Making the Health Care System Safer: Keynote Address

Third Annual Patient Safety Research Conference

Proceedings of the third annual patient safety research conference.

Keynote Address

Sister Mary Jean Ryan
CEO, SSM Healthcare

Thank you very much, Dr. Clancy, for raising people's expectations to a level that I can never hope to achieve.

Good morning, everyone. I am delighted to be here and consider it a genuine privilege to speak to you as a group of people who are committed to safety and performance excellence. That commitment speaks highly for you as members of the human family. I can only hope that what I say this morning will assist your efforts in some small way. I have a feeling that you're interested in hearing what we're doing in the area of patient safety as well as what we've learned from the Malcolm Baldridge National Quality Award process. Before I get to that, I'd like to share a story that I heard recently.

It's about four hospital presidents named Leo, Karla, Frank, and Steve. One day, after many successful years, they got together over dinner to discuss the holiday gifts that they had given to their elderly system CEO who lived in another city. Leo said, "I had a huge house built for her."

Karla said, "I had a $100,000 theater installed in that house for her."

Frank said, "I had my Mercedes dealer deliver her an SL-600 with a chauffeur."

Steve said, "Listen to what I got her. You know how she loved reading the Bible, and you know she can't read anymore because she can't see. I happened to meet a priest who told me about a parrot that could recite the entire Bible. It took 20 monks 12 years to teach him. I got her that parrot." The other hospital presidents were very impressed.

After the holidays, the CEO sent the following thank you notes. "Dear Leo, the house you built is so huge I live in only one room but I have to clean the whole thing. Thanks anyway."

"Dear Karla, you gave me an expensive theater with Dolby sound. It can hold 50 people, but all of my friends are dead, I've lost my hearing, and am nearly blind. I never use it. Thank you for the gesture just the same."

"Dear Frank, I'm too old to travel, I stay home. I have my groceries delivered, so I never use the Mercedes. Incidentally, the driver you hired sounds like a chipmunk. The thought was good. Thanks."

"Dearest Steve, you are the only one to have the good sense to give a little thought to your gift. Thank you. The chicken was delicious."

I hope you'll find my remarks this morning if not delicious, at least food for thought.

The focus of my remarks this morning and the reason that our presence here is so essential is that we in health care have a moral obligation to keep our patients safe. I want to discuss this morning some of the things that we have done at SSM to improve patient safety. In order to do that, I really need to discuss our culture of performance excellence as well. In so doing, I want to explore why an organization strives to achieve performance excellence and how that quest for excellence enhances safety.

When the Institute of Medicine (IOM) issued its report on medical errors in late 1999, SSM Healthcare was well-positioned to respond in a meaningful way. Before I tell you what we did, I want to explain why we were so well prepared and that's the Baldridge part of the story.

The fact that SSM was the first health care recipient of the Baldridge Award in 2002 was extraordinary because the pundits had suggested that a large health care system would be too complex to receive the Baldridge. The prevailing wisdom was that a single hospital or perhaps a small system would most likely become the first to receive it. So how did it happen that an organization of our size and complexity came to win the Baldridge? After all, we have 23,300 employees, 5,000 physicians at 20 hospitals, 3 nursing homes, an information center, plus homecare, physician offices, and a host of other services in four Midwest States.

The question we were asked most frequently was, "How did you do it?" The short answer is hard work, unwavering focus, and above all perseverance, with which you are very familiar. The reality is that more than anything else, it was the people of SSM Healthcare that made it happen, the employees, the physicians, the volunteers. Everyday, no matter how tired or stressed they are, the people of SSM Healthcare do whatever is necessary to bring our mission to life. Our mission states, "Through our exceptional health care services, we reveal the healing presence of God."

I can say without reservation that because of Baldridge, we are much closer to achieving our mission today than ever before, and that equates to being a better organization. Receiving the award itself is a wonderful acknowledgement of how much we have improved. In truth, Baldridge is a whole lot more than an award. First, it's an excellent tool for organizational assessment. In this respect, it helps you identify your strengths as well as your opportunities for improvement. Baldridge doesn't tell you how to run your organization. It's up to you to decide that. Once you have decided, Baldridge helps you determine if you're doing what you say you're doing. When you write that 50-page application, you'll learn more about your organization than you ever thought possible because the seven categories provide a comprehensive assessment of every aspect of your organization.

