1 Reflections & Ruminations20+ Year Patient Safety Journey Jim Conway Adjunct Faculty (ret.), HSPH Trustee, Winchester Hospital/LHS Trustee, Lahey Health System 3/30/2017 MCPME Annual Meeting

2 For your service to your patients, families, staff, and communities.3/30/2017 MCPME Annual Meeting

3 Outline Reflections and RuminationsReflections Over Twenty Years Improvement Ruminations Creative Tension, etc. Key Learning: Betsy Lehman Arrogance Of Excellence Never Worry Alone Engaging at Every Level Interaction for Improvement Scope: Problem /Opportunity Systematic Improvement Boards on Board Respectful Management Culture / Teamwork Safety About Staff Too Respect PS: More Than Inpatient PS: Essential Part of Value Struggles: Field & Classroom Most Change Fails Elegant Silos Spray And Pray Waterfall, Projectitis Try To Do Everything… 3/30/2017 MCPME Annual Meeting

4 … a personal story followed by … a professional story3/30/2017 MCPME Annual Meeting

5 “Jim, you better come home. I think dad is dead”August 19, 1980 Avoidable death at 73 John Conway 5 3/30/2017 MCPME Annual Meeting 5

6 Important Early Pre-WorkPatient & parent partnership “No force…” Risk Management Rounds: Better together... 3/30/2017 MCPME Annual Meeting

7 Creative Tension Creative tension comes from clearly seeing where we want to be, our 'vision', and telling the truth about where we are, our 'current reality’. The gap between the two generates a natural tension. The Fifth Discipline: The Art and Practice of the Learning Organization Peter Senge, st edition, paperback edition, xxiii, 413 p., ISBN 3/30/2017 MCPME Annual Meeting

8 Key DFCI Learning After the Betsy Lehman TragedyBurden Responsibility Power 3/30/2017 MCPME Annual Meeting

9 Key Learning The responsibility and power of all leadership [trustee, clinical and administrative] over safety The need for relentless vigilance to safety, risk, error, near-miss, harm Addressing the multiple victims of error The crucial role the design of systems and application of technology play in support of safe practice by excellent staff The synergy of interdisciplinary practice and team work Patient and Family Centered Care 3/30/2017 MCPME Annual Meeting

10 Our systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time. We as leaders must put in systems that support safe practice. 3/30/2017 MCPME Annual Meeting

11 Arrogance of ExcellenceRisk of Great Organizations Focus only on the great stuff and forget to confront the suffering, harm, tragedy, and waste 3/30/2017 MCPME Annual Meeting

12 Organization: Fair and Just CultureOne that values fair, objective and explicit decision rules for determining accountability and culpability subsequent to an adverse event. Connor, M., Duncombe, D., Barclay, E., Bartel, S., Borden, C., Gross, E., Miller, C. and Ponte, P.R., Creating a fair and just culture: One institution's path toward organizational change. The Joint Commission Journal on Quality and Patient Safety, 33(10), pp 3/30/2017 MCPME Annual Meeting

13 “Aren’t you EVER Satisfied?” “No!”High Reliability Organizing Weick & Sutcliffe Preoccupation with failure Reluctance to simplify interpretations Sensitivity to operations Commitment to resilience Deference to expertise Weick, K. E., Sutcliffe, K. M., & Obstfeld, D. (1999). Organizing for high reliability: Processes of collective mindfulness. In B. M. Staw & L. L. Cummings (Eds.), Research in organizational behavior, vol. 21 (pp. 81–123). Greenwich, CT: JAI Press, Inc. 3/30/2017 MCPME Annual Meeting

14 Never Worry Alone Susan Block, MDWho can we invite into this discussion for a better outcome? 3/30/2017 MCPME Annual Meeting

15 Engaging At Every Level: Especially at the Front LineThe higher you get to the top, the less you know how the work really gets done 3/30/2017 MCPME Annual Meeting

16 Zeev slide 16 3/30/2017 MCPME Annual Meeting

17 Set the Expectation Position People for Success Hold Them AccountableWithout clarity of expectations, deviance can’t stand out. Roger Berkowitz, Trustee, DFCI CEO, Legal Sea Foods 3/30/2017 MCPME Annual Meeting

18 Presentation to CMS ... the interaction…3/30/2017 MCPME Annual Meeting

19 Systematic ImprovementIHI Framework for Leadership for Improvement Setting Direction: Mission, Vision and Strategy Systematic Improvement Changing the old Making the future attractive PULL PUSH Ideas Will Execution Establish the Foundation 3/30/2017 MCPME Annual Meeting

