Welcome to the
TMIT High Performer Webinar:
Chasing Zero: Leadership Toolbox
Hosted by TMIT
For resource downloads go to:
www.safetyleaders.org
© 2010 TMIT
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Welcome
Charles Denham, MD
Chairman, TMIT
Co-chairman, NQF Safe Practices Consensus Committee
Chairman, Leapfrog Safe Practices Program
TMIT High Performer Webinar
November 8, 2010
© 2010 TMIT
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© 2010 TMIT
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Disclosure Statement
The following panelists certify:

that unless otherwise noted below, each presenter provided full disclosure information,
does not intend to discuss an unapproved/investigative use of a commercial
product/device, and has no significant financial relationship(s) to disclose. If
unapproved uses of products are discussed, presenters are expected to disclose this
to participants.
Charles Denham: Chairman, TMIT; education grant (CareFusion) and co-production with Discovery
Channel
Charlotte Guglielmi: Employed by Beth Israel Deaconess Medical Center
Paula Graling: Employed by INOVA Fairfax Hospital
Jennifer Dingman: has no relevant financial interests in this presentation
© 2010 TMIT
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Roundtable Panelists
© 2010 TMIT
Charles Denham
Charlotte L. Guglielmi
Paula Graling
Jennifer Dingman
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Chasing Zero Hospital Leaders
Toolbox Overview
Charles Denham, MD
Chairman, TMIT
Co-chairman, NQF Safe Practices Consensus Committee
Chairman, Leapfrog Safe Practices Program
TMIT High Performer Webinar
November 8, 2010
© 2010 TMIT
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TMIT Mission
Accelerate performance solutions that
save lives, save money, and build value
in the communities we serve and
ventures we undertake.
© 2010 TMIT
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Culture
2010 NQF Report
Consent & Disclosure
Consent and Disclosure
Workforce
Information Management and
Continuity of Care
Medication Management
Healthcare-Associated
Infections
Condition- &
Site-Specific Practices
© 2010 TMIT
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National Collaboratives Provide Performance Metrics:
Impact Calculators Provide
CFO Validated Performance Impact
“Extraordinary impact through ordinary things…”
Chasing Zero is the first in a series of
documentaries produced by TMIT that targets
consumers, caregivers, and healthcare leaders.
The goal is to inspire them to act now to prevent
healthcare harm. The war on healthcare harm is
not targeting bad people, but bad systems.
These support systems no longer protect
caregivers and patients as healthcare has
become more complex and fragmented.
Healthcare harm has risen from the 8th leading cause of death to the 3rd leading
cause of death when we include infections we have given patients during care.
“20 jumbo jets are crashing every week in American healthcare”
The documentary was shot in multiple locations around the world. Interviews of
World Health Organization leaders were undertaken in Geneva and London. Dennis
Quaid was filmed on the movie set of Soul Surfer on Oahu, Hawaii. Caregivers
were shot in action at their hospitals including the Brigham and Women’s Hospital,
the Mayo Clinic, the Cleveland Clinic, Johns Hopkins, and the Vanderbilt University
Medical Center.
“Zero is the number … Now is the time”
Narrator Dennis Quaid
Our goal is to reinforce role models of great caregivers and healthcare leaders, and
to open dialogue among governance and leadership teams at America’s hospitals
and healthcare organizations so our care will be safer and more reliable.
DVD Contents and Bonus Features
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Chasing Zero documentary feature – 53-minute run time
Medical articles for background reading and continuing education:
• Chasing Zero: Can Reality Meet the Rhetoric? by Charles Denham, Peter
Angood, Donald Berwick, Leah Binder, Carolyn Clancy, Janet Corrigan, and David
Hunt
• The Chasing Zero Department: Making Idealized Design a Reality by Charles
Denham, Peter Angood, Donald Berwick, Leah Binder, Carolyn Clancy, Janet
Corrigan, and David Hunt
• Story Power by Dennis Quaid, Julie Thao, and Charles Denham
• The No Outcome - No Income Tsunami is Here: Are You a Surfer, Swimmer,
or Sinker? by Charles Denham
Web links to receive free assets, such as the National Quality Forum 2010 Safe
Practices for Better Healthcare, in return for survey responses to safe practices
adoption.
Messages from funding organization leaders.
Web links to view other resource materials from Discovery Channel, AORN,
CareFusion, TMIT, and other patient safety organizations.
Stories of great healthcare leaders and caregiver role
models communicate the actions that we can take to
save lives, save money, and deliver value to the
communities we serve.
Visit DiscoveryChannelCME.com
Chasing Zero online at www.ChasingZeroMovie.com
Chasing Zero™ is a trademark of CareFusion Corporation
This program was produced with educational grants funding from CareFusion, AORN, and TMIT.
