is harmful to have surgery, it hurts. You could use the term “harm” in that context. Surgery could be considered an intentional harm, but it may be necessary. There are also harms that are unintentional and unpreventable. For example, if I give you a medication that you never had before, and you have an allergic reaction to it, we can call it a harm. It was not intended, like surgery might be. And it was not preventable, because you never used the medication before. And let us say there’s no way to test for it. I think when people talk about zero harm, they are not talking about those things, not talking about intentional harm in the course of appropriate therapy, and not talking about things that are unpreventable, or unavoidable, like an allergic reaction that you couldn’t predict. We are talking about preventable harms. So, that would be a lot of things like surgical site infections, certain medication errors, central line-associated bloodstream infections; there are a variety of preventable harms that we already have the knowledge to prevent.

Sarah Mossburg: The term “zero harm” is commonly used in safety these days. As you have mentioned, it is often espoused in healthcare systems as a value. A colleague recently mentioned to me that they had zero harm pins. You have written about some of the challenges related to a goal of zero harm. What are some of your thoughts on zero harm as a goal?

Eric Thomas: First of all, I'd acknowledge that we are used to seeing stretch goals, or idealized goals. Jim Collins, a popular business book author, identified some companies with goals that he called Big Hairy Audacious Goals. People in the management literature might call them idealized goals or stretch goals. For example, John F. Kennedy said that we're going to send a man to the moon and return him safely before the decade is out. That was an amazing goal. We have this sense that if we set lofty goals, they will inspire us to meet them. I think that is true; if you set a goal that is specific, you can actually measure it, and it's actionable, meaning there is a method to achieve it. But in health care right now I would argue we don't have the means to have zero preventable harm.

We should be striving toward zero preventable harm, but there's just not the knowledge to prevent all of the preventable harms that we have right now. Healthcare systems are generally very stretched and taxed, and providers are burned out. Healthcare systems do not make millions and millions of dollars in profit that they can reinvest into this kind of a goal like some other private companies can, so it is not clear that we really have the means to do it. The other problem that happens when you have a goal that is hard to meet is that people on the front lines start to game the system. So, if the C-suite says our goal is zero preventable harm and we're going to measure that and hold you accountable for it, then at the unit level, the nurse manager, the medical director, the clinicians will say, “Okay, if you want zero harm, then you're going to get zero harms. We are not going to report the preventable harm, or we're going to redefine the harms in a way to say, well, that wasn't really preventable.” So you get this gaming behavior that is obviously detrimental to learning and to really improving care. There'll be a tendency toward gaming if these goals are associated with rewards and punishments, whether financial incentives or rankings. Daniel Pink wrote a book called Drive that talks about how external rewards and punishments, or even just external rewards, reduce people's intrinsic motivation to do the right thing. To summarize, I would say that goals like zero harm can incentivize people to game the system. They can reduce intrinsic motivation, and it's not clear that we even have the ability to do it right now.

Another problem I have with zero harm is that setting idealized goals is not how organizations become excellent. They become good by focusing on improvement and getting better. In 2016, Richard Bohmer wrote an article for the New England Journal of Medicine about healthcare organizations having success in quality and safety. He says they “constantly make small-scale changes to their structures and processes, over long periods.” And then he remarks, “Major change emerges from aggregation of marginal gains.”¹ So it is these small things that you focus on daily that create excellence and improvement over time, not focusing on this goal of zero.

Sarah Mossburg: Rather than that overarching Big Hairy Audacious Goal, it's better to have marginal improvements that add up over time. And in the long run, these improvements get you there, is that right?

Eric Thomas: Exactly. I can give you a non-healthcare illustration. A couple of the swimmers who competed in the recent Olympic games were coached by Eddie Reese. He has been the coach of the University of Texas men's swim team since 1979, and his teams have won 15 national championships, more than any swim coach ever. They win the most championships, but the goal at the beginning of each year is not to win the championship. The goal is for each person to get better and for them to care about each other as a team. When you have that laser focus on improvement and supporting each other, you end up being the best. It is not by saying, “Oh, we're going to win or else.”

Sarah Mossburg: Some people who espouse the benefits of idealized goals feel that lofty goals provide inspiration to staff. Are there any situations where clinicians might find that type of goal motivating?

Eric Thomas: In my experience, clinicians see zero harm goals as insincere because they realize that they are not attainable. When they see leadership touting zero harm to the public, they say, “You know, this isn't possible.” From that perspective, it is demoralizing, as opposed to inspiring.

Sarah Mossburg: Like you said at the beginning, zero harm is an important value for health care. How do we clarify for staff that it’s something we are espousing as a value versus as a measurable goal?