20 Built off IHI Boards on Board Plank 2015: Some Recommended PracticesSetting aims Changing the environment, structures, processes, and culture Know your aims Set / broadcast expectations Strategic & compliance Allocate significant time to quality, safety, risk Getting data and hearing stories Focus is on all harm/ not tip High reliability systems Meet patient, family, community Measure and evolve cultural variation Find canaries: readmissions Promote team building Be transparent Respectfully manage serious adverse events Understand variation Get out and about organization Engagement in credentialing Establishing and monitoring system-level measures Learning Conduct applied in-service and continuing education Respect but don’t get lost in core and process measures Establishing executive accountability Value focus: clinical, financial, service, experience “dance” Clinical, financial, service, experience outcomes Measure & manage across care continuum 3/30/2017 MCPME Annual Meeting

21 Respectful Management of Serious Clinical Adverse EventsI was treated with RESPECT 3/30/2017 MCPME Annual Meeting

22 In the Aftermath of Harm… Patient, Family, Staff, Organization22 In the Aftermath of Harm… Patient, Family, Staff, Organization Empathy Apology Disclosure Resolution Support Learning Assessment Improvement 3/30/2017 MCPME Annual Meeting

23 Creating Awareness is Just the StartRespectful Mgmt. White Paper > 70,000 views of content > 30,000 downloads Slow movement in the field 3/30/2017 MCPME Annual Meeting

24 Michigan Keystone InitiativeCulture / Teamwork The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care. Michigan Keystone Initiative 3/30/2017 MCPME Annual Meeting

25 Culture Is Related To Clinical & Operational OutcomesMedication errors Back injuries Patient satisfaction Nurse turnover & absenteeism AHRQ Patient Safety Indicators Nurse satisfaction Urinary tract infections Needle sticks Re-admissions Malpractice claims ...and more. Useful References for Culture-to-Outcomes Linkage: Hansen et al. (2011) Curry et al. (2011) Pettker et al. (2009) Singer et al. (2009) Vogus & Sutcliffe (2007) Mark et al. (2007) Naveh et al. (2006) Hofmann & Mark (2006) Katz-Navon et al. (2005) 3/30/2017 MCPME Annual Meeting Courtesy A. Frankel MD

26 How Culture is ImbeddedPrimary What leaders do, pay attention to measure and reward on a regular basis How leaders react to critical incidents and organizational crises incidents and organizational crises Deliberate role modeling, teaching and coaching Observed criteria by which leaders allocate rewards and status Observed criteria by which leaders recruit, select, promote, retire and terminate organizational members E. Schein. Organizational Culture and Leadership Publicly Verifiable 3/30/2017 MCPME Annual Meeting

27 Safety Is About Staff Too!3/30/2017 MCPME Annual Meeting

28 Employee Workplace Illness/Injury Harm BubbleGOAL: 0 There have been 304 Employee Illnesses/Injuries reported through FY employees were seriously harmed*. *Serious Harm is defined by Mass Serious Reportable Events (i.e. lost work time, work restrictions, follow up testing required related to injury) Bloodborne Pathogen/Sharps Exposure 36 Material Handling 25 Challenging Person/Situation 34 Employee Safety FY 2013 (Entire) Fall/Slip/Trip 86 Struck or Injured by 47 Patient Handling 48 Other/Misc 28 3/30/2017 MCPME Annual Meeting 28

29 At the end of the day… NOTHING is more importantRespect At the end of the day… NOTHING is more important 3/30/2017 MCPME Annual Meeting

30 RUMINATIONS 3/30/2017 MCPME Annual Meeting

31 Patent Safety: More than In-PatientAcross the Continuum Into the Home & Community 3/30/2017 MCPME Annual Meeting

32 Quality and Patient Safety Essential Parts of the Value Equation3/30/2017 MCPME Annual Meeting

33 Struggles Reported in the Classroom and the FieldChange Failure Waterfall Siloes Projectitis Spray & Pray Focus 3/30/2017 MCPME Annual Meeting

34 Most Change Fails Everyone 3/30/2017 MCPME Annual Meeting

35 Elegant Silos 3/30/2017 MCPME Annual Meeting

36 Spray and Pray 3/30/2017 MCPME Annual Meeting

37 Projectitis The Waterfall“Every day I come to work I feel like I’m sitting at the bottom of a waterfall. The stuff keeps coming and coming” Staff RN 3/30/2017 MCPME Annual Meeting

38 If you try to do everything, you could accomplish nothing.Focus Align Prioritize Driver Diagram 3/30/2017 MCPME Annual Meeting

39 Closing on Professional and Personal NoteFor all we have accomplished together... ... There is so much more to learn and do 3/30/2017 MCPME Annual Meeting

40 John Kelsch, Xerox Quality Health Care In America ProjectTo do things differently, we must see things differently. When we see things we haven’t noticed before, we can ask questions we didn’t know to ask before. John Kelsch, Xerox Quality Health Care In America Project 3/30/2017 MCPME Annual Meeting