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Leaders Toolbox Content
DVDs Include:
• Chasing Zero – full movie
• Chasing Zero – movie with discussion breaks
• Chasing Zero Trailer
• Hospital Leaders Guide
© 2010 TMIT
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Leaders Toolbox Content
Toolbox Videos:
• Infections
• Disclosure
• Technology Adoption
• Care of the Caregiver
• Listening and Share Rounds
• Patient and Family Involvement
• Checklists
© 2010 TMIT
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Leaders Toolbox Content
Additional Resources:
• Toolbox Overview video (How to use the DVD)
• AORN Correct Site Surgery Toolkit
• Journal of Patient Safety Articles
• Joint Commission JQPS/Julie Thao articles
• Health Affairs – Jha/Epstein article
• NQF Safe Practices
• Discussion Questions (PDF handout for various
points in movie)
• Continuing Education Resources/Web Links
(AORN, CareFusion, Discovery Channel, TMIT)
© 2010 TMIT
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Advancing Patient Safety: Available
Tools for Perioperative Nursing
Charlotte L. Guglielmi, RN, BSN, MA, CNOR
Perioperative Nurse Specialist
Beth Israel Deaconess Medical Center
TMIT High Performer Webinar
November 8, 2010
© 2010 TMIT
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© 2010 TMIT
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Checklists
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© 2010 TMIT
Living, evolving instruments
Methodical reminders
They are not to-do lists
Aviation checklists have a critical construction
‒ Challenge
‒ Verify
‒ Response
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Principles of Patient Safety to Be Considered
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© 2010 TMIT
Enhancing communication
Building in redundancies & cross-checks
Standardization
Simplification
Forcing function
Grassroots empowered to lead change
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Problems or Risk of Checklists
• Can be misunderstood as rules
• Some people consider them another “to-do” list
• May suggest absence in the application of critical
thinking
• Can result in failure to use open communication
• Toleration of deviance from checklist among team
members could result in patient harm
© 2010 TMIT
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Checklist Basics: Applying the Elements
• Concise
• Standardized
• Easily understood
Operation of Fire Extinguishers
by the user
• Force a function
• Promote communication
P ull the pin.
A im low, at the base of the fire.
S queeze the handle.
S weep from side to side
(Source: Beth Israel Medical Center Employee
Comprehensive Education Module)
© 2010 TMIT
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Advancing Patient Safety: Available
Tools for Perioperative Nursing
Paula R. Graling, DNP, RN, CNOR
Clinical Nurse Specialist, INOVA Fairfax Hospital
TMIT High Performer Webinar
November 8, 2010
© 2010 TMIT
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The Operating Room
Team Members
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Clinical Concerns: Errors seen in the OR
• Wrong site surgery
• Specimen management
• Retained sponges
or instruments
• Medication safety
• Incompatible blood
transfusions
• Surgical fires
© 2010 TMIT
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Identified Trends
• Non-compliance with
formal verification
procedures
• Inaccurate or
incomplete
communication among
team
• Failure to engage the
patient in the process
© 2010 TMIT
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What did we attempt to do?
• To establish collaborative responsibility and
accountability for safety in the OR
• To implement a newly designed surgical safety
checklist
• To assess changes in culture following
introduction of a newly designed checklist and
team safety training
• To determine the rate of surgical safety events
after using the new checklist
© 2010 TMIT
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Checklist Implementation
© 2010 TMIT
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Our success
• Demonstrated a methodology to establish
accountability for patient safety in the operating
room
‒ Assessing culture
‒ Implementing a safety checklist
‒ Measuring outcomes
◦ Compliance with the checklist process
◦ Clinical and operational outcomes
© 2010 TMIT
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Leadership Recommendations
• Organizations need to create infrastructure to
sustain excellence in patient safety and quality
• Outcomes measures identified as indicators of
cohesiveness and communication within
perioperative team
• Consistent approach to sustain cultural change
• Must have Safety Champions on a local level
© 2010 TMIT
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How can the leadership tool box help?
• Access to research and strong evidence
• Merge with real life experience
‒ Accentuate the reality
‒ It can never happen to us (awareness)
• Academic relationships
• Design collaborative initiatives (accountability)
• Capacity to do work within existing structures
‒ Practice/Quality Committees (ability)
• Make a difference (action)
‒ Depend on the early adopters to help lead change and
move to institutionalization
© 2010 TMIT
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The Role of the Patient Advocate
Jennifer Dingman
Founder, Persons United Limiting Substandards and Errors
in Healthcare (PULSE), Colorado Division
Co-founder, PULSE American Division
TMIT Patient Advocate Team Member
TMIT High Performer Webinar
November 8, 2010
© 2010 TMIT
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Roundtable Q & A
© 2010 TMIT
Charles Denham
Charlotte L. Guglielmi
Paula Graling
Jennifer Dingman
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