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. She's talking with some of our caregivers about this very important topic.

Shannon Phillips, MD: This is Dr. Shannon Phillips. I'm the Chief Patient Experience Officer at Intermountain Healthcare. Today's topic is one of my favorites: safety. I’ll have my colleagues in the Office of Patient Experience introduce themselves. Elizabeth?

Elizabeth McKnight: I'm Elizabeth McKnight, and I am the System Director of Patient Safety.

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

Shannon Phillips, MD: All right. In every meeting at Intermountain Healthcare, we start with a story, and we honor that ... Actually, that culture and that tradition has come out of our safety journey. This is no different. Anybody got a good story?

Elizabeth McKnight: Well, I have one I would like to share. This is a story that to me speaks to where we want to be moving this year as we think about how patient safety and high reliability impacts a much broader experience for our patients than just what we might typically have called safety in the past. This is a story about one of our pharmacists who was working with a patient and had a conversation about the price of an antibiotic. The patient unfortunately had heard a different price quoted by someone working in home health, and so rather than allowing this situation and this alarm of the patient about the cost of this medication, which was essential for good care, to get any farther, she heard what he was concerned about and said, "Let me find out more."

She wound up making some phone calls, resolving the concern about the price, so that that patient was able to go ahead and go home on this medication and be well taken care of, reduce the risk of having a readmission, and also feel safe and listened to in this encounter about something that really started off as a financial irritant, and really had a good experience in the end. In fact, he gave that pharmacist a big hug. That's the kind of thing we'd like to be able to hit on, as we're talking about any one of those things, really looking at how it impacts patient safety, but also, is there a quality piece to it? Is there an experience piece? How can we walk into that room and really take care of all of those things for our patients?

Shannon Phillips, MD: Thank you. I think what it's making me reflect on is patients just expect to be safe. There's a lot of complexity in this. Think of all of the loopholes that sat in front of that patient that might have prevented them from what should be, I presume, a very successful outcome if you can follow through on your treatment plan. There's so many pieces of Swiss cheese, right? I like cheese, but Swiss cheese in my work I'm not grooving on. How do we get ahead of the Swiss cheese?

Mike Woodruff, MD: Makes me think about how, as you suggested, how easy it is for that kind of, we could call it an error, but that kind of outcome to happen. If we hadn't really been present and listening to that patient, and been willing to stop and respond to that patient's needs in the moment, then we would have missed that. That patient could have gone home and not filled the prescription and had a bad outcome.

Shannon Phillips, MD: I'm feeling a little bit of error prevention techniques in what you're saying, Dr. Woodruff.

Mike Woodruff, MD: That's a shocker.

Shannon Phillips, MD: That might not be by accident, right?

Elizabeth McKnight: A classic stop and resolve.

Shannon Phillips, MD: There you go.

Elizabeth McKnight: Beautifully performed, but really, that's a high reliability technique that we can use across the board.

Shannon Phillips, MD: This organization, a few years ago, started a journey which is called here Zero Harm. Where'd that come from? How'd we get there, and how are we doing on that journey?

Elizabeth McKnight: Okay. I would say it's going really well. We've had great commitment by our frontline, by our providers, to participate in training around how to use the error prevention techniques. What does it look like when you are working in a high reliability environment? At this point in time, we have seen a decline in our serious safety events. We know that we still have a lot of work to do, but we've got real traction with the safety culture that we've been building over the last few years. Now we're at a point where we can use this foundation really to expand the work that we're doing and take on some new challenges that confront us in patient safety and elsewhere.

Shannon Phillips, MD: What's the thing that keeps you up at night these days?

Mike Woodruff, MD: Well, I think it gets back to your previous question of, what can we do to avoid the holes in the Swiss cheese, falling through the holes in the Swiss cheese?

Shannon Phillips, MD: You're going to talk about Swiss cheese again, are you? Go for it.

Mike Woodruff, MD: It's lunchtime. It is lunchtime. I think the concept of ... How do we get a caregiver to be present in the moment reliably and listen reliably, take the time? Because these things take time. They need to be free from distraction, and they need to be focused on listening to the patient. How do we set up that space for the caregiver? That involves eliminating work that doesn't add value from their day. It involves an organizational approach to focusing on the patient and the caregiver, so that they can have time to have these really authentic interactions like the one we heard in that story that promote safety.

