LEADERSHIP ASSIGNMENT PART 2

Quality/patient safety

20 years after To Err Is Human A look back on the landmark study on human error and broken systems

by Brian Ward

On November 29, 1999, the landmark study To Err Is Human: Building a Safer Health System was released. In it, the authors claimed that to prevent countless instances of medical errors and harm, providers needed to stop placing blame on individuals and start looking at the systems those individuals worked in instead. This was completely at odds with the prevailing culture in healthcare, and its release kicked off the patient safety movement as we know it.

Twenty years later, providers are still trying to achieve zero harm. While no one would say that we’re close to that goal, a lot of progress has been made—progress that’s saved many lives.

When it came out

Klaus Nether is the executive director of high reliability product delivery at The Joint Commission Center for Trans- forming Healthcare. He was working in laboratory manage- ment when he first read the report.

“Many times, especially with liability issues, it becomes very difficult to be open and honest and transparent about errors that occur in healthcare,” he says. “When To Err Is Human came out, it was groundbreaking because it brought all that to light.”

Nether says everyone he has met in healthcare wants to do the best job they can. But even at the best facilities, there are processes and systems that don’t work as expected—some- times resulting in harm or death. Learning to prioritize patients and fix errors rather than laying blame has been a step forward, in his opinion.

“For me personally, from a laboratory standpoint, I think it changed my way of thinking,” he added. “Because it was always about ‘How good were we?’ and we were always 95% good or 97%, 99% good. But we never thought of the flip side of it—1%, 3%, 5% errors and what that actually meant and the magnitude of it.”

Anne Marie Benedicto, MPP, MPH, vice president of The Joint Commission Center for Transforming Healthcare, remembers when To Err came out.

January 2020 | Volume 21, Issue No. 1

In this Issue

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“When a positive and open culture is created, great things happen and everyone benefits, especially patients.”

PSMJ decade review, part two

Looking ahead to 2020 and beyond.

Waters of life

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Drug diversion in the opioid crisis

A return to TJC’s Quick Safety 48 alert, and how to keep medicines in the correct hands.

Five strategies for treating opioid addiction

System-level strategies for hospitals to improve prevention, identification, and treatment of opioid use disorder.

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“I was fairly young in healthcare,” she says. “I thought that this whole idea that you can’t prevent people from making mistakes because it’s part of the human condition—to fail, to make mistakes, to not always be 100% vigilant because we’re not robots—I thought that wasn’t a big deal. Coming in as a fairly new person in healthcare, I made mistakes several times a day.”

After spending more time in healthcare, Benedicto realized why the report was such a big leap. There’s a huge pressure to be perfect, she says, because mistakes can result in harm to the patient and staff.

“Instead of expecting people to be doing 120% every day and every time, it might be easier to address the systems and

structures that support them so it’s easi- er for them to not make mistakes.”

Anne Marie Benedicto, MPP, MPH

“We put such a high bar on perfection in how we perform, without really understanding that it’s not about making people perfect,” she says—adding that other industries do understand this. “It’s making systems as good and strong as they can be so you’re supporting the humans in them and creating an envi- ronment where they can do their best work.”

It’s hazardous when healthcare systems require providers to be super vigilant to avoid patient harm, she says. It’s detrimental to have a culture that punishes people for making mistakes, even when those mistakes are based on flawed systems. And it’s an issue when there’s no infrastructure to learn from mistakes and use those lessons to make your system stronger.

“What we have in healthcare is really good, smart, talented people working in flawed systems,” she adds. “And we expect heroic behavior every day when some- times instead of expecting people to be doing 120% every day and every time, it might be easier to address the systems and structures that support them so it’s easier for them to not make mistakes. And if they do make mistakes, there are enough protections within your system that mistakes don’t always result in harm. [So] people can just be human and make errors.”

What’s changed?

