TMIT High Performer Webinar:
Chasing Zero Leaders Toolbox: Your Action Pack
September 23, 2010
Webinar Transcript
Charles Denham: Good day! This is Charles Denham, Chairman of the Texas Medical Institute of
Technology, TMIT, and it is a real privilege for me today to introduce our panelists in a very special
program. This program addresses the documentary, Chasing Zero: Winning the War on Healthcare Harm,
and a leaders' toolbox that will go with the documentary, which we are providing free to all of the
attendees of this webinar, as well as everyone globally who are interested in using it. Again, we have to
thank AORN, our Association of Perioperative Registered Nurses, and CareFusion for the unconditional
grants that were made to TMIT to make the movie possible, and Discovery Channel for sharing that with
us. We have a tremendous number of experts that have participated in this, and we are going to show
you an action pack that hospitals can put into work as you continue with your journey through healthcare
reform and patient safety.
First, just a couple of housekeeping details: If your audio is low, please go down to the WebEx volume
bar, which you will see in the slide that I am showing on slide #3, and if you cannot still get good audio –
and we have had audio problems in the past when we have a tremendous number of participants –
request the phone and click on the "request" button at the bottom of the slide. I am now on the next slide,
which is the landing page, or the home page of Safetyleaders.org. If you do not have the slides, you can
go to www.safetyleaders.org, and in the menu panel to the right of the Chasing Zero video view window,
rd
you can click on the webinars and the link for the September 23 webinar, and you will find the page that
I am showing on the next slide, for those that have the slides. You may download the slides in 2 to 3
business days. You will have the opportunity of downloading the transcript of this message as well as the
slide, and will also be able to watch the Chasing Zero documentary and other assets that are going to be
addressed in this webinar. Our disclosure statement you may read from your screens for each one of the
speakers and panelists. We have already declared the relationships with AORN, and CareFusion
regarding the documentary Chasing Zero. No products or services will be addressed in this presentation.
My roundtable panel I am really pleased to introduce: Dennis Quaid is going to be with us today by audio
in a pre-recorded manner. Dennis is shooting the movie Footloose and could not be with us today, but is
with us in spirit. We have Steve Rel, patient advocate, one of the co-authors of the National Quality
Forum Safe Practices Patient and Family Chapter, Chapter 9; Sue Sheridan by audio, who is flying back
from Geneva right now, who was at a World Health Organization meeting earlier this week; Dr. Steve
Swensen, who unfortunately also is pre-recorded because he had some duties today that would not allow
him to be on the panel in person; we have Tom Van Dawark, who is the former Board Chair of Virginia
Mason and a CEO from the maritime industry; we have Charlotte Guglielmi, who is the President of
AORN; and we have Dan Henderson, a medical student and Vice-President of the American Medical
Students' Association, who is the co-author and actually the lead author on an article, "Check a Box. Save
a Life.", that was covered in the movie and was also in the documentary.
I would like to open with a couple of words of inspiration from Steve Rel, patient advocate, a champion for
improving patient safety after the loss of his 10-year-old, Braxton Rel. We are so honored to have Steve
open us with his message and call to action to those of us that are on the webinar. Steve Rel?
Steve Rel: I would like to thank you all and welcome you to this webinar for being leaders in the
healthcare industry and having the courage to help us save lives. I hope that someday my son's providers
will have the same courage that you show, to help right the wrongs of my 10-year-old son Braxton. I thank
you all from the bottom of my heart from my family. Thank you.
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Charles Denham: We'd like to remind those that haven't seen Chasing Zero yet that Steve and his family
shared their life and their experience for one purpose, and that was in the honor of their son Braxton, so
that such events would not happen in your hospital, and to really ignite the passions of those that want to
do better in each of their hospitals. You see a picture of Braxton with his mom Lorna in this next slide. I
am going to ask Kyle now to play a recording that is part of a video that will be on the leadership toolbox
of this documentary that will be distributed and also be found on our website that we are working on here
as we speak in Laguna Beach at our site on the West Coast. We have a pre-recorded message that is
from a portion of a video that will be on that leadership toolbox, specifically directed at board members
and CEOs, the C-suite and leaders. Kyle?
Susan Sheridan: We'd like to make a call to action to all boards and their CEOs, to watch this video,
Chasing Zero, in its entirety with their entire board, and use the toolbox that comes with it, and even
dedicate some special time for retreat to really dive into this information, because we are confident this
will save lives.
Steve Rel: There is so much devastation like the loss of the life of my son Braxton, it demands that CEOs
and board members come to action. Ground Zero does start in the boardroom...
Charles Denham: Thank you, Kyle. I am going to just introduce, with a few moments a review of some
slides, the toolbox, Chasing Zero, where we are heading, and then we will have our panelists, who are
wonderful people, address the issue.
Our TMIT mission is to accelerate performance solutions that save lives, save money, and build value in
the communities we serve and the ventures we undertake. TMIT is so grateful for the support of so many
organizations like the Mayo Clinic, the Cleveland Clinic, Vanderbilt University Medical Center, the
Brigham and Women's Hospital in the Harvard-affiliated hospitals, the Catholic Healthcare Partners, and
a whole host of other organizations that are collaborating with us and have collaborated with us.
The National Quality Forum Safe Practices for Better Healthcare are on slide 12. These are the major
functional divisions of this report. Haley Burgess was one of our team leads on this initiative, who is on
this webinar with us, and we are grateful for her leadership, and 500 subject matter experts who in one
way or another contributed to the update in 2010 that was released at the National Press Club by Dennis
Quaid with our Assistant Secretary of Health and a number of leaders of our government, including Dr.
Don Wright, who is leading the war on healthcare-associated infections through the new Office of
Healthcare Quality in the secretary's office.
The next slide takes us back to our landing page, and it shows our quick-start packages for implementing
the National Quality Forum Safe Practices. We made a theme of the documentary to focus on these, and
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Dennis Quaid announced and released the 2010 practices on April 12 of this year at the National Press
Club that are in the documentary and will be in the future documentaries. We are again grateful for the
financial support from AORN and from CareFusion and the partnership with Discovery Channel. As you
go on our website, you are able to watch the entire video and watch the short trailer of the video, both of
which will be on the toolbox DVD that will be made available to all U.S. hospitals. We are anticipating
sending this DVD to at least four (4) members of each hospital, with a cover letter from Dennis Quaid and
myself with a request and a call to action to watch the Ground Zero video that is directly targeting board
members with great input from Tom Van Dawark and Sue Sheridan and Steve Rel, and a whole host of
others who are helping us with the C-suite and board interface. Then we will also provide this DVD for
others that would like to order it, and we will make it so that they can order it at cost. We are also
deploying it to the more than 1,300 patient safety officers whom we have been involved in helping train.
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The next slide is a slide of our next documentary entitled Out of the Danger Zone*, where we are going to
address the human performance factors that are normal to all of us that create an opportunity for us to
make honest mistakes. I like to say in presentations that we have islands of greatness in American
healthcare, no question, but between these islands are a sea of safety support system failures, and our
patients and our caregivers and our communities are drowning between the islands. I had the honor of
speaking to 650 healthcare hospital leaders in Europe in Zurich last week and was able to step before
th
them and say, "I know we're 37 in the world in quality. I know we're double or triple the cost of any of the
industrialized nations. What have I to help you with?" I said, "Please learn from our lessons of these
system failures." Out of the Danger Zone will be addressing military aviation, airlines, nuclear power,
nuclear submarines, the aerospace program. We will be shooting the last shuttle mission with interviews
of General Charles Bolden, the administrator of NASA, and a whole host of other folks that were in the
original movie.
I would like to now address CareMoms – it's one more program that we have. We are starting a
grassroots initiative led by Sue Sheridan and Steve Rel and the patient advocates who many of you know
who work with us: Jenny Dingman, Dan Ford, Arlene Salamendra, Patti O'Regan, and Mary Foley, who
all are contributing to this grassroots effort to help put positive pressure on our hospitals through
distribution of Chasing Zero and our other initiatives through the National Quality Forum Safe Practices.