Shannon Phillips, MD: I think about what you say, and I reflect back on healthcare. I might try and make an EMR analogy, but I might not. We have, over these last many years, had so many new things put upon us. I don't mean that all bad, but regulatory expectations. We've learned a lot about what great care should look like, and we've created checklists and bundles and things for people to do. A lot of it feels like it got bolted on to a chassis that's been around in medicine for decades, right? They're all good things to do. I'm a big fan of bundles and checklists and reliable care, and we haven't really fundamentally gone back and said, "Are we designed right to do this?" We just keep bolting things on as opposed to saying, "If we were going to design it today, what would it look like?"

To your point, some good safety principles, let's get rid of the things that are not value add, that are not delivering extraordinary care, because the more of those things that are there, the more risk to the patient. Let's make sure everybody gets to participate at the top of their license, so that they feel challenged and stimulated and feel like they're great contributors. Is healthcare ready to redesign itself, or are we just going to keep bolting on? Because I think that's a constant tension for, safety is one more thing to do, one more thing to do, just do this. Are we ready to say, "Maybe we need a 21st century chassis for medicine today"?

Mike Woodruff, MD: Well, that's an easy question.

Shannon Phillips, MD: Oh, well, good. Thank you for solving it.

Mike Woodruff, MD: I think we're clearly at a point in healthcare where we're going to have to redesign or we're going to be redesigned by someone who does it more efficiently in the market. I think if we look at our processes, which are, as you said, bolted on and complex, if we look at it from the patient's standpoint, there may be an opportunity to reimagine those processes in a simpler way that flow with the patient, instead of the patient having to jump around throughout the system. Probably if we keep the principles of safety in mind, the safety and the patient experience in mind, that those old processes can be redesigned in a safer way, so there're not as many gaps, not as many opportunities for...not as many holes in the Swiss cheese, to bring it back to the cheese.

Shannon Phillips, MD: Here you go again. All right. You said a couple things there: one, the principles of safety, and two, the patient's experience. I think the principles of safety are things like, if we know the safe way to do a procedure, that we all are reliable to following those processes, and we should lean them and make them right. I think for patients, they don't know if there're eight steps or 10. They want to feel safe. I'm not sure that we as caregivers appreciate those nuances back and forth. What are your thoughts about safe principles and practice and high reliability, and feeling safe? Are they the same thing? Can they be similar, or are they different?

Mike Woodruff, MD: One way into that question is, if you think about one of the fundamental ways we operate in healthcare, which is on teams or teaming, working together with people with varied skills in order to serve the patient, if we think about the patient as a member of that team, then we really do have to hear that voice, because it's a valuable piece of data for the team to make its decisions. Listening to the needs of the patient, the need to feel safe, I think then becomes part of the diagnostic and the care process in that sense.

Shannon Phillips, MD: Yeah, I think the feeling of safe for a lot of patients ... We've been asking patients over these months, what's extraordinary look like, an extraordinary experience? They repeatedly will say feeling safe is one of those attributes. When you dig on that a little bit, they talk about ... When you say, "Well, what is feeling safe? What's that about," and it really gets to the relationship you build with someone. Are you talking to me? Are you answering my questions? Are you communicating? Are you listening? Communication is two-way. It's those attributes that actually underpin feeling safe as opposed to the 10 steps to put in a central line, just to take an example. I'm not sure, as we think about our safety journey and our high reliability practices and principles across care delivery, that we've necessarily added that nuance, that feeling safe to a patient is maybe not about what we think of and reducing unnecessary variation. How do we raise people's consciousness in that space?

Elizabeth McKnight: Well, one of the things, when we think about our high reliability techniques, that we've been working on, most of those are communication techniques, and they really do generalize to other settings. As we have become better communicators within our teams and now bring in the patient, I think we've really built some good skills in our care areas. It's just making that additional step to think, what is the patient feeling? How can we bring the patient into these situations so that we're all communicating? That's really going to give us safer, higher quality, better care most certainly.

Mike Woodruff, MD: Also, I think there's a lot of great work going on in bringing the patient voice into design and decision-making across healthcare and across Intermountain. The involvement of patient advisors and patient and family advisory councils in our decision-making process, in our thoughts around how we design our care, is a really valuable voice. I think coupled with that bringing the voice out through stories to frontline caregivers is very powerful. One example that comes to mind is the idea that a patient can have two totally different experiences going into surgery at two different hospitals in the same healthcare system. The reaction to that is a feeling of uncertainty, and wow, one of these must be better than the other. Am I getting the better care now, or am I getting the worse care? So, a feeling of not being safe because of a perception, a very real perception, of variation in care, which might not have any clinical meaning or risk, but gives the perception of an inconsistent approach.

