Patient Safety Leadership

Peter Pronovost MD PhDProfessor, Schools of Medicine and Public HealthDirector, 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

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Elizabeth Dayton, Joint Commission Journal, Jan. 2007

Seniorleaders

Teamleaders

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 climateTeamwork 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?)

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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”