123: Safer Together | The Architecture of a Movement
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See You Now is a podcast highlighting the innovative and human-centered solutions that nurses are coming up with to solve for today's most challenging healthcare problems, created in collaboration with Johnson & Johnson and the American Nurses Association. Welcome to See You Now. I'm Rebecca McEnroy, executive producer for See You Now and guest host for this special episode, the first in our series looking at safety in healthcare.

I was in my first year of pediatric residency. It was 3 o'clock in the morning. I was awoken in my on-call bed by the nurse telling me it was time to do the next exchange transfusion on baby Jones.

In May of 2024, Don Berwick, founder of the Institute for Healthcare Improvement, addressed students, researchers, early career professionals, safety executives, and healthcare leaders at the Institute for Healthcare Improvement's Patient Safety Congress. The title of his address, From Still Not Safe to Safety Ready. Now, exchange transfusions no longer in this country are

are done, or rarely if at all, though they're still necessary in other countries, and I'll give you a little bit of the background. The basic medical stuff here, it's that the baby inside the pregnant mother can have a blood type that's incompatible with the mother's blood, in which the baby's blood is recognized as a foreign material by the mother's blood, usually because of the presence in the baby of the Rh protein, the Rh antigen on the surface of the baby's blood cells.

When the baby's in utero, he's protected more or less from the consequences of this, but the mother is developing circulating antibodies to attack the baby's red blood cells. And once the baby is born, that baby's in trouble. The treatment at that time was pretty dramatic. It was an exchange transfusion. What you basically did was take out

the baby's blood from the baby and put in a type of blood that the mother's antibodies would not attack. And that was done through a series of procedures about every six or eight hours through several days. And when I said I was awoken for the exchange transfusion, it was the next time to do that procedure for baby Jones. So I awoke Leary and went to the bedside. I cannulated the bag and hung it up.

attached all to me and then turned the stopcock and began that procedure. It's really peculiar how vividly I remember the feeling of that blood. As I drew it into the syringe from Baby Jones, it started to be very sticky, like I couldn't really pull it easily. And I got more and more worried as I continued this procedure.

And then I got really worried because Baby Jones didn't look so good. Baby Jones was turning gray. His heart rate went through the ceiling. He was squirming. And I did not know what was going on. What Don didn't know was that the hospital's blood bank policy was to separate blood into two components, plasma and packed red cells. Before transfusing, those components were supposed to be recombined. Whole blood in two bags meant to be made whole again.

But only one bag had been used, only the packed cells, no plasma. The result? Blood that was 95% red cells, far too thick to circulate properly. The baby's heart couldn't pump it. We went into action, the resident on call. Mike stepped in, he managed to initiate and redo the change transfusion.

The baby obviously looked better, but went into renal failure and over the next several days was precarious with kidney damage, which then resolved and so far as I know the baby went home. At the moment though, all I knew was that a disaster was in my hands and I had caused it. I was killing a baby. Mike, who's also a personal friend, I remember came over to me, put his arm around me and he said, "Don, this could have happened to anybody.

Let's just move on. You know, I appreciated the consolation, but I didn't believe it for a minute. This couldn't happen to anyone. It could happen only to a stupid, inexperienced me. Too dumb, too blind, too careless to notice the bag of plasma. Mike consoled me, we resuscitated the baby, and I went to my on-call room and I cried. What happened next is all too easy to summarize.

Nothing happened. For the exchange transfusions procedures and the training of young residents, nothing was learned. Nothing was changed. I had trained in a hospital that did not centrifuge blood when it was donated. That's where I did my first exchange transfusions. And I went to a second hospital where the blood was routinely centrifuged. And today I could look at that as a hole in the Swiss cheese.

But nobody did then. I didn't. This is See You Now.

We're really at a turning point in healthcare about how we think about harm. There's a kind of celebration in just being able to talk about it. You can't have patient safety and the best outcomes if you don't have a safe workforce and a workforce that feels good about themselves and has a sense of well-being. A culture of fear, a culture of blame is poison for safety.

What we were looking at was what's the bundle to architect total system safety. With Patricia's ambitious vision, a lot of people came to that table, public sector, private sector, government, commercial. And I never thought they'd all be able to work together to produce a common plan. I doubted it from the start. I was dead wrong.

What we're talking about here is far more than sentimental notions. These are essential realities for a workforce to be able to perform their best and optimize care for patients. Every day in hospitals, clinics, nursing homes, and homes across the country, people turn to health care for help, for healing, for hope.