Further, Baldridge isn't just an assessment tool. It's also a superb business model because you begin to see what you're doing well, what you're not doing well, and what you're not doing that you thought you were doing. It helps you understand those core systems, processes, and critical linkages across the seven categories. Of course, you also begin to realize very quickly the lack of these core systems, processes, and linkages. I know I don't need to tell you how important these linkages can be when it comes to ensuring patient safety.

When you get the feedback from your Baldridge application, and, if you're fortunate, from a side visit, you'll learn what you can do to improve your organization vastly. Frankly, that Baldridge feedback has provided the least expensive and the best consulting services that we've ever received, bar none. Over the 4 years that we applied, we received more than 200 pages of feedback from highly trained, experienced, dedicated, and professional examiners who spent literally hundreds of hours with our application and on the site visits.

However, I want to assure you that even as a Baldridge recipient, SSM Healthcare is by no means perfect. In fact, many organizations are doing many things a lot better than we are. Our goal is to learn from them as we continue our improvement efforts. Continue we must and continue we will. To me, the quest for excellence, which includes ensuring the absolute safety of our patients, is a matter of integrity, and because of that, we can never stop looking for ways to improve.

As I said before, at SSM, we're a far better organization today than we ever were before and frankly much of that came about because of our Baldridge process. I can honestly say that looking back on our quality journey, there were no miracles, even in our organization, just steady progress, and a belief in a vision that we could become a great organization. Truly, it's about perseverance. Perseverance isn't trendy in these days when we've come to expect instant gratification. Ask Nelson Mandela about perseverance. Ask Rosa Parks. Ask Christopher Reeve.

Here's a story about perseverance. In 1968, an Ethiopian runner by the name of Mamo Wolde won the Olympic marathon. Over an hour later, the Tanzanian runner by the name of John Awarhe finished last, his leg bleeding after a serious fall. A reporter asked him, "Why did you bother to carry on with a serious injury and no hope of coming in anything but last?"

He panted in reply, "My country did not send me 7,000 miles to the Olympics to start a race. They sent me 7,000 miles to finish it."

You're probably sitting there asking yourself, "And this has exactly what to do with safety?" It certainly takes perseverance to be an Olympic athlete. It will take incredible perseverance, combined with enormous creativity, to make our patients truly safe.

In my mind, while it is possible to achieve incremental improvements to make health care safer, a completely safe environment will require a systemic overhaul of the entire health care system. That's the only way that we'll ever get to the underlying elements that make our patients 100 percent safe. When will that happen? I'm sad to say, it may not be soon.

This reminds me of the story of two elderly men who had been friends for decades. Over the years, they had shared all kinds of activities and adventures, but lately, their activities had been limited to meeting a few times a week to play cards. One day, while they were playing cards, one of them looked at the other and said, "Now don't get mad at me. I know we've been friends for a long time, but I just can't think of your name. I've thought and thought, but I can't remember it. Please tell me what your name is."

His friend glared at him; for at least 3 minutes, he glared. Finally, he said, "How soon do you need to know?"

How soon do we need systemic reform? We need it now. I don't know how soon we will achieve it. I know that we can't use the need for systemic change as an excuse to avoid doing whatever we can to make health care safer right now. For us at SSM Healthcare, safety is one of the key components of performance excellence. We've drawn on the strength of our culture to make patient safety one of our top priorities for improvement.

That brings me back to the now legendary IOM report of 1999. Even before the release of that report, our entities and practitioners were using continuous quality improvement (CQI) to improve safety. However, at that time, we had no coordinated system effort. Our CQI culture of working in teams combined with that focused approach that Baldridge helped us achieve made it possible for us to respond quickly and decisively to the IOM report by launching what we called a clinical collaborative. Since 1999 as a system, we have had eight of these clinical collaboratives, which both Baldridge and the Joint Commission have cited as a best practice.

