1. 1 High Reliability Conference Munson Health System Matthew J. Schreiber, MD Spectrum Health Vice President, Hospital Quality and System Safety October 2015

2. Why Are You Here? To Do Meaningful Work that Makes A Difference in the Lives of Others 2

3. Why Are You Here? We are all here on earth to help others; what on earth the others are here for I don’t know. --W.H. Auden 3

4. Stand [And Stay Standing] If.... You have been a patient and experienced preventable harm You have a close friend or family member who has experienced preventable harm You have been part of a case where someone experienced preventable harm You would call our ER if the person closest to you had a serious condition and you would want to make sure particular doctors and nurses, and staff were involved in their care 4

5. 5 Why Am I Here?

6. The system is broken I am part of the system Therefore, I must change if the system is to achieve meaningfully different results 6

7. My personal story of Harm Baby T 7

8. Price of Entry Primum non nocere 8

9. What Safety Isn’t Be more careful Try harder Blame management Project Clinical problem Hospital problem 9

10. What Safety IS A lifestyle change A Leadership method Prioritization/focus delivery schema Continuous improvement philosophy Patient/employee/leadership activation Outcome measure Reliability platform that supports all necessary efforts Intrinsic accountability 10

11. 11 98,000 5 minutes, 22 seconds 200,000 2 minutes, 38 seconds 3 rd -6 th Leading Cause of Death!

12. Tobacco Kills 443,000 Annually 12

13. Harm Happens We don’t just work here, we live here Harm can happen to anyone Harm affects everyone including the care team Preventable harm happens on our watch Simple, easily performed behaviors and habits can prevent the majority of harm High functioning multi-disciplinary teams are the antidote to complexity Teamwork is a trained skill that gets practiced until you can’t get it wrong. 13

14. A Deceptively Simple Formula 14

15. Change Is Hard—That’s Why You Need to Go First If You want to change the world, you must first change the conversation. The world is listening—what are you going to say? Inspiration is the work of leadership We are the leaders 15

16. Poll the audience Who thinks safety behavior is an important and meaningful part of our job that makes a difference to patients? Who thinks doctors think this is an important part of their job and makes a difference to patients? Who thinks doctors and staff should have similar expectations and accountability as it relates to safety? Who thinks doctors and staff will have similar expectations and accountability as it relates to safety? Who has been rewarded and recognized for “stopping the line” when they had a concern? Even if it was unfounded? 16

17. Key Messages Preventable harm happens here on our watch No one is doing anything TO us, WE are doing this FOR ourselves It is amazing what people will tell you if only you ask Real leaders dismantle power distance and find and fix issues aggressively Whether or not we want to take this on, this work will get done and it will be done under the hot white light of public scrutiny. I don’t like the odds of me against the world. Great work has happened and we have great people. This is an opportunity to focus and deliver even better results because at the end of the day, we don’t just work here, we live here. 17

18. Serious Safety Event Event that reaches the patient and results in death, life-threatening consequences, or serious physical or psychological injury Cause Analysis Level: RCA Precursor Safety Event Event that reaches the patient and results in minimal to no harm Cause Analysis Level: RCA or ACA Near Miss Event that almost happened - the error was caught by one last detection barrier Cause Analysis Level: Trend, ACA Precursor Safety Events Serious Safety Events Near Miss Safety Event Classification SEC SM Deviations in generally accepted performance standards. © 2006, HPI, LLC Copyright 2007. Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

19. The Monkey On Our Back All we need to change is everything This is really a clinical problem, isn’t it? What’s different this time? 19

20. What Do You Mean Safety is Everything and Everything Is Safety? HPI’s implementation plan is both evidence and experience- based and delivers 80% reduction in SSER in 3 years Safety is the most engaging value for healthcare workers Safety creates behavioral reliability, behavioral reliability is a tide that floats all boats Safety program creates learning infrastructure and builds leadership and teamwork capability Safety is a strong driver of quality, quality is weak driver of safety We say safety is our core value—is that what we look for in our partners or what they see in us? 20

21. Key Safety Behaviors Telling stories DCI 5:1 Feedback Rounding to Influence ARCC Validate and Verify Ask Clarifying Questions STAR 21

22. Tips for Story Telling Share your convictions on patient or personal safety Explain how safety contributes to our mission Explain how our policy & practice contribute to safety Tell a story about something good that we did Tell a story about something bad that happened to us Tell a story about harm in another healthcare system Tell a story about another system preventing harm 22

23. Tips for Story Telling 23 Read a Safety Success Story from your office/Department Read a Safety Success Story from another Department Review our SH Safety Behavior Expectations Teach applications of our Safety Behaviors to our jobs Discuss the importance of reporting problems Discuss the importance of speaking-up for safety Ask staff to be safe, and explain how Thank staff for practicing / working safely

