1. Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group

2. Leading Change: Universal Challenge of Technical and Adaptive Work

4. Technical Challenges Can be solved with existing science or technology Issues or challenges for which there is an answer

6. Adaptive Challenges Require a change of values, attitudes or beliefs

7. The Birds Eye View Technical and Adaptive Challenges in Quality and Safety Efforts Nationally JCAHO Core Measures CMS NQF Internationally WHO/ World Alliance for Patient Safety

8. 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)

9. Central Mandate Local Wisdom Scientifically Sound Feasible x

11. Elizabeth Dayton, Joint Commission Journal, Jan. 2007

12. Senior leaders Team leaders Staff EngageHow does this make the world a better place? EducateWhat do we need to do? ExecuteHow can we do it with my resources and culture? EvaluateHow do we know we improved safety? Pronovost: Health Services Research 2006

13. 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

14. 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

15. Leadership Action for Staff Keep patients your North Star Walk a process Reflect on perceived losses with change Commit to identify and mitigate hazards

16. Time periodMedian CRBSI rateIncidence rate ratio Baseline2.71 Peri intervention1.6076 0-3 months00.62 4-6 months00.56 7-9 months00.47 10-12 months00.42 13-15 months00.37 16-18 months00.34 2 year results from 103 ICUs Pronovost NEJM 2006

17. Keystone ICU Safety Dashboard 20042006 How often did we harm (BSI) 2.8/10000 How often do we do what we should 66%95% How often did we learn100s % Needs improvement in Safety climate Teamwork climate 84% 82% 41% 47%

18. Lessons Learned Need to get technical and adaptive work right –Centralized measurement –Local ownership

19. 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?

20. 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?)

21. 21 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