Overview of the Role and Responsibilities of the Patient
Safety Officer
The Quality Colloquium at Harvard
21 August 2005 Douglas B. Dotan, MA, CQIA (ASQ)
President, CRG Medical, Inc.
www.crgmedical.com
Patient Safety Quality Management Solutions
NOW WE WILLHAVE NO MOREACCIDENTS!!
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“If there is any Doubt,There is No Doubt”
Colonel Ran Ronen, Commander of the Israel Air Force Flight Training Academy, 1968
• The basis of a Culture of Safety• Most mishaps occur during training• Flight Safety Branch then functioned within the
Training Command – high IAF mishap rate• Transition from French to US equipment• Mishap rate did not decrease over the next 10
years• No formal training for Flight Safety Officers
Change Came with New Leadership
• 1978 General Benjamin Peled, commander of the Israel Air Force disbanded the Flight Safety Branch in the Training Command
• Created the independent Directorate for Safety and Quality Inspection that was empowered by him and subordinate only to him
• The new Mishap Investigation Branch was charged to conduct safety and not punitive investigations
• Investigators became empowered professionals and received the appropriate training
Mishaps Reduced by 50% in 5 years
• In 1980 the safety policies and procedures were re-written and a computerized classification for mishaps was designed and implemented
• The Directorate began to learn that failures were often systemic and began providing preventive action recommendations
• Wing Safety Officers received training and became part of the near-miss debriefing process – reporting went up, mishaps down
The (Patient) Safety Officer- Patient = Someone under medical care- Safe = Free from harm- Safety = Freedom from danger- Officer = One who holds an office of
trust or authority
So is the Patient Safety Officer the one trusted to keep those under medical care free from danger? Is the role of the Patient Safety Officer any different from the Flight Safety Officer, Ship Safety Officer, Industrial Safety Officer, etc?
• Take Command• Lead by Example• Listen Aggressively• Communicate Purpose and
Meaning• Create a Climate of Trust• Look for Results, Not
Salutes• Take Calculated Risks• Go beyond Standard
Procedure• Build up your people• Generate Unity• Improve your People’s
Quality of Life
USS Benfold - Successes
• In 1998 – operated on 75% of their budget• Reduced “mission degrading” equipment
failures from 75 in 1997 to 24 in 1998• Returned $600K from the ship’s
$2.4million maintenance budget and $800K from $3 million repair budget
• Cut redeployment cycle from 52 days – 22 in port and 30 at sea to 19 days – 5 in port and 14 at sea.
Sometimes Mistakes Do Happen
And Often It’s Not Your Fault …..
It’s time to leave your Comfort Zone and Chart your own Course
• Once you squander an opportunity you can never get it back
• No one person can stay on top of it all
• You need to get more out of your people and challenge them to step up to the plate
• Are your people free to question conventional wisdom and dream up better ways to do their jobs?
DON’T BOTHER …..
• If the CEO does not hold herself/himself personally responsible and accountable
• If the Patient Safety Officer (PSO) is not part of the Senior Management Team of the hospital
• If the PSO is not empowered by the CEO and reports to anyone else but the CEO
• If safety investigations are conducted for punitive and corrective action instead of safety and preventive action
• If the CIO is not part of the Patient Safety team
What should I work on?
• Focus on system enablers – what are the conditions that allow events to propagate
• Identify the micro-systems that surround an event
• Find out what are the barriers that prevent people from feeling safe to talk, report and share their stories
Earn the Trust of Clinicians
• Do not look at the clinicians as the enemy
• Most clinicians think you are out to “get them” – if you are not a clinician you have to earn their respect
• You need to nurture and grow this relationship
• This is hard work, be patient, look upon it as a journey
Physicians are our Biggest Problem They Still do not Totally Buy-in
• 3 years concentrated on processes to reduce Wrong Side surgery in the OR - used the Time-out
• Most surgeons thought this was a waste of time• The circulating nurse will not start the case without
the time-out• The biggest complainer about 3 months ago did
not conduct the time-out appropriately and performed a wrong-side surgery
• The patient discovered the error after the surgery • After a RCA, the surgeon was there and said “I
was wrong about this, we really need to do the time-out”
Wind The Clock!
