How providers can curb unnecessary care with a 'do no harm' campaign

When two doctors started the Do No Harm Project at the University of Colorado-Denver, it was simply because they recognized that healthcare overuse is "an urgent ethical issue" in the medical field, said co-founder Brandon Combs, M.D., in a Thursday webinar hosted by the Lown Institute.

Two and a half years later, the project--which asks medical residents to write "vignettes," or short narratives, about cases in which they think medical overuse occurred--has won numerous awards and inspired the "Teachable Moments" series in JAMA Internal Medicine. Its success has led Combs and his fellow founder, Tanner J. Caverly, M.D., to try to help a wider group of providers implement a similar project at their institutions.  

At the core of the initiative is the idea that clinicians should do "as much as possible for the patient [and] as little as possible to the patient," Combs said, adding, "This really has been our rallying cry from Day One of the Do No Harm Project."

Combs also sought to make the distinction between more obvious patient harms--malpractice and errors--and what he termed "reasonable overuse," such as ordering unnecessary tests or procedures. The latter is harder to pin down but can be just has harmful and costly, which is why it's the focus of the Do No Harm Project, Combs said. Groups such as the American College of Physicians (ACP) also have sought to crack down on medical overuse, FiercePracticeManagement has reported.

For institutions that want to follow the Do No Harm Project's lead, Combs laid out the following best practices in the webinar:

Think big, start small. The University of Colorado identified three initial goals in its campaign: recognize harms from overuse, start a conversation about it and change the local culture, Combs said, adding that providers don't have to do it all overnight.

Find your niche. The project's founders decided to focus on clinical vignettes because "patient stories are very powerful" and can be great rallying cries for change, according to Combs. Thus, the project asks its participants to note whenever patient harms occur whether the medical intervention they received were unneeded or unwanted, and how they think clinicians could do better going forward.

Make it stick. One key to UC-Denver's success was the involvement of supportive faculty, particularly its chief medical resident, who served as both a facilitator and educator for participants, Combs said. The group also made sure to work around residents' schedules and a created website for posting vignettes and other resources.

Don't underestimate your potential. The Do No Harm Project was able to extend its reach and credibility far beyond what its founders expected by partnering with JAMA Internal Medicine to publish the participants' vignettes "Teachable Moment" series. Furthermore, "the impact that you can have even with a small local program can really be robust," Combs said.

Don't do it alone. In addition to its partnership with JAMA, the Do No Harm Project also asked for help from the ACP, whose local members served as judges in a competition that chose the best vignettes for publication and awarded prizes to their creators.

Measure and celebrate success. "If you're going to take the time, measure the impact to see if it's important," Combs said, adding that it's also key to share these results as widely as possible so that others can replicate your success.

While the project has faced some challenges--mainly centered on the large time commitment it requires and the difficulty of identifying reasonable overuse--Combs said some of the barriers he and Caverly anticipated didn't materialize. For instance, it made a huge difference that the facility's administration, residents and patients were all on board with the project. "The bottom line is that this is doable--it just needs a committed champion," Combs said.

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