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Overview of the Role and Responsibilities of the Patient Safety Officer


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Title: Overview of the Role and Responsibilities of the Patient Safety Officer

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
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
  • No formal training for Flight Safety Officers

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

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

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
  • Is the role of the Patient Safety Officer any
    different from the Flight Safety Officer, Ship
    Safety Officer, Industrial Safety Officer, etc?

  • 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

Sometimes Mistakes Do Happen
And Often Its Not Your Fault ..
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?

  • 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

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

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
  • You need to nurture and grow this relationship
  • This is hard work, be patient, look upon it as a

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
  • After a RCA, the surgeon was there and said I
    was wrong about this, we really need to do the

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.  

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.

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.

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.

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

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
  • - 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.

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
  • 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?

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

The downside of being a PSO
  • Change is hard. Inertia takes the lead
  • Change is NOT always progress, sometimes it is
  • 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

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
  • 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

What more is needed?
  • Introduction of norms that inculcate learning
  • Non-punitive safety reporting culture in
    professional schools and graduate training
  • Support from consumers, patient advocacy groups,
    regulators, and accreditors
  • A certain amount of trial-and-error will be
  • Legal protection for reporters must be
    reinforced, where incident reporting systems have
    been successful in gaining acceptance and

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
  • 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).

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 are tied to higher governing values.
  • Fears and attitudes appear to limit the
    usefulness of structural incentives already in

Analysis of near-misses reveals the following
  • 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.

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
  • Lack of commitment of senior management to
    near-miss reporting
  • Lack of incentive to report near misses
  • Dis-incentives for reporting near misses

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.

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

Patient Safety Week
  • Monetary awards to two top suggestions to
    contribute to patient safety from rank and file
  • 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

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

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

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

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
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