Let me define what I mean by clinical collaborative. At SSM Healthcare, physicians and other clinicians from our hospitals come together to focus on a compelling topic and achieve fast track results. Safety certainly qualified as a compelling topic and our safety collaborative was up and running within months of the issuance of that report. Interest was significant from our entities but participation was voluntary with participants opting to focus on improving the issues that they believed to be the most pressing in their particular entity.

You may be thinking that this approach was somewhat scattered, and you would be right. As the national landscape changed in the aftermath of the IOM report and more data about safety and health care became available, we decided that a focused approach was needed. In January 2002, we launched our Achieving Exceptional Safety clinical collaborative. This time, participation was mandatory and teams from every entity focused on the same things:16 practices with the greatest potential for improving patient safety including such things as hand washing, surgical site markings, dangerous abbreviations, and reporting near misses, all of which I know you're familiar with. Simple things, at the same time, not so simple. Simple or not, one thing that has helped SSM achieve success with these practices is the development of a blame-free culture.

As you know all too well, the traditional hospital environment punished people who made mistakes. This is not exactly an incentive for people to report the very mistakes that could be helpful in avoiding future mistakes. I can tell you what it's like to work in a culture where blaming is the norm because I know of a young nurse who overmedicated a patient and administered 10 times what was ordered. Fortunately, the patient suffered no ill effects. The nurse noted the error on the chart, but did not report it to anyone. When the resident made rounds, he circled that note in bright red and the nurse was then called in to the director of nursing services and reprimanded. Do you think that she felt comfortable bringing up questions or talking about how this error could have been prevented in the first place? I can tell you she did not because I was that young nurse. I made a mistake and I should have been accountable for it.

The point is, when people are blamed for mistakes, or fear they will be, we miss a valuable opportunity to collect data to help us improve the process breakdowns that result in errors. As I mentioned, at SSM Healthcare, we're attempting to create a blame-free culture and not only do we want people to report their mistakes, we especially want to know about mistakes that almost happened, that is near misses.

I want to discuss a near-miss program at one of our hospitals, SSM St. Joseph Hospital West in Lake St. Louis, Missouri. Through its participation in our safety clinical collaborative, St. Joseph's learned about a form for near misses that was being used by one of our other hospitals. St. Joseph's kicked the whole thing up a notch and began a monthly drawing for prizes to reward employees who turned in near miss forms, in other words, employees who reported that they almost made a mistake became eligible for a reward. In the first year, more than 100 forms were turned in and 45 of those led to process improvements that actually made the hospital safer. In the areas where process improvements were implemented based on those near miss forms, St. Joseph's has had zero errors. Following the success of St. Joseph's program, we added the near miss reporting form to our list of 16 best practices to be replicated across the system. The folks at St. Joseph's became our champions for near miss reporting. Spreading best practices like this is an essential part of our collaborative work.

Another very creative safety initiative came from our SSM DePaul Health Center in St. Louis. Every year, DePaul has about 96,000 patient transports. Approximately 95 percent of the patients excluding those in the ICU are transported to ancillary areas by unlicensed personnel. Patients can be away from their unit anywhere from 45 minutes to 4 hours. How do transporters know the severity of the patient's condition or whether the patient has a high probability of falling or becoming confused? To ensure good communication among the various individuals involved in transporting as well as those doing the procedures, the CQI team developed the hall pass.

The hall pass is a form that monitors a patient's condition during visits to ancillary areas. It's filled in by the patient's nurse as well as by the ancillary department where the patient undergoes testing. The hall pass includes contact information for the patient's nurse, information about the patient's medical condition, and updates about changes in the patient's condition that could occur because of procedures. It also indicates very clearly when patients require a nurse during transport. This ensures that no patient goes to a testing area without proper clinical coverage. We developed the hall pass to foster communication among the various silos because communication helps us keep our patients safe. That's the truth. You may find more significance in the short answer. The hall pass was the direct result of a sentinel event.

