It Starts at the Top: CEO and Board Responsibility and Accountability for Patient Safety

1. It Starts at the Top: CEO and Board Responsibility and Accountability for Patient Safety Lucian L. Leape, MD The Michigan Health and Safety Coalition Patient Safety Summit April 30, 2003

2. The idea that medical errors are caused by bad systems is a transforming concept

3. A Transforming Concept 1. Errors are normal behavior 2. The causes of errors are not obscure

4. Causes of Errors Habit Anger Interruptions Anxiety Hurry Boredom Fatigue Fear

5. A Transforming Concept 1. Errors are normal behavior 2. The causes of errors are not obscure 3. Human errors result from latent errors

6. Latent Errors • Design of work • Conditions of work • Training • Design and maintenance of equipment

7. Latent Errors Design characteristics that induce errors by: a) Creating conditions that generate known causes of errors OR b) Requiring work that exceeds the capacity of the human brain

8. The Real Word Healthy appearing decrepit 69 year old male, mentally alert but forgetful The skin was moist and dry Occasional, constant, infrequent headaches Patient was alert and unresponsive Rectal examination revealed a normal sized thyroid She stated that she had been constipated for most of her life, until she got a divorce

9. Levels of Safety Design, Management, “Blunt” Training, Policies, Regulations Rules Provider “Sharp”

10. Accident Causation Model Latent Errors Systems Defects Triggering Factors Unsafe Acts Errors Defenses Defenses ACCIDENT

11. Take-Home Messages 1)Medical injuries are not inevitable – most are preventable 2)They’re not your fault – it’s faulty systems 3)They are your responsibility 4)It’s much easier to change systems than to change people

13. Faced with the choice of changing one’s mind and proving that there is no need to do so, almost everybody gets busy on the proof. John Kenneth Galbraith

14. The “Silence” Of Deed: The failure of physician and hospital leaders to respond with corrective action to studies documenting severe and preventable quality problems Millenson, Health Affairs 2003

15. The “Silence” Of Word: The absence of a thorough discussion of the tragic consequences of that lack of response Millenson, Health Affairs 2003

17. Accountability = Responsibility Not: • “Who’s to blame?” • “Who’s head shall roll?” But: • “How do we make it happen?” • “What are the lines of responsibility?”

18. Accountability as Responsibility • At the heart of the culture change we need to make health care safe • Meaningful accountability is a collaborative, supportive, and reciprocal activity

19. Heart of Culture Change • Must have clear responsibility to make the changes needed • Responsibility for safety must trump personal preferences • Safety is everyone’s responsibility

20. Accountability as Responsibility • At the heart of the culture change we need to make health care safe • Meaningful accountability is a collaborative, supportive, and reciprocal activity

22. Reciprocal Accountability Statutory Authority v. Moral Authority

24. Reciprocal Accountability 1. Implementing best safety practices 2. Dealing with problem doctors

25. Accountability Regulators Hospitals Professionals

26. Accountability Regulators Hospitals Professionals

27. Accountability Regulators Hospitals Professionals

28. Accountability Regulators Hospitals Professionals

29. JCAHO Safety Goals • Two patient identifiers for medications or blood products • Verification of surgical patient identity • Verbal order verification • Standardized abbreviations • Removal of concentrated electrolytes

30. JCAHO Safety Goals • Standardized drug concentrations • Preoperative verification – wrong site • Mark your site with patient • Free-flow protection for IV pumps • Preventive maintenance for alarms • Adequate alarm volume

31. Accountability Regulators Hospitals Professionals

32. NCPS TIPS – December 2002 • Interpretation of their intent • Related information • Facility resources • What you need to do

33. NCPS TIPS – December 2002 You need to not only show policies that address these stated goals, but more importantly, develop outcome measures that show you are consistently meeting the new policies…(and) document compliance

34. Accountability Regulators Hospitals Professionals

35. Accountability Regulators Patients Hospitals Professionals

36. Reciprocal Accountability 1. Implementing best safety practices 2. Dealing with problem doctors

38. What’s Wrong? 1. Takes too long 2. Early warning signs are ignored 3. Totally reactive

39. Our “Non-System” • Implicit • Personal • Punitive

40. Defining Problem Doctors as Disciplinary Problems • “Hung up” on punishing - Want to “weed them out” - Methods are personal, individual, emotional, judgmental • Safety objective: prevention - Method: objective

41. Types of Problem Doctors 1. The impaired physician Substance abuse - alcohol / drugs Psychiatric problems Physical illness 2. Declining Competency 3. Personality Problems Disruptive physician Refuses to follow rules Abusive behavior Abusive with patients

42. An Effective Professional Accountability System • Adopt performance standards • Adherence is a condition of appointment to staff • Adherence is monitored (everyone) • Broad repertoire of methods for remediation Goal: doctor remain in practice

43. Treat All Co-workers with Respect • No hostile behavior (raised voice, insults, public reprimands) • No humiliation of residents and nurses • No derogatory comments about colleagues • Accept challenges to the authority gradient for safety

44. Accountability and Professionalism • Accountable to our patients – “put client’s interest above your own” • Accountable to our colleagues – “ensure high standards of practice” • Accountable to ourselves - “maintain skills and competence”