I would like to now just stop talking, and I always laughingly talk about Dennis and I, when we are on TV
together – Beauty and the Beast. I think it's better, even though we don't have him physically there, he
does have a great voice and you can hear the passion in his voice regarding his commitment to patient
safety. Kyle, would you play the recording of Dennis that was prepared for this webinar?
Dennis Quaid: The real sweet spot, or safety envelope for high-performance care, is the intersection of
three systems: leadership, safe practices, and technology. When these support systems are functioning
within the right organizational culture, we get great care, and we get safe care. America has the means to
dramatically reduce preventable harm to almost zero. So my mission is to drive awareness: awareness of
both the harm and the opportunity to save countless lives. It happens one little soul at a time. The
concepts, tools, and resources are gifts of knowledge from our nation's greatest quality leaders and gifts
of support from our funding partners. Please put them to work. The onus is on you to make sure we
protect our patients, our caregivers, and their families. God bless you for your efforts.
Charles Denham: So the next slide, slide 21, reflects some of the activities that we have been
undertaking. Most recently we shot video for Out of the Danger Zone, flying up to Montana in the airplane
that you see behind Dennis in the top left side of the picture. We addressed again instrumentation,
checklists, and a whole host of other issues. In our next movie, Out of the Danger Zone... in the first
movie, we highlighted more of the Mayo Clinic with the Brigham and Women's Hospital, Cleveland Clinic,
Vanderbilt Medical University, and other organizations as kind of supporting cast members. As we go
forward with the work that we are doing in Out of the Danger Zone, Dennis will be addressing a number of
the technology issues in this sweet spot of leadership, practices and technologies, and how they as
support systems – if engaged leaders, predictable safe practices and technologies can be implemented –
we do get a performance envelope that is high-performance care. The Brigham and Women's Hospital
will be the lead character with the other hospitals in support, and a number of stories including organ
donorship and a whole host of other stories and continued stories from our very first documentary. The
picture to the left – as we go counterclockwise around the page – the picture to the left has Dennis and I
being interviewed by the press. We frequently say that the rules of the press are, number one, if it bleeds,
it leads, so they want to talk about traumatic events. Second is never let the facts get between you and a
*N.B.: The documentary is now titled Surfing the Healthcare Tsunami: Bring Your Best Board™. [0125-12]
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good story, and to them, a good story is they want to talk about trauma that drives ratings. We understand
that. They are now in a business. The pressure is doing that. The third issue is they are always looking for
a controversy, combat or contradiction. Dennis and I prayerfully, thoughtfully, prepare every time we are
interviewed to try to get the message across that it isn't bad people, it's bad systems; that these support
systems are the systems that really need to be addressed, and that it isn't you as caregivers, but that we
need to fix systems. Systems are very hard to describe. They are very hard to understand. They sound
like jargon, and it sounds like we are deferring blame, yet it is these systems that cause the major
problems. Dennis very eloquently in his C-SPAN-covered testimony to Congress really addressed how
things happened with the heparin accident, and we all know there are heparin accidents every month. We
also know there are CT scan accidents now with high doses being delivered to patients with delivery to
the brain from CT scan – again, from support systems and not individual recklessness of caregivers, but
just systems. As we go counterclockwise around Dennis, we shot in the flight up to Montana, and we are
now digging into the technology systems. The continuation of Out of the Danger Zone will build on the
Chasing Zero message that we have already had, and as we now move forward, we will talk about the
toolbox that we have prepared for you and will continue to prepare for you. There will be toolboxes for
each one of the upcoming documentaries. Out of the Danger Zone is next. The one following that will be
Staying Alive, that follows a patient from preop to operation through postop, starting with the primary care
doctor, going to the surgeon, through the whole procedure at hospital, back to the surgeon, and back to
the primary caregiver. The quote that you see on the slide 22, "It happens one little soul at a time.", we
got that recording from a meeting that we had with Sully Sullenberger, the hero that landed on the
Hudson, truly a great leader. Congressman Dana Rohrabacher, Dennis Quaid, John Nance, Dr. Steve
Swensen, who you will hear from in a moment, and a number of other experts who are helping develop a
concept for the NTSB, the National Transportation Safety Board, approach to accidents.
So a lot of initiatives upcoming. We will talk more about the toolbox during this webinar. However, we
have the series of documentaries coming. All will focus on the sweet spot between leadership, practices,
and technologies: engaged leaders, practices that deliver, predictable outcomes, and the technologies
that enable them. It all starts with leaders, and I can't think of a better segue to Tom Van Dawark than this
leadership issue. Tom is tireless in his dedication to help board members understand their responsibility
and has been a terrific contributor to this initiative globally. He was the Chairman of Virginia Mason
Hospital, who we all know is a terrific trendsetter and one of our great leaders in quality, and came to that
post as a CEO from the maritime industry and applied the principles he learned as a CEO that reported to
a board, then to a board chair, who then was in the chairmanship role of a hospital, and now he is
contributing his gifts to helping all of us adopt patient safety principles, safe practices, and the appropriate
technologies. We are really honored to have such a tremendous individual who, as every moment that I
spend with Tom, I am more appreciative of his wonderful gift that he is giving to us nationally. Tom, would
you take it away?
Tom Van Dawark: Thank you, Chuck. Good morning to all. From my perspective as a CEO working in
the maritime transportation industry, chasing my own zero in terms of oil spills and then carrying it on into
the boardroom at Virginia Mason, getting the board involved, engaged, in safety and quality excellent is
imperative. It is critical. The buck stops with us as board members. Getting the board increasingly
involved may be easier than you think. Board members in large part want to make a difference. They may
not know the severity of the crisis, they may not know how they can help, but from a board and from an
individual member perspective, they are a great resource and they do want to make a difference. So, if
you turn to the first slide, "Five Reasons to Engage Your Board in Chasing Zero," the first reason is that
patient safety is obviously core to your vision and true mission. Patients expect a safe experience, and
your regulators are demanding a safe experience. Certainly the crisis is real. We all know the national
numbers, and in your own hospital, most likely you are not at zero, nor are you at 100% in terms of the
compliance issues that you want to have.
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Secondly, the board ultimately is responsible for patient and safety. We have a fiduciary responsibility,
more an ethical responsibility, and a business responsibility for safety and quality that is just as important,
or more so, than our financial responsibilities.
Third, to get to where we want to go in safety and quality, change is going to be required. We are going to
have to see changes on the governance process and procedure side, which certainly need to be led by
the board, and operational practices are going to have to be changed. Those need to be led by the CEO,
but in many cases, the board has a role here, too – certainly for supporting the CEO in all endeavors, and
in many cases, standing side-by-side with the CEO and saying, "This is what needs to be changed, and
we are supporting management in these initiatives."
Fourth, at the end of the day, the board provides resources, and the more that they are engaged in your
safety and quality work and know what you are doing on a day-in, day-out basis, the better position that
they are in to properly prioritize the resources that are needed for your leadership, your systems, and
your technology enhancements and improvements.
Item #5, which I think in some cases we forget throughout the organization, is that board members can
bring some unique experiences and expertise to the safety and quality mission, and quite often they see
issues in a different light and can challenge the "we have always done it this way." We found at Virginia
Mason that bringing board members into safety and quality and credentialing and so forth was extremely
valuable in getting to a closer no-harm scenario than we had been in the past.
So, how do you get your board engaged or get them to a point where they are participating to a larger
degree than they have in the past? I will jump to bullet #5 on the second slide first, and that is finding a
way to ensure that your board routinely, what I would call, sees and is seen by patients and staff. What I
mean by that is that they have an opportunity to see what the organization does on a 24/7 perspective,
and from the eyes of the patient, and from the eyes of the caregivers at the bedside. What I mean by, "is
seen by patients and staff" is that they have an opportunity to ask patients, to ask our own caregivers,
how are we doing? What can we do better? How can the board become more involved? And simply
provide a thank you, both to the patient and certainly to the staff. The two most important and powerful
ways to see and be seen, from my perspective, are: number one, get the patient into the boardroom; and
number two, get board members out rounding with staff in both your hospital and your clinic. The board
needs to be able to put a face on the statistics that they see day-in and day-out, and they need to be able
to do the same when they see statistics on staff satisfaction, patient service levels, and so forth. When we
first brought the patient into the boardroom, I had allocated 10 minutes for the discussion. The first two
discussions were feel-good stories, and those were important. We moved to the first challenging story – I
had the same 10 minutes on the agenda – and an hour and 25 minutes later, we were through and
finished a conversation that was probably transformational in terms of the way we looked at the service
responsibilities that we have as a board member.
