Overview of the Role and Responsibilities of the Patient Safety Officer

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Overview of the Role and Responsibilities of the
Patient Safety Officer

• The Quality Colloquium at Harvard
• 21 August 2005

Douglas B. Dotan, MA, CQIA (ASQ) President, CRG
Medical, Inc. ddotan_at_crgmedical.com
www.crgmedical.com Patient Safety Quality
Management Solutions
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NOW WE WILL HAVE NO MORE ACCIDENTS!!
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If there is any Doubt,There is No Doubt
Colonel Ran Ronen, Commander of the Israel Air
Force Flight Training Academy, 1968

• The basis of a Culture of Safety
• Most mishaps occur during training
• Flight Safety Branch then functioned within the
  Training Command high IAF mishap rate
• Transition from French to US equipment
• Mishap rate did not decrease over the next 10
  years
• No formal training for Flight Safety Officers

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Change Came with New Leadership

• 1978 General Benjamin Peled, commander of the
  Israel Air Force disbanded the Flight Safety
  Branch in the Training Command
• Created the independent Directorate for Safety
  and Quality Inspection that was empowered by him
  and subordinate only to him
• The new Mishap Investigation Branch was charged
  to conduct safety and not punitive investigations
• Investigators became empowered professionals and
  received the appropriate training

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Mishaps Reduced by 50 in 5 years

• In 1980 the safety policies and procedures were
  re-written and a computerized classification for
  mishaps was designed and implemented
• The Directorate began to learn that failures were
  often systemic and began providing preventive
  action recommendations
• Wing Safety Officers received training and became
  part of the near-miss debriefing process
  reporting went up, mishaps down

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The (Patient) Safety Officer

• - Patient Someone under medical care
• - Safe Free from harm
• - Safety Freedom from danger
• - Officer One who holds an office of
  trust or authority
• So is the Patient Safety Officer the one trusted
  to keep those under medical care free from
  danger?
• Is the role of the Patient Safety Officer any
  different from the Flight Safety Officer, Ship
  Safety Officer, Industrial Safety Officer, etc?

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• Take Command
• Lead by Example
• Listen Aggressively
• Communicate Purpose and Meaning
• Create a Climate of Trust
• Look for Results, Not Salutes
• Take Calculated Risks
• Go beyond Standard Procedure
• Build up your people
• Generate Unity
• Improve your Peoples Quality of Life

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USS Benfold - Successes

• In 1998 operated on 75 of their budget
• Reduced mission degrading equipment failures
  from 75 in 1997 to 24 in 1998
• Returned 600K from the ships 2.4million
  maintenance budget and 800K from 3 million
  repair budget
• Cut redeployment cycle from 52 days 22 in port
  and 30 at sea to 19 days 5 in port and 14 at
  sea.

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Sometimes Mistakes Do Happen
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And Often Its Not Your Fault ..
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Its time to leave your Comfort Zone and Chart
your own Course

• Once you squander an opportunity you can never
  get it back
• No one person can stay on top of it all
• You need to get more out of your people and
  challenge them to step up to the plate
• Are your people free to question conventional
  wisdom and dream up better ways to do their jobs?

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DONT BOTHER ..

• If the CEO does not hold herself/himself
  personally responsible and accountable
• If the Patient Safety Officer (PSO) is not part
  of the Senior Management Team of the hospital
• If the PSO is not empowered by the CEO and
  reports to anyone else but the CEO
• If safety investigations are conducted for
  punitive and corrective action instead of safety
  and preventive action
• If the CIO is not part of the Patient Safety team

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What should I work on?

• Focus on system enablers what are the
  conditions that allow events to propagate
• Identify the micro-systems that surround an event
• Find out what are the barriers that prevent
  people from feeling safe to talk, report and
  share their stories

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Earn the Trust of Clinicians

• Do not look at the clinicians as the enemy
• Most clinicians think you are out to get them
  if you are not a clinician you have to earn their
  respect
• You need to nurture and grow this relationship
• This is hard work, be patient, look upon it as a
  journey

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Physicians are our Biggest Problem They Still do
not Totally Buy-in

• 3 years concentrated on processes to reduce Wrong
  Side surgery in the OR - used the Time-out
• Most surgeons thought this was a waste of time
• The circulating nurse will not start the case
  without the time-out
• The biggest complainer about 3 months ago did not
  conduct the time-out appropriately and performed
  a wrong-side surgery
• The patient discovered the error after the
  surgery
• After a RCA, the surgeon was there and said I
  was wrong about this, we really need to do the
  time-out

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Wind The Clock!
The Aviators Time-out Prevents Turning a Small
Malfunction into a Catastrophic Failure
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What the PSO Hates the most

• To be told, we knew that was happening, we
  didnt think it was worth stating anything
• - Faculty who doesnt see patients after
  surgery - everyone knew, except ..
• - The call bell cables were missing or broken -
  The nurses managers had to pay for them because
  they connected to the TV console.
• At the time an auxiliary enterprise ran the TV
  service which was a fee generating function - so
  they didnt buy them.  

