Prisoners of the System or Prisoners of our own Thinking?

1. When at some future date the high court of history sits in judgment on each one of us … our success or failure in whatever office we hold will be measured by the answers to four questions: Were we truly men of courage…? Were we truly men of integrity …? Were we truly men of judgment …? Were we truly men of dedication …?

2. Prisoners of the System or Prisoners of our own Thinking? • Leaders could not see the consequences of their own policies, even when they were warned in advance that their own survival was at stake – Barbara Tuchman, The March of Folly. • We live in no less perilous times today, and the same learning disabilities persist, along with their consequences. Peter M. Senge “The Fifth Discipline”

3. True Pro-activeness comes from seeing how we contribute to our own problems • “We tend to see life as a series of events, and for every event, we think there is one obvious cause.” • “Our explanations distract us from seeing the longer term patterns of change that lie behind the events and from understanding the causes of those patterns.” • “The primary threats to our survival, both of our organizations and of our societies, come not from sudden events but from slow, gradual processes.”

4. We have met the enemy and he is us!“Pogo” by Walt Kelley • Structure produces behavior and changing underlying structures can produce different patterns of behavior. • Since structure in human systems includes the ‘operating policies’ of the decision makers in the system, redesigning our own decision making redesigns the system structure.

5. Increasing Quality and Lowering Costs Can go hand in hand over time • Basic improvements in work processes could: • eliminate rework • eliminate quality inspectors • reduce customer complaints • lower warranty costs • increase customer loyalty • reduce advertizing and sales promotion costs • You can have both goals – if you are willing to wait for one while focusing on the other.

6. Up front Costs = Long Term Returns • Investing time and money to develop new skills and methods of “assembly”, including new methods for involving everyone responsible for improving quality, is an up front “cost.” • Quality and costs may both go up in the ensuing months although some cost savings (like reduced rework) may be achieved fairly quickly, the full range of cost savings may take several years to harvest.

7. The Patient Safety and Quality Improvement Act of 2005http://www.pso.ahrq.gov/contact/contract/.htm • Enacted in response to growing concern about patient safety in the United States and the Institute of Medicine’s 1999 report, To Err is Human: Building a Safer Health System • The goal of the act is to improve patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients

8. The PS&QI Act signifies the Federal Government’s commitment to fostering a culture of patient safety • Communication Barriers, Identification of Patterns, Eliminating PS Risks and Hazards • Federal Legal Privilege and Confidentiality Protections • What are “Patient Safety Work Product” and “Patient Safety Evaluation Systems?” • A Network of Patient Safety Databases (NPSD)

9. Patient Safety Officers and The Patient Safety and Quality Improvement Act • Are our institutions knowledgeable about the intent and the value that the act brings to quality improvement in the delivery of care? • Are our leaders educated and trained in the skills needed to take advantage of this opportunity to bring performance excellence to our institutions?

10. Are we ready to implement the PS & QI Act?' • Are we ready to share the patient safety knowledge we learn in co-competition with each other, and are we committed to do this? • Are we desirous of creating learning organizations for continual performance improvement? • What are our plans to achieve these goals?

11. How well do we Communicate? • Is your workplace culture open, honest, and supportive? • Is information widely shared in a transparent manner or is it withheld and limited? • What are your practices and policies around handling medical errors? 

12. Kenneth J. Abrams, MD, MBA Senior Vice-President, Clinical Operations Associate Chief Medical Officer North Shore-LIJ Health System Great Neck, NY

13. Speed happens when people… …truly trust each other Edward Marshall

14. Creating a team built on trust Source: Picrew image from www.flickr.com/photos/jaredsmith/303673741/ accessed on 8/13/08 , patient image from www.abc.net.au/news/newsitems/200607/s1677583.htm accessed on 8/13/08

15. The State of Trust • In the United States: (2005 Harris Poll) • 22% trust the media • 8% trust political parties • 27% trust the government • 12% trust big companies

16. The State of Trust • In healthcare: • What is the relationship like between physicians & hospitals? • How are the major insurance carriers viewed by consumers, hospitals, physicians? • How well do your performance improvement teams function? How are their plans for improvement embraced?

17. Till the Soil, Cultivate Trust • The Economics of Trust Trust = Speed + Cost Adapted with permission from CoveyLink Worldwide

18. Trust taxes vs. Trust Dividends

19. Reframing the role of physicians in the care team… …from Captain of the Ship to Conductor of the Symphony Source: Orchestra Imaging from Chang W. Lee/ The New York Times captured from http://www.nytimes.com/2008/02/27/world/asia/27symphony.html?_r=1&oref=slogin accessed on 8/13/08; Operating Room Image from www.smilesinternationalfoundation.org accessed on 8/13/08

20. Is "I am sorry" a component of disclosure? • When a family member is admitted to the hospital, do you pick up the phone and call someone to "help" ensure that things are handled properly? If so, why? • Are we prepared to lead toward a culture of learning and away from a punitive culture?  What challenges need to be overcome in order to be successful?

21. Creating high trust teams… Source:….

22. Communication Barriers, Identification of Patterns, Eliminating PS Risks and Hazards • The Act creates Patient Safety Organizations (PSOs) to collect, aggregate, and analyze confidential information reported by health care providers. • Currently, patient safety improvement efforts are hampered by the fear of discovery of peer deliberations, resulting in under-reporting of events and an inability to aggregate sufficient patient safety event data analysis. • By analyzing patient safety event information, PSOs will be able to identify patterns of failures, and propose measures to eliminate patient safety risks and hazards.

23. Federal Legal Privilege and Confidentiality Protections • Many providers fear that patient safety event reports could be used against them in medical malpractice cases or in disciplinary proceedings. • The Act addresses these fears by providing Federal legal privilege and confidentiality protections to information that is assembled and reported by providers to a PSO or developed by a PSO (“patient safety work product”) for the conduct of patient safety activities. • The Act also significantly limits the use of this information in criminal, civil, and administrative proceedings. The Act includes provisions for monetary penalties for violations of confidentiality of privilege protections.

24. What are “Patient Safety Work Product” and “Patient Safety Evaluation Systems?” • The Act specifies the role of PSOs and defines “patient safety work product” and “patient safety evaluation systems,” which focus on how patient safety event information is collected, developed, analyzed, and maintained. • The Act has specific requirements for PSOs such as: • PSOs are required to work with more than one provider. • Eligible organizations include public or private entities, profit or not-for-profit entities, such as hospital chains, and other entities that establish special components. • Ineligible organizations include insurance companies or their affiliates.

25. A Network of Patient Safety Databases (NPSD) • The Act calls for the establishment of a Network of Patient Safety Databases (NPSD) to provide an interactive, evidence-based management resource for providers, PSOs and other entities. • The NPSD will be used to analyze national and regional statistics including trends and patterns of patient safety events. • The NPSD will employ common formats (definitions, data elements, and so on) and will promote interoperability among reporting systems. • The Department of Health and Human Services will provide technical assistance to PSOs.

26. The Laws of the Fifth Discipline • Today’s problems come from yesterday’s “solutions.” • The harder you push, the harder the system pushes back. • Behavior grows better before it grows worse. • The easy way out usually leads back in. • The cure can be worse than the disease. • Faster is slower. • Cause and effect are not closely related in time and space. • Small changes can produce big results – but the areas of highest leverage are often the least obvious. • You can have your cake and eat it too – but not at once. • Dividing the elephant in half does not produce two small elephants. • There is no blame – the cure lies in your relationship with your “enemy.”