The Aviators Time-out
Prevents Turning a Small Malfunction into a Catastrophic Failure
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Angled DecksAviation Safety Center
Naval Aviation Maintenance ProgramRAG (FRS) Concept Initiated
NATOPS ProgramSquadron Safety Program
System Safety Aircraft DesignACT
Culture/ Simulators
MFOQA
Angled DecksAviation Safety Center
Naval Aviation Maintenance ProgramRAG (FRS) Concept Initiated
NATOPS ProgramSquadron Safety Program
System Safety Aircraft DesignACT
Culture/ SimulatorsCulture/ Simulators
MFOQAMFOQA
776 aircraftdestroyed in
1954
776 aircraftdestroyed in
1954
Fiscal YearFiscal Year
26 aircraftdestroyed in
FY 03in flightmishaps
26 aircraftdestroyed in
FY 03in flightmishaps
SMARTER AIRCRAFTThe Next Step ?
SMARTER AIRCRAFTSMARTER AIRCRAFTThe Next StepThe Next Step ??
Naval Aviation Class AFlight Mishap Rate
FY 50 - 03
Naval Aviation Class ANaval Aviation Class AFlight Mishap RateFlight Mishap Rate
FY 50 FY 50 -- 0303
FY03 Rate = 2.37
What the PSO Hates the most
To be told, “we knew that was happening, we didn’t think it was worth stating anything”
- Faculty who doesn’t see patients after surgery - everyone knew, except …..
- The call bell cables were missing or broken - The nurses managers had to pay for them because they connected to the TV console.
At the time an auxiliary enterprise ran the TV service which was a fee generating function - so they didn’t buy them.
Remarks from 45 years in healthcare safety, quality, JCAHO, risk etc.
• Given the challenges of managing GenX'rs and the group ahead of them, heaven help us when the group behind them arrives on the scene, creating a culture of patient safety.
• I have yet to get my happy campers to that point. Intellectually they know the answers and know what the NPSG's are.
• Do they cut corners in a heartbeat? Of course.
What Motivates?
• Not all the literature and stories about the catastrophes in patient safety can motivate them to do what is right without exception.
• The larger facilities say they've got a handle on it---and spend $$$$$ and $$$$ to make care safer, I bet they still fight it daily.
Why Do Good People Violate Good Policies
• Too many other conflicting priorities in health care these days, and even good and hard working people are still human beings.
• It's one of those basic rules - If you take the time to do it right the first time, you don't have to deal with the clean up.
• Not all the well designed systems and technology can make it absolutely safe if people just cannot buy in and do it consistently.
Leadership is the Clue
• They MUST be on board and must be physically present in patient care areas demonstrating their expectations.
• And even that doesn't work consistently, because they have to go home and shower and sleep on occasion.
• And the problem is the leaders are the ones hardest hit with the conflicting priorities.
Middle Management is the Clue
Middle managers are the deputies to rely on to enforce a consistent approach - in a $$$$ crunch, who gets cut first? We need:- Middle managers who are bears on patient safety - Obvious communication and handoff going both ways between executive leaders and their deputiesIf there are enough middle managers to make consistency happen..maybe you have a prayer.
Dichotomies of the roleHow do we do our work?
– Promote vs Cheerleading– Leader vs Facilitator– Sung vs Unsung - in front or behind the scenes?– Coach? Internal consultant? Counselor? – On a pedestal or in a vice?– Worst problem: no one recognizes that there are problems?– OR Staff are afraid to report for fear of punishment. Ex: 3
med error rules in Texas.– Our worst fear:
Was any of it worth it? Did we make a difference?
Why do we see the same errors over and over?
What does Management Want?– How many masters? Boss, CEO CNO, the C suite
and its internal conflicts - add 2 more C’s- compliance and corporate
– Values of the administrator and the medical staff: what do they want: ROI? Nothing to report to the State? Fewer compensable events? Retention of staff? Improved morale? Lower patient LOS- and infections- but why? Fewer claims and lawsuits? No bad press?
– Woe to the administrator who says, I want fewer incidents! You’ll get that alright! You’ll never hear anything.
– Even with strong management support, we are not always sure what management wants
– And: physicians want to be involved, but that means 1. they want their pet project worked on, and 2. they often are in charge of projects they do not have the skill to manage
The downside of being a PSO
– Change is hard. Inertia takes the lead– Change is NOT always progress, sometimes it is worse – Why do we think we solved a problem, set up a process, to
have it go awry? Why do we continually relearn the same information?
– Sometimes you really don’t want to know what is the underlying cause - it is too painful
– Change hurts: it creates turmoil. Doubles work for a while. It isn’t static, it is really continuous, thus when do you ever see success? Change is truly risky behavior
– TIME FRAME we select an issue that has been a problem for- years – We want to solve it in two 1 ½ hour meetings and want it fixed right away! Goals are 5 years objectives and tasks are weeks or months. Our units of measure on success are off a unit!
