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

• Issues or challenges for which there is “an answer”

Adaptive Challenges

• Require a change of values, attitudes or beliefs

The Birds’ Eye ViewTechnical and Adaptive Challenges in

Quality and Safety EffortsNationally

• JCAHO Core Measures• CMS • NQF

Internationally• WHO/ World Alliance for Patient Safety

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)

Central Mandate

Local Wisdom

Scientifically Sound Feasible

xx

Elizabeth Dayton, Joint Commission Journal, Jan. 2007

Senior

leaders

Team

leaders

Staff

Engage How does this make the world a better place?

Educate What do we need to do?

Execute How can we do it with my resources and culture?

Evaluate How do we know we improved safety?

Pronovost: Health Services Research 2006

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

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

Leadership Action for Staff

• Keep patients your North Star

• Walk a process

• Reflect on perceived losses with change

• Commit to identify and mitigate hazards

Time period Median CRBSI rate Incidence rate ratio

Baseline 2.7 1

Peri intervention 1.6 076

0-3 months 0 0.62

4-6 months 0 0.56

7-9 months 0 0.47

10-12 months 0 0.42

13-15 months 0 0.37

16-18 months 0 0.34

2 year results from 103 ICUs

Pronovost NEJM 2006

Keystone ICU Safety Dashboard

2004 2006

How often did we harm (BSI)

2.8/1000 0

How often do we do what we should

66% 95%

How often did we learn 100s 100s

% Needs improvement in Safety climate

Teamwork climate

84%

82%

41%

47%

Lessons Learned

Need to get technical and adaptive work right– Centralized measurement– Local ownership

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?

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?)

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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”