“If transparency were a medication, it would be a blockbuster, with billions of dollars in sales and accolades the world over. While it is crucial to be mindful of the obstacles to transparency and the tensions—and the fact that many stakeholders benefit from our current largely nontransparent system—our review convinces us that a health care system that embraces transparency across the four domains will be one that produces safer care, better outcomes, and more trust among all of the involved parties. Notwithstanding the potential rewards, making this happen will depend on powerful, courageous leadership and an underlying culture of safety.”
The previous paragraph comes from the fifth and final National Patient Safety Foundation’s Lucian Leape Institute (LLI) White Paper entitled, “Shining a Light: Safer Health Care through Transparency”. Each of the five white papers address key issues that healthcare stakeholders will need to successfully manage if healthcare is to achieve zero preventable harm. I was honored to be part of the panel that helped create this paper and the 39 recommendations for greater transparency throughout healthcare.
Defining transparency as “the free, uninhibited flow of information that is open to the scrutiny of others”, the paper provides recommendations in four different domains of transparency:
- Transparency between clinicians and patients (illustrated by disclosure after medical errors)
- Transparency among clinicians themselves (illustrated by peer review and other mechanisms to share information within health care delivery organizations)
- Transparency of health care organizations with one another (illustrated by regional or national collaboratives)
- Transparency of both clinicians and organizations with the public (illustrated by public reporting of quality and safety data)
I encourage everyone to visit the LLI website and download the White Paper (click here for a copy). Increased transparency is critical to any Patient Safety mission. Greater transparency throughout the system is not only ethically correct, but will lead to improved outcomes, fewer errors, more satisfied patients, and lower costs.
We have recently been reminded just how powerful the pen remains in stirring the hearts and minds of men and women around the world. And, we have often discussed on ETY how stories can change ideals, culture and even societal norms. With this knowledge in mind, we wanted to share the following opportunity offered by one of our Telluride Experience sponsors, The Doctors Company Foundation, in Partnership With The Lucian Leape Institute at The National Safety Patient Safety Foundation. This patient safety centered organization and partner is once again hosting a Young Physicians Patient Safety Award and essay contest for young physicians in training interested in sharing their story related to a personal experience with patient safety through the 4th year of medical school. The deadline to enter an essay is 5pm ET, February 2nd, and additional information on entering can be found below, as well as at the Doctors Company Foundation website.
Our Telluride Alum have been blogging and reflecting with great depth on wisdom gained in only the early years of their healthcare careers regarding just how complex an issue all things patient safety related can be. The hope is that at least a few will share their stories, along with their writing talents and passion for patient safety via this venue! Excerpts of essays from 2014 winners can be found in the ETY post, Sharing the Doctors Company Foundation 2014 Award Winning Essays. These winning essays have already served as safety moments in a large health system, as well as inspired peers to think and act differently when it comes to keeping patients safe.
In brief, The Doctors Company Foundation Young Physicians Patient Safety Award recognizes young physicians for:
…their personal insight into the importance of applying the principles of patient safety to reduce the incidence of medical error. Individuals are invited to submit essays about patient safety events they personally experienced during clinical rotations. The essays will be judged by a panel selected by the Lucian Leape Institute of the National Patient Safety Foundation (NPSF). Six winners will be selected and each will receive a $5,000 award, which will be presented at the Association of American Medical College’s (AAMC) Integrating Quality meeting in Chicago, June 2015.
- As of July 1, 2014 applicants must be either a 3rd or 4th year student in an American medical school
- Award is for the best essay explaining your most instructional patient safety event during a clinical rotation-one that resulted in a personal transformation
- Award will be presented by The Doctors Company Foundation at AAMC’s Integrating Quality meeting in Chicago
- Essays will be judged and winners selected by panel identified by NPSF, all review committee decisions are final
- In 500-1,000 words describe the most instructional patient safety event you experienced, one that resulted in a personal transformation. The essay should have an emotional impact on the reader and provide a lesson that is transferable to other medical students and medical professionals.
- Explain how the event impacted your learning and growth and how the experience will help you to provide the safest care to your current and future patients. You must include examples of how to improve any system errors or processes that contributed to the adverse patient event and explain how you will ensure that the changes are implemented.
Description of relevant events for the essay includes any patient safety event, including “near misses”. A patient safety event is a process or an act of omission or commission that results in hazardous health care conditions and/or unintended harm to the patient. The event is often a consequence of a systems failure or error. Examples include medication related errors, communications errors, health care – associated infections, medical record errors, identification errors and delays in responding to critical diagnostics.
Essays must maintain the confidentiality and integrity of the patient and location of the event. Please use fictitious names and locations in the essay.
Breakout sessions at last week’s Lucian Leape Forum included Dr. Lucian Leape himself, Paul O’Neill, Former Chairman and CEO, Alcoa, 72nd Secretary of the US Treasury and more. I had the long-awaited pleasure of hearing Paul O’Neill speak in person, during his breakout session entitled, Operationalizing, Disseminating and Implementing Joy & Meaning In Work and Workforce Safety, along with Julie Morath, RN, MS, President & CEO, Hospital Quality Institute of California. O’Neill’s unwavering standards and expectations in business, and for healthcare, have been an inspiration for many. Therefore, it came as no surprise that he seemed irritated with our progress to date, pulling no punches when asking the group how many of us in the room knew the real-time facts about injury to the people who do the work in our hospitals, and, did a system currently exist to provide that information with a 24-hour lapse? No one in the room raised a hand, and he shared that only 6/100 in a recent audience responded affirmatively to the same questions.