– Must have a head of steel, heart of gold, strong shoulders and ability to pass credit to others
Barriers and Incentives to Standardization of Patient Safety Data
Systems • How can we transform
the current culture of blame and resistance to one of learning and increasing safety?
• Understanding the balance of barriers and incentives to reporting is the first step.
• Existing barriers:
- legal
- regulatory
- financial
- technological
- political• Additional barriers
- lack of authorization
- lack of good models
- evidence of impact
What more is needed?
• Introduction of norms that inculcate learning
• Non-punitive safety reporting culture in professional schools and graduate training programs
• Support from consumers, patient advocacy groups, regulators, and accreditors
• A certain amount of trial-and-error will be necessary.
• Legal protection for reporters must be reinforced, where incident reporting systems have been successful in gaining acceptance and credibility
The impact of barriers and incentives on individuals, organizations, and society
• Powerful disincentives to reporting depend on:
- The organizational culture
- Include extra work
- Skepticism
- Lack of trust
- Fear of reprisals
- Lack of effectiveness of present reporting systems
• Incentives to reporting include:- Confidentiality- Some degree of immunity- Philanthropy (when reporters identify with injured patients and other health care providers that could benefit from the data)- Educational (when reporters learn from reporting about their adverse events).
Complex interdependence exists between all barriers and incentives to
reporting at the individual, organizational, and societal levels.
• Incentives for society include:
- accountability
- transparency
- enhanced community relations
- sustained trust and confidence in the health care system.
• Barriers are more visible and specific than incentives.
• Incentives are tied to higher governing values.
• Fears and attitudes appear to limit the usefulness of structural incentives already in place.
Analysis of near-misses reveals the following information:
• Fewer barriers to data collection exist when no injury occurred
• Recovery strategies can be studied to enhance proactive interventions
• Hindsight bias is effectively eliminated since with no patient harm, there are no legal or administrative recriminations.
Near-miss reporting: a critical factor toward improving patient safety.
The contributing factors for the lack of near miss reporting are:
• Fear of disciplinary action• Lack of understanding of what constitutes
a near miss• Lack of commitment of senior
management to near-miss reporting• Lack of incentive to report near misses• Dis-incentives for reporting near misses
The Good News
• Near miss reporting appears to be gaining acceptance in the health care industry.
• Barriers to near-miss reporting are increasingly being recognized and addressed.
Remarks from a 12 year Medical Director responsible for quality and patient complaints
• We really do have issues about patient safety• Many complaints really represented safety
issues• Hard to distinguish between quality and safety• Institutional patient safety task force involving
nurses, clinicians, pharmacists, quality people, Co-chaired by the CEO and Medical Director
• Multidisciplinary group enabled going after issues and take on projects POE to prevent errors
• Internet-based Patient Safety hotline – anybody who has an issue can report
Patient Safety Week
• Monetary awards – to two top suggestions to contribute to patient safety from rank and file people
• Cynical physicians do not think patient safety is a problem and it does not apply to them
• Team based activity• There are steps that move along, if someone
drops the ball in step 2, we may find problems in Step 8
Near-miss Reporting – A Free Lesson
• Near–misses are an extremely rich source of information on the how the process works (or not)
• Web-based near-miss reporting system to help find systemic cause
• If someone is provided with an easy to use reporting system we found they will use it – but this takes a tremendous amount of training
A Simple Intervention
• Inordinately high number of falls• Call system, by luck of the draw we
determined that 50% of the call buttons did not work on a number of floors
• The nurses on the floors were complaining about the call buttons for a number of years
• After fixing the call system, the number of falls went down to where they ought to be
Problems and Solutions • People know there are problems• Figure out way to work around them• Unfortunately one day someone gets into trouble• Seeing change in culture• Fascinated with the aviation safety contribution to
patient safety in the peri-operative areas. • “I love the idea of the Checklist and pre-op and
post-op team meeting”• Improving the hand-off and communication is
where we can learn from aviation to do better
Take Home MessagesFrom a West Texas woman who works in a
big medical school facility on a barrier island in Texas• Over and above everything the PSO has to have
a passion for good patient outcomes• PSO has to like to fix things• PSO must be someone who enjoys operations • Has to hang in there – be patient with people,
they will eventually get on the wagon with you• Do not loose heart• We celebrate what we consider our victories• Yes, we’ve changed the culture at the hospital –
one disaster at a time
