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

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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

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

a transforming concept
A Transforming Concept

1. Errors are normal behavior

2. The causes of errors are not obscure

causes of errors
Causes of Errors

Habit Anger

Interruptions Anxiety

Hurry Boredom

Fatigue Fear

a transforming concept1
A Transforming Concept

1. Errors are normal behavior

2. The causes of errors are not obscure

3. Human errors result from latent errors

latent errors
Latent Errors
  • Design of work
  • Conditions of work
  • Training
  • Design and maintenance

of equipment

latent errors1
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

the real word
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

levels of safety
Levels of Safety

Design, Management,

“Blunt” Training, Policies,

Regulations

Rules

Provider

“Sharp”

accident causation model
Accident Causation Model

Latent Errors

Systems Defects

Triggering Factors

Unsafe

Acts

Errors

Defenses

Defenses

ACCIDENT

take home messages
Take-Home Messages

1)Medical injuries are not inevitable – most are preventable

2)They’re not your fault – it’s faulty systems

3)They are your responsibility

4)It’s much easier to change systems than to change people

slide13
Faced with the choice of changing one’s mind and proving that there is no need to do so, almost everybody gets busy on the proof.

John Kenneth Galbraith

the silence
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

the silence1
The “Silence”

Of Word:

The absence of a thorough discussion of the tragic consequences of that lack of response

Millenson, Health Affairs 2003

accountability responsibility
Accountability = Responsibility

Not:

  • “Who’s to blame?”
  • “Who’s head shall roll?”

But:

  • “How do we make it happen?”
  • “What are the lines of responsibility?”
accountability as responsibility
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
heart of culture change
Heart of Culture Change
  • Must have clear responsibility to make the changes needed
  • Responsibility for safety must trump personal preferences
  • Safety is everyone’s responsibility
accountability as responsibility1
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
reciprocal accountability
Reciprocal Accountability

Statutory Authority

v.

Moral Authority

reciprocal accountability1
Reciprocal Accountability

1. Implementing best safety practices

2. Dealing with problem doctors

accountability
Accountability

Regulators

Hospitals

Professionals

accountability1
Accountability

Regulators

Hospitals

Professionals

accountability2
Accountability

Regulators

Hospitals

Professionals

accountability3
Accountability

Regulators

Hospitals

Professionals

jcaho safety goals
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
jcaho safety goals1
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
accountability4
Accountability

Regulators

Hospitals

Professionals

ncps tips december 2002
NCPS TIPS – December 2002
  • Interpretation of their intent
  • Related information
  • Facility resources
  • What you need to do
ncps tips december 20021
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

accountability5
Accountability

Regulators

Hospitals

Professionals

accountability6
Accountability

Regulators

Patients

Hospitals

Professionals

reciprocal accountability2
Reciprocal Accountability

1. Implementing best safety practices

2. Dealing with problem doctors

what s wrong
What’s Wrong?

1. Takes too long

2. Early warning signs are ignored

3. Totally reactive

our non system
Our “Non-System”
  • Implicit
  • Personal
  • Punitive
defining problem doctors as disciplinary problems
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

types of problem doctors
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

an effective professional accountability system
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

treat all co workers with respect
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
accountability and professionalism
Accountability and Professionalism
  • Accountable to our patients – “put client’s interest above your own”
  • Accountable to our colleagues – “ensure high standards of practice”
  • Accountable to ourselves - “maintain skills and competence”