1. Patient Safety In the Health Delivery “System” Where we have been? Where are we now? Where must we go? Jim Conway jconway@ihi.org

2. Are We Making Progress? Absolutely! Engaging People within/across organizations – Patients, families, staff, leadership, governance Setting Aims – All or nothing Confronting Realities – Suffering, harm, tragedy, death, waste Implementing Interventions – Leapfrog/NQF, IHI Campaigns, Keystone, SCIP Using Tools and Science – Lean, Six Sigma, Toyota, RCA, FMEA

3. Are We Making Progress? Absolutely! Implementing New Standards – Joint Commission Conducting Research Having Conversations – Disclosure, fair and just culture, transparency, shared learning Seeing Results – Elimination of VAP, SSI, CLI, Pressure Ulcers, preventable harm

4. ARE WE SAFER? What’s the Bottom Line: Health Care System YES, in many organizations more of the time BUT, there is exceptional variation – Within organizations – Among organizations NOT safer for every patient every time – Not safer for every staff member every time

5. WHY DID WE FAIL TO ACHIEVE RECOMMENDATIONS First, It’s a Failure of Leadership Set the expectation Position for success Hold accountable Over time

6. In a New US Survey of Hospital Governance and the Quality of Care… Only 20% of board chairs reported the board chair, board itself, or a subcommittee as one of the two most influential forces on quality. Among the low performing hospitals, no respondent reported their performance as worse than the typical US hospital. A little over half identified clinical quality as one of the two top priorities for board oversight. Fewer than one-third of nonprofit hospitals had formal board training programs that included quality. Jha A, Epstein A. Health Aff (Millwood). 2010;29(1): published online 6 November 2009; 10.1377/hlthaff.2009.0297] 6

7. ACHE Annual Top 3 Survey Top Issues Confronting Hospital CEOs Issue200420052006200720082009 Financial challenges71%67%72%70%77%76% Health Care Reform-- 53% Care— uninsured36%35%37%38%41%37% Pt Safety & Quality-- 43%32% MD/hosp. relations32%33%40%35%32%25% Gov. mandates19%16%23%22%26%20% Patient satisfaction13%18%16%17%22%15% Personnel shortages33%36%30% 13% Patient safety16%20%27%29%-- Quality18%23%29%33%-- Notes: QI and Safety combined in 2008, Others below 10% in 2008 included technology, NFP status, and disaster preparedness

8. WHY DID WE FAIL TO ACHIEVE RECOMMENDATIONS Other reasons: – “Sorry seams to be the hardest word” – Lots of projects and not transformation – Failure to focus and prioritize – Over dependency on people – Lack of urgency – Tolerate poor performance among peers – Ineffective measures and limited transparency – Education /competency standards not required

9. WHAT WILL IT TAKE, OUR PRIORITIES Values-based leadership at every level Poor performance declared unacceptable – Burden, responsibility, power Organized around the patient and family Urgency and everywhere Clarity of our aim; do what by when Transformation built a foundation of reliability – NQF Safe Practice, IHI Improvement Map, Joint Commission – Across the system Measurement / Transparency / Alignment

10. Which preventable death is ok? Hospital Trustee If you knew, why didn’t you do? Bristol Inquiry