This plenary took place on Tuesday, October 6, at 8:30 am at the International Conference on Communication in Healthcare (ICCH), in Miami Beach, Florida, USA. The Path to Safe and Reliable Healthcare Michael Leonard, MD Michael Leonard, MD, is the Physician Leader for Patient Safety at Kaiser Permanente, a Principal at Pascal Metrics, and a Faculty member at the Institute for Healthcare Improvement (IHI). An Honors graduate of the University of Missouri School of Medicine, Michael did his postgraduate training in Internal Medicine and Anesthesiology at Harvard’s Beth Israel Hospital in Boston, with fellowship training in cardiac anesthesia. Michael was a practicing anaesthesiologist for 14 years with the Colorado Permanente Medical Group, where he was Chief of Anesthesia, Chief of Surgical Services, and Chairman of the Board of Directors. In 1999, he helped Kaiser forge a collaborative relationship with Dr. Robert Helmreich’s Human Factors Research Project to work on the application of human factors teamwork and communication training in medicine. For the past several years, he has taught extensively throughout the Kaiser system and outside organizations in high-risk areas such as surgery, obstetrics, critical care and others to enhance safety. His relationships with outside organizations include Duke, Baylor, Sloan Kettering, ICSI, Minnesota Children’s, Ascension, Adventist, VHA, Greater New York Hospital Association and others. At the IHI, he has been active in several domains, including the Patient Safety Officer Training Course, Transforming Care at the Bedside, the Superior Performance Initiative in the United Kingdom, and Patient Safety Scotland.

1. The Path to Safe & Reliable Healthcare Michael Leonard, MD

6. Safety Attitudes Questionnaire: Items Are Grouped Into Six Factors © 2008 Pascal Metrics Factor: Definition Example Items Job Satisfaction: Positivity about the work experience I like my job This hospital is a good place to work Teamwork Climate: Perceived quality of collaboration between personnel Disagreements in this clinical area are appropriately resolved (i.e., what is best for the patient) Our doctors and nurses work together as a well coordinated team Safety Climate: Perceptions of a strong and proactive organizational commitment to safety I would feel safe being treated in this clinical area Medical errors are handled appropriately in this clinical area Perceptions of Management: Approval of managerial action Hospital management supports my daily efforts in this clinical area Hospital management does not knowingly compromise the safety of patients Stress Recognition: Acknowledgement of how performance is influenced by stressors I am less effective at work when fatigued When my workload becomes excessive, my performance is impaired Working Conditions: Perceived quality of the work environment and logistical support (staffing, training, etc.) Trainees in my discipline are adequately supervised This hospital deals constructively with problem personnel

7. % of respondents reporting above adequate teamwork Teamwork in the eye of the beholder: ICU RNs and ICU MDs rate each other 62 Michigan ICUs 2004 Only ICUs with 5 or more physicians reported here (all had 5 or more RNs)

8. Teamwork Climate Across Michigan ICUs © 2008 Pascal Metrics The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care No BSI = 5 months or more w/ zero

9. Teamwork Climate Across Occupations © 2008 Pascal Metrics

10. “ The physicians and nurses here work together as a well-coordinated team.” © 2008 Pascal Metrics

11. “ In this clinical area, it is difficult to speak up if I perceive a problem with patient care.” © 2008 Pascal Metrics

12. “ Disagreements in this clinical area are resolved appropriately (i.e. Not who is right, but what is best for the patient).” © 2008 Pascal Metrics

13. “ Nurse input is well received in this clinical area.” © 2008 Pascal Metrics

14. Labor and Delivery Collaboration Map ⓒ 2008 Lotus Forum Inc. ⓒ 2008 Lotus Forum Inc. Table 1: Labor and Delivery Respondent Demographics a LVN/OB is licensed vocational nurse/obstetrical technician Job Position Response Rate (Returned/Admin) Age Mean Years (± SD) Obstetrician 67% (494/739) 45 (9.91) Anesthesiologist 54% (213/401) 44 (7.83) Registered Nurse 77% (1877/2442) 42 (10.71) LVN/OB a 81% (227/280) 42 (10.95) Nurse Manager & Charge Nurse 79% (136/172) 46 (7.56) OBSTETRICIANS ANESTHESIOLOGISTS NURSE MANAGERS/ CHARGE NURSES REGISTERED NURSES LVN/OB TECHNICIANS

15. Within Hosp #22, which units are the most/least culturally positive?

16. Radar Diagram

17. HUMAN FACTORS: Performance in a Complex Environment

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25. Effective Communication and Teamwork Requires: © 2008 Pascal Metrics Structured Communication SBAR Assertion/Critical Language Key words, the ability to speak up and stop the show Psychological Safety An environment of respect Effective Leadership Flat hierarchy, sharing the plan, continuously inviting other team members into the conversation, explicitly asking people to share questions or concerns, using people’s names

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30. “ I know the names of all the personnel that I worked with during my last shift” © 2008 Pascal Metrics

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35. Courtesy Dr. David Morehead

46. ICU Percent of Patients Receiving all Four Aspects Of Ventilator Bundle © 2008 Pascal Metrics Inc. Annotations 1: Marked beds at 30 degree angle 2: Fact Sheet for staff education 3: Poster with weekly data feedback 4: Vent bundle posted in all vent patient rooms 5: Began initial trials of Daily goal sheet and pre-extubation sheet 6: Initiated Powerpoint education for RT/RN 7: Initiated Clinical Pharm rounds 8: 1st test of multidisciplinary rounds 9: Expanded use of Pre-extubation sheet 10: Staff education on Goal sheet; mini inservices on unit on SBT and Pre-extubation sheet 11: Incorporated Goal Sheet into Multidisciplinary Rounds 12: Impact Extravaganza (staff/MD education) 13: Expanded multidisciplinary rounds to include additional disciplines 14: Check compliance on night shift past 2 weeks 15: New sign at HOB, 16: One on one follow up by Nursing & RT managers on collaboratiion in weaning process