2. How Can States and Institutions Work Together to Create a Culture of Safety Concrete Actions to Improve Patient Safety Julie Morath, M.S., R.N. Chief Operating Officer and Chief Executive Nurse, Children’s Hospital and Clinics, Minneapolis/St. Paul, MN

3. The Leader’s Role Creating and Leading a Patient Safety Manifesto Patient Safety Manifesto A Public Declaration of Intent for Action

4. Patient Safety Manifesto 1.Declaring an Urgent Problem 2.Accepting Leadership Responsibility 3.Gaining Knowledge and Tools 4.Ensuring Accountability 5.Confronting Myths 6.Aligning External Controls 7.Accelerating Change

5. What We Learned  Myths and expectation of perfection are deeply rooted  Fear of failure, blame, and sanction permeate health care  Learning and understanding complexity is critical to creating safety  Stories and conversations create safety  Keep the cases alive: revisit issues · “I don’t know what it means now” · “It is disturbing” · “It is not concluded” · “friction-less dissemination”

6.  “Accounting” or reporting that loses the story is a waste  Errors are sources of learning and resiliency  Errors define margins of safety  Follow and break rules  Prioritize on themes/archetypes  Safety requires a team  Safety is as much about recovery as prevention What We Learned

7. “RECIPROCAL ACCOUNTABILITY” This is not about telling people to be more careful

8. Simple Rules to Remember Fix what you can Fix what you can Tell what you fixed Tell what you fixed Find someone who can fix what you cannot Find someone who can fix what you cannot

9. “Nothing about me without me” “If it looks wrong, it is wrong” Disclosure and truth-telling

10. “ Overlearn” Key Safety Concepts Swiss cheese Swiss cheese Blunt and sharp end Blunt and sharp end Hindsight bias Hindsight bias High Reliability Organization (HRO) High Reliability Organization (HRO)

11. Executive Session Three levels of success Three levels of success – in the ideas and behavior of members – in challenging professionals outside the confines of the group – in changing conventional wisdom “Who loses sleep over this problem of patient safety?”

12. Engagement of State Officials and Hospital Leaders Start the dialogue Start the dialogue Educate Educate Review the regulatory experience Review the regulatory experience Identify common ground Identify common ground Work to close gaps Work to close gaps

13. Hospital Leaders Positional leaders Positional leaders Leaders in medical/professional staff Leaders in medical/professional staff Attitude/informed leaders Attitude/informed leaders

14. Patient Safety Improvement Corps Structure to present “ideas” Structure to present “ideas” Methods to evaluate effectiveness of interventions Methods to evaluate effectiveness of interventions Deployment/ dissemination strategies within and across the organization Deployment/ dissemination strategies within and across the organization

15. State official potential pitfalls Individual and isolated problem focused response Individual and isolated problem focused response Protection of the public versus improvement of the system, e.g., “heads must roll” Protection of the public versus improvement of the system, e.g., “heads must roll” Public accountability and expectations versus space for improvement Public accountability and expectations versus space for improvement

16. State official potential pitfalls “Watchdog” relationship versus partnership relationships “Watchdog” relationship versus partnership relationships Distance from real world issues Distance from real world issues