So, getting your board to see what you do from a patient's perspective and a staff perspective is very,
very important and can really help you on your voyage to get to where you want to be in safety and
quality. If you have to make the case for needed change, my suggestion would be that you find a way to
show the Chasing Zero either trailer or full video. Accompany it with some quick work that you do in terms
of answering questions that are posed by the video and bringing forth to the board five or ten key, critical
issues that you think are important in terms of your gap to zero and 100% in the organization, and provide
some examples of organizations who have gotten to where they want to be with respect to safety and
quality. The examples are out there, and there is nothing better than seeing that you are not having to reinvent the wheel with respect to where you need to go. Also, make the case for needed board
involvement in your change initiatives. As we chatted on the first slide, the board needs to provide
resources, they can be very helpful on an individual basis, and they need to be involved. Also, include
your board members in your safety improvement work. Your performance improvement initiatives that you
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have going on – hopefully you have a patient involved with that – put a board member on the team once
in a while. Let them see what goes on in terms of the performance improvement action that you have
underway. Let them weigh in; let them see what the patients have to say and our own caregivers have to
say. It is an educational opportunity for the board, and it's an opportunity for the board to provide their
experience and expertise, which I think you will find very helpful.
Lastly -- and hopefully you are already here in a number of ways – include the board members in what I
would call your routine safety and safety supporting work. Board members should be on the safety and
quality committee, they should have an involvement in credentialing, and I think the best case is that they
are on your credentialing committee as a board member. Hopefully you have a people and/or a culture
committee. Board members can involve themselves there from the expertise they bring from other
businesses, and obviously they should be on the compensation committee, hopefully tying safety and
quality performance to pay for performance, merit reviews, and evaluations that are going on throughout
the organization. So the board can be very, very helpful, and as strange as it may seem, they may now
know exactly the situation that you are in safety and quality-wise. They may not have been asked to
properly weigh in with their expertise and experience, but I can assure you that once you get the board on
board, to borrow the IHI term, it can make a significant difference in supporting what you are doing day-in
and day-out on safety and quality.
Charles Denham: Thank you very much, Tom, and I really appreciate the attention that you have really
paid to the specifics. When we get to the Q&A section, we will be asking you about what boards think
about and what they are aware of. We will move on to Dr. Swensen, but we've got generous time for our
Q&A, so we will come back to that because many of our safety leaders are not sure what boards think
about and whether they are interested and whether they want to know or not. My experience is that they
really do. They just don't know what they don't know, and they don't know that it's okay to ask dumb
questions, so sometimes they are fearful to engage, and there is a great dialogue every time there is.
I'm going to move on to Dr. Steve Swensen, who unfortunately couldn't be with us today. Dr. Swensen is
a radiologist. He was formerly the Chairman of Radiology in Rochester, Minnesota for the Mayo Clinic,
and is now the Director of Quality for all of the Mayo Clinic facilities, including the three main campuses,
as well as the Mayo Foundation. He is an extraordinary individual. He represents Mayo Clinic so well
because he is so deeply humbled, absolutely brilliant, and a huge contributor to the national and the
global scene in patient safety and quality, and definitely a leader to watch in the safety movement as we
go forward. Dr. Swensen was unable to be with us today, but he did want to be able to give his message
to you, so we have a recorded message. My first question to him was regarding the Chasing Zero
documentary, and in the documentary, he addressed, after he had seen the Quaid accident on TV, what
happened to him. This has always been really inspirational to us as he describes what happened to him
as he watched the events unfold on the news. It is in Chasing Zero, but I think it's great to hear a recap
from him. Kyle, would you play that clip?
Stephen Swensen: I still remember that morning, and I heard the story of the Quaid heparin accident.
Even though I was working out, I felt a chill, and I thought, "Could that happen at the Mayo Clinic?" And
the answer I had to give was "yes." So, that day, top leaders got together and asked ourselves, "What
should we do to look at the safety net we need to have in place at all of our 22 hospitals so that wouldn't
happen at Mayo Clinic?". It's a great story of how the pharmacy leadership and the hospital leadership got
together, troubleshot, and looked for every possibility of how it could happen at Mayo Clinic, and we did
our best with the systems and the processes and the safety net and the placement of the heparin, so on,
to make sure that we would absolutely minimize the chance of that ever happening. So, it's the kind of
story where you hear something B whether it is an event at Mayo Clinic or another hospital like this one B
you've got to be able to be open-minded enough to take every one as a learning opportunity.
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Charles Denham: So then I asked Dr. Swensen -- and I'm sure what's in your mind is B at a great place
like the Mayo Clinic, what did they find? Did they find something to fix or make better, and if they could
do it at the Mayo Clinic, what about us out at the front lines? So I asked him, "Did you find things to fix or
make better?"
Stephen Swensen: We find things every day that we can make better, and it's one of the workforce
competencies that we always try to enhance, and that is a mindfulness and a sense of humility that, as
good as we might be and think we are, we have opportunities every hour to improve some part of our
care for patients. And so that mindfulness, in always looking for those opportunities, is a key for high
reliability, and it's something we work on every day.
Charles Denham: So then, what I did was I asked Dr. Swensen to really address one of the neat
innovations that we uncovered in shooting the Discovery Channel documentary. We went to the Mayo
Clinic, and we always ask, "Are there some breakthrough innovations that we could tell stories about,
either in the documentary or in our toolboxes or in the work that we do at TMIT?", because every time we
go do a shoot, we are shooting for the movie, but we are also shooting for anything we can find to share
with other organizations. The other criteria was that we didn't ask for things that the Mayo Clinic might be
doing that is splitting the atom of healthcare, but really, whether there are everyday things that could
deliver extraordinary impact that you could do today. That was kind of our mantra. Are there everyday
things that anyone could do, that they could start today, that we might be aware of? Dr. Swensen gave it
some real thought, and he came back to us with some very neat solutions and innovations that we hadn't
even anticipated as we were heading to shoot the documentary with our producer, Matt Listiak. So we
reviewed a grid, and we said, "Boy, this Share Round, this sounds great." So I asked Dr. Swensen to
recap Share Rounds for you, which is in the documentary Chasing Zero, but also, we have it in a much
deeper dive in the toolbox so that you could implement that at your organization. So, Share Rounds. Kyle,
would you play it?
Stephen Swensen: Share Rounds is a really neat Mayo innovation. It is a front-line solution to one of the
areas that we know that all American hospitals, including Mayo Clinic, have some vulnerability, and that is
in hand-off and communication. So this is a story... so often, we get great ideas from the National Quality
Forum or LeapFrog, and we think that the Mayo leadership has great ideas, but I can tell you that where
we get most of our traction and most of our real progress is when front-line leaders and staff, who are
caring for patients every day, find something that makes a difference, and then we spread that. That's
really the essence of moving towards high reliability, when we have everybody in the workforce engaged
and looking for better systems and processes and ways to care for patients that don't come from
Washington, DC, or California, or you know, the state capital of Minnesota. They come from people who
are right there engaged. And Share Rounds is a story about that.
