What are the roles of …  Healthcare organizations  The system itself … to enhance the system Jim Conway SVP & Chief Operations Officer Dana-Farber Cancer Institute

Organizations  Accept the reality: excellent but certainly not perfect  Enhance systems to support safe practice  Patients and staff  Grow interdisciplinary care and practice  Implement true patient and family centered care  Take a real balanced approach to managing risks  Institution  Patients and family members  Staff  Bust down some of those mental models  Provide “gutsy” leadership  Model the way, mobilize the effort

What Does Leadership Look Like?  Lead and are accountable for ongoing safety program  Establish a non-punitive environment; Set the tone  Ensure interdisciplinary incident review; At the table  Honestly discuss safety throughout organization  Probe staff on what feels unsafe; honest conversations  Resources available and systems support safe practice  Patient and Family Centered  Probe accountability, responsibility, and competence  Ensure communication and education  Make QI the way we all do the work

Mental Models…  You have plenty of errors and near misses  Errors overwhelming are about bad systems not people  Firing staff / writing new policy will do little to reduce error  Disclosure of error is good for all involved  Errors don’t erode trust; the way you handle them does  Patient’s already know about unexpected outcomes  We don’t know what patients and families want / need  RCA is more powerful than one-on-one investigation  Very little is confidential  You can talk about openly about error, survive and thrive  It’s a very different day

Organizing Principles Shared vision for quality and safety Vigilance to safety is "the way we do the work" Leadership & staff participate in balanced process Patient and family centered Data driven with a commitment to measurement Learning organization with knowledge transfer Focused, prioritized, systematic with G & O High reliability processes Achieve synergies and mitigate failures of teams Clear accountability, responsibility &competence Constant tension; seeking, learning, changing

System  Commit to IOM Model of Care TOGETHER  Safe  Effective  Patient Centered  Timely  Efficient  Equitable  Develop the will  Create the tables  Come to the table and stay at the table  Not easy but certainly right  Fundamental and not incremental change

DRAFT Vision: In the management of incidents/adverse events, all segments of the Massachusetts healthcare system utilize a jointly derived framework for accountability that is broadly viewed as just.  Goal 1: On September 22, 2003, principals of the Mass healthcare system develop a more comprehensive understanding of the dimensions of accountability on the individual, shared, and system levels  Goal 2: By October, 2004, through systematic and inclusive process a model framework for the accountability is brought forward  Goal 3: By January, 2005, the framework is widely implemented across the state

An old Russian Folktale... An old Russian folktale tells of the family gathered for dinner, in the midst of which the youngest daughter is sent to the cellar to fetch more wine. After she does not return for several minutes, the youngest son is sent to find her. He finds her seated upon the cellar stairs, weeping bitterly. Upon his inquiry, she explains to him that she has seen a hatchet stuck into the ceiling at the foot of the stairs. "What if it should fall?" she cries. "How terrible to think that someone might be hurt!" Whereupon, her brother also begins to cry and sits beside her. One by one, most of the family is sent to find the missing ones, and one by one they, too, are overcome with realization of the enormity of risk. Finally, the old grandmother, left alone, goes to find out what has happened to the family. She finds them weeping together on the cellar stairs. But when they explain the reason for their paralysis, she strides briskly down the stairs, grabs the hatchet, and pulls it from the ceiling. The moral of this story, as I was taught it, is: don't be overwhelmed by thinking about problems, do something about them.

Journey  Burden  Responsibility  Power