Leadership for Safety: Getting the Board on BoardEssential Hospitals Engagement NetworkAugust 22, 2013

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OUR NEW NAME

We’ve rebranded! The National Association of Public Hospitals and Health Systems is now America’s Essential Hospitals. Although we’ve changed our name, our mission is the same: to champion hospitals and health systems that provide the highest quality of service to all by achieving the best health outcomes for every patient, especially those in greatest need. The new name underscores our members’ continuing public commitment and the essential nature of our work to care for the most vulnerable and provide vital community services, such as trauma care and disaster response.

This is an exciting time for us and our members, as we lean forward into new care models, opportunities and challenges of reform, and quality and safety innovations that often take root in our member systems. Our new website address: www.EssentialHospitals.org

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CHAT FEATURE

• Please use the Chat Box on the webinar screen to type your question or comment at any time.

• NOW: Use the Chat Box to sign in. Enter your organization and names of all people in the room.

Leadership for SafetyWeb WorkshopAugust 22, 2013

James L. Reinertsen, M.D.www.reinertsengroup.com

307.353.2299

Action Planning ChecklistLeadership Behaviors and Tools Actions PlannedTake personal ownership of safety in your organization

Eliminate the denominator: How many patients did we harm last year?Be transparent: wall displays, open discussion of serious safety events…

Start every meeting with a patient storyFrame safety aims in reference to the theoretical ideal

Do “reality rounding” on key safety practices

Executive visits to safety teamsDaily safety huddleMake hard decisions that change the culture—on both values and technical performance!

Assignment 1: Start with a Story

• What: – Start every leadership meeting with a story about a patient who

was harmed (or a near miss).– Your own organization, recent, serious, scripted, no medical

details, emphasize the impact on patient and family– If possible, chosen to illustrate data to be reviewed later in the

meeting• How:

– Three minutes, plus questions for clarification– No amateur-hour armchair problem solving!

• Who:– Senior executive, does not need to be CNO or CMO! – If you want to add 100x impact, ask patient or family member

Let’s hear your field reports

1. What meeting did you start with a patient harm story? Who was in the room?

2. What story did you choose?3. How did you tell it? How long did it take? 4. What went well? 5. What didn’t go so well? 6. Did you get into any long digressions and discussions?

Why?7. What was the overall impact on the meeting?8. What was your main learning from the experience?9. Would you do it again? Make it a regular part of your

leadership practices?

“We started our meeting today with a story about a recent needless death in

our hospital. And we’re going to keep on telling one, every meeting, until there

isn’t a story to tell.”

Board Chair of a Colorado Hospital

Assignment 2: Eliminate the Denominator

• Modify your displays of safety data so that it’s clear how many people were harmed.

• Examples:• Number of patients who became infected• Number of patients who developed pressure ulcers• Number of patients who fell and were injured• Total number of patients harmed

Example from Harbor UCLA…

• 35% overall decrease in Harm (statistically significant at p = 0.002%)

Adverse Drug Event

CAUTI CLABSI SSI VAP Falls Pressure Ulcers

Total Harm

0

20

40

60

80

100

120

140

160

6

39 3527 27

10 16

160

5

39

1712 7 6

17

103

20112012

Lower Scores are Bet -ter

Harm Scores 2012 with Comparative Data from 2011

Let’s hear how it’s going in the field

• Which safety reports did you modify?• Who did you show them to? Board? Quality

Committee? Medical Staff leadership? Executive team?

• What was the reaction to “eliminating the denominator?” – Shock at the number of people harmed?– Did anyone say “Why didn’t we know about this before?”– Did this display method change the conversation in any

way? How, exactly?

Next:

• Web Workshop – September 19, 2013, noon EST

• Assignment: – Transparency! Display your harm data

someplace it’s never been seen before—e.g. hallways of care units, on hospital website, at medical staff annual meeting….

– Come to the workshop and tell us what it was like to “go naked in public!”

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SAVE THE DATE

Leadership for Safety: Yes, it’s PersonalA Workshop for CEOs, Board Members and C-Suite Leaders

October 7, 20139:30 am – 4:30 pm PST

San Mateo Marriott | San Mateo, Calif.

Deadline to register: Sept. 13, 2013

More information: http://tc.nphhi.org/Archive/EHEN-Events/Leadership-for-Safety-Yes-Its-Personal-A-Workshop-for-CEOs-Board-Members-and-C-Suite-Leaders

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THANK YOU FOR ATTENDING

• Next Leadership webinar: September 19 @ 12 pm EST

• Evaluation: Feedback survey can be accessed in the chat box.

• Essential Hospitals Engagement Network website: http://tc.nphhi.org/Collaborate