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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?)
21
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”