Charles Denham: So Share Rounds, briefly, for those of you that haven't watched the documentary, are
the process of nurses doing reports in front of the patients and families, so handing off the patient at the
end of a shift from the first nurse to the second nurse, and describing what has occurred in the prior shift,
what we're looking for in the next shift, the reasons for what we're doing, and engaging the patient and
family in that. Unbelievably, this is I think what we call the holy grail. It improves patient satisfaction,
doctor satisfaction, nurse satisfaction, improves patient safety tangibly and measurably, and actually, if
done correctly, takes less time than typical reports because if you look at the time of the nurse over the
trajectory of an entire shift, there is less time having to be spent with the patient, addressing some of the
nuisance items, and more time on direct care. So it really is one of those terrific innovations that can be
done in any location. So I asked Dr. Swensen, as a short question, "Would you recommend the quality
leaders and administrative leaders undertake and review Share Rounds as an opportunity for their
organization?", and here's what he said:
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Stephen Swensen: Share Rounds is one of those innovations that we know is effective, and doesn't cost
us a nickel. In fact, it saves us money. It's something that anyone can do at any hospital from a critical
access one to a 2,000-bed hospital without any high technology. It is such a patient-centered way of
sharing information between nursing staff as they go from one shift to another, in front of the patient, in
front of the family, with an extra set of ears or two to hear what's going on with the patient, who is
listening, and giving that feedback. It is a double-check system that's very human-friendly and something
everybody can do, and I think everybody should do.
Charles Denham: So then I asked Dr. Swensen regarding another Mayo innovation that we discovered
in our documentary at the Mayo Clinic, regarding high-contact surfaces in patient rooms, which is really a
very special innovation that came from the meat-packing industry to measure high-contact surfaces and
then develop checklists to clean those high-contact surfaces to reduce infection. Kyle, please play that.
Stephen Swensen: I love this story, because this is another front-line story where staff B who are not in
the C-suite, they don't have a bunch of initials after their name, but they're the most important colleagues
we have at Mayo Clinic B they are front-line folks caring for patients directly, and they saw an opportunity
to improve the care of patients by looking for possible sources of infection. These front-line workers got
engaged spontaneously with no big committees or boards at Mayo Clinic or the Director of Quality saying
anything. They saw an opportunity, they took it, they made a checklist, they proved the case by the story
you hear, and now we're spreading that throughout Mayo Clinic. If all any institution does is what they
hear from national organizations or state regulatory groups, they can be good, but to be great, you've got
to have front-line staff take the initiative when they see an opportunity to make the care of patients better
and safer.
Charles Denham: So then I asked Dr. Swensen regarding the Chasing Zero documentary, now that their
organization was part of this documentary, I asked him to describe what he thought the value of the
Chasing Zero documentary was.
Stephen Swensen: The Chasing Zero feature is just a wonderful, philanthropic story of healthcare safety
in the world. And the leverage of these series of stories grabs your heart and connects your mind, which
wants to do something with your heart, which knows you need to, and gives you some really outstanding
ideas about what can be done without thousands of dollars of investment. What you learn in this video is
the importance of safety in the care of patients, and that most of the efforts can be done at any hospital in
the world with simple changes in processes that anyone could afford – in fact, can't afford not to do.
Charles Denham: So we thank Dr. Swensen for his contribution, and I had the honor and really a distinct
privilege to be able to give a keynote speech to all of the procedural physicians, staff, administrators, and
the operating room staff – all of the surgeons as well as the administrators of the surgical service. I met
with their teams on Sunday night, gave a speech Monday, spent time with them all day Monday, and I
was overwhelmed by the fact that even the Mayo Clinic – not once did they tell me how great they were,
but in every turn of every page of the day and discussions with Dr. Claude Deschamps and their
wonderful team, all we talked about was how they could be better, what they could do better, dealing with
issues of hierarchy and the power gradients in the OR, and speaking up all the things that we are
addressing everywhere. But the interesting thing was, here is one of our really terrific cultures, and one of
the great signs of a great culture is the deep humility of servant leadership. So, we thank Dr. Swensen for
his help, and I thanked him on the phone, and here is his thank-you back to us and to you.
Stephen Swensen: Thank you, Dr. Denham, for what you're doing for patients all over the world. This is
a wonderful story and a wonderful gift.
Charles Denham: Now it's my privilege to introduce Char Guglielmi, who is a terrific participant in the
Chasing Zero documentary. She is a perioperative nurse specialist at the Beth Israel Deaconess Medical
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Center, and is also the President of AORN. She is distinguished on many levels in the areas of nursing,
and we had the privilege of shooting a portion of the video – and she is in the main Chasing Zero video,
which we shot on-site in the operating room with her – and we are very pleased to have her address the
issue of checklists. Char, please take it away.
Charlotte Guglielmi: Thank you, Chuck. As we move forward with our agenda of chasing zero, more
and more attention is being focused on the topic of checklists. Whenever the topic is raised, it usually
ensues a debate, and the question is: do they hold promise, or are they raising problems? I truly believe
that there is great promise in the future that embraces checklists as a tool that we use in this toolbox in
our everyday quest to reach chasing zero. There is no question for us, that those who practice B
especially in the surgical environment – that technology is exploding, production pressure is increasing,
patients are more complex, and stress in the environment is at its all-time high.
And so now to the question of checklists. What are checklists? Checklists were defined in a recent article
as having the following characteristics, and I love this definition: They are living, evolving instruments to
be adapted as needed. In high-stress, high-tension situations, they can be used as methodical reminders.
For example, when resolving an incorrect count in an operating room, a well-crafted checklist could
ensure that all steps of a resolution process occurred, and those things usually happen when our
caregivers are under most stress. There is no question that there is a buy-in from all of the disciplines that
checklists should never be to-do lists. In taking from our colleagues in aviation, I really like the point that
Dr. Karl brings forward in his article, that the constructs of checklists are to challenge, to verify, and to
validate a response. I think this is really important as we move forward with our discussion.
There are some safety principles you see on the slide of patients and what we need to think about when
we're considering patient safety. If you think about the application of these principles to checklists, the
following things will come forward. Let's think about it this way: Checklists structure communication, serve
as process reminders, serve as reminders of how to function in stressful situations, provide tools for
unintentional omissions, and create a platform for consistent review of critical information. When you take
those elements and look at the elements on the screen, you can see how checklists really make sense.
Before we think about the promise the checklists give us, let's get at the question of the problems, and
let's get that out of the way. They can be misunderstood as rules. They can be thought of by staff with
negative connotations – another paper to fill out, another box to check on the electronic record. And
sometimes following the rules so closely can really shut down the communication that we are all working
hard to open up. This especially occurs when teams work together all the time. So that's something to
think about. Clearly, problems related to checklists can be mitigated through great education, great
understanding, and most importantly of all, using empowered point-of-care staff to continue to make
these tools **** and relevant to the care they deliver every day.
Now let's look deeper at the promise in checklists. Checklists can be basic and simple. Without regard to
their complexity, there are five elements that should be part of every checklist: they must be concise,
standardized, easily understood by the user, force a function, and promote communication. Let's take the
stop sign, for example. We see it everyday, all over the world, in millions of languages. Think about it for a
minute. A stop sign is a checklist. Why? It's concise, it's standardized, it's easy to understand. When I'm
driving and I see a stop sign, it elicits my fixed response from me; I stop, and if I don't, anybody else in the
car starts yelling at me. It forces communication. Another simple checklist that we all see broadly used is
the PASS acronym for operating a fire extinguisher. How do you remember what you do? The acronym
is on the screen, and you can see that the elements that we talked about earlier are all imbedded in the
operation of that checklist in using the acronym "PASS."
I'm sure that the 2009 World Health Organization Surgical Safety Checklist displayed on the screen is
familiar to many of you. The evidence is overwhelming that its application has made the surgical
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experience safer all over the world. It's a seminal document in our arsenal of tools. It uses all of the
elements that we discussed on the previous slide about the construct. It also has the ability to be modified
to meet local **** Again, it goes back to empowered point-of-care staff speaking out about what's relative
in their practice. AORN strives to be an indispensable resource for perioperative nurses and the teams in
which they engage in their partnering for care. Our members told us that they were terribly excited about
the possibilities that the surgical safety checklist brought forward to them, but they were struggling with
how to marry that checklist with the elements they needed to achieve every day to meet the regulatory
requirements. So AORN listened, we partnered with experts from all over the country, including Dr.
Gawande, and we created the following checklist. This is the AORN Comprehensive Surgical Checklist.
Your blue colors tell you the elements that were in the WHO Safer Surgery Checklist we just used before.
