patient safety leadership peter pronovost md phd professor, schools of medicine and public health...
TRANSCRIPT
![Page 1: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/1.jpg)
Patient Safety Leadership
Peter Pronovost MD PhD
Professor, Schools of Medicine and Public Health
Director, JHU Quality & Safety Research Group
![Page 2: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/2.jpg)
Leading Change:
Universal Challenge of Technical and Adaptive Work
![Page 3: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/3.jpg)
![Page 4: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/4.jpg)
Technical Challenges
• Can be solved with existing science or technology
• Issues or challenges for which there is “an answer”
![Page 5: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/5.jpg)
![Page 6: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/6.jpg)
Adaptive Challenges
• Require a change of values, attitudes or beliefs
![Page 7: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/7.jpg)
The Birds’ Eye ViewTechnical and Adaptive Challenges in
Quality and Safety EffortsNationally
• JCAHO Core Measures• CMS • NQF
Internationally• WHO/ World Alliance for Patient Safety
![Page 8: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/8.jpg)
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)
![Page 9: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/9.jpg)
Central Mandate
Local Wisdom
Scientifically Sound Feasible
xx
![Page 10: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/10.jpg)
![Page 11: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/11.jpg)
Elizabeth Dayton, Joint Commission Journal, Jan. 2007
![Page 12: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/12.jpg)
Senior
leaders
Team
leaders
Staff
Engage How does this make the world a better place?
Educate What do we need to do?
Execute How can we do it with my resources and culture?
Evaluate How do we know we improved safety?
Pronovost: Health Services Research 2006
![Page 13: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/13.jpg)
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
![Page 14: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/14.jpg)
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
![Page 15: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/15.jpg)
Leadership Action for Staff
• Keep patients your North Star
• Walk a process
• Reflect on perceived losses with change
• Commit to identify and mitigate hazards
![Page 16: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/16.jpg)
Time period Median CRBSI rate Incidence rate ratio
Baseline 2.7 1
Peri intervention 1.6 076
0-3 months 0 0.62
4-6 months 0 0.56
7-9 months 0 0.47
10-12 months 0 0.42
13-15 months 0 0.37
16-18 months 0 0.34
2 year results from 103 ICUs
Pronovost NEJM 2006
![Page 17: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/17.jpg)
Keystone ICU Safety Dashboard
2004 2006
How often did we harm (BSI)
2.8/1000 0
How often do we do what we should
66% 95%
How often did we learn 100s 100s
% Needs improvement in Safety climate
Teamwork climate
84%
82%
41%
47%
![Page 18: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/18.jpg)
Lessons Learned
Need to get technical and adaptive work right– Centralized measurement– Local ownership
![Page 19: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/19.jpg)
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?
![Page 20: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/20.jpg)
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?)
![Page 21: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/21.jpg)
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”
![Page 22: Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group](https://reader036.vdocuments.net/reader036/viewer/2022070305/55141022550346e7488b4feb/html5/thumbnails/22.jpg)