Fortunately, at SSM Healthcare, we see opportunities for improvement in everything, especially in sentinel events. It's part of our moral obligation to do whatever we can to ensure the safety of our patients. Another area we're focusing on in our safety collaborative is reducing dangerous abbreviations. Over a 6-month period, we identified the four abbreviations in order writing conventions most likely to causes patient harm. They are U for units, QD for every day, leading zeros, that is not writing zero before the decimal, and lagging zeros, not writing zero after the decimal. As we know, the abbreviation for daily, QD, can easily be confused for QID, which means 4 times daily. You can see where a mistake reading the abbreviation for a pharmaceutical dosage could be fatal. Similarly, I know this is far-fetched, but if handwriting is less than perfect, 5.0 milligrams can easily be read as 50 milligrams. You get the point. Once we identified these abbreviations and order writing conventions, we began to focus on eliminating them. As you know, physicians are trained to use abbreviations like QD or 5.0 in medical school. When we asked them to eliminate those abbreviations and to write "daily," or just 5 instead of 5.0, it's often difficult for them to change old habits. It takes conscious effort to change unconscious behavior. Employees have figured out some creative ways to raise consciousness.

In one instance, our St. Mary's Hospital in Madison, Wisconsin, placed posters with reminders about dangerous abbreviations inside restrooms utilized by physicians. Because of this type of effort, we've reduced our use of dangerous abbreviations across SSM from 22 percent when we began in January 2002 to 3 percent at the end of last year. That's a reduction of more than 50 percent, but frankly, our goal is zero.

Reducing errors of medication administration is just as important for the patient as making sure that we don't use dangerous abbreviations. While our achieving exceptional safety collaborative is devoted exclusively to safety, all of our collaborative work relates to safety in some way. For example, in our collaborative on improving the secondary prevention of acute myocardial infarction, we're working to increase the use of certain life-saving medications for patients who have had heart attacks. In this collaborative, we have been able to increase the percent of patients leaving the hospital with an order for lipid lowering agents from 44 percent in 1999 to 70 percent in 2003. As with everything that we do, we will continue to improve those results.

All of this is great. I would be less than honest if I didn't tell you that I'm very pleased with our results to date. I would also be less than honest if I told you that we've done all we can to make our patients safe. Here's where it gets difficult. Despite all of the excellent work that's been done, I cannot say without doubt that our patients are safe. I don't think there is anyone in the room who can say that for sure, despite the exceptional work that you may be doing. I would venture to say that the work that we've done at SSM Healthcare is merely the tip of the iceberg, the easy part, the obvious.

The hard work that lies ahead is this: we must address issues underlying safety, and we have to find a way to assess the true outcomes of our safety work. What's really needed to make our patients safe is a fundamental change in health care delivery. I would suggest to you that the lack of integrated and coordinated care and the lack of communication among various caregivers and between caregivers and patients are the serious threats to the safety of our patients. I sure wish I had an answer.

Looking back 50 years ago when times were less complex, Mrs. Reilly would go to see Dr. Smith, her physician, and he pretty much knew all about her. When she went to the hospital, he visited her and took care of her. In 2004, Mrs. Reilly is admitted to the hospital where she is treated by Dr. Walton, a hospitalist who is a very competent physician. Dr. Walton takes excellent care of Mrs. Reilly before and after her surgery during her entire hospital stay and he makes sure that she leaves the hospital with appropriate medications. The threat to her safety occurs if Dr. Smith is not informed that Mrs. Reilly is on Coumadin®, a blood thinning medication that needs close monitoring. Everything might have gone very well during Mrs. Reilly's stay in the hospital. The surgical site was accurately marked and there were no dangerous abbreviations on her medical chart. A safety issue arises when Mrs. Reilly goes home on Coumadin® and is not monitored appropriately by Dr. Smith because of a communication failure. She is a woman at risk.

Please understand that in no way am I suggesting that hospitalists are not excellent caregivers. In fact, we have many exceptional hospitalists at SSM Healthcare. I use this only as an example of the complexities of communication that arise in today's health care environment that may jeopardize the safety of our patients. As health care has become more and more specialized and technically advanced, the underpinning, that traditional communication between doctor and patient as well as among caregivers is much more complex. Patients today have a variety of tests at a variety of locations and visit a number of specialists. While each and every caregiver is responsible for the patient's care, who then is ultimately responsible to oversee and coordinate the care? This basic structural issue will not go away. It is extremely complex. It must be addressed. It is a monumental issue at the heart of patient safety that begs for improvement. As people of integrity, we know this. As people of integrity, we must act.

