surgical patient safety officer figurehead or clinical leader

1. Surgical Patient Safety OfficerFigurehead or Clinical Leader? Ara A. Chalian MD, FACS Surgical Patient Safety Officer University Of Pennsylvania Health System Associate Professor Director of Facial Plastic and Reconstructive Surgery Department of Otorhinolaryngology: Head and Neck Surgery University of Pennsylvania Philadelphia, PA USA

3. Purpose This paper examines surgical patient safety officer (SPSO) role As implemented in US tertiary hospital Late 2004 Coincided with Health System CMO Qualified change with analysis of Transmission of information to and from SPSO Span of surgical patient safety programming Coincided with Health System CMO Qualified change with analysis of Transmission of information to and from SPSO Span of surgical patient safety programmingCoincided with Health System CMO Qualified change with analysis of Transmission of information to and from SPSO Span of surgical patient safety programming

4. SPSO Dilemma Big Brother Objective counselor

5. Figurehead versus Clinical Leader Role Respect Trusted Action Challenger /challenged Develop/Evaluate role implementation Generate performance improvement Offer recommendations to hospitals

6. SPSO Role Concerns about current role design Lacks specificity Suffers variable implementation Lacks targeted outcomes Limited resources Inter-agency, international discourse Sparse scholarly literature

7. Health System Patient Safety

8. Surgical Environment

9. Context Only Frankel et al speak to PSO role Frankel, A. Gandhi, T. K. and Bates, D. W. (2003). Improving patient safety across a large integrated health care delivery system. IJQHC 15 (suppl. 1), i31-i40. Structure System safety advisory group Patient safety officer Patient safety leaders

10. Outline Problem Purpose Context Analysis Strategy Effects Lessons Message

11. Problem Figurehead vs Clinical Leader We asked� Is the SPSO role one of sentinel events reviewer and regulatory figurehead alone? Or are there opportunities to achieve new levels of clinical and inter-professional leadership? Do clinicians what anyone to tell them what to do to make patient care safer? Don�t clinicians already focus on safe patient care, The answers probably is yes and no�. They focus, do they really know how systems and process apply to their own behaviours and practices, and to their practices in the continuum of health care today. Have they been educated in systems and process in their training education that has spanned their formative years, have they been taught more than individual accountability� The answers are shockingly � no. Previously taught .. I am responsible and the system answers and works for me , nurses and others follow my recommendations/orders� very patriarchal to the point that in most systems until recent decades patient often unaware of diagnosis , outcome projections and did not participate in choice regarding care much less their healthcare. Don�t clinicians already focus on safe patient care, The answers probably is yes and no�. They focus, do they really know how systems and process apply to their own behaviours and practices, and to their practices in the continuum of health care today. Have they been educated in systems and process in their training education that has spanned their formative years, have they been taught more than individual accountability� The answers are shockingly � no. Previously taught .. I am responsible and the system answers and works for me , nurses and others follow my recommendations/orders� very patriarchal to the point that in most systems until recent decades patient often unaware of diagnosis , outcome projections and did not participate in choice regarding care much less their healthcare.

12. Accountability- �life was simple� Doctor Departments Nurses.other fields

13. Context United States (US) health care safety National Patient Safety Goals http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

14. Safety Goals Plus Medicine reconciliation Patient Participation Falls prevention Communication and handoffs Site of surgery Surgical site infections Blood stream infection

15. 2008 U. S. National Patient Safety Goals For Hospitals Goal 1: Improve the accuracy of patient identification. Goal 2: Improve the effectiveness of communication among caregivers. Goal 3: Improve the safety of using medications. Goal 7: Reduce the risk of health care-associated infections. Goal 8: Accurately and completely reconcile medications across the continuum of care. Goal 9: Reduce the risk of patient harm resulting from falls. Goal 13: Encourage patients� active involvement in their own care as a patient safety strategy. Goal 15: The organization identifies safety risks inherent in its patient population. Goal 16: Improve recognition and response to changes in a patient�s condition.

16. Who communicates with staff Administrative leadership is necessary in Safety Strategic roles Enhance achievement? Exemplar is patient safety officer (PSO) Strategic roles assure program adherence Do these positions enhance achievement? Exemplar is patient safety officer (PSO) Strategic roles assure program adherence Do these positions enhance achievement? Exemplar is patient safety officer (PSO)

17. Hospital Organization Organizational divides Boardroom to basement Pragmatics and Dichotomies Believers and dreamers Doers and realists

18. Hospital/Departmental Administration Efficiency Management Overhead Safety Quality Outcomes

19. Surgical Continuum of Care

20. Typical surgical patient NPO p MN Home to hosp Admissions PRA (Pre-op) Surgery suite PACU (Post-op) ICU or Ward

21. Context Surgical patient safety officer (SPSO) One of multiple PSO roles Strategic role in hospital safety Critical nature of surgical care continuum Contrasts with Frankel�s description Different administrative structure Different PSO role definition

22. Organizational Chart

23. SPSO Strategy Initial SPSO focus Safety processes Safety rounds Outcomes analysis Sentinel events review Midstream evaluation Clinician work groups resisted SPSO How to develop role?

24. Clinician Responses -Resistence Of efforts to examine falls prevention in peri-operative care: �We have falls over there?� Of root cause analysis invitations: �I suspect there is a lack of understandings about the organizational structure of the OR. I run the OR��

25. Analysis US hospital administration Many performance processes Rich data sources US health care paradox Practice still difficult to improve For Clinicians paradox creates scepticism Clinicians distrust new roles and processes Do such new initiatives help or harm?

26. SPSO Effects Clinician resistance cited negative responses to initiatives Recitation of policy elicited specific resistance Punitive counselling argued and resisted

27. Administrative Risk? SPSO role Figurehead? Leader? Evaluate role implementation Generate performance improvement Offer recommendations to hospitals

28. Surgical Safety Continuum

29. Clinical Leadership Implementation How to do it? Committee structure Patient safety Medicolegal Incidents and occurrences Patient safety directors CEQI Special projects

30. Managing SPSO Role Blameless Culture Characteristics Commitment Contributions Improvement mechanisms Standardized processes Protocols Pathways Cross training Examples � case equipmentExamples � case equipment

31. Managing SPSO Role Evaluation Root cause analysis Incident reporting Failure mode effects and analysis Routine safety process Distinguish Hawthorne effect Real change Generalizing change

32. Refine Role - SPSO Strategy Role refinement Development of structured counselling Creating partnerships with clinicians Informing work groups Met increased resistance Response Refined counselling strategies Emphasized root cause and failure modes

33. Clinician Response Change to general positive feedback �On behalf of the team, I want to thank you�We are very fortunate to have such an outstanding leader as our SPSO!� Increased spontaneous reports of events �There was an incident in the OR yesterday that needs attention.�

34. SPSO Effects Clinician response Not uniform with some resistance and refusal Decreased reactivity around figureheads Relatively consistently positive Increased statements of trust Positive were credibility, approachability, and engagement

35. Lessons Learnt SPSO role can be positive and beneficial safety management clinical leadership Success requires evaluation and refinement Role implementation Leadership characteristics can be learned

36. Recommendations Patient Safety Goals guide SPSO implementation Can improve hospital patient safety management Can adapt to hospital characteristics and clinician needs SPSO role offers flexible leadership Choose for leadership skills and clinical expertise

37. Figurehead New role Business as usual?

38. Clinical Leader New role Creativity Innovation Skill

39. Questions and Comments

40. Thank You Ara Chalian Ara.chalian@uphs.upenn.edu