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1. The Evolution of the Patient Safety Movement:Reflections on a Decade of Successes, Failures, and Surprises For more information about today’s webinar, Feel free to contact me at Anthony_Sarchiapone@mcgraw-hill.com To learn more about AccessMedicine, visit AccessMedicine.com

2. The Evolution of the Patient Safety Movement:Reflections on a Decade of Successes, Failures, and Surprises James Shanahan Associate Publisher McGraw-Hill Medical

3. The Evolution of the Patient Safety Movement:Reflections on a Decade of Successes, Failures, and Surprises Robert M. Wachter, MD Professor, Associate Chairman, and Chief, Division of Hospital Medicine, University of California, San FranciscoChair, American Board of Internal Medicine

4. I am not in the office at the moment. Please send any work to be translated.

5. Successes, Failures, Surprises and Epiphanies in Patient Safety The Pace of Change The Limitations of Top-Down Approaches IT is Harder Than it Looks The Importance of Culture The Need to Balance “No Blame” and Accountability Looking Ahead and Dealing with Change

6. 44,000-98,000 2000: The Patient Safety Field Begins

7. The Healthcare World of 2000 Quality/safety assumed to be quite good No business case to improve safety/quality No local expertise, research or best practices Little concerted effort by healthcare leaders or physicians to improve quality/safety

8. 2000 2002 2004 2006 2008 2010 2012

9. Successes, Failures, Surprises and Epiphanies in Patient Safety The Pace of Change The Limitations of Top-Down Approaches IT is Harder Than it Looks The Importance of Culture The Need to Balance “No Blame” and Accountability Looking Ahead and Dealing with Change

10. The Checklist: A Bottom-Up Innovation in US • Dr. Peter Pronovost develops checklist for CLABSI (evidence->bundles->checklist) • Tries it at home (Johns Hopkins): it works • Puts together a state-wide study in Michigan • Demonstrates effectiveness in NEJM study • Popularized in article, book by Atul Gawande, extended to surgery (WHO surgical checklist) • Diffuses through US, with govt support

11. Arrives in UK via Federal Mandate “Another top-down mandate.” One UK surgeon

12. The Surprise: Healthcare is a Complex Adaptive System • System and external environment constantly changing • Uncertainty and paradox are inherent properties • Problems cannot be solved in a machine-like fashion (but can sometimes be “moved forward” that way) • Individuals are independent – but highly interdependent – creative decision-makers • Solutions often emerge from minimal specifications and simple rules; overspecification can get in the way From Brenda Zimmerman

13. Successes, Failures, Surprises and Epiphanies in Patient Safety • The Pace of Change • The Limitations of Top-Down Approaches • IT is Harder Than it Looks • The Importance of Culture • The Need to Balance “No Blame” and Accountability • Looking Ahead and Dealing with Change

14. Healthcare IT: Some Surprising Problems Emerge • Getting better, but juxtaposition with breathtaking state of IT in the rest of our lives ever-more jarring • Early glowing studies not generalizable to vendor-built systems • Unforeseen consequences • Growing literature on IT-related safety hazards • That said, we must computerize, and it’ll probably help

15. “The patient is still at the center, but more as an icon for another entity clothed in binary garments: the ‘iPatient.’ Often, emergency room personnel have already scanned, tested, and diagnosed, so that interns meet a fully formed iPatient long before seeing the real patient. The iPatient’s blood counts and emanations are tracked and trended like a Dow Jones Index, and pop-up flags remind caregivers to feed or bleed. iPatients are handily discussed (or ‘card-flipped’) in the bunker [the team’s conference room], while the real patients keep the beds warm and ensure that the folders bearing their names stay alive on the computer.” Abraham Verghese, NEJM 2008

16. A 7-year-old Girl’s Depiction of her MD Visit Toll E. The cost of technology. JAMA 2012

18. The “Glass Cockpit Syndrome”: The Tragedy of Air France 447

19. Successes, Failures, Surprises and Epiphanies in Patient Safety • The Pace of Change • The Limitations of Top-Down Approaches • IT is Harder Than it Looks • The Importance of Culture • The Need to Balance “No Blame” and Accountability • Looking Ahead and Dealing with Change

20. “The core structure of medicine – how health care is organized and practiced – emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves….We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency… and to designing medicine accordingly….