There is a story that I've grown very fond of that illustrates at a very human level what can happen when care is not coordinated. Rachel Naomi Remen is a physician and author of two wonderful books, Kitchen Table Wisdom: Stories that Heal and My Grandfather's Blessings: Stories of Strength, Refuge, and Belonging, the latter being the book from which this story comes. Dr. Remen told a story about Molly, one of her former patients who had been hospitalized with fractures of both elbows. She had been in an automobile accident as she was driving to the airport in a city 2,000 miles away from her home. When she awoke in the hospital, her arms were encased in rigid casts that went from her shoulders to her wrists. She could become dangerously ill if she inadvertently ate the wrong things. It was critical that her food needs were addressed while she was in the hospital.

Soon after she was settled in her bed, a dietician took more than an hour to document carefully her unusual food needs. "The questions that she asked were so thoughtful," Molly told Dr. Remen, "she really knew her stuff. In all of these years, no one has ever asked me some of those questions or understood so quickly and completely how things were with me. I was really impressed."

Within a few hours, special food was ordered for Molly. Three times a day, this food was served to her by food service staff that brought it to her bedside, put it on her bed table, and left it on a tray. Then they left. The first time this happened, she told Dr. Remen, "I just sat there looking at the food unable to feed myself. I was certain that someone would come in to help me, but no one did. After a while, the woman in the next bed noticed that I could not eat. Trailing her own IV lines, she got out of bed and fed me my dinner." That same thing happened at every meal in the 4 days that Molly was in the hospital without the use of her arms. No one on the staff ever offered to feed her. Day after day, the right food would be bought in and the patient in the next bed would feed it to her.

Now, you may be thinking, and rightly so, why didn't Molly ask for help. That's absurd. It is absurd. How often are patients invisible in the health care environment? How often do we create situations in which patients have no voice despite the fact that they are the greatest authorities of all about themselves? At our St. Mary's Hospital in Jefferson City, Missouri, the capital of Missouri, we're developing some scripting in which we say to the patient among other things, "If something doesn't feel right during your stay, please let us know."

The St. Louis Post-Dispatch ran a story not long ago about a patient who chose a more dramatic way to let the hospital know that something didn't feel right. I quote, "Police in an unnamed town in the northeast chased down a patient from a medical center who, apparently fed up with the hospital regimen, had fled the building on foot clad only in his gown. He was dragging his wheeled IV pole behind him as he exited into a driving rain."

I hate to think that something like that or like Molly's story could happen at SSM Healthcare or at any hospital for that matter. We want the hospital experience to be a positive one in which the patient is safe, receives the highest quality care, and experiences caring and compassion with everyone with whom they come in contact.

That hospital failed Molly, certainly not intentionally. Nevertheless, is that story so different from the communication breakdown between the hospitalist and Mrs. Reilly's doctor about Coumadin®? The caregivers did not intentionally fail the patients, but nonetheless, the best interests of the patient were not served in either case. In health care, no one intends to do anything that's not in the best interest of the patient. However, as Dr. Don Brecken points out, and I quote again, "Every system is perfectly designed to achieve the results it achieves. We can put competent providers into a lousy system and the system will win every time. Therefore, if we want different levels of performance, we need to design different systems."

As we work toward achieving safety in health care, we'll have to think differently and design different systems. However, at my age, I have attained some semblance of wisdom and I realize that while I may not have all of the answers, I can help create an environment that cultivates the leadership necessary eventually to find those answers.

Part of our goal is to help our employees receive the scientific knowledge that they need to provide the best and safest care. An equally essential part of that equation is about leadership in the broadest sense of the word. If I were to ask who the leaders are in your organization, would you immediately think of the CEO and others in executive administration? Doubtless they are. They've probably proved it in some way. I happen to believe that the leadership that builds an excellent organization is not the CEO making one pivotal decision. Rather it's the minute-by-minute and day-by-day actions of every employee wanting to learn more, wanting to teach more, and wanting to improve everything that they do.

