It Starts at the Top: CEO and Board Responsibility and Accountability for Patient Safety

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It Starts at the Top CEO and Board
Responsibility and Accountability for Patient
Safety

• Lucian L. Leape, MD
• The Michigan Health and Safety Coalition Patient
  Safety Summit
• April 30, 2003

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• The idea that medical errors are caused by bad
  systems is a transforming concept

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A Transforming Concept

• 1. Errors are normal behavior
• 2. The causes of errors are not obscure

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Causes of Errors

• Habit Anger
• Interruptions Anxiety
• Hurry Boredom
• Fatigue Fear

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A Transforming Concept

• 1. Errors are normal behavior
• 2. The causes of errors are not obscure
• 3. Human errors result from latent errors

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Latent Errors

• Design of work
• Conditions of work
• Training
• Design and maintenance
• of equipment

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Latent Errors

• Design characteristics that induce errors by
• a) Creating conditions that generate known causes
  of errors
• OR
• b) Requiring work that exceeds the capacity of
  the human brain

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The Real Word

• Healthy appearing decrepit 69 year old male,
  mentally alert but forgetful
• The skin was moist and dry
• Occasional, constant, infrequent headaches
• Patient was alert and unresponsive
• Rectal examination revealed a normal sized
  thyroid
• She stated that she had been constipated for most
  of her life, until she got a divorce

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Levels of Safety

• Design, Management,
• Blunt Training, Policies,
• Regulations
• Rules
• Provider
• Sharp

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Accident Causation Model
Latent Errors
Systems Defects
Triggering Factors
Unsafe Acts
Errors
Defenses
Defenses
ACCIDENT
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Take-Home Messages

• 1) Medical injuries are not inevitable most
  are preventable
• 2) Theyre not your fault its faulty systems
• 3) They are your responsibility
• 4) Its much easier to change systems than to
  change people

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• Faced with the choice of changing ones mind
  and proving that there is no need to do so,
  almost everybody gets busy on the proof.
• John Kenneth Galbraith

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The Silence

• Of Deed
• The failure of physician and hospital leaders to
  respond with corrective action to studies
  documenting severe and preventable quality
  problems
• Millenson, Health Affairs 2003

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The Silence

• Of Word
• The absence of a thorough discussion of the
  tragic consequences of that lack of response
• Millenson, Health Affairs 2003

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Accountability Responsibility

• Not
• Whos to blame?
• Whos head shall roll?
• But
• How do we make it happen?
• What are the lines of responsibility?

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Accountability as Responsibility

• At the heart of the culture change we need to
  make health care safe
• Meaningful accountability is a collaborative,
  supportive, and reciprocal activity

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Heart of Culture Change

• Must have clear responsibility to make the
  changes needed
• Responsibility for safety must trump personal
  preferences
• Safety is everyones responsibility

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Accountability as Responsibility

• At the heart of the culture change we need to
  make health care safe
• Meaningful accountability is a collaborative,
  supportive, and reciprocal activity

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Reciprocal Accountability

• Statutory Authority
• v.
• Moral Authority

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Reciprocal Accountability

• 1. Implementing best safety practices
• 2. Dealing with problem doctors

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Accountability
Regulators
Professionals
Hospitals
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Accountability
Regulators
Professionals
Hospitals
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Accountability
Regulators
Professionals
Hospitals
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Accountability
Regulators
Professionals
Hospitals
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JCAHO Safety Goals

• Two patient identifiers for medications or blood
  products
• Verification of surgical patient identity
• Verbal order verification
• Standardized abbreviations
• Removal of concentrated electrolytes

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JCAHO Safety Goals

• Standardized drug concentrations
• Preoperative verification wrong site
• Mark your site with patient
• Free-flow protection for IV pumps
• Preventive maintenance for alarms
• Adequate alarm volume

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Accountability
Regulators
Professionals
Hospitals
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NCPS TIPS December 2002

• Interpretation of their intent
• Related information
• Facility resources
• What you need to do

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NCPS TIPS December 2002

• You need to not only show policies that address
  these stated goals, but more importantly, develop
  outcome measures that show you are consistently
  meeting the new policies(and) document compliance

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Accountability
Regulators
Professionals
Hospitals
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Accountability
Regulators
Patients
Professionals
Hospitals
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Reciprocal Accountability

• 1. Implementing best safety practices
• 2. Dealing with problem doctors

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Whats Wrong?

• 1. Takes too long
• 2. Early warning signs are ignored
• 3. Totally reactive

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Our Non-System

• Implicit
• Personal
• Punitive

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Defining Problem Doctors as Disciplinary Problems

• Hung up on punishing
• - Want to weed them out
• - Methods are personal, individual,
  emotional, judgmental
• Safety objective prevention
• - Method objective

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Types of Problem Doctors

• 1. The impaired physician
• Substance abuse - alcohol / drugs
• Psychiatric problems
• Physical illness
• 2. Declining Competency
• 3. Personality Problems
• Disruptive physician
• Refuses to follow rules
• Abusive behavior
• Abusive with patients

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An Effective Professional Accountability System

• Adopt performance standards
• Adherence is a condition of appointment to staff
• Adherence is monitored (everyone)
• Broad repertoire of methods for remediation
• Goal doctor remain in practice

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Treat All Co-workers with Respect

• No hostile behavior (raised voice, insults,
  public reprimands)
• No humiliation of residents and nurses
• No derogatory comments about colleagues
• Accept challenges to the authority gradient for
  safety

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Accountability and Professionalism

• Accountable to our patients put clients
  interest above your own
• Accountable to our colleagues ensure high
  standards of practice
• Accountable to ourselves - maintain skills and
  competence

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