Shannon Phillips, MD: That's a great story for feeling safe, right? In a time when you need to focus on what's in front of you, you're questioning yourself and the care, again maybe with no difference in outcome, but we've made it difficult for a patient to trust, to spend their time on healing. That's a great story. Back to cheese, since it's the theme. Where's the cheese? What's the cheese? If I visualize Swiss cheese, I think about all of those openings or potential ways things slip out as being critical to call out. If we are on truly a Zero Harm safe journey in high reliability, we want to call out those pieces. I think of that as situational awareness. If someone comes in, and there are three things about them that put them at risk, and there are two things that could possibly happen that would endanger the patient, how good are we at identifying the holes and having a mitigation plan in place to make sure the patient doesn't slip through? How well are we doing that today? I sort of think of it as, gosh, if we could pull that off, patients would really be safe, right? If we really were intentional in that space, we've got it, right? Are we there? What's in the way? How do we be really great at situational awareness?

Mike Woodruff, MD: Well, I think there's opportunity there. We, I think, in healthcare have focused for a long time on the recognition of those holes or those vulnerabilities, and saying, "Be careful. Do a better job. Work harder. Avoid the holes in the Swiss cheese," which we know is the least-

Shannon Phillips, MD: Okay, you just said all the things that we want people to never say.

Mike Woodruff, MD: ...the least effective techniques.

Shannon Phillips, MD: Right, exactly.

Mike Woodruff, MD: We know that designing, or forcing functions into our technology, into our work environments, are the most effective way to really make it hard to do the wrong thing and easy to do the right thing. I think it's our responsibility as leaders and as administrators, as clinical content developers, every level of the healthcare organization, to design our systems so that it is hard to do the wrong thing and harm the patient.

Shannon Phillips, MD: Sounds like a little bit of human factors, right, engineering? Is there not some teaming that comes in that as well, the communication piece? I think about stories I've shared here a few times, where we admitted a patient to the hospital and we knew what the worst thing was that could go wrong, but who's we? Because we certainly didn't share with people who maybe had less experience what could go wrong and what the signs and symptoms would be. The Swiss cheese worked. This young patient fell through all the holes with a very bad outcome. There's a communication piece, design well, and do we share? There are a lot of handoffs in healthcare, right? How do we do this better?

Elizabeth McKnight: Well, we are seeing, in certain places, not everywhere, we are seeing leaders who will start the conversation and say, "We've got a patient. Here's what's going on. What are our next steps? If this happens, what are we going to do?" So, really, doing some proactive planning around a particular patient and engaging those patients sometimes in those conversations. Here's what we're planning to do if this happens. If this happens, here's what next steps will be, and so really having that situational awareness that extends not only to the care team, but also bringing in that patient so that they feel there's a safety plan. I understand what could happen and how my team will keep me safe. We don't do that 100% of the time, but it's one of the things that we're seeing, given our safety culture that we've built over the last few years, people are free to do and to really raise those kinds of concerns and get a plan in place to help out a particular patient.

Mike Woodruff, MD: One of the things we're hoping to build on is the use of structured handoffs to formalize that. We have some structured handoff tools built. There are a couple of them in use across our organization, but the idea of always including certain information that you're passing off, and in fact, combining that structured handoff with a warm handoff, an in-person or via video link handoff, that involves the patient in the conversation is a really fertile ground for improving our patient safety.

Shannon Phillips, MD: Nice, telehealth and safe handoffs. I'm feeling some future work. Yay. If I was to ask you what's most critical for a robust, thriving culture of safety, what comes to mind?

Mike Woodruff, MD: One of the foundations has to be a safe culture for reporting and for speaking up. You could call it a just culture, but a culture in which there's no retribution when someone speaks up and raises a concern. Because the concern may not align with the expectations of the particular group, that's not a reason to not listen. Every voice has to be heard, and people have to feel that it's a) safe to speak up, but also easy to speak up and easy to report concerns. Combining that with a technological approach that makes it at your fingertips to report safety events is very top of mind for us.

