the leadership system at work: creating a culture of
TRANSCRIPT
The Leadership System at Work:Creating a Culture of Patient Safety
Pattie Skriba
Vice President – Learning and Organizational Effectiveness
Tamara Schaeffer
Director – Patient Safety
Imagine a Culture Where….
-- Jim Collins
Disciplined people who engage in
disciplined thought and who take
disciplined action
Leadership System
Vehicle for deploying vision and values
Sets expectations for performance and
performance improvement
Builds loyalty and teamwork on shared goals
5
Lots of Leader Expectations
Learn, Improve& Innovate
Organize, Plan & Align
MissionValues
Philosophy
UnderstandStakeholder Requirements
IntegrityPassionCaring
CommunitySuppliersPartners
PhysiciansVolunteersAssociatesFamilies
Patient
1
Develop, RewardRecognize
AccountabilityFor Results
Perform To Plan
Set Direction & Establish Goals
Patient
Our Vision:To provide an exceptional patient experience marked by superior health outcomes, service, and value.
Community
Suppliers
Partners
Physicians
Volunteers
Associates
Families
Who Is on Our Team
Mission
Values
Philosophy
Our Beliefs
Integrity
Passion
Caring
Core Leader
Traits
Patient
Who We
Serve
Who We Are
Organize,
Plan & Align
Perform to
Plan
Develop, Reward
& Recognize
Learn, Improve
& Innovate
What Leaders Must Accomplish
Set Direction
Establish Goals
PatientCommunity
Suppliers
Partners
Physicians
Volunteers
Associates
Families
Mission
Values
Philosophy
Integrity
Passion
Caring
1
Understand
Stakeholder Requirements
1
Accountability
for Results
PatientCommunity
Suppliers
Partners
Physicians
Volunteers
Associates
Families
Mission
Values
Philosophy
Integrity
Passion
Caring
Organize,
Plan & Align
Perform to
Plan
Develop, Reward
& Recognize
Learn, Improve
& Innovate
Set Direction
Establish Goals
What Leaders Cannot Delegate
Leadership System
Understand
Stakeholder Requirements
1
Accountability
for Results
PatientCommunity
Suppliers
Partners
Physicians
Volunteers
Associates
Families
Mission
Values
Philosophy
Integrity
Passion
Caring
Organize,
Plan & Align
Perform to
Plan
Develop, Reward
& Recognize
Learn, Improve
& Innovate
Set Direction
Establish Goals
World-Class Criteria
1.a(4)
How do Senior Leaders Create a Culture of
Patient Safety?
Everything
Rises and Falls
on
Leadership
Who Requires Safe, High Quality Care?
Patients
Physicians
Associates
100 DaysSince Last Serious
Safety Event
Strategic Objective: No Harm to Patients
Decrease Mortality
Reduce Complications
Eliminate Ventilator-Associated
Pneumonia
Increase Compliance with Hand
Hygiene Practices
Increase Near Miss Reporting
Organizational Goal
% Hand Hygiene Compliance
Director
Divisional Roll-Up - % Compliance
Manager Goal
Unit Compliance
Frontline Associates
Every Time! Before & After
Organize, Plan and Align
Hand HygienePercent Compliance
0
10
20
30
40
50
60
70
80
90
100
ICU Ventilator-Associated Pneumonia
Per 1000 ventilator days
0 0.3 0.3 0 0
2006 2007 2008 2009 2010
0.25
0.55
0.65
0.74
2003 2005 2007 2010
Mortality (Actual/Expected)
Develop
Causal Analysis Workshops for All Leaders
Systems Training for Clinical Associates
Just Culture Classes – All Leaders
Reinforcement of Just Culture in Daily
Huddles and Staff Meetings
0
1
2
3
4
5
6
7
8
Jan-
09 Feb
Mar
Apr
May
June July
Aug
Sept Oct
Nov Dec
Jan-
10 Feb
Mar
Apr
May
June July
Aug
Sept Oct
Nov Dec
Learn, Improve and Innovate
Patient Safety Event Reporting Rate
Learn, Improve and Innovate
0
50
100
150
200
250
2008 2009 2010
RCA's
ACA's
Total Analyses
Causal Analyses Completed
Malpractice Costs (in millions) Total Insurance Expense
2006 2007 2008 2009 2010
Do
lla
rs (
in m
illi
on
s)
Go
od
83% Reduction
0
20
40
60
80
100
0 20 40 60 80 100
Rate
of
Imp
rov
em
en
t
Performance
Patient Safety Results
24
100th
Percentile
for Patient Safety
Source:
Thomson Reuters
2004-2008
Thank You
Questions
Panelists:
Sandy Churchill, Vice President – Quality /
Patient Safety
Dr. Chuck Derus, Vice President – Medical
Management