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The Hospital Leaders Toolbox provides leaders – from the boardroom to the front line – with concepts, tools, and resources to win the war on healthcare harm.

See our featured video, Ground Zero: The Boardroom, Not the Bedside, in the player below.

Click here for terms and conditions of use for Chasing Zero: Winning the War on Healthcare Harm documentary and the Hospital Leaders Toolbox


HHS: 1 In 7 Experiences Adverse Event During Hospital Stay
The Department of Health and Human Services, Office of the Inspector General, released an important report related to patient safety on November 16, 2010, entitled Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries – featured in an article on USAToday.com. To download the report, click here.
 

Leaders Guide:

TMIT has produced these assets and multimedia materials for hospital and community leaders. They are also developed for the most important people in your communities, your "CFOs": the "Chief Family Officers," women between 20 and 70 years of age who make 70% of all healthcare decisions. In the documentary, Chasing Zero: Winning the War on Healthcare Harm, TMIT used real hospital accounts of patients and caregivers as a lens to focus our attention on the heroes in healthcare who can make us all better.

The documentary was shot in Geneva, London, on the movie set of Soul Surfer in Hawaii, and at some of the United States' greatest hospitals, including the Brigham and Women's Hospital, the Cleveland Clinic, Vanderbilt Medical Center, Johns Hopkins, and the Mayo Clinic.

Everyone involved was humbled by the response to the film. There has been a groundswell of media coverage and great interest from hospital leaders and even from government officials around the world. The filmmakers are even more humbled by the continually growing interest in the message.

Healthcare leaders know the "what," the "when," the "where," and the "how" we need in order to act; however, we have a major awareness problem. Most hospital leaders and consumers are just starting to realize that we are in a crisis, and that typical quality and safety programs are not preventing hospital accidents. This is where Dennis Quaid has been a godsend – his impact has been enormous. He has put his celebrity on three battle lines in this war: engaging leaders, adoption of safe practices, and implementation of technologies that enable them. At the National Press Club, he issued a call to action to adopt the National Quality Forum Safe Practices in front of 300 media leaders, which gave patient safety a huge lift. These carefully developed practices have been synchronized across all of our major certifying, quality, and purchasing organizations, including Medicare, The Joint Commission, The Leapfrog Group, and the Institute for Healthcare Improvement. They were developed by the rigorous process defined by the U.S. Congress and are now available to be tied to purchasing and healthcare reform; however, until Dennis talked about them, they were unknown by most governance board members and by many hospital leaders.

Even though the Safe Practices specifically define how boards, CEOs, and leadership teams need to work, without Dennis, this documentary, and resulting press, the NQF Safe Practices Consensus Report would be another book on a shelf... or another unfunded program that a hospital safety officer wished he had sold in the boardroom. You could say that Dennis is the Right Guy, with the Right Stuff, for the Right Cause. You see, he is like us and we know him... both in the movies AND in real life... as a dad, as a husband, and as a hero.

In the documentary, Dennis addresses two shocking truths: the magnitude of healthcare harm and how much of that harm is preventable. However, he has now discovered a third. That ground zero in the war on healthcare harm is not at the bedside... it's in the boardroom. Not where the accidents happen, but where leaders fund and approve the leadership, practice, and technology systems.

So why produce documentaries, why work with supplier companies and caregiver organizations, and why develop multimedia resources? In this world of 10-second sound bites and 24-hour news cycles, it is virtually impossible to explain why hospital accidents are caused by systems failures and why these failures lie on the shoulders of those in the boardroom. It is much easier to make a caregiver or a hospital the bad guy... the villain. In interviews, Dennis Quaid and Dr. Charles Denham, CEO of TMIT, did their best to address the cause: not bad people, but bad systems. Yet even they could not get the message across in a few seconds. TV producers, consumers, and even hospital executives glaze over and think they are speaking jargon.

So what specifically are systems? Old leadership systems are a command-and-control model with the boss telling us what to do and delegating everything to "good people"; and new systems are teams working toward a common goal. Old practice systems are operations are done in a haphazard, un-standardized way; and new practice systems use standardized, endorsed practices, checklists, and a pause before surgery. Old technology systems are paper medical records; and new technology systems are electronic medical records and computerized prescriber order entry (CPOE).

Since the release of the film, TMIT convened governance experts and leaders from maritime, aerospace, aviation, government, and hospitality industries, and even included national heroes. The leaders came to the conclusion that the greatest impact they can have is in the boardroom – that this is where they need to focus... because the leaders own the systems. Governance boards possess huge power for transformation, yet many are just not informed, or don't feel accountable. Systems failures are hard to understand because they are complicated, systems are invisible, part of our infrastructure, and have evolved into failure – this just didn't happen overnight. The failures are no one's fault; however, fixing them is the leaders' responsibility.