Elizabeth McKnight: Mm-hmm (affirmative), and really saying thank you when people do raise concerns, particularly when maybe a concern isn't really justified, there's maybe not a real patient safety issue at hand, still saying, "Thank you for raising that. I'm glad you're thinking about that. I'm glad you're supporting our whole team by raising questions." I think that's what we're working on.

Shannon Phillips, MD: Foundational, sure. Where I think the biggest risk in, well, biggest, there may be many, in safe culture sometimes are physicians, right? I know, Mike, you've done a little thinking about what the message might be for providers around how they contribute to safety and a safe culture in our organization. What were some of the things that you think we should spend some focus time on with our providers?

Mike Woodruff, MD: Well, I think we really have to start thinking, as is happening nationally now, about diagnostic safety and about how mindful we are of the safety of how we approach diagnoses. As a physician, I think it's easy to underestimate how powerful my voice is on a team, and how even my demeanor, my mood, one word, could really shut down the communication lines on a team, depending on who else is on that team, and particularly with the patient. We've seen this again and again. To enable that, I think, takes intentional practice of asking for input from team members, expressing uncertainty, and particularly in a high risk diagnostic part of the process when we're ready to discharge somebody or ready to terminate a resuscitation or a code, we stop and we take a time-out, and ask the team, "Are there any other thoughts or concerns? Let's make sure we've got the right diagnosis here." Additionally, having situational awareness. We're in an era where we have a ton of information to digest in almost every clinical situation. Really being aware and present, not multitasking, trying to avoid interruptions, that's easier said than done, but being mindful that we may not be able to digest all the information, and then asking for team members to help us handle that.

Shannon Phillips, MD: That sounds like approachability, being cognizant. I think some of the best stories I've heard from physicians are things that take no extra time. You've pointed that out, so just simply asking, "Does anyone else have anything to contribute? Is there anything we're missing?" An open-ended question takes no time and opens the door for people to share. Another technique I have seen is sharing stories, so making the case in front of you or the patient in the bed real, bringing the humanistic side, what do you know about them as a person, to give people that sense, the holistic sense of the patient and their family and what they're going through to make that connection. Neither of those things take but seconds, and really, I think, change the dynamic amongst the team members, so powerful.

Elizabeth McKnight: Yeah. It's the pause we need to refocus and say, "Here's this patient. Let's go forward."

Shannon Phillips, MD: Mm-hmm (affirmative), so being present for them, not doing it to them but with them. I think patients really see safety as honestly table stakes. They don't think about it, right? They think about how kind we were, that we thought of something before they anticipated it. The connection is there. They expect if they're coming in, we're taking great care of them, great outcomes, not harmed. Yet we need to spend very intentional time on making sure that they can expect that it's foundational and nurturing that. I think one of the things I am struck by, joining the organization only in the more recent time, is that journey needs nurturing. That journey to be safe, to be highly reliable, doesn't just happen alone. You're stressing communication, really important. I think we also have to be intentional in our leaders' presence in this, so that the frontline sees how important it is, that it is, along with speaking up, not punitive but nurturing and expecting, empowering people to be able to stop the line and make the change that's needed. It's a great journey here, and you all are actually bringing high reliability principles to the other work we're doing in the Office of Patient Experience, so that we can keep it simple for our caregivers, so that it's not do this for safety, do this for quality, do that for experience, but that we can apply many of these principles more broadly. If I said you get one word to describe what's most important in safety right now, and they can't be the same word, so somebody gets to go first, what would it be? What's top of mind?

Elizabeth McKnight: I think it's that-

Shannon Phillips, MD: One word.

Elizabeth McKnight: ...relationships that you mentioned earlier.

Shannon Phillips, MD: Relationships.

Elizabeth McKnight: Yeah, it's really having that connection with our patient and our caregivers.

Shannon Phillips, MD: Okay. Dr. Woodruff? And it's not cheese.

Mike Woodruff, MD: It's definitely not cheese. I would choose listening, because I think that encompasses a number of concepts. To listen, you have to be present, to truly listen. You have to be mindful and aware of who you're speaking with and what information they might be giving you. You have to take time. We, I think, all know that we live in a culture of rushing now. We've seen in many other fields, we've seen the negative effects of that culture of rushing and the culture of multitasking. We know that that's not safe. Bringing that to healthcare, I think, is probably the new frontier for us.

Shannon Phillips, MD: Okay, relationships and listening. It's a good place to stop. Thanks for the time.

Mike Woodruff, MD: Thank you.

Elizabeth McKnight: Thank you.