24. Daily Check In What it is: A huddle of the leader and direct reports at the start of the day to maintain awareness of operations and to give direction about priority and responsibility for problem resolution. Senior Leader Daily Check-In Agenda Significant safety, quality, or service concerns from previous day High-risk, out-of-the-norm activities or issues anticipated today From the leader: Critical Questions for Safety & Quality 24

25. Two Kinds of Feedback in 5:1 Positive Feedback Encouraging someone to continue practicing an observed behavior Top Positive Reinforcements 1. Head nod 2. “Yes” 3. “Thank you” Negative Feedback Discouraging someone from continuing to practice an observed behavior Top Negative Reinforcements 1. Furrowed brow 2. “No” 3. Offering a practice tip Adapted from Bringing Out the Best in People, by Dr. Aubrey Daniels (1994)

26. Rounding to Influence Be with your people Observe for expected safety behaviors Recognize & reward Ask for problems, then fix causes On your unit and on other units 26

27. 27 Validate &Verify Technique Validate: Does it make sense to me? Verify: Check with an independent, qualified source Patient Technology Professionals Medical Record Documentation Procedures & References It’s okay not to know… It’s NOT okay not to find out.

28. Speaking Up “The lesson of medical school was that you are a singular crusader. It's about how the individual operates. If you were lucky a smart nurse would tell you if you were about to do something really dumb.” Harlan Krumholz, M.D. Singular according to Webster: Individual Exceptional 28

29. ARCC A responsibility to protect in a manner of mutual respect – an assertion and escalation technique 29 Use the lightest touch possible… Ask a question Make a Request Voice a Concern If no success… Use Chain of Command A Great Safety Phrase: “I have a concern…”

30. Pt JC “The Fox knows many things, but the hedgehog knows one big thing....Hedgehogs...simplify a complex world into a single organizing idea...that unifies and guides everything.” --Jim Collins What if no one speaks up? 30

31. 31 Ask Questions Ask one to two clarifying questions: ■ In all high risk situations ■ When information is incomplete ■ When Information is not clear Why… To make sure that you really understand what’s being communicated so that you don’t make a decision based on a wrong assumption. How… Phrase your questions in a manner that will give an answer that improves your understanding of the information. Asking clarifying questions can reduce the risk of making an error by 2½ times! A Good Safety Phrase: “Let me ask a clarifying question…”

32. STAR Pause for 1 to 2 seconds to focus your attention on the task at hand. Consider the action you’re about to take. Concentrate and carry out the task. Check to make sure that the task was done right and that you got the right result. 32 STOP is the most important step. It gives your brain a chance to catch up with what your hands are getting ready to do.

34. Wrong Site Procedures Wrong site procedures happen more than 80 times per week in the US Universal Protocol mandated in 2004 Review of medical liability settlements from 1990 – 2010 revealed payments of more than $1.3B. More than 10,000 “never events” with average pay out of $133,055 http://www.amednews.com/article/20130121/profession/130129976/2/ http://www.amednews.com/article/20130121/ 90% of injured patients do not receive indemnity payments. Every age of physician had events Likely sorely underestimated because reporting still largely voluntary. 34

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36. I Don’t Have Time For All This We will become northern Michigan's indispensable system of health care by driving collaboration and coordination that results in care that is of the highest quality, easy to use, and close to home. 36

37. Only You Can Prevent Forest Fires Assume the worst while hoping for the best and plan accordingly If you think something might not be right, speak up and give the team a chance to verify If you see something, say something. If someone says something, take the time to prove it is NOT an issue Participate actively in brief, time-out, and debrief 37

38. What Do We Know? Safety is hard because it takes 100% of people 100% of time 38

39. Your Homework 1. Get involved in safety leadership, training, implementation 2. Lead by example—give and receive peer checking/coaching, have your heart in it 3. Reward and recognize good safety behavior 4. Speak Up using ARCC 5. Tell a safety story next week 39

40. Your Homework 6. Have a huddle 7. Tell your Friends about the conference 8. File a report 9. Reduce the power gradient with intention 10. Change the conversation by doing something the culture doesn’t expect 40

41. Success Is A Balance of Inspiration And Perspiration 41 Perhaps the most valuable result of all education is the ability to make yourself do the thing you have to do, when it ought to be done, whether you like it or not. --Thomas Henry Huxley Whatever we learn to do, we learn by actually doing it: men come to be builders, for instance, by building and harp players by playing the harp. In the same way,…by doing brave acts, we come to brave. --Aristotle Be the change you wish to see --Mahatma Gandhi

43. A Worthy Goal When you were born you cried while the world rejoiced. Live your life in such a way that when you die the world cries while you rejoice. --Robin Sharma 43