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Patient Safety Leadership

Patient Safety Leadership. Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group. Leading Change: Universal Challenge of Technical and Adaptive Work. Technical Challenges. Can be solved with existing science or technology

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Patient Safety Leadership

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  1. Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group

  2. Leading Change: Universal Challenge of Technical and Adaptive Work

  3. Technical Challenges • Can be solved with existing science or technology • Issues or challenges for which there is “an answer”

  4. Adaptive Challenges • Require a change of values, attitudes or beliefs

  5. The Birds’ Eye View Technical and Adaptive Challenges in Quality and Safety Efforts Nationally • JCAHO Core Measures • CMS • NQF Internationally • WHO/ World Alliance for Patient Safety

  6. The Birds’ Eye View Technical and Adaptive Challenges in Quality and Safety Efforts • TPSC • Improve Culture • Reduce CLABSI • Reduce MRSA • Minimum 25% reduction in surgical complications (SCIP measures)

  7. Central Mandate x Scientifically Sound Feasible Local Wisdom

  8. Elizabeth Dayton, Joint Commission Journal, Jan. 2007

  9. Pronovost: Health Services Research 2006

  10. Leadership Actions for Senior Leaders • Keep patients your North Star • Tell your own Josie Story • Commit resources to safety • Adopt a unit as part of CUSP • Commit to valid measurement

  11. Leadership Actions for Team Leaders • Keep Patients your North Star • Voice of patient • Focus and Execute • Walk a process • Identify barriers (who wins who loses) • Project management • Maintain momentum • Communicate with senior leaders • Create valid measurement system

  12. Leadership Action for Staff • Keep patients your North Star • Walk a process • Reflect on perceived losses with change • Commit to identify and mitigate hazards

  13. 2 year results from 103 ICUs Pronovost NEJM 2006

  14. Keystone ICU Safety Dashboard

  15. Lessons Learned Need to get technical and adaptive work right • Centralized measurement • Local ownership

  16. Lessons Learned • Adaptive lessons • Commit that harm is untenable; make harm visible • What does this look like in your health care setting? • Ohana • How will you share what you learn with other teams in the collaborative? • Local modification of execution • How will you adapt implementation in light of your organizational culture?

  17. Lessons Learned • Technical lessons • Link culture and specific outcomes • How will you link culture scores and clinical results? • Data quality control • Does your project team include and respect expertise of technical and adaptive experts ? (Infection control, education, QI, organizational development etc?)

  18. Leading Change • Technical and Adaptive Work • One of most common leadership mistakes is expecting technical solutions to solve adaptive challenges…. Ron Heifetz “Leadership without Easy Answers” 21

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