Moving Beyond the Horizon: Where are we going? How will we get there?

1. Moving Beyond the Horizon: Where are we going?How will we get there? Chris Goeschel RN MP MPS ScD (candidate) October 30, 2008 cgoesch1@jhmi.edu

2. What I Will Share: • Context for Tracking Quality and Patient Safety Progress • Possible implications for : • Patients and their families • Patient Safety Leaders • Public Policy

3. Bench to Bedside: Superhighway 2 Lane Paved Road Dirt Path Health Services Research Basic Research Clinical Research Health Understanding disease biology Identifying effective therapies Ensuring therapies are used safety and effectively $1 1 penny

4. Stretching The Penny Effectively: Organize Safety Research and Work • Measuring Patient Safety • Translating Evidence Into Practice (TRiP)* • Identifying and Mitigating Hazards • Improving Culture and Communication • Building Capacity • Organizing for Safety Pronovost, Circulation, in press

5. Root Causes of Sentinel Events (All categories; 1995-2004) Average number of root causes cited per RCA = 3.1 Percent of 2966 events

6. Root Causes of Sentinel Events (All categories; 2006) Average number of root causes cited per RCA = 5.3 Percent of 516 events

7. Leading Change • One of most common leadership mistakes is expecting technical solutions to solve adaptive problems…. • Ron Heifetz “Leadership without Easy Answers

8. Looming Challenges Success Leads to New Horizons: • Increased accountability • Better science • Create a more efficient knowledge market • Improve efficiency and effectiveness of learning • Determine how safe we can afford to be • Develop a framework for trumping autonomy • Establish tighter links with payment

11. CMS : Linking Payment with Quality and Safety Measures Hospitals : currently required to report 30 quality measures on their claims for Medicare inpatient services • (to qualify for a full update to their FY 2009 payment rates).  CMS is proposing to add 43 quality measures • (in order to get the full inflation update for FY 2010) Total number of measures in FY 2009 = 73.

12. Number of Uninsured • Increasingly more uninsured: • 2000: 38.7 million uninsured • 2006: 47 million uninsured.

13. Why is this work Important?

15. Reminders for the Journey • Stay focused on original aims • Minimize the bias in data collection • Reduce the quantity not the quality of data • Expect projects to stall at intervals

16. Enduring Lessons • Understand the differences between leadership and authority: cultivate leaders • Keep a laser sharp focus on patients • Strive to find the sweet spot between scientifically sound and feasible interventions and measures • Match project goals, objectives and database design in the beginning

17. What is the elephant in the room for YOU? Physician Engagement Board Engagement CEO Engagement YOUR OWN Engagement?

18. In your Hospital? • Briefings/Debriefings • SSI • Mislabeled Specimens

19. Premortem Step 4: Have you Revisited your List? • Periodically review the “premortem” list to resensitize yourself and the other members of the team to problems that may be emerging.

20. How Does this Make the WORLD a Better Place? WE are more alike than different and none of us can do this work alone……….. YOU are a World Leader

21. Leaders Do Not Need to KNOW the answers………Leaders DO need to Confront The IssuesAnd Persevere

22. The Journey “ Excellence is more of a habit than a virtue” Aristotle “Never doubt that a small group of thoughtful committed citizens can change the world. Indeed, it’s the only thing that ever has.” Margaret Meade