TSB Transportation Safety Summit
"Disciplinary" case study from health care
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
- geographic area
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?
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
- 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
- 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
- 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.
- Date modified: