Energizing Frontline Staff in Patient Safety

1. Energizing Frontline Staff in Patient Safety Joseph T. Cooke, M.D Chief Quality and Patient Safety Officer NYP-WCMC

2. Mistakes even happen at elite hospitals • Jessica Santillan • Betsey Lehman • Libby Zion

3. . Human Factors • No one makes an error on purpose. • Everyone makes dumb mistakes every day • No one admits an error if you punish them for it.

4. Human Factors • “Constantly adapting to demanding, complex, and fragmented systems, the clinician’s struggle to reach the elusive goal of providing safe care is heroic.”Partnership for Patient Safety Video Theme

5. Latent Failures Triggers Accident Defenses “Normal” operations Complex systems fail because of the combination of multiple small failures, each individually insufficient to cause an accident. These failures are latentin the system and their pattern changes over time. Modified from Reason, 1990

6. Spinning the squirrel cagedoes not work

7. The Critical Elements • A true commitment to patient safety by the organization's leaders • Safety as a system property, not a project or initiative • Creating an organization that builds patient safety into it's fabric • Frontline workers need to free from blame for human factor or system flaws • Communication and teamwork training • Simulation • Walk Rounds

8. Walk Rounds: A Leadership Management Tool • Leadership “carries the banner of safety” • Promote communication of patient safety issues between providers, senior leaders, and Board of Trustees • Promote culture of patient safety • Encourage staff to share ideas and concerns • Create a culture where employees: • Feel valued • “What it means to me” • Have adequate information regarding patient safety • Feel that the leaders are approachable • Have the knowledge, tools, equipment and support to promote patient safety • Assume responsibility and accountability for creating a safe care environment

9. Students Perspectives on Leadership after the Walk Rounds • “Safety is always on my mind but the role of leadership really changed in my mind…I thought the blue suits were only interested in numbers…so it was great to see how concerned they were about the safety of patients and staff.” • “The sense that the leadership of this hospital is so committed to patient safety by conducting these rounds is admirable. We usually hear how cold the administrators are and this changed my mind.”

10. Obstetric Safety

11. Economic Benefit

13. Lessons Learned • Rigor is essential • Quality resources needed • Flexibility is necessary • Adapt to each hospital • Scheduling is a nightmare • Demands on students time • Executive schedules