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Remarks from 45 years in healthcare safety,
quality, JCAHO, risk etc.

• Given the challenges of managing GenX'rs and the
  group ahead of them, heaven help us when the
  group behind them arrives on the scene, creating
  a culture of patient safety.
• I have yet to get my happy campers to that point.
  Intellectually they know the answers and know
  what the NPSG's are.
• Do they cut corners in a heartbeat? Of course.

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What Motivates?

• Not all the literature and stories about the
  catastrophes in patient safety can motivate them
  to do what is right without exception.
• The larger facilities say they've got a handle on
  it---and spend and to make care safer,
  I bet they still fight it daily.

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Why Do Good People Violate Good Policies

• Too many other conflicting priorities in health
  care these days, and even good and hard working
  people are still human beings.
• It's one of those basic rules - If you take the
  time to do it right the first time, you don't
  have to deal with the clean up.
• Not all the well designed systems and technology
  can make it absolutely safe if people just cannot
  buy in and do it consistently.

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Leadership is the Clue

• They MUST be on board and must be physically
  present in patient care areas demonstrating their
  expectations.
• And even that doesn't work consistently, because
  they have to go home and shower and sleep on
  occasion.
• And the problem is the leaders are the ones
  hardest hit with the conflicting priorities.

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Middle Management is the Clue

• Middle managers are the deputies to rely on to
  enforce a consistent approach - in a crunch,
  who gets cut first?
• We need
• - Middle managers who are bears on patient
  safety
• - Obvious communication and handoff going both
  ways between executive leaders and their deputies
• If there are enough middle managers to make
  consistency happen..maybe you have a prayer.

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Dichotomies of the roleHow do we do our work?

• Promote vs Cheerleading
• Leader vs Facilitator
• Sung vs Unsung - in front or behind the scenes?
• Coach? Internal consultant? Counselor?
• On a pedestal or in a vice?
• Worst problem no one recognizes that there are
  problems?
• OR Staff are afraid to report for fear of
  punishment. Ex 3 med error rules in Texas.
• Our worst fear
• Was any of it worth it?
• Did we make a difference?
• Why do we see the same errors over and over?

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What does Management Want?

• How many masters?  Boss, CEO CNO, the C suite and
  its internal conflicts - add 2 more Cs-
  compliance and corporate
• Values of the administrator and the medical
  staff what do they want ROI? Nothing to report
  to the State? Fewer compensable events? Retention
  of staff? Improved morale? Lower patient LOS- and
  infections- but why? Fewer claims and lawsuits?
  No bad press? 
• Woe to the administrator who says, I want fewer
  incidents! Youll get that alright! Youll never
  hear anything.
• Even with strong management support, we are not
  always sure what management wants
• And physicians want to be involved, but that
  means 1. they want their pet project worked on,
  and 2. they often are in charge of projects they
  do not have the skill to manage

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The downside of being a PSO

• Change is hard. Inertia takes the lead
• Change is NOT always progress, sometimes it is
  worse
• Why do we think we solved a problem, set up a
  process, to have it go awry? Why do we
  continually relearn the same information?
• Sometimes you really dont want to know what is
  the underlying cause - it is too painful
• Change hurts it creates turmoil. Doubles work
  for a while. It isnt static, it is really
  continuous, thus when do you ever see success?
  Change is truly risky behavior
• TIME FRAME we select an issue that has been a
  problem for- years We want to solve it in two 1
  ½ hour meetings and want it fixed right away! 
  Goals are 5 years objectives and tasks are weeks
  or months. Our units of measure on success are
  off a unit!
• Must have a head of steel, heart of gold, strong
  shoulders and ability to pass credit to others

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Barriers and Incentives to Standardization of
Patient Safety Data Systems

• How can we transform the current culture of blame
  and resistance to one of learning and increasing
  safety?
• Understanding the balance of barriers and
  incentives to reporting is the first step.