“We’re too far away from this type of excellence,” he said, following with a story that while at Alcoa, the company’s screen saver included real-time safety data. When a particularly concerning near miss appeared on his screen one day, O’Neill picked up the phone and called the team in Russia where it had occurred, asking for more information about what had happened. The personal attention to this near miss resonated throughout the organization, furthering the culture and behaviors that make organizations stronger. It’s this type of response and awareness to healthcare professional harm, as well as patient harm, that will move us to where we need to be.
“Why can’t we do this (in healthcare)?” was O’Neill’s resounding and animated challenge, many in the room knowing full well why we have not. Healthcare culture, leadership that says one thing but fails to support the necessary changes at pivotal moments, inertia–all of these however, are choices made by leadership. Either you’re in or you’re out.
Much of O’Neill’s breakout session was based on the LLI white paper, Through the Eyes of the Workforce, a must read for anyone serious about improving the quality and safety of care. Key takeaways from this breakout, as well as the summary session that followed, include:
- It will be very challenging to protect patients if we first can’t protect our own.
- The physical and psychological safety of our healthcare workforce is pivotal to ever improving the quality and safety of care.
- Real leadership is enabling not controlling.
- A leader’s first responsibility is to his/her people.
- Safety is not negotiable – it’s not a trade-off. You figure out how to pay for it. A pre-condition is that people who work ‘here’ will not get hurt.
- Habitually excellent organizations don’t “report” – they share information and act in a timely way when things go wrong.
- The response is key when people do share information. You can shut down a reporting culture in a heartbeat if you criticize someone for what/how/where they shared information.
- How would your healthcare workforce answer O’Neill’s 3 Questions: 1) Am I treated with dignity and respect by everyone each day? 2) Do I have what I need so I can make a contribution that gives meaning to my life? 3) Am I recognized and thanked for what I do?
We were reminded that it is hard to make a business case for healthcare professional safety, but data also shows that unhappy, un-empathetic, uninspired or unrecognized healthcare professionals directly impact the safety of patients, which directly impacts the “business case” in immeasurable ways. Too often, many in healthcare have observed our colleagues defend or excuse sub-optimal results, or continue to look the other way when observing behaviors that clearly are not in the best interest of colleagues or patients. O’Neill’s unwillingness to compromise standards or expectations is not only inspiring, those values created a company in Alcoa with a safety record that set the bar for his industry, as well as other high-risk industries. O’Neill left the group with many pearls, but following is one that particularly resonated along with advice from the world of storytelling:
“Organizations are either habitually excellent or they’re not – there’s no in between,” said O’Neill.
“Do or not do, there is no try,” fictional sage Yoda advises via the story world of Star Wars.
It is time for healthcare to do differently.
The 7th Annual National Patient Safety Foundation and Lucian Leape Institute Forum and Gala was held last week in Boston, gathering patient safety leaders together to share knowledge, recharge and re-energize their efforts in making care safer for healthcare professionals and patients. The opening keynote, Using Informal Influence to Drive Positive Change in Healthcare, was given by Andrew Knight, PhD. Assistant Professor, Organizational Behavior, Olin Business School, Washington University. Knight has studied innovation implementation, leadership and teams in high risk environments, such as the surgical suite, ICUs, Emergency Departments and the military.
Knight’s talk provided a number of take home tools for healthcare leaders to approach internal change with new power. He supplied a different lens through which to view company politics, one that allows for consideration of “the other” versus leaving a footprint on even your mother’s forehead to reach the top. He shared insight into the influence skills and the collaboration across teams necessary to move quality and safety initiatives forward. And, he stressed that data alone has not been the sole catalyst for the large-scale adoption of change needed to make the healthcare workplace as safe as we need it to be, using the tragic story of Ignac Semmelweis as evidence. Many are familiar with Semmelweis’ story–the doctor who discovered hand washing as a “cure” for the high number of deaths related to childbirth in Vienna clinics. His findings at the time went against the medical community’s thinking of the day, with physicians even taking offense at the request to wash their hands before caring for a patient. Unable to convince, or influence, others of his findings during his lifetime, Semmelweis was ultimately committed to a psychiatric hospital at the age of 47, and beaten by guards two weeks after his arrival. As the story goes, Semmelweis died shortly after from the same infection he was trying to protect patients from through hand washing. This simple, cost-effective step in the delivery of care at the desired 100% adoption rate still eludes health systems today.
Additional takeaways from Knight’s talk include the following. He is an excellent speaker and the topic couldn’t be more timely for healthcare.
- When it comes to navigating the waters of company politics, do you consider yourself an innocent lamb, a straight shooter, a survivalist, company politician or Machiavellian? Knight asked the group to respond via a text message survey. Results showed a normal distribution, the majority claiming to be survivalists with one Machiavellian in the group, prompting Knight to tongue-in-cheek, warn all to watch their backs.
- A more realistic view of company politics was offered, such as: Instead of considering what tactics might be used to influence someone, walk a mile in their shoes to understand exactly how what you offer might affect another. Or, instead of kissing up to those in power, feel free to compliment those you admire!
- Driving positive change is hard work! A 2005 study showed more than 50% of attempts to implement innovations end in failure, and that over $500 Billion is wasted annually on new technology implementations, according to Morgan Stanley
- To implement change, groups outside one’s direct circle of influence need to buy-in, collaborate, support, and supply resources to be successful. Influence skills can help gain the buy-in!
- Informal influence at all levels of the organization is what makes for the successful adoption of new initiatives.
- A numeric equation to map the political landscape related to change was provided, quantifying the amount of current support for any given project, by any given stakeholder, indicating likelihood of success.
- “For most change initiatives we need commitment. Compliance is rarely enough.”