My idea of a leader is this:

  • A leader is someone who takes the initiative to do a job better in a more efficient way.
  • A leader is someone who sees a way to improve a process and speaks up without hesitation to change it.
  • A leader is someone who extends herself or himself to others with compassion and thinks of ways to be helpful.
  • A leader is someone who is confident of his or her abilities and freely expresses that confidence not in arrogance but in humility.

Real leadership is not about authority, control, or giving orders. It's not about titles and executive benefits. The leadership I'm talking about does not necessarily concern corporate strategic planning or executive decision-making. Clearly, both are vital to organizations, and I don't deny that there are individuals who must be accountable for the overall success of the enterprise. What I see as real leadership is being responsible for what happens in our area of work whatever that area happens to be. It's about being accountable and holding others to account. It's about owning our work and performing our jobs with integrity as an expression of our creativity, our commitment, and ourselves. Whether leadership is inherited or a developed trait, people who are real leaders demonstrate the ability to step out, show their colors, and spread the word.

When a company succeeds or fails, the first place people look to is the CEO. What plans or decisions did he or she approve? What hiring or lay offs took place? What reorganizations occurred? What businesses were acquired or divested? What investments were made? Underneath the obvious accountability is another accountability that I think is more critical to success; the accountability for creating a climate in which leaders at all levels can emerge and thrive.

If I've learned anything from our quality journey, it's to give up the illusion that because I am the CEO, I am the leader and everyone else is a follower or that a few chosen people with executive titles are the leaders ready and willing to imbue the entire organization with their infinite wisdom. While some of us do provide executive leadership for the system or for facilities within the system, we say there is no one at SSM Healthcare who is not a leader.

  • Employees lead when they know their voice is heard.
  • They lead when they know they are respected members of the team regardless of their title or salary.
  • They lead when they know that they can have an idea and carry it out.
  • They lead when they know that they can speak and be listened to with respect.
  • They lead when they know that not everything has to be spelled out in a formal plan before it can happen.

Leaders are ordinary people who do extraordinary things when the need arises. On September 11, 2001, no one told the heroes of United Airlines Flight 93 what to do. They rose to the occasion and called on the leadership and courage within themselves and their actions changed history.

I want to tell you one final story about one of our leaders at SSM Healthcare. His name is Bill Schoenhard. When Bill was a graduate student in health care administration, he had to have surgery for a tumor that turned out to be benign. He elected to have it at a top 10 best hospital in St. Louis. After his surgery, he was in the hospital for 7 or 8 days. That tells you how long ago this was. One day, the wife of a classmate was visiting him when the nurse came in with his pill. Only this pill, unlike all of the others he had taken, was blue. When Bill asked the nurse about it, she checked her paperwork and somewhat indignantly told him that it was correct. In so doing, in effect the nurse took away Bill's voice.

Fortunately, the visitor was in the room and when Bill passed out, she got the nurse. They called a code and the next thing that he remembers is waking up in a bed surrounded by the code team, hooked up to all sorts of equipment, and having a chest X-ray. As you might imagine, this experience made a strong and lasting impression on Bill. Fortunately, today, he is the Executive Vice President and Chief Operating Officer of SSM Healthcare. Not surprisingly, he is a champion of patient safety.

Earlier in my remarks, I suggested that successfully addressing the issue of patient safety would take perseverance and creativity and that the issue is enormously complex. I admitted that I don't have the answers. All I can do is encourage you to commit yourselves to creating opportunities in your organizations for leadership to thrive and the answers will come. The German poet Goethe has this to say about commitment. "The moment one definitely commits oneself, then providence moves too. All sorts of things occur to help one that would never otherwise have occurred. Whatever you can do or dream that you can, begin it. Boldness has genius, power, and magic in it. Begin it now."

I know you wouldn't be in this audience if you hadn't already begun. I urge you to continue the quest for safety by creating opportunities in your organization for leadership to thrive. You must do this really as a matter of integrity. You absolutely have to.