The green elements represent The Joint Commission's 2010 National Patient Safety Goals, and the
orange elements are common to both. The box at the bottom helps give guidance around some of the
elements our members told us they need. How do they engage the SCIP initiative, for example, in this
workflow in their operating room. This is a really great example of how we can take the needs of point-ofcare members, who are 42,000 strong, and bring it together to provide a tool that is used for safer surgery
everyday.
If we had a lot more time and time wasn't at a premium on today's agenda, I could speak of many other
demonstrations of the promise of checklists. The results of applying checklists to prevent hospitalacquired infections B for example, the work with central lines, the work with urinary catheter insertions B
are well-documented in the initiative. AORN is currently working in partnership with SAGES, The Society
of Advanced Gastric and Endoscopic Surgery. We are about to release a new checklist for surgical teams
to use when they're preparing operating rooms to do very complex, minimally invasive surgery
procedures. We keep looking for opportunities to use checklists to help us chase zero, and we're really
delighted to have an opportunity to participate in today's webinar.
Charles Denham: Char, thank you so much. You are a terrific contributor, and AORN is one of our
favorite organizations to work with. We always laughingly refer to AORN as the "get-it-done crowd,"
because we can always count on them to be a great partner, they always have put patients and
caregivers first, and the biggest thing is that they execute and they do a fabulous job of that kind of
diligence. It's a real honor to have worked with you on Chasing Zero and the toolbox as we go forward.
AORN has been wonderful about providing CEU credits for watching Chasing Zero, as has Discovery
Channel, and we are anticipating soon-to-be announced opportunities of more collaborations with AORN
around the documentary. It has now been seen by 3.4 million viewers, with 25,000 watching it per month,
and we have growing numbers that are watching it for CEU and CME credits. We anticipate some
regional initiatives that we may be announcing shortly in collaboration with multiple groups, and in being
able to leverage this movie as a door opener.
Now to introduce Dan Henderson, a future physician. Dan is the Vice-President of The Leadership
Development for the American Medical Students Association. It's America's oldest and largest
organization, that has more than 60,000 future physicians. In addition to serving on the organization's
Board of Trustees, Dan supports a national network of student leaders through the organization's
Continuous Professional Development Program. He is a fourth-year medical student, and he is on leave
going to Harvard School of Public Health to get his master's. I have to share – we're ahead of schedule
here, which is wonderful, and we'll have lots of Q&A.
I do want to share a brief story with you. Dr. Don Berwick invited me over to have lunch with him at one of
the Lucian Leape Institute meetings when I was in Boston, and I also serve at Harvard in the Advanced
Leadership Initiative and have an instructor's appointment at the School of Public Health and was there
on other projects. Don invited me over to sit down and visit about the next great adventure we might
contemplate. As I was starting to share with him something inspirational that someone had shared with
me in our network, he said, "Chuck, I have to stop you. I'm so excited. I have to tell you what's going on at
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IHI." I said, "Well, what is it, Don?" He said, "A group of medical students have self-organized at IHI,
taken over one of our conference rooms, and as I speak, they are putting together a program regarding
the World Health Organization checklist, and they're excited about undertaking that initiative in a selfdirected manner through our open school, which has now got over 185 chapters and healthcare students
from all over the world." I was amazed at this, and Don and I just reveled over this. We got on Don's cell
phone and called Shannon Mills over at IHI, and Don arranged for me to come over and meet the
students. I said, "Don, what if I were to put together a high-definition, broadcast-quality crew to shoot this
story of this group for the Discovery Channel?" Within 24 hours, with the great help of our team and our
producer, Matt Listiak, remotely from California, we assembled a high-definition crew, shot video of the
healthcare students and medical students B each one of them and them together as a group – and then
subsequently put them in the Chasing Zero documentary. Then months later, I asked Dan, I said, "Dan,
could you, over the next four days, write an article regarding the initiative "Check a Box. Save a Life.", and
do that by Friday at 5:00?" He said, "I'll do it," which was a herculean task, because I said, "If you could
get it to me by then, I'll try to see that we can get it through a fast-track full peer review process and have
the article published within three months." That was achieved because of initiative, entrepreneurship, and
the dedication of this one medical student and his five colleagues that wrote the article, and it all started
with Don Berwick just being amazed at the initiative of these healthcare students who decided to take
safety and run with it. Dan, take it away. Dan Henderson?
Dan Henderson: Oops, sorry! Can you hear me now?
Charles Denham: There we go. I bet you were on mute.
Dan Henderson: I think that was the case. Well, thank you, Dr. Denham, for that great introduction. It's a
real treat to be on with over 1,000 attendees, and it's always fun to work with TMIT, because I think that
you folks have the kind of energy that students have, so we play off of each other really well. I'm calling in
from sunny Boston to tell all of you about that initiative, "Check a Box. Save a Life.", and kind of present
how we were able to take checklists and turn them into a campaign – a bonafide social movement – and
then also to kind of make the case for involving student leaders in all of the work that you're doing as
safety leaders across the country.
When I look at the attendee list, I see that there are a lot of people in teaching hospitals, so I bet you are
interfacing with health profession students, and there's probably a lot of untapped capacity. So, what I
want to talk about – a couple of items here – to sort of give you some insight into the mindset of students
like myself and the people I work with, both as a medical and public health student and someone who
supports the network, as Chuck mentioned. I try to understand and answer the needs of healthcare
students in approaching problems in patient safety, as well as just balancing out the demands of a pretty
intense course schedule. I also want to spend a lot of time talking about that campaign we did, which I am
sort of calling "grassroots 2.0" here, and then kind of make the case for working with health students, as I
mentioned, and getting you all as involved as people like Don Berwick and Dr. Denham have been.
This slide is just sort of giving you some insights into the psyche of student leaders. Obviously this isn't
from one of my neurology textbooks, but there are a couple of main drivers that help students approach
challenges and tasks and decide what to do. Altruism is obviously a big driver for people who decide to
pursue care as a profession. We have put off a lot of gratification for a long time in the name of a higher
calling, so we often will approach a question and think, "How is what I'm about to do gonna increase the
good in the world, or gonna help my patients?" There is also achievement. Getting the grades to get into
and through health professional school isn't easy, so if we weren't a little competitive and a little selfdriven to get those A's, we probably wouldn't have made it. So, asking ourselves, "How is what I'm about
to do gonna help me become a better provider or potentially harm my training?", achievement is a big
driver. Then, of course, anxiety. How am I ever gonna finish studying? So, it's important to understand
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kind of what attracts students to challenges and what are big sources of energy, but also our limitations
can be.
So in thinking about this, we tried to develop sort of a campaign, which we called, as you can see here,
"Check a Box. Save a Life." That's a pretty exciting name – "Save a Life." That actually came from the
statistics published by Dr. Atul Gawande and others in the New England Journal about the surgical
checklist. You all know it works really, really well, and the actual number needed to treat – the number of
times it needs to be used in order to save a life (and this is on average, of course) – is about 143. As a
medical student, when I rotated through a surgical ward, I did about four cases a day, six days a week, for
about six weeks. So, if you do the math, that adds up to more than that number needed to treat. It's 144.
So what we realized is that just a group of us sitting around the table talking about the checklist had the
capacity ourselves to save a handful of lives if only we were to use the checklist. Now imagine if we
spread it to our friends in our hospitals. We realized that the surgical checklist had a lot of potential to
become a movement, so you can see how we have tried to frame that here. We invited Dr. Berwick and
Dr. Gawande, and we were amazed that they were willing to join us and give keynote speeches. The
campaign centered around a webcast, just like this one, with hopefully as many students as possible
tuning in to sort of offer them an easy barrier to entry, to take that first step in learning about the checklist
and wanting to get involved and spread it. That again sort of answers those three drivers I mentioned.
I want to talk quickly about the first impact and how many people we reached. Our numbers show that we
reached about 1,400 attendees, which is a lot for medical students, but it's so amazing to see that we've
got 1,000 on this webinar. So I mentioned, I'm in public health school now. I look at a lot of epidemiology
diagrams, and it's funny to see how the spread of this campaign really sort of took on an epidemic or an
outbreak-type character. On the bottom of this chart, you see time, and at the beginning is when we
opened the survey. Then, very exponentially, people signed up – up to about 182 at the final count –
unique sites signing on to tune in and show the webcast either to one person at home or audiences of
over 50 students. Then, if you just look at the sign-up rate by day, you can see that there's a really
interesting character here. So we see sort of a slow rise, then a small peak, then a larger peak, and then
a larger peak. What we realized is that people were spreading this message through their Facebook,
through their Twitter profiles, through lots and lots of organizational networks that they had. So we think
that this sort of represents the first pulse of people telling their contacts, then those people telling more
people, and then those people telling more people. So it really was a 3 degrees of separation spread.