When To Err Is Human came out and healthcare organizations digested what it meant, a lot of attention and resources were directed at healthcare improvement. How can we strengthen our practice? How can we make things better? How can we incorporate improvement methodology into healthcare?

There was a recognition that this was necessary, Benedicto says, and much has been done. There’s been progress on things like healthcare-acquired infections, with rates continuing to decline. Nether points to decreases in central line–associated bloodstream infections, falls, and falls with injuries.

“However,” Benedicto says, “if we got healthcare leaders together and asked them, ‘Are you happy with the state of improvement? Have we achieved zero harm? Are healthcare organizations as safe as they could be?’ I think generally we will hear people say, ‘No, we are not where we need to be.’ ”

“There’s still a lot of work to do,” Nether adds. “I think one of the things healthcare organizations strug- gle a lot with is sustaining the improvements they make. There’s so many different variables that get introduced into an organization. One of the things that I see is that people leave one organization or come in from another, bringing a variation to the process that sometimes results in bad outcomes.”

“It was always about ‘How good were we?’ and we were always 95% good

or 97%, 99% good. But we never thought of the flip side of it—1%, 3%,

5% errors and what that actually meant and the magnitude of it.”

Klaus Nether

Aviation and nuclear power

You might have heard the airline industry or nuclear power industries cited as examples of high reliability organizations. True, there have been some famous and catastrophic disasters in both those fields. But since then, they’ve built off of past mistakes to become some of the safest industries around.

“If you compare their rates of harm to healthcare, we pale in comparison; we have much more harm than commercial airlines or nuclear power,” Benedicto says.

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“And that’s because the mindset, culture, and practices that support that outcome of nearly zero harm in airline and nuclear power is very different from healthcare.”

The commercial airlines have such low rates of harm that they’ve learned to become even safer by investigating events and variations in their process that have not resulted in harm. While healthcare organiza- tions have more than enough harmful errors, Benedicto says there’s been a growing awareness of the need to study close calls—events or mistakes that happened but didn’t harm the patient.

“Those are free lessons—you didn’t harm anyone, but you can see the flaws in your system,” she says.

While the safety of the healthcare industry is often compared to that of commercial aviation and nuclear power, some argue that healthcare is too different for the comparison to be fair. And Benedicto says there’s truth to that.

“Even a small hospital is a very complex organiza- tion,” she says. “I think the level of complexity in healthcare organizations is bigger than even a nuclear power plant, which is amazing if you think about it. And if you start looking at healthcare organizations now, the gigantic systems that are being created and formed, you can see the level of complexity is increas- ing. It’s not quite apples to apples [with nuclear power].”

Another barrier is that healthcare organizations have not built the infrastructure they need to make improvements common practice. Dawn Allbee works at The Joint Commission Center for Transforming Healthcare as the executive director of customer engagement. Part of the Center’s work is helping healthcare organizations strengthen their robust pro- cess improvement programs.

“The key thing is having the tools to do [improve- ment],” Allbee says. “Currently, healthcare organiza- tions are looking for the best practice to fix hand hygiene, the best practice to eliminate wrong-site surgery. Best practices work when the causes are few and variation is little.”

With persistent healthcare problems, she says, you need a strong set of tools to identify where the root causes are. That’s not something healthcare organiza- tions necessarily have, she says, but it’s something they need.

“Everything we’ve been doing to this point [to solve problems] has been working to a modest level,” she

says. “But you really need to dig in deep to understand what those root causes are to come up with that tar- geted solution to solve that problem vs. ‘We think this might work, let’s try this—oh, it didn’t work; let’s try something else.’ ”

People working in healthcare are there for the patients, she says, and need to be caring directly for those patients. That can limit their time for improve- ment training.

“However, it’s very important to give them the toolset so they can go ahead and work on these im- provements in their daily work,” she says.

What’s next?

“This is a very exciting time to be in healthcare,” Benedicto says. “A lot of the things we’ve taken for granted—hierarchies in healthcare, the way organiza- tions engage their employees, what kind of investments they make—all those ideas are being challenged, and we are starting to see very exciting results in organiza- tions who have made a commitment to zero harm.”

“You really need to dig in deep to under- stand what those root causes are to

come up with that targeted solution to solve that problem vs. ‘We think this might work, let’s try this—oh, it didn’t

work; let’s try something else.’” Dawn Allbee

As a next step, she says, leaders need to recognize that zero harm is achievable. It’s their job—they set the vision for their organization, allocate resources, and ultimately are the ones who make zero harm possible. However, in a recent Center study on zero harm and care excellence, 77% of respondents identified leader- ship as a barrier to excellence.

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“That’s not my experience talking to a lot of health- care leaders across the country; they’re very committed to excellence,” says Benedicto. “But there appears to be a disconnection between that commitment and what their team sees and experiences.”

Leaders need to visibly and vocally set the goal of zero harm, she says, and “connect the dots so that people see that ‘This is our goal, this is how we’re going to get there, and this is what I expect from you.’ ”

Those types of communications and the actions that follow them show providers that their leaders value the pursuit of excellence just as much as they do. What strikes Benedicto about the goal of zero harm—as put forth in To Err Is Human—is that even within very complex organizations, safety comes down to the people and leaders within them.

“When staff starts getting engaged in zero harm and see their role in keeping patients safe and doing the best work they can, you can really see an organization change,” she says. “That transformation to high reliabil- ity, you need to have near-perfect systems, you need to become a strong organization to produce zero harm. It’s probably the biggest transformational journey any of us will see right now in healthcare, and it’s a long-term journey, but it is an exciting one.”

“It’ll probably be a 10-year journey, but if you commit you’ll see change in six months, three months,” she adds. “And that kind of change accrues to become transformation.”

Patient safety

Providing excellent care through training and culture by Thom Wellington

The most successful hospitals not only focus on patient safety and positive outcomes, they also create a collective winning mindset within the organization. When a positive and open culture is created, great things happen and everyone benefits, especially pa- tients. Two leaders—one in the Navy and one at a top-five hospital system—had simple but effective ways to create a culture that drove success. They understood they could not change the individuals or the physical

environment, so they focused on what they could change: culture and attitudes.

Captain D. Michael Abrashoff’s book, It’s Your Ship, is a surprisingly apt read for hospital administra- tors that want to improve outcomes. When Captain Abrashoff took the helm of the USS Benfold, it was the worst-performing ship in the Navy. Though it was loaded with the most advanced technology, the crew did not fully understand their mission. But instead of scrutinizing his team, Abrashoff took a different approach. While analyzing each process on the ship, he asked, “Is there a better way to do what you do?”

“When a positive and open culture is cre- ated, great things happen and everyone

benefits, especially patients.” Thom Wellington

The approach paid off as he started making small changes to practices based upon this feedback. Soon, more suggestions came in, and new approaches and protocols were established. The crew felt like they were part of the management process and were eager to learn more skills. In response, Abrashoff started duplicate training to ensure at least two people always knew each job task and received continual training. Part of being a team is filling in for other members when needed with no loss of skill set.

When a leader demonstrates that employee input is important and incorporates suggestions, attitudes change. According to Abrashoff, “Some leaders feel that by keeping people in the dark, they maintain a measure of control. But that is a leader’s folly and an organization’s failure. Secrecy spawns isolation, not success.” Aboard a ship are sailors from every type of background and education—and a hospital’s staff is similarly diverse. Making sure everyone feels they are part of the team and have a voice is the key to pushing success to excellence.

The Cleveland Clinic, like other prominent healthcare systems, embraces change to optimize patient outcomes. Former CEO Toby Cosgrove, MD, understood leading was not about him, but about empowering the entire team to achieve superior results. Like Abrashoff, Cosgrove created a culture that allowed everyone to be set up for success—with the patient as the focus.

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