• Existing barriers
• - legal
• - regulatory
• - financial
• - technological
• - political
• Additional barriers
• - lack of authorization
• - lack of good models
• - evidence of impact

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What more is needed?

• Introduction of norms that inculcate learning
• Non-punitive safety reporting culture in
  professional schools and graduate training
  programs
• Support from consumers, patient advocacy groups,
  regulators, and accreditors

• A certain amount of trial-and-error will be
  necessary.
• Legal protection for reporters must be
  reinforced, where incident reporting systems have
  been successful in gaining acceptance and
  credibility

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The impact of barriers and incentives on
individuals, organizations, and society

• Powerful disincentives to reporting depend on
• - The organizational culture
• - Include extra work
• - Skepticism
• - Lack of trust
• - Fear of reprisals
• - Lack of effectiveness of present reporting
  systems

• Incentives to reporting include
• - Confidentiality
• - Some degree of immunity
• - Philanthropy (when reporters identify with
  injured patients and other health care providers
  that could benefit from the data)
• - Educational (when reporters learn from
  reporting about their adverse events).

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Complex interdependence exists between all
barriers and incentives to reporting at the
individual, organizational, and societal levels.

• Incentives for society include
• - accountability
• - transparency
• - enhanced community relations
• - sustained trust and confidence in the health
  care system.

• Barriers are more visible and specific than
  incentives.
• Incentives are tied to higher governing values.
• Fears and attitudes appear to limit the
  usefulness of structural incentives already in
  place.

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Analysis of near-misses reveals the following
information

• Fewer barriers to data collection exist when no
  injury occurred
• Recovery strategies can be studied to enhance
  proactive interventions
• Hindsight bias is effectively eliminated since
  with no patient harm, there are no legal or
  administrative recriminations.

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Near-miss reporting a critical factor toward
improving patient safety.

• The contributing factors for the lack of near
  miss reporting are
• Fear of disciplinary action
• Lack of understanding of what constitutes a near
  miss
• Lack of commitment of senior management to
  near-miss reporting
• Lack of incentive to report near misses
• Dis-incentives for reporting near misses

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The Good News

• Near miss reporting appears to be gaining
  acceptance in the health care industry.
• Barriers to near-miss reporting are increasingly
  being recognized and addressed.

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Remarks from a 12 year Medical Director
responsible for quality and patient complaints

• We really do have issues about patient safety
• Many complaints really represented safety issues
• Hard to distinguish between quality and safety
• Institutional patient safety task force involving
  nurses, clinicians, pharmacists, quality people,
  Co-chaired by the CEO and Medical Director
• Multidisciplinary group enabled going after
  issues and take on projects POE to prevent errors
• Internet-based Patient Safety hotline anybody
  who has an issue can report

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Patient Safety Week

• Monetary awards to two top suggestions to
  contribute to patient safety from rank and file
  people
• Cynical physicians do not think patient safety is
  a problem and it does not apply to them
• Team based activity
• There are steps that move along, if someone drops
  the ball in step 2, we may find problems in Step 8

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Near-miss Reporting A Free Lesson

• Nearmisses are an extremely rich source of
  information on the how the process works (or not)
• Web-based near-miss reporting system to help find
  systemic cause
• If someone is provided with an easy to use
  reporting system we found they will use it but
  this takes a tremendous amount of training

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A Simple Intervention

• Inordinately high number of falls
• Call system, by luck of the draw we determined
  that 50 of the call buttons did not work on a
  number of floors
• The nurses on the floors were complaining about
  the call buttons for a number of years
• After fixing the call system, the number of falls
  went down to where they ought to be

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Problems and Solutions

• People know there are problems
• Figure out way to work around them
• Unfortunately one day someone gets into trouble
• Seeing change in culture
• Fascinated with the aviation safety contribution
  to patient safety in the peri-operative areas.
• I love the idea of the Checklist and pre-op and
  post-op team meeting
• Improving the hand-off and communication is where
  we can learn from aviation to do better

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Take Home MessagesFrom a West Texas woman who
works in a big medical school facility on a
barrier island in Texas

• Over and above everything the PSO has to have a
  passion for good patient outcomes
• PSO has to like to fix things
• PSO must be someone who enjoys operations
• Has to hang in there be patient with people,
  they will eventually get on the wagon with you
• Do not loose heart
• We celebrate what we consider our victories
• Yes, weve changed the culture at the hospital
  one disaster at a time