As I near the end of my remarks, I would like to offer a further thought from Rachel Naomi Remen, the physician who told the story about Molly, the woman with the two fractured elbows. Dr. Remen says, "There is a parable about the difference between heaven and hell. In hell, people are seated at a table overflowing with delicious food but they have splints on their elbows and so they cannot reach their mouths with their spoons. They sit through eternity experiencing a terrible hunger in the midst of abundance. In heaven, people are also seated at a table overflowing with delicious food. They too have splints on their elbows and cannot reach their mouths. But in heaven, people eat using their spoons to feed one another." She goes on to say, "Perhaps hell is always of our own making. In the end, the difference between heaven and hell may only be that in hell, people have forgotten how to bless one another."

Before I leave you, I want to offer you my own personal blessing. May you be blessed with enough challenges to keep life interesting but not daunting. May you know the infinite goodness that resides within you. May you enjoy peace and happiness. May you never forget how to bless one another. Thank you very much and God bless you.

Discussion

Dr. Clancy: Although we have numerous people with sophisticated expertise in measurement here, I think the response from the audience here is self-evident. I'm not sure that any of us will hear the words "leadership" or "integrity" in quite the same way again. Sister Mary Jean is willing to take questions if people have any.

Female speaker: What does SSM stand for?

Sister Ryan: It's merely a historical artifact. It used to stand for something. The Sisters of St. Mary originally started the system that is now SSM. However, a group of those sisters broke off and formed their own congregation before 1900. In 1985, we all came back together, but we said, "Maybe Sisters of St. Mary isn't what we are anymore," because they were the Sisters of St. Francis of Merryville, so we became the Franciscan Sisters of Mary. Our system name shortly after we formed was the Sisters of St. Mary Healthcare System. We abbreviated that to SSM Healthcare System. Just about the time that we decided to keep Franciscan Sisters of Mary as our congregational name, we had just purchased all new stationery. I said, "We're not doing it again." SSM no longer stands for Sisters of St. Mary, but it is a historical artifact.

Female speaker 2: I have a question about how you deal with middle management. In my work with organizations, I find that sometimes the frontline gets it and maybe top leadership gets it and that middle layer is still somehow deeply suspicious that they won't be supported, that they really can't change how they do things.

Sister Ryan: I don't know that we've solved that. If you are working with organizations, familiar with organizations where top management is getting this, I would like to know those organizations. Frankly, I talk to many groups and the middle managers seem to be the ones in my mind who get it, who want to get it, who know that it's the right thing to do. Their question is usually, "How do I get my CEO to do this?" I think that sometimes it's a matter of really continuing that support, providing the ongoing education that middle managers need, really expecting things from them that are part of their role.

In some respects, we almost created a monster in health care. We said, "You're the director of radiology and you're the director of the laboratory, and you have to make those things work. You're responsible for them." We never said, "You're going to have to work together." Then these silos were created. Now, we're working to say, "How do we get the silos to come together to do things?"

I just think it's a matter of constantly inviting people to participate. If they don't participate, they can't work in the organization. It's as simple as that. We've had a few of those. I'm glad to say we don't have an exodus, but we've had a few.

Male speaker: Many of my family members are actually cared for in your hospital in Jefferson City. Their experiences there, both good and bad, are the reason I'm here today. Thank you. I have to say it's mostly on the good side that I'm here. Nonetheless, the bad experiences are certainly telling. About halfway through your talk you said that there was a need for fundamental change. While I don't want to get off your message about the importance of making small changes and what you have achieved with small changes, what are the fundamental changes from your perspective that we need to tackle first?

Sister Ryan: I think there are so many aspects to this thing that my poor wisdom will certainly never be able to look at this comprehensively. Let's look at the part that I really don't like to look at all that much. If you look at the financing of health care or not financing of health care, what do we do with 45 million uninsured people? We treat them in our emergency rooms, the most expensive place in the hospital. You all know this. If you could take the money that we don't get taking care of people in the emergency room and could convert that to preventive care, how different would that be?

I think prevention is one of these pieces. I think that some of this will have to start back in the schools. I think physicians will have to be educated differently. I think all health care professionals will have to be educated differently. I think they need to learn how to work as members of teams. This captain of the ship thing is quite a problem. This is a team of people working together. That team of people has to communicate.

I think what I'll do is write down your question and go back and see if I can get a better answer to this because even in our own system, we have to be able to make some of these fundamental changes. I think Baldridge has helped us do a lot of this because it gave us a focus, a discipline, and a framework to do this. It taught us where these linkages are coming in. Those were things that we really did not have a good sense about before. Our challenge is really continuing to involve physicians in a way that's meaningful for them that really provides opportunities for patients to come receive the best care, receive it safely, and go home happy about the experience that they had. Not that they'd like to come back very often, but if they have to come back, would they want to come back to our facility?

I don't know what it means without that fundamental change. If you look at medication errors, some of the things that we've done got us all the way back to the drug manufacturers, the way they package stuff. Is that a fundamental change? I don't know. It's pretty fundamental if they're packaging two terribly opposite drugs in the same color box that basically has the same wrapping. I think that everyone has to look at this and say, "Where are these breakdowns occurring the most?" and see what you can do about that.

I don't know that anyone has a grand scheme for fundamental system change. As Don says, and we found this out, every system is designed to achieve the results it achieves. If it's a bad system, results will be bad. I think first, one fundamental change is let's stop blaming people for mistakes—which would encourage them to come forward.

I was asked several years ago to speak at a meeting in St. Louis on medication errors or medical errors. The person that called me said, "Would you be willing to speak at this conference and say that there are mistakes in health care?"

I said, "As opposed to what?"

I know that I didn't answer that very well. It prompts me to go back and give that some additional thought. I'd also like to know what didn't work for you in the hospital.

Male speaker: I have on my Pilot a daily reminder that tells me much to my dismay that a new RAND study confirms correct care is given less than 60 percent of the time with little variation across diverse communities. That, of course, was the New England Journal article that had a large appendix to it. I'm happy to beam this to anyone who wants to carry this also. This of course is a frightening thing to look at and makes me lose sleep on a daily basis. When we tried to bring this issue to some leaders of medical education to include medical error in their curriculum, we were met with horror that the curriculum would have to undergo yet another revision. I'd be interested in hearing how you would respond to this very unfortunate study and I'd be interested in hearing Dr. Clancy's view. It seems so dismaying to be faced with this.

Sister Ryan: We've had some similar conversations with medical schools. It wasn't a medical school but a nursing school at a university and they had taken something out of the curriculum that we thought was very basic. We said, "That really needs to go back in that curriculum." They told us it would take 5 years to get it back in the curriculum. I don't understand those things. I'm sure that medical school is no different.

The problem, that you raised extraordinarily well, is physicians have already learned bad habits when they come out of medical school. Then they get into the field and practice and those bad habits are enhanced. Whether it's dangerous abbreviations or whatever, they have to unlearn all of that and then relearn the right thing. We have so many physicians who are serving as mentors and teachers who also learned the wrong things that those are compounded and continued. I know some people who are working in medical schools right now. We're working very closely with them to see what it is that we really need to be able to do to help make those changes. It has to happen there. It has to happen in all professional educational schools.

Dr. Clancy: Let met just add to that by saying the other day I had the pleasure of speaking at a meeting sponsored by the American Board of Medical Specialty Societies. There was a lot of discussion about how residency programs can address the Accreditation Council for Graduate Medical Education requirements to focus on systems based practice and so forth. I found the suggestions and the conversations about curriculum incredibly specific. I also had an interesting conversation with people here last night.

I think the good news is we almost can't make a mistake moving forward because there is so little happening for medical students. The observation that was made to me is that figuring out how to do that in a way that's relevant and real and isn't threatening. After all, as a student you're in this mindset that if I study hard enough, know it all, and just don't sleep, I'll be in control. The counterpart to that is something on which I think we all need to work. I'd certainly be interested in generating more discussion about that at this meeting and following up.

Before we launch you into your break and spreading out into multiple sessions throughout the next couple of days, I want to acknowledge Deborah Queenan, in addition to the many people on this team. She has worked very hard to take all of your evaluations from last year very seriously and to use that as a foundation for creating this year's meeting. I wanted to thank her specifically again.


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Current as of July 2005
Internet Citation: Making the Health Care System Safer: Keynote Address: Third Annual Patient Safety Research Conference. July 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/other/ptsconf3/ptsconf3b.html