TSB Transportation Safety Summit

"Disciplinary" case study from health care

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Jack Davis
Chairman and CEO, Mobile Inc.
Ottawa, Ontario, 21 April, 2016

Check against delivery.

Slide 1: "Disciplinary" case study from health care

  • Jack Davis
  • Chairman, CEO.Mobile Inc.
  • (former President & CEO, Calgary Health Region)
  • TSB Transportation Safety Summit 2016

Slide 2: Preamble

  • (former) Calgary Health Region (2004)
    • geographic area
      • 39,260 sq km
    • 14 communities
      • 12 acute care sites
      • 40 care centres
      • 7,836 beds/spaces
    • healthcare providers
      • 24,000 employees
      • 2,150 doctors
      • 3,917 volunteers
    • Map of Calgary Health Region

Slide 3: Outline

  • Part 1
    • Events of 2004
  • Part 2
    • What did I do?
    • What was the outcome?
    • What effect did it have on the organization?
  • Summary

Slide 4: Part 1: Events of 2004

  • Unexpected deaths of two ICU patients.
    • undergoing continuous renal replacement therapy
    • potassium chloride (KCl) used instead of intended sodium chloride (NaCl)
  • We could have had 34 deaths!.
  • Pictures of boxes and vials of potassium chloride

Slide 5: Part 1: 2004

Front page of Calgary Herald, March 19, 2004

Slide 6: Part 1: 2004

News article in the Calgary Herald.

Slide 7: Initial reaction: Shame & Blame

Dialysis drug mix-up demands fatality probe news article

Slide 8: Part 1: 2004

Pharmacy staff to answer for deaths news article

Slide 9: Part 2: What did I do

Photo still of CBC news interview

Slide 10: Part 2: What did I do

Facing up to double jeopardy new article

Slide 11: What I started to do

  • Considered disciplining in accordance with expectations
    • To calm the noise in the media
  • Listened to advice
    • Legal
    • Insurance
    • Medical professionals
    • Safety experts

Slide 12: A fork in the road

  • The press was calling for ‘blood”
  • My rethinking
    • ‘You can't run your life by catering to the media.”
  • My experts were saying
    • “This has happened before; there are methodologies to sort this out. Let's get going!”
  • My thought
    • They had science and insight behind what they were saying − not making it up.

Slide 13: A cold weekend day in the spring

  • A walk in the snow led to a decision
    • “Somebody else could be making the same error elsewhere….”
  • What should we do?
    • What would make the system better?
    • What would save lives?
    • What would alleviate pain & suffering
  • What you line it up that way
    • There are no other options!

Slide 14: What we'd done well by that time

  • Full disclosure with family
    • Explained all the facts
    • Rare at that time
  • Shared problem with other HC systems
    • To avoid other deaths
    • Also rare at that time
  • Went public: held news conference
    • Were open, honest & transparent

Slide 15: What I did

  • Dealt with Pharmacy Technicians
    • Off with pay during the 3 investigations
    • Given counselling
    • Not disciplined or blamed.

Slide 16: Part 2: What was the outcome

Photo still of new press interview

Slide 17: Allocation of resources

  • An individual at the Executive Level
    • With appropriate authority
    • Responsible & accountable
  • $ 5M CAD od $5B CAD budget
    • HAVE budget for safety!
    • Relatively modest investments
    • Most good things relatively inexpensive

Slide 18: Some of ‘WHAT' we did

  • Board Committee for Safety
  • Safety Department, with a VP & $
  • Code of Conduct
  • 4 related policies
    • Disclosure
    • Reporting
    • Informing
    • Just & Trusting Culture
  • Safety briefings before meetings
  • Reporting software
  • Patient Family Advisory Council
    • Active member of Region's Safety Committee

Slide 19: Our culture was the problem

  • Hierarchical
  • Individual responsability
  • No sense of system
  • Organised for failure
  • Shame & blame
  • Picutre of ruins

Slide 20: System needed to change

  • If a system is inappropriately punitive
    • Takes energy to suppress negative feelings
    • Contributes to low morale & low energy
    • If your energy is low, you can't care
  • Needed: appropriately non-punitive system
    • Just and trusting culture
    • More energy: Cross-over conversations
    • Focused on family centred care
  • The whole system will improve!

 [Slide 21: Part 2: Effect on organization?

Photo of CEO

Slide 22: Blinding light of the obvious

We have the teams and the expertise to solve these problems!

Slide 23: From need to effect!

  • Aim was to change the culture
    • Amended to Code of Conduct
    • Instituted Just & Trusting Culture Policy
    • Changed how we approached accountability
  • People were
    • Happier & more engaged
    • Ready to improve the safety of the system

Slide 24: Deb Prouse & Steve Long

Photo os Deb Prouse & Steve Long.

Slide 25: Gave people confidence

  • If something goes wrong
    • It's usually NOT about the individual being incompetent and / or needing punishment
    • Generally it's a failure in the system that needs to be addressed

Slide 26: Just & Trusting Culture Policy

  • Picture of Just and Trusting Culture Policy
  • Errors – when there has been failure in the provision of care to a patient and the health-care provider did not deviate from established policies, procedures, standards or guidelines, then the health-care provider will not be disciplined by the Region.

Slide 27: Summary 1

  • The mission of healthcare
    • Saving lives
    • Avoiding unnecessary pain & suffering
    • Improving the quality of life
  • Take everything back to these points
    • These are the reasons we work in healthcare
  • Doing the right thing is easier than you think!

Slide 28: Summary 2

Leadership – a critical success factor cartoon.

Slide 29: Acknowledgements

  • I would like to thank three people who have direct experience in the area & who have helped with this presentation
    • Ward Flemons MD FRCPC
    • Jan Davies MSc MD FRCPC FRAeS
    • Carmella Steinke RRT MPA.