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Reflections on Safety is a monthly column presenting the insights of Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement (IHI). Dr. Gandhi was president and CEO of the National Patient Safety Foundation prior to its merger with IHI in May 2017.


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Leadership, Culture, Communication at the Heart of Safety

Posted By Administration, Monday, June 13, 2016
The 18th Annual NPSF Patient Safety Congress emphasized the importance of psychological safety, patients and families as partners,
and greater transparency to make us safer.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


Regular readers of this column know that the National Patient Safety Foundation has been very focused in recent months on the issues of leadership and culture in health care. Our attention to these interdependent factors, which are vital to advancing patient safety, continued at the 2016 NPSF Patient Safety Congress—the Heart of Safety—held last month in Scottsdale.

Amy Edmondson, PhD, AM,
Novartis Professor of Leadership and Management at Harvard Business School and a member of the NPSF Lucian Leape Institute, led an enlightening keynote session on teaming, which she defined as “coordinating and collaborating, across boundaries, without the luxury of stable team structures.” In health care systems that operate 24 hours a day, 7 days per week, the need for effective teaming is obvious. If the team is not effective, they won’t perform at their best, and safety could be compromised.

Prof. Edmondson explained that psychological safety is essential for patient safety and is a hallmark of effective teams. Psychological safety, “a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes,” is best created by inclusive leadership. Leaders can create this kind of environment by being accessible, by proactively inviting opinions of others, and by acknowledging that they, too, are human, and subject to fallibility.

We also talked a lot this year about communication. Ben Moulton, JD, MPH, senior vice president, Informed Medical Decisions Foundation, led a panel on shared decision making, emphasizing that, often, there is no “right” course of action; the patient’s wishes are paramount in deciding upon a care plan. Among the evidence he cited was a study showing that decision aids lead to greater knowledge among patients, greater comfort with their decisions, fewer patients remaining undecided about a procedure, and fewer choosing major surgery.

Communication and resolution after medical error was the focus of one of our Immersion Workshops led by Tom Gallagher, MD, professor and associate chair, Department of Medicine, University of Washington, and Rick Boothman, JD, chief risk officer, University of Michigan Health System. During our meeting, the Agency for Healthcare Research & Quality released its Communication and Optimal Resolution (CANDOR) Toolkit, and Erin Grace, MHA, of AHRQ was on hand to discuss it with attendees. The new toolkit gives hospitals and health systems the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication and timely resolution for patients and caregivers.

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These topics were brought to life for attendees by Patty Skolnik and Beth Daley Ullem, mothers, patient advocates, and members of the NPSF Board of Advisors, who shared tragic and powerful personal stories of how their families were affected by medical harm. When it comes to engaging patients in their care and creating transparency around medical errors and adverse outcomes, the health care sector has a long way to go. But our faculty for these programs showed us what is possible and how much it truly matters.

Professional meetings are designed to provoke thought, and Kaveh Shojania, MD, director of the Centre for Quality and Improvement and Patient Safety at the University of Toronto and editor-in-chief of BMJ Quality & Safety did just that in offering his assessment of recent, important patient safety research. He discussed a range of topics, including diagnostic error, the impact that rudeness has on team performance, trends in adverse events over time, incident reporting, fall prevention, and high-risk prescribing in primary care. His suggestions that we revisit our thinking on areas such as harm measurement, falls, and safety reporting, have surely generated discussion among attendees.

We closed with a valuable keynote session led by resiliency expert Paula Davis-Laack, who inspired us with her tips for how health care professionals can beat burnout.

We were also very pleased to recognize exceptional work through the awards given at Congress. (Read about the poster awards here and other awards here.)

This year, as every year, I learned a lot from the presentations and from those I had a chance to speak to during our networking sessions. I know attendees left with practical tactics to take home to advance their patient safety activities. The feedback we receive is very important as it helps us shape the program over the years, so we are grateful to those who’ve gotten in touch as well as those who have completed the attendee survey. We are already working on next year, so stay tuned.

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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.

Tags:  2016 NPSF Congress  communication  culture  leadership 

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