The most egregious patient safety events or clear healthcare harm such as wrong-site surgery, a medication accident that kills or nearly kills patients – such as the newborn twins of Dennis and Kimberly Quaid – and the contamination of healthy patients with dirty instruments are very clear accidents. However, these kinds of events are just the tip of the iceberg. Almost 100,000 deaths are due to infections that healthcare providers give to patients.

Support system breakdowns, which cause 95% of hospital accidents, are the enemy that never sleeps, which can steal away the lifeblood of our communities. These breakdowns are due to increased demand for care and eroded capacity to deliver it. Our support systems have eroded through passive neglect and active cost-cutting – both are the responsibility of the leaders, not the caregivers. We are treating sicker and sicker patients more and more quickly, with more and more complex treatments, through an increasingly fragmented set of caregivers.

Like our highway infrastructure, if we keep increasing demand while not maintaining the infrastructure, accidents start to happen. Then, if we actively damage the infrastructure with blind cost cuts, we further increase the risk. We really blame the caregivers who are driving our patients through the highways of care when we are pushing them faster and faster through dangerous streets with no guard rails. Part of our infrastructure is the talent of the caregivers and how they work together. Many of these caregivers are in a state of learned helplessness, knowing that they are not delivering great care, but feeling as if they are captives of processes that they feel unable to change.

If one were to think of a hospital as the human body and our infrastructure systems as organs, we might say that we are in multi-organ failure and things are breaking down. Like a cancer in our culture, learned helplessness and hopelessness can spread and can bring a whole organization down. Yet as Jim Collins, author of Good to Great, says, great organizations look in the mirror and are vigilant, knowing that their support systems are vulnerable. It is essential that we focus on the fundamentals.

Great hospital trustees and leadership teams can use the medical model to examine the safety systems, just as doctors do when they evaluate a patient, these leaders can take a history, review tests and data, ask for new tests, make a diagnosis, treat the problems, and monitor the results to make sure they have a cure.

Our hospitals are in multi-system organ failure and many have the cancer of hopelessness that is spreading through their ranks. The boards and the leadership teams can save them and save the sacred trust of their patients. The multimedia resources on TMIT's DVDs and websites will support your teams. Video clips, reference papers, checklists, and tools are provided for your use. For boards and leadership teams, TMIT has prepared a version of the film with natural stopping points, so that you may ask key questions that can help you examine your systems.

Since this video is really just a guide, let's look at some of the questions leaders need to ask themselves. The questions are organized using the 4A model of innovation that is used in the National Quality Forum Safe Practices.

Awareness: The biggest problem for governance and hospital leaders is being aware of their performance gaps. That is the gap between where they are and where they need to be, not whether they are above average. No one wins an award for being the cream of the crap, yet many leaders are happy with being "above average" without recognizing that "average" hospitals have huge safety problems.

Accountability: Innovation adoption is directly related to personal accountability of people to deliverables and a date certain. Existence of programs with no goals is a guarantee of systems failure. To quote Don Berwick, our new head of the Centers for Medicare & Medicaid Services, "Some is not a number, soon is not a time."

Ability: Hospitals can be aware of their performance gaps and make teams accountable to close their gaps; however, if they do not have the ability to close those gaps, they only create helplessness and hopelessness. This is where leaders need to invest dark-green dollars and capacity into building skills and technologies.

Finally, ACTION: It is the line-of-sight actions that together make for change – the everyday execution against a timeline that really matters.

TMIT is continually updating how-to guides for adopting the many innovations shown in the feature-length documentary, Chasing Zero, to serve your leadership, quality, and community teams in their own war on healthcare harm.

Watch for Sue Sheridan, Steve Rel, and other families who have lost loved ones as they now start grassroots movements to help moms and dads improve their local hospitals. We know that the hand that rocks the cradle can change the world... and we know our nation's hospitals need their help. Don't allow another mom, another dad, another child, or another caregiver to suffer from another preventable error. It's not about statistics; it's about these patient and caregiver stories.

Hospital and community leaders don't need to know all the answers... they just need to ask the right questions. And it's time to ask them.



Chasing Zero® is a registered trademark of CareFusion Corporation.


SafetyLeaders®, CareMoms®, and SpeakerLink® are trademarks of HCC Corp., licensed to TMIT