21. But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to ‘protocol’ the MRI.” AtulGawande, The New Yorker 2011

22. Teamwork level felt to be “high” Sexton, British Medical Journal, 2000

23. Believe that decisions of the “leader” should not be questioned Sexton, BMJ 2000

24. Safety Culture is Unit-Based Safety Climate Across 49 Units in One Hospital Safety Climate Across 100 Hospitals Pronovost/Sexton, QSHC 2005

25. Successes, Failures, Surprises and Epiphanies in Patient Safety • The Pace of Change • The Limitations of Top-Down Approaches • IT is Harder Than it Looks • The Importance of Culture • The Need to Balance “No Blame” and Accountability • Looking Ahead and Dealing with Change

26. Balancing “No Blame” and Accountability • The “No Blame,”“It’s the System, Stupid” approach has been crucial • Most errors are “slips” – expected behavior by humans, particularly when engaged in “automatic behaviors” • Can only be fixed by improving systems (checklists, double-checks, standardization, IT, other new technology…)

27. At the Junction, the Message Gets a Little Garbled… NoBlAccoblantabimety

29. James Reason Understood This Tension in 1997 A ‘no-blame’ culture is neither feasible nor desirable. A small proportion of human unsafe acts are egregious… and warrant sanctions, severe ones in some cases. A blanket amnesty on all unsafe acts would lack credibility in the eyes of the workforce. More importantly, it would be seen to oppose natural justice. What is needed is a just culture, an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information – but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior. Reason, Managing the Risks…

30. Individual Accountability:The Hand Washing Story Wachter and Pronovost, NEJM 2009 Typical hand hygiene rates circa 1999: 10-30% Over last decade, tremendous push to improve (via transparency, social pressures, and more) Many organizations now at 40-70%, and stuck “It’s a Systems Problem”: Education, dispensers every 3 feet A systems problem? Really?

31. Who Decided that a 60% Hand Washing Rate is a “Systems Problem”?

32. The Bottom Line: Clinicians, leaders and organizations will be held accountable for safety “‘No blame’ is not a moral imperative (even if it seems so to providers, it most definitely does not to patients). Rather, it’s a tactic to achieve ends for which providers and healthcare organizations will be held accountable. ” Wachter and Pronovost, NEJM 2009

33. Successes, Failures, Surprises and Epiphanies in Patient Safety • The Pace of Change • The Limitations of Top-Down Approaches • IT is Harder Than it Looks • The Importance of Culture • The Challenges of Measurement • The Need to Balance “No Blame” and Accountability • Looking Ahead and Dealing with Change

35. [The] reduction in reimbursement and increasing consolidation threatens to make the focus on economics, size, and market competitiveness take precedence over getting better in terms of quality and safety. This will be in part because the ‘line of sight’ from senior leaders to the front lines of care will be even more distant. Gary Kaplan, MD CEO, Virginia Mason Health System

36. Could this be worse?

37. “We think that the anxiety, demoralization, and sense of loss of control that afflict all too many healthcare professionals today comes not from finding themselves to be participants in systems of care, but rather from finding themselves lacking the skills and knowledge to thrive as effective, proud, and well-oriented agents of change in those systems…. A physician equipped to help improve healthcare will be not demoralized, but optimistic; not helpless in the face of complexity, but empowered; not frightened by measurement, but made curious and more interested; not forced by culture to wear the mask of the lonely hero, but armed with confidence to make a better contribution to the whole.” Don Berwick, Acad Med 2010

38. Thank You for attending The Evolution of the Patient Safety Movement:Reflections on a Decade of Successes, Failures, and Surprises For more information about today’s webinar, feel free to contact me at anthony_sarchiapone@mcgraw-hill.com To learn more about AccessMedicine, visit AccessMedicine.com