Ultimately what we got was a completely global reach to about 11 countries, so we were totally blown
away by this. We had originally planned to call it National Safe Surgery Day; then we saw that people had
signed up in Israel and Pakistan, and we had to change the name. So, that was our incredible (for us),
initial impact. Now I want to talk about sort of what happened next.
Getting people to tune in and get informed was that first step that we needed to make easy, and we
needed to make it fun, and I think we did. What's interesting was, we didn't know if people tuning in could
actually make a difference or actually save lives, and I'm convinced that it did. So, a couple of quick
stories here: The medical student on the top right is a friend of mine. His name is Ben, and he goes to
school at the University of Illinois in Chicago. He was really excited about the checklist, and he asked for
some help in getting it implemented, which is a pretty lofty goal. So we talked about who he might be able
to partner with, and he recognized that there were two very supportive, approachable mentors in the
safety leadership faculty at the U of IC. Dr. David Mayer and Dr. Timothy McDonald were people he had
worked with, and they were both safety leaders who have participated, I think, in TMIT programs before.
So Ben approached them and posed the idea of students rotating through anesthesiology and surgery
actually using the checklist and leading it into the operating rooms. They were excited, so just a couple of
months later, that checklist was being used in every single operating room. So instead of one student,
one life, it was being done across the hospital. I know that now it's actually into the electronic medical
records system as part of the computer. So that was an incredible impact that has certainly saved lives.
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Ben went back to address it, and he said the first day it was implemented, he saw a person going in for a
hand surgery, that was about to be.. or, the site was inaccurately marked, and it potentially could have
been a wrong-site surgery were that checklist not in place. We also produced an app for the iPhone. It's
free, so anyone out there, we'd love for you to download it. It is produced on a student budget, so it's not
as nice as the $10 version, but this is just another way to leverage new technology and put this checklist
into the hands of everyone who is going through operating rooms. Then we also wanted to take sort of
the message of safety out of the OR, so we developed a patient-student questionnaire tool to empower
patients in asking questions and double-checking us with their own checklists. Then, as Dr. Denham
mentioned, we published this article, which I think tells the story in sort of a fun way, so I'd encourage
people to read it. It was a lot of fun to write. Then, finally, we attempted to reconvene to take the
campaign into another year, and we had about 55 health students signed up to attend a special congress
at the IHI BMJ International Forum in Nice. Then, lo and behold, the Icelandic volcano cut our numbers
from 55 to 4 – the few people who got out there and then were trapped by the volcanic ash. So it was
amazing that there was so much interest, but what was sort of a side lesson that was unexpected was we
had had all of this success with an online meeting, and then when we tried to use the older technology –
the in-person meeting B Mother Nature stood in our way. So it was another lesson about how effective
online, social media and new technologies can really be.
So in terms of future directions, we were so excited to see this getting to Chasing Zero, and now we are
seeing Chasing Zero as a good operating point for another student campaign. So I just kind of want to
make the case... I think we all are somewhat familiar with Willie Sutton's law – go where the money is –
and this is Sutton's exception. The students will generally bring a lot of energy, a lot of passion, and a lot
of capacity to the table for free. Come to us where the money isn't, and leveraging our natural passion
and our ability to organize and our membership in lots of organizations nationwide, is a great way to get
the message of safety leadership spread far and wide. Just to sort of prove that, just some quick surveys
here: We asked a group of 100 medical students at a conference B and you can see, 7 is "strongly agree"
and 1 is "strongly disagree" – you can see that by and large, the big majority want more patient safety
training. They are interested in material that comes outside of the school curriculum. They are interested
in putting on projects or events – so really engaging their classmates – and then, very surprisingly, a large
number of people had not heard of the National Quality Forum Safe Practices. Not only is there interest,
but there's a real need and a real vacuum to be filled by getting safety leadership into the hands of health
profession students.
So finally, I just want to put this charge to all of you. I see some of my friends who are health students out
there, and I see a lot of people who are working in teaching hospitals. This is a picture from the hour that
Dr. Berwick, now CMS administrator, spent with us, working through the challenges of our campaign. So,
ask yourself, "What would Don do?" If you can find the time to work with students, to teach us and help
us take the lead on this, you can have a tremendous impact, and that's kind of it. In summary, think about
involving students as ambassadors of the checklist of safety leadership, consider our mindset and how
we could fit in to the work you are already doing, and think about the future impact of people who enter a
profession at age 24 and will be in it for 30, 40 or 50 years, in terms of that number needed to treat and
that impact in saving lives and saving money. That's my whole presentation, so I'll turn it back over to Dr.
Denham. Thanks, everyone, for listening.
Charles Denham: Thank you very much, Dan. I just really appreciate your energy and passion and what
you bring to the table. So now as we open up our Q&A, I brought the slide back to slide #14, which is the
Hospital Leaders' Toolbox. I have Tom Van Dawark here at our conference center in Laguna Beach,
California, and as soon as we wrap up this session, we will be diving in to completing the scripts for the
toolbox. The toolbox consists of the 53-minute movie that has natural stopping points for you to lead your
teams. Whether you are a safety officer, whether you are a CEO, whether you are a board member,
whether you are a medical student, or whether you are a nursing leader or allied care provider, the
documentary was really designed to give you a chance to open... it's kind of a back door to the inner
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workings of a hospital for dialogue. As you see the bottom of the slide, there will be a leaders' guide, and
we have a video that's about 30 minutes that will be Ground Zero. Ground Zero comes from the
expression that ground zero in the war on healthcare harm is in the boardroom, not at the bedside. It is in
the boardroom where the CEOs and the CFOs and the COOs make decisions; it is where the board of
directors and the board chair presiding over that group meet 9-13 times a year; it is where the quality
committee leader of the board makes very important presentations and reviews information; and the
system failures are tied to that domain. So, the toolbox will have videos regarding the C-suite – and I'm
going to ask a question of Tom Van Dawark in a moment; infections – you see the tabs across the bottom
– 15 minutes on healthcare-associated infections; disclosure using the Braxton Rel and the Sue Sheridan
stories; care of the caregiver using the Julie Thao story; technology adoption of bar codes, skin
preparations, healthcare-associated infection identification systems, CPOE and other technologies; the
art of listening and addressing the performance factors, issues in communication, and that patients and
families, and again, very importantly, as Char addressed, checklists. So I'm going to ask the first question
of Tom Van Dawark. Tom, can you tell us, what makes board members tick? Are they really
approachable? Are they really interested in what we might share regarding patient safety? What are they
worried about and what are they interested in? Tell us a little bit about who they are.
Tom Van Dawark: I think the answer to the question in almost all cases is the board members really do
want to make a difference. Historically our boards have been put together with individuals who... frankly,
their primary role was to raise money in the community and/or who knew people who could. That is
changing over time, and as new board members come on, they only spend about 20 hours a year actually
in the boardroom, but they want to be able to make a difference while they are there. Of course, there's a
lot of work that goes on in the committee, but these are people who are representatives of the community,
i.e. they should be representing the patient. They want to do well. In many cases, they don't know the
questions to ask. In some cases, they are kind of overwhelmed with things like medical technology, the
knowledge of healthcare that others have that they don't have. What we need to be able to do is to better
explain the role that they can play in the organization, and particularly in safety and quality. The more
board members we can get onto our boards, into the safety and quality committee, who come from other
industries where safety and quality is a primary responsibility, that's a huge plus for the board and for the
organization B being able to discuss how checklists have worked in the maritime industry, for example,
and the airline industry, for example, for 25 years. So there's a wealth of knowledge there that we need to
be able to derive from our board. They need to be approached. They need to be asked. And I think in
many cases, you'll find they are very willing to jump in and make a difference.