Eric Thomas: I think it's what we were talking about before. You work towards it by having measurable goals that you know are taking you towards your value. It's doing things like decreasing the rates of certain events in a clinical area and giving the staff the support to do that. Then celebrating when it happens and spreading that good news around the organization, spreading the best practices throughout the organization. There are some things that we can keep at zero. Those should be measured, monitored, and celebrated. So, you have intensive care units that go months or years without any ventilator-associated pneumonias or have no central line bloodstream infections. I would argue that you might have zero harm goals for specific events, where you have the knowledge and the ability to prevent them. Then that is inspiring to people, to know that they can accomplish zero harm. But it is demoralizing to talk about goals that are not reachable. It is also messy to communicate. It is very hard for leaders to communicate that the goal is zero. “I know that it's not really zero because people are still harmed by unavoidable things” is a complicated message to use for inspiration.

Sarah Mossburg: The proposed CMS Patient Safety Structural Measure includes a specification that the organization's strategic plan publicly shares a commitment to zero preventable harm. Given your thoughts in this conversation, I am wondering what your reaction is to CMS putting a public commitment to zero harm into a proposed quality measure?

Eric Thomas: I would encourage them, for the reasons we discussed, not to have the public zero harm commitment. I have looked at the other structural measures, and I think they are fantastic. I really like the movement towards structural measures as opposed to the discrete measures of outcomes, the traditional kind of quality metrics. I like many of the structural measures, like the one about a commitment to transparency with patients after harm or implementing communication and resolution programs. I think it's good for CMS to try to hold hospitals accountable for some of these things. But when it comes to this kind of zero harm goal, I would just repeat that I think it is not a good thing to do. A better structural measure could direct hospitals to set a goal for year-over-year improvement in the rates of preventable harm. It wouldn't be hard to change that structural measure from zero harm to improvements on reducing preventable harms

Sarah Mossburg: Are there areas where you're in agreement with someone who holds the opposing viewpoint on zero harm?

Eric Thomas: I’m certainly in agreement that it would be wonderful if zero preventable harm were true, and I look forward to that maybe happening someday. Where I disagree is in the path toward that vision of zero. I would just say it's not by holding organizations accountable for zero as a goal, it's going to be through other types of goals.

Sarah Mossburg: You’ve talked about the importance of incremental goals that hospitals have the means to implement for year-over-year improvement. Are there other strategies to improve safety that you’d advocate?

Eric Thomas: Yes, there is a lot more to improving safety than just goal setting. I would focus on things like teamwork and communication, safety culture, and better engagement with patients, their families and partners in care. That is another important part of this conversation, if you are a leader of an organization, how could you look a family member or a patient in the face and say, “No, we do not have a goal of zero harm.” I mean, that is hard. It is much easier to tell families and the public that our goal is zero harm. It is easier to say that, but as I have told you, I do not think that is how you are really going to improve safety.

Sarah Mossburg: It is difficult to say to someone, we know that we're going to have a number of harms, and our goal is to have slightly fewer harms year-over-year.

Eric Thomas: You know, in some cases that may be a hard conversation, but in other cases, it's not. Patients understand that healthcare is incredibly complex. It also depends on what you are talking about. This is another problem with zero harm: some things can be zero, and others cannot. There can be a goal of zero for things we know how to prevent, like central line-associated bloodstream infections. There are some processes in health care that we can map out in linear steps. We can make sure these processes happen the right way every time. And we should expect perfection in certain things.

There are other things we do that are not predictable. I'm a primary care physician. If you come to me tomorrow with a week of abdominal pain, the list of possible causes is extremely long. It may be that we immediately figure it out, and you need to go to the emergency room and have your appendix taken out. Or it is just as likely that we are going to embark on an outpatient diagnostic evaluation. You might go to get blood tests. You might get a CT scan. Your symptoms are going to change in the meantime. We are going to communicate about it. We are going to narrow it down to a few things. We are going to try this or that medicine. You may see a specialist. You may not be able to see the specialist for a week. I am going to try to call and get you in. I mean, this sequence is not predictable. You cannot force that care pathway to happen a certain way every time. And you do not know what is going to happen. We're working together to try to do this safely, quickly, and efficiently, but it's not the kind of thing where you can say, “Zero things will go wrong,” because I don't know how it's going to happen every time. We can identify things that we have to do to try to make complex care safe, and we can know where the process may go wrong. And we can work together with communication and transparency about health information and decision-making. But it is still going to be hard to make that turn out perfectly every time.

Sarah Mossburg: Some proponents for zero harm state that the organizational setting and leadership culture can determine the effect of a zero harm goal. To your mind, is there an evolution in an organization's approach to safety, a place where it becomes appropriate for them to set these Big Hairy Audacious Goals?

Eric Thomas: There could be organizations that have the resources to try realistically to move toward that goal. And they could have leadership that leads in a way that is non-punitive and supportive. Those factors could help them avoid some of the negative unintended consequences of zero harm goals that I mentioned before. I think it is possible. It is rare that we have organizations staffed by leaders that can do that. It requires leadership not just at the top but also at the unit level and throughout an organization to pull that off.

Sarah Mossburg: Thanks for joining us today, Dr. Thomas. We enjoyed the conversation.

Eric Thomas: You are welcome. Thank you for having me.

Bohmer RMJ. The hard work of health care transformation. N Engl J Med. 2016;375(8):709-711. [Available at]

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers