Mark Briesacher, MD: I'm Dr. Mark Briesacher, the Chief Physician Executive at Intermountain Healthcare. Today we have a guest host, Dr. Shannon Phillips, who’s our Chief Patient Experience Officer, and she's talking with some of our caregivers about this very important topic.

Shannon Phillips, MD: Hi. This is Dr. Shannon Phillips. I'm the Chief Patient Experience Officer at Intermountain Healthcare. And today I have two of my colleagues in the Office of Patient Experience from Clinical Risk Management. I'll ask them to introduce themselves.

Julie Wright, RN: Hi, I'm Julie Wright. I am a registered nurse, and I'm the System Director of Clinical Risk Management for Intermountain Healthcare in the Office of Patient Experience.

Mike Woodruff, MD: I'm Mike Woodruff. I'm an emergency physician, practicing emergency physician, and I'm Medical Director of Patient Safety and Clinical Risk in the Office of Patient Experience for Intermountain.

Shannon Phillips, MD: All right. So, here we are. Risk management for many people in healthcare is not, it's not like a happy place, right? It says innately it's there to help us when we're at our most vulnerable, right? We have failed a patient and likely their family and loved ones, and we probably want to learn from that, but it's not necessarily always that simple. And I think people might not think of clinical risk as something that would sit in the Office of Patient Experience. So, there're legal implications and insurance implications. And there's kind of a shroud of secrecy that often sits around risk. So why...Make that connection for me between risk and the Office of Patient Experience.

Mike Woodruff, MD: Well when I previously thought about risk and risk management I thought about the organization feeling risk. And the organization managing that risk. And really, in this view, it's the patient's risk. It's the caregiver's risk. And it's our job, I think, to support reducing that risk to the patient, reducing that risk to the caregiver, and reformulating the way we approach it. We're not secret about it. We're open about it because there really is, our activity is at the base of what we want to do as caregivers, as nurses and doctors, to keep our patients safe and not harm them.

Julie Wright, RN: Right. And one of the keys to high reliability as it pertains to safety or anything is a preoccupation with failure. And that is, unfortunately, we are humans taking care of humans. And we, mistakes happen, so it's that preoccupation that we deal with, and how that does affect our patients and our caregivers. Clinical risk, it's a little bit like going to the, you know, when you have something bad happen and you go to see the doctor; you really don't want to be there, but you're glad they're there when you see them. If something's happened that you need them, you're really grateful that they're there, and that's kind of our goal in clinical risk—to be a support for caregivers when they are, to our caregivers and patients, when they are at their most vulnerable, because we've made a mistake or even just had a bad outcome that was unexpected whether we made a mistake or not, having that support.

Mike Woodruff, MD: And if you think about, if our goal is to keep our patients healthy and they have an outcome that is not health, our response being embracing the patient, embracing the family, embracing the care team, feels a lot more in line with our mission than to step back and say something bad may have happened. Let's keep it a secret. And providing care after those unexpected outcomes, unanticipated outcomes, is actually probably some of the most impactful care we could provide. Especially to our caregivers, who have to then go back and continue to care for others.

Shannon Phillips, MD: So this is the caring of providing care, right? Then emotional support, that being present for somebody in a time of need. So risk management for a long time, clinical risk management, has been maybe a legal entity. And I think still is in a good number of healthcare organizations around the country. They're great partners in this, but can you tease apart for me why it's different?

Julie Wright, RN: Yes, we can. When clinical risk management is aligned with legal and malpractice, you lose the learning that you can get from events. There are different protections in place for legal; we have different legal protections for something that's being litigated than there is for quality improvement. So the separation that's taking, that's taken place and putting clinical risk in the Office of Patient Experience allows us not only to respond differently to these events and put our patients and caregivers at the center rather than protecting the-

Shannon Phillips, MD: Quiet, don't talk about this, right? Those sorts of things.

Julie Wright, RN: Yeah, instead of taking that to deny and defend, it more allows us to openly investigate and learn, especially when we made errors in the process. Another opportunity that One Intermountain has given us is to look at care breakdown across the continuum. At Intermountain, we have our home care and our Medical Group and facilities across the state where patients are transported. And we now have the opportunity to learn from a whole episode of care rather than its pieces in different areas and really get to root causes of our failures.

Shannon Phillips, MD: So that sounds awfully patient-centered that we might not think just about what happened in a hospital or a clinic, but that actually follow the journey of the patient. Do we learn differently about what went wrong when we follow that continuum versus someone's visit, the piece in the hospital or in the clinic? What do you think?

Mike Woodruff, MD: Well again, I think it's thinking through the perspective of the patient or looking through the eyes of the patient at the care that's provided. Sometimes it doesn't matter if one silo doesn't think there was a problem, because if the patient feels that there was a problem, if the family doesn't feel safe, then we've harmed their experience. And so that's something that can emerge in this idea of looking from the patient's perspective at the care that was provided across all of the encounters. And if you think about the patient's view of coming to the clinic, trying to make an appointment at the clinic. Coming to the emergency department, getting admitted to the hospital, they might have very different experiences along that continuum.

And one of our responsibilities as One Intermountain is just to take a look at that whole experience and make it seamless so that the patient feels throughout the process, safe.

Shannon Phillips, MD: How do we make sure caregivers feel safe in this?

Mike Woodruff, MD: I think the...From a physician's perspective, it feels much more authentic to me and much safer if I know that if something goes wrong that we're going to embrace the patient and we're going to say something went wrong, we're so sorry instead of, and if there was a problem, that we're going to fix it. Or at least help support fixing it. And as a physician, the alternative model of waiting and worrying and perhaps the fear of a lawsuit that will tie me up for years perhaps in giving depositions and worrying and questioning myself, that's a big emotional toll.

Shannon Phillips, MD: So maybe being active in learning, being able to be part of that conversation, takes some of that anxiety, nervousness, not being comfortable, out of it.

Mike Woodruff, MD: I think a lot of our caregivers do an early disclosure process when they realize that an error has been made or an unanticipated outcome has occurred. This is about supporting that desire of caregivers to be open and honest and caring towards their patients.

Julie Wright, RN: Okay, and also, communication between. It's not just physicians that care that worry, that empowering all caregivers to be able to speak up and be part of that learning process and getting all the different perspectives. And as Mike said, including the patients. We know that often not everything that happens during an episode of care is in the documentation. We wish it was, but a lot of the story is told by talking to the people involved, and that's where the real learning takes place.

Shannon Phillips, MD: So I think this work is, you know, you mentioned preoccupation with failure as one of the key principles of high reliability. And I think what we're talking about here, done well, is also foundational for safety culture. Right? How we get up and come to this every day. You guys are doing some important work here around identifying, rapid identification of things that go wrong. Some work in disclosure and resolution and caring for our caregivers. Do you want to share a little bit about that journey you were on and why it maybe matters for our organization and our patients?

Julie Wright, RN: Yeah. Yes, well historically because we've been working a little bit in silos, or when an organization works in silos, there is a delay often or inconsistency in identifying and realizing that a mistake has been made. Or even just a bad outcome. What we're doing is creating consistency across our organization about what constitutes an adverse event or an unexpected outcome, how it's reported and how we respond by getting in quickly, getting people's account of what happens. By completing RCAs quickly, we can mitigate problems and ongoing risks, but we can also...The learning is much better when it's fresh on people's minds.

Shannon Phillips, MD: So the sooner we know something the more quickly we have the opportunity to learn. Ask if we need a system improvement and take care of that. And that feels very powerful, healing, and a great learn. We're also able to serve the patient and those caregivers in the event more promptly. And I think there's something to be gained there, right?

Mike Woodruff, MD: Agreed. And I think it's also a powerful institutional message that we take this, this is of paramount importance to the organization, is safety. The analogy to the airline industry has been made a few times.

Shannon Phillips, MD: Oh, careful there! You know, some people don't like that. I'm a fan though.

Mike Woodruff, MD: There's not a one to one correlation. Healthcare is very complex. But the reason the airline industry has achieved success in safety is not because they show up a month later to investigate a crash when it happens. Right? I mean they're there the next day. I heard this said very well recently. And they don't delay because they can't get a doctor or nurse to come to a meeting. They're there on scene as soon as the event happens to investigate and learn and gather as much information while it's fresh so that the organization can learn.

Shannon Phillips, MD: So we've...Previously in healthcare, you know, you use the term deny and defend. There's been the, you kind of had to suffer in silence when something went wrong, right? Doctor, nurse, pharmacist, anybody, because there was this fear. I think we can only take as good a care of our patients as we take care of each other. And that's getting some attention in this process as well. Do you want to share a little bit about how we might be able to do better by and heal our caregivers in this process of earlier disclosure and resolution?

Mike Woodruff, MD: Well, Julie will be able to explain better, but I've seen it in our legal team. They smile. They smile more when they're talking about these early disclosures and early resolution because it feels more authentic to them.

Julie Wright, RN: I think as caregivers, especially clinicians, those of us who work in clinical care, there really is an expectation of perfection because when we make a mistake, somebody can be hurt very badly.

Shannon Phillips, MD: We're hard on ourselves.

Julie Wright, RN: We're very hard on ourselves. And so this rapid response, this show of support not only opens the doors to discuss it and talk about it for learning, but it's also very healing to be able to say, "This is what I saw. This is what I did." And have somebody say, "Okay, let's fix it together." Rather than, let's be silent. There's just an associated, I hate to say shame, but that is kind of what it is that goes along with that and it feeds that expectation of perfection. We want to be highly reliable and we want our systems to aid us as humans taking care of humans and not hurting patients. But as caregivers, that expectation is not realistic. And that's what we need to keep in mind and respond appropriately when things happen.

Shannon Phillips, MD: And so we have the opportunity to meet people's emotional needs in this time as well, right? Do you want to comment a little bit to what's either in place or on tap for helping people? Like you said, we think we should be perfect and never make a mistake and, for goodness sake, never hurt a patient. How are we helping people in that moment deal with it?

Julie Wright, RN: Part of our systematic early disclosure process that's going to be coming is that when an adverse event or unexpected outcome happens, then two teams, for a lack of a better word, are deployed. One to support the patient and whether we made a mistake or not, say we're so sorry that this happened and what questions do you have? How are you feeling? How are you doing? But another team is deployed to help the caregivers the same way and say, "We're so sorry this happened. And how are you doing? And what we can we do to support you?"

Just acknowledging none of us want anything bad to happen to our patients, ever. And that's not why we're here. That's not why we're in healthcare. When it does, really caregivers are a second victim, and it can impact you long term. And just knowing that they have that support and immediate deployment of a team to support them and see what their needs are and help them through that.

Shannon Phillips, MD: It's pretty powerful. If I asked you what's the most common underlying reason that we have serious events with patients, is that too general a statement? Or what's top of mind for you that we can work on and be better at?

Julie Wright, RN: It is not too broad. I could tell you the one key behavior that plays into almost every serious event is listening. We don't listen to what are patients are saying. We don't listen to what our teams are saying. It is being present in the moment and actually actively listening to what those around us are saying. That is a key component of almost every safety event that we see.

Mike Woodruff, MD: It often feels, as a healthcare provider, feels like your responsibility is to talk and to have answers and to teach and to reassure and to say that you know what the answer is. But it turns out that the most effective way to function on a team is often to listen to your team. And having situational awareness of not just vital signs and laboratories, but also of the family's concern and the patient's concern is key to us making the correct diagnosis and doing the right things for our patients.

Shannon Phillips, MD: All right, well you've opened that door so I'm going to jump in with both my feet. I am struck, and of course, one of the things we do in this role is, it's all hindsight, right? But I am struck by the diagnostic opportunities that we encounter where we had something in front of us and we didn't see it. And I think as so many healthcare organizations have worked on high reliability and the principles and the applications in making our systems reliable over and over again, this is a cognitive space. It's very personal both, for any clinician who is confronted with a patient and symptoms and data. And we get it wrong quite a bit. So your thoughts on that space. And I see it in risk. I see it in our safety culture, but how do we battle that?

Mike Woodruff, MD: I think we have to acknowledge the environment in which we're delivering healthcare today, which is one where we have much more information. I'm not going to say bombarding, but I actually just said bombarding. So we have a lot of information to assimilate and we have a lot of demands on our time. And it seems like almost an impossible task as an individual to overcome that and to handle it well. But if you think about it as a team, I think that there might be an answer to breakdown some of this onslaught of information and assimilate it and listen to the team's concerns about that information and then use the team to formulate an accurate diagnosis.

Shannon Phillips, MD: Right. I think we're really, the place I think we're best at it probably are code situations. You know where everybody has a clear role. We're going about a relatively structured process and that step back where the team leader says, "Is anybody, can anybody think of anything else? Are we missing anything?" And giving that, you know, that kind of social, like you said to the team, think about what else could this be? And it seems like we have a long way to go in the bigger picture around diagnostic safety.

Mike Woodruff, MD: We do. One area where we do it well, I think, is with clinical pharmacists. The role of the clinical pharmacist is ever expanding. And finding smart ways to use that expertise to really understand the risks of medications and the way that medications are delivered is an area where we can, I think, score pretty fairly large wins.

Shannon Phillips, MD: Score some points on the win board. Good. Excellent. As we wrap up, any parting thoughts? This is an important space. How is this going to be extraordinary for our patients and our caregivers?

Mike Woodruff, MD: Well, I echo Julie's calling out of listening, because if you think of the whole healthcare, listening to the patient, I think you start to think of a different way to provide healthcare rather than the healthcare system thinking about individuals and hospitals and clinics. It's really listening to the patient and the family and what they need from their healthcare journey. I think that will get us to a different place.

Shannon Phillips, MD: Okay. Julie.

Julie Wright, RN: I think overall just, you know, taking, knowing that it's all, in every failure there's an opportunity to learn. And if we take that and do it effectively, if we master clinical risk effectively, it will support all of our fundamentals. It will support all of our care. There's not a board goal related to clinical risk. There's not a...But done well, it supports everything else. So it is an important space, and the message I'd like to send is that we are really here to support our caregivers and our patients when the worst things happen. That's what we are about.

Shannon Phillips, MD: Yeah, I think if I look out a couple years, I would see clinical risk management as, like you said, as a support, but as a place where people know we're going to do right by our patients, by our caregivers, for the organization, and the community we serve. And I'm really excited about the work you guys are doing. So thanks for your time.

Julie Wright, RN: Thank you.

Mike Woodruff, MD: Thank you.