Charles Denham: Tom, one more quick question, and that pertains to the future plans that we have of
building a best practices portal. Can you describe the vision for this concept of best practices for boards,
as well as best practices to engage with your board?
Tom Van Dawark: Yes. The intent is that we build a one-stop shop of governance best practices for both
the board and CEO and C-suite, and that that is a governance team, if you will; that rather than a scatter
diagram of plots and ideas in terms of best practices that are out there in literature and so forth, that we
pull all that in to one portal that is available to the board; it is written in governance language, shall we
say, without a lot of acronyms, tied to the NQF Safe Practices; and that the boards who are engaged who
want to make a real difference in safety and quality can go to the portal, they can pull off best practices
that are applicable to where they are in their voyage to zero harm, they can share back their best
practices for upgrades to the portal, and that there are various other resources available in the portal for
questions that may be asked by boards who are engaged and want to make a difference in safety and
quality. I think it is very, very exciting, and I think it's a resource that the boards dearly need and have not
had up until this point. I think it can make a huge difference in terms of getting our boards more involved
than they have been on safety and quality.
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Charles Denham: Thanks very much, Tom. I want to shift gears for a moment now to Char. Char, what
are the biggest barriers that you're seeing out at the front-line hospitals through your constituencies in
adopting the checklist? Do you have any tips for our attendees of this webinar on how to overcome some
of those barriers?
Charlotte Guglielmi: Just a moment. I think the biggest thing that we need to do when we want to look
at how do we overcome the barriers, in the first place, is finding a champion B finding the champions
within the physician leadership and within the C-suite. In my facility, we have a safety huddle that is Csuite, chief of surgery, chief of anesthesia, chief of perioperative services, and every week we look at
what are the questions and how do they move forward. If you get a surgeon champion to stand up and
say, "This really works," it helps you every time move it forward. Also, when you're putting a checklist in
place, make sure that the people who are going to use it are part of its construct. If you put out a checklist
and say, "Use this checklist," people aren't going to want to do it; but if you put out a question, "We need
to create a tool on how we're going to make doing A, B, C better – how do we want to do it?"... Our staff
told us, when we were able to take elements out because The Joint Commission didn't ask for quite as
much, "Don't take it away from us, because we've taught everybody to use it. Our patients are safer
because we do. Leave it there." Listen to your staff. The answer is listening to the providers.
Charles Denham: Char, any tips on dealing with the physicians that say, "Look, I've always done it this
way. I don't need to have that. I don't think it really applies to me."?
Charlotte Guglielmi: You know, Chuck, I think if you identify, within your midst, surgeons who have
found the checklists have prevented an error for them, and they speak up loudly about it, that's where
your real answer comes from. Because if you get somebody who something didn't happen because the
checklist was in place – if you were using a count checklist for example, you ran the checklist and
everybody had forgotten to do a step and went back and redid it, and you didn't retain a sponge – that's
the story you want to tell in your operating room. We've done it by using some of those experiences with
our surgeons at multidisciplinary safety rounds – we do those quarterly – and we've also done it through
training videos. When those docs get on board for you, they're the best resource you have out there.
Charles Denham: We were especially gratified by the comment by Dr. Mike Henderson, who is just
another terrific champion of the same ilk as Dr. Steve Swensen. Dr. Mike Henderson is the Chief of
Quality for the Cleveland Clinic B a tremendous colleague, a wonderful guy, and one of our folks in the
Chasing Zero documentary for those of you that haven't watched it B and he describes how there might
have been some challenges originally, but that they really did embrace the checklist once the value was
seen by surgeons in high-volume practices. So the toolbox that you all will find available to you, probably
in the next six weeks, will never be done. We are going to continue, in honor of those that have helped
fund us and contributed all of their time, to just continue to update the concepts, the tools, and the
resources that we'll have in the toolbox, which you will be able to download. That's why I have this page
up. Char, a final question, or I'll just ask you to comment on your wrong-site surgery package. AORN has
graciously offered to provide that package in the toolbox and make that available as kind of part of this
offering to help catalyze and stimulate improvement in safety. You want to give us a quick 30 seconds,
and then I'll to go Dan Henderson.
Charlotte Guglielmi: We have a comprehensive toolkit for wrong-site surgery that we developed a few
years back, and it has been spread all over the country. It gives all of the things that you need to really
implement a program to prevent wrong-site surgery. We have really engaged this year, Chuck, in a
broader campaign. We've asked our members and anybody they work with to get people to get on board
B take a pledge, do a time-out for one patient, every procedure, every time B and to sign on for that. So
we hope that those kinds of things in conjunction with the elements such as the education pieces B the
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videos, the sample policies and procedures, and the checklists that are in the toolkits B can provide a
place for people to get started.
Charles Denham: Great. Thank you very much. And just some of the highlights of some of the questions
we're getting, because of time...we want to finish on time. All of the assets will be available for full
download off of the web. All of the articles from the Journal for Patient Safety, the Health Affairs article
that addresses board engagement – and I'm going to come back to Tom before we finish this session to
talk about the surprising findings of Ashish Jhah and Arnie Milstein in their article B but that article, as well
as the articles from The Joint Commission regarding the Julie Powell story, will all be available on the
DVD, as well as on the website. The DVD B which may be opened as a DVD on your DVD machine to
play the movie and play the various portions of the movie B if you put it in your computer, you can open it
as a CD and be able to have all of those documents and be able to have those with copyright authority to
be able to use them, in addition to having this toolbox for the wrong-site surgery that AORN so graciously
is providing. We will be providing these over time, and then after the DVDs...one of the questions was,
who receives the DVD? We'll be sending the DVD to the board chair, to the CEO, to the chief medical
officer or patient safety officer, depending on whose address that we have, and the chief nursing officer.
They will be sent independently and directly, and we'll be encouraging them to be used not only to be
shown as a CME or CEU program, but actually for board retreats and for other purposes that perhaps the
leadership and governance teams could use, and then the individual organizations to be able to use them
for specific areas of healthcare-associated infection, prevention of medication errors, and a number of
elements. So, I'd like to come back now to Dan, and just address one of the most surprising B and it's not
surprising after you think about it B but that healthcare students don't have the baggage of the way we've
always done it. To quote Warren Buffet, "The chains of habit are too light to be felt, so they're too heavy
to break.", you all don't have those chains of habit. Almost universally when I talk to healthcare students B
pharmacy students, medical students, nursing students B the biggest, most important thing on their mind
is not harming a patient. Is that a consistent finding with you, Dan, and can you share a little bit more of
what makes out healthcare students tick and why they're so excited about patient safety?
Dan Henderson: Well, thanks, Dr. Denham. That is absolutely a concern at the heart of every student's
experiences. The first day you set foot into that exam room or onto that hospital ward, are you gonna hurt
someone. We're vocal about that. It's something that I began to hear from my classmates and began to
voice from the very first patient I saw just in an outpatient setting as a first-year, and I still hear it from
friends who are residents. So, empowering ourselves with whatever we can to prevent harm from
happening to our patients is a huge motivator for all the excitement around patient safety; at least, that's
my take on it. When you can offer someone something that you can show will help them be safer, will
help protect their patients, everyone wants to get involved.
Charles Denham: Great. Thank you so much. I'm watching our time, and you all have been such
wonderful panelists to be on time. Tom, I'd like to come back to you and ask you to react, as you have
before, to the Ashish Jhah and Arnie Epstein article. It was a survey article based on a very, very carefully
designed study of the review and interviews of 1,000 board chairs of our hospitals across the nation, with
over-sampling in the top 10% in quality and the bottom 10% in quality, and the finding was that not one of
the board chairs in the bottom 10% in quality thought they were below average. Most thought they were
above average; a few thought that they were average, but not one of them thought they were below
average, and these are in the bottom cellar of quality across our country. Is it denial? Are they getting
incomplete information? What do you think is going on there?
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Tom Van Dawark: Well, first of all, it's a pretty staggering and sobering comment, isn't it, wherein we
have ultimate responsibility at the board level, starting with the board chair in terms of safety and quality,
and we don't know where we are at this particular point in time. I think it's a combination of a number of
things. I think our way out of this is to ask some questions – either the board chair asking questions, or
individual board members asking questions, or questions that are passed to board members to ask in the
next board meeting. Watching the Chasing Zero series, there are obviously eight or ten really key
questions that come up when you watch that. Number one on my mind would be, can these sorts of
incidents – with respect to the way we treat our patients and the way we treat our own caregivers B can
those happen in our own organization? If we can find five or eight of those – and they are very easy to
find – put them in front of the board or an individual board member, that's going to start the process.
Board members, again, want to do well. They may be fairly naive in terms of safety and quality
measurements at this point in time, but we've got to get them to a point where they are very comfortable
in asking questions, they know enough about the metrics to at least be dangerous (i.e., asking some
really probing questions), and I think the... I don't remember each of the points that Ashish made in their
article with respect to where they found high-performance areas. It certainly was where there was a board
safety and quality committee B it was where the board had an agenda item on safety and quality, for
example B those are easy fixes to begin the process of getting the board involved in safety and quality. It
doesn't have to cost a lot of money. We don't have to put a lot of investment in this. We can ask some
questions, we can put some board committees together, pool together the best resources out of the
board, and get on the track to zero harm.
Charles Denham: Fantastic. Thank you so much. Char, quick question for you, and then I'll come to Dan,
and then we'll come back to Steve Rel and finish on time. Char, how can those of us that are quality
leaders – chief medical officers, we have a lot that come on our webinars, patient safety officers, CEOs,
COOs, and others that aren't in the nursing area – how can we help the folks that you serve – the OR
directors and those that are involved in perioperative nursing care from preop, op, postop, and your entire
constituency – can you give us one or two things that are practical and tactical we could do this week? If
we're in an acute care facility or in a surgery center and we can help out those in your constituency, what
would it be?
Charlotte Guglielmi: I think the first thing that you can do, you are doing, and that's trying to get to the
board of trustees, the board of directors, and helping them to understand the whole safety agenda from
the point of care back to the board room. I think that's the most important thing that we can do today. The
toolkit is valuable. How do you introduce that? How do you get that beyond the baseline? I think that's
the most important thing we can do, Chuck. And continue the dialogue with the point-of-care deliverers B
working with Dan, for example, as a young medical student B that's our future. If we can engage
grassroots at that level into our safety agenda, they're not going to know anything different when they get
out there, and they're going to be able to promote it.
Charles Denham: Thank you, Char. I'm going to come back to Tom with one of the questions from Lance
Roberts, and I've been trying to kind of capture some of the questions. For those that have submitted
questions that we don't answer, we'll try to respond from our panelists to some specific, maybe technical
questions or those pertaining to supplier companies that may be best thought over before responded to.
Lance Roberts asked, "Can you comment on the usefulness and future applicability and enhancement of
the 4A model that frames the original NQF Safe Practice 1, which is awareness, accountability, ability,
and action." Let me respond to that last part of the question and then go to Tom, and then I'll have a
question for Dan.
So, the 4A model of awareness, accountability, ability, and action is the framework that we use for a
number of the safe practices: awareness meaning aware of your performance gap; accountability
meaning who is accountable to change certain behaviors to close the gap; ability meaning resources and
know-how – you know, you can be aware and accountable, but not be able to make a change; and then
the final A is action. What are the line-of-sight actions, if undertaken in aggregate, that would close the
gap? That is the 4A model. The future generation of this as a tool will be to cross-walk it against three
systems: the leadership systems, the practice systems, and technology systems. We are going to look at
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engagement of great leadership with a fellowship program we're launching next year for upper-level
leaders. The greatest, best talent that we have of the mid- to upper-level management – and we're going
to help fashion and engage the skills and know-how for engagement of leaders to engage them – if we
cross-walk the 4A's with leadership systems, we know we can do a lot. Second are practices. We're going
to keep updating the evidentiary base for the current set and be identifying others that could have high
impact, like bar code and pain management. And then the third area is technology. Once you have
engaged leaders and predictable practices that deliver verifiable outcomes against the evidence, that's
when you bring in the technology – not the technology first, that can replicate errors or make harm worse.
If you add one more dimension – so you've got leadership, practices, and technology cross-walked
against the 4 A's – now think of looking at the third dimension, and that is your SWOT: what are our
strengths, weakness, opportunities and threats? We are applying this model right now to the CT scan
accidents that are occurring around the country with high dose delivered to the brain in folks that are
getting CTs, as well as children. So that's the second part of the question. The first part of the question
was, "What's the applicability of the 4A model?". Tom, could you answer that? Then we'll go to Dan with
our last question.
Tom Van Dawark: I have been exposed to the 4A model just recently, and there was a comment made
earlier about the NQF Safe Practices. I have to admit that a year ago, I was aware of the NQF Safe
Practices, but from a board perspective, we really weren't working with them, which is very interesting.
But the 4A's... as I go back and look at my safety and quality experiences in maritime, we didn't call it the
4 A's, but it was the logical process that we used to think through both preventing an accident from
occurring, reporting an accident that did occur, and doing a corrective action. I think it's very applicable,
with the understanding that a lot of people have not worked with the concept before.
Charles Denham: Thanks, Tom. Final question – we're right on time to close, will maybe go a minute
over – Dan, if we've got nursing students, medical students, pharmacy students at our facility this week,
what's one thing we could do to help them out this week? Is there something we could do for them B
something that would be out of the blue that we could do to help our students?
Dan Henderson: Well, that's a great question to end on. I mean, there are already so many great
opportunities to spread the word through Chasing Zero and all of the other things you've got in the pipe
on winning the war on healthcare harm, but I think the first thing to do is to sit down and ask students that
same question B find out what the specific challenges are in the hospital, and mainly what you're doing is
you're lifting the culture for the student so that they know it's safe that when they see something, they
should say something. That's such an easy and beginning step, and it means so much to us when we can
feel like we can make a difference in patient safety for the people that we are trying to care for.
Charles Denham: Listen, I would like to thank all of you terrific panelists. We are very excited about the
toolbox that we are formulating. We're going to get it out. We'd like to have respondents. We'll do another
webinar once it's out, and we'll be surveying everybody to see what we could do to make them better.
We'd like to un-mute Stephen Rel because we'd like Steve to close us. In the end, there's all the process
and the problems and the challenges and the barriers, but what brought us to this moment of this
webinar, prayerfully, thoughtfully, energetically, is to help patients and families. If Steve Rel and his
family, who are now letting their story be our story... they are sharing their struggles and their pain and
agony so that we won't let this happen to another child or another mom or another dad in our community.
Steve, would you close us, and allow us to be thinking about you and Braxton and your family as we
close, so that as we move on to our days, that we remember that the purpose for patient safety is all
about patients; it's not about us.
Steve Rel: Yes. Thank you, Chuck. I'd like to thank all of you for spending part of your day with us to help
us save lives. I would like to ask you – no, I'd really like to demand you – to go forward today and watch
Chasing Zero and help us save lives. Chasing Zero is now. Zero is the number. No loss of life is
acceptable. Please try to do something today to help honor my son Braxton's short life and make sure this
happens to nobody else, and may you all feel the Braxton breeze blow today. Thank you very much.
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Charles Denham: Thank you, Steve. We often laugh and celebrate Braxton's life by...somehow there's
a wind blowing somewhere when we're together, and we always say it's the Braxton breeze, and it's there
to encourage us. So, I think there's nothing better than closing on the Braxton breeze. I'd like to announce
that we are going to have our next webinar from Washington, D.C. We will have top leaders from the
Obama administration and CEOs from all over the country that will be convening and will be addressing
healthcare-associated infections and the trajectory that we're being led through healthcare reform in
reducing healthcare-associated infections. So, we'll be broadcasting it live over the web from Washington,
th
D.C. on the 28 of October. We thank you for all of your attention. There will be transcripts of this
program that will be available on our website, and the toolbox elements will start to becoming available.
We'll be sending them to all hospitals, but you'll also be able to order them for the cost of the duplication.
Now, it's an honor to close the webinar. Steve, thank you for giving us those inspirational words.
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