And every day, even with the very best of intentions, care doesn't always go as planned. Mistakes happen, alarms are missed, diagnoses are delayed, treatments go wrong. It's been over 25 years since the groundbreaking report to "Air is Human: Building a Safer Healthcare System" broke the silence surrounding medical error and revealed that preventable harm in healthcare was not rare, but tragically common.

The report made clear these errors weren't caused by bad people, but by good people working in broken systems. And yet, a generation later, preventable harm is still with us. And at the same time, violence against healthcare workers is on the rise. Despite decades of effort and innovation, our healthcare systems continue to fall short in terms of safety for patients, failing both patients and the people that care for them.

Nurses and clinicians bear the emotional toll of being blamed for failures that are out of their control. While the opportunity to learn from mistakes is too often lost, with record understaffing, burnout, mandatory overtime, and mounting documentation demands, the pressure to provide safe care has never been higher or the stakes more urgent.

But just as the report to Air is Human sparked a movement, a new chapter is now unfolding. One rooted in the belief that we can and must do better.

When it comes to violence against healthcare workers and nurses, the American Nurses Association calls on every employer, policymaker, and healthcare leader to ensure that nurses can work in environments free from incivility, bullying, and harm, emphasizing that the nursing profession will not tolerate violence of any kind through policy and legislative action, education, reporting protections, and advocacy for nurses who have been victimized by violence.

The ANA is working to shift not only policy, but the very culture of healthcare. That focus on culture and leadership is also at the heart of a bold and necessary shift toward total systems safety. In this episode, we meet two integral leaders working to build a comprehensive, coordinated approach to preventing harm and protecting both patients and the healthcare workforce.

charting a path forward that prioritizes leadership, culture, equity, workforce well-being, learning, and support at every level. Hi, I'm Patricia McGaffigan. I am Senior Advisor for Safety and President of the Certification Board for Professionals in Patient Safety at the Institute for Healthcare Improvement.

IHI is really at the epicenter of using the science of improvement to make health and healthcare better for everyone around the world. I am a nurse by background. I've worked in clinical practice, mostly in peds. I've taught

And then I took what I thought would be a one year detour into the medical device industry and stayed there for a couple of decades because I landed in transformative environments doing work to focus on making care safer. And when the National Patient Safety Foundation moved to Boston, I jumped at the chance to join them.

and did so as the Senior Vice President of Safety Programs. We ultimately merged with the Institute for Healthcare Improvement in 2017, and my work is highly centered on patient

and workforce safety and well-being. I have the privilege of co-chairing the National Steering Committee for Patient Safety. The NSC is the public-private partnership of well over 35 organizations that have created and are supporting the implementation of the Safer Together National Action Plan.

which helps organizations understand their current state when it comes to key foundational practices in safety and provides a blueprint for organizations to be able to make meaningful improvements that will transform and lead to more sustainable patient safety.

I'm Don Berwick. I'm a pediatrician by training. I was the founding chief executive officer of the Institute for Healthcare Improvement, IHI, which works all over the world. I left there after 19 years to go to Washington to work for President Obama to run the Medicare and Medicaid system and then returned to Boston. I actually ran for governor in Massachusetts for the Democratic nomination. I didn't win that, but I had a great time. And then I came back to IHI where I am a senior fellow.

I view my work as trying to get everyone in healthcare, especially leaders, but not just focused on quality, focused on the patient exactly in the center of our screen all the time. And there's lots of dimensions to that, but there's no better lead than safety. If you haven't got a safe environment for patients, then the rest of excellence is going to be very hard. So I have had the benefit of working with people like Patricia McGaffigan on trying to make the world of healthcare better.

I don't know a clinician who isn't intimately familiar with harm to patients and with their own human frailties. I mean, in normal life, we make mistakes all the time. Error is just part of who we are. We're not perfect. When you bring that into the clinical setting, things happen that aren't good for patients. And hopefully most of the time, actually, they get intercepted. But error is part of normal life.

It is not a sin. It's almost never, ever intentional. That's extremely rare.

And actually, we have pretty good evidence that clinicians blame themselves even when they aren't involved. So that's the human side of things going wrong. The other thing is that perfection and care of patients is not an individual sport. We take care of patients together, inevitably, specialists with each other, nurses and doctors together, technicians, infrastructure. And most of the time when something goes wrong with a patient, actually, it isn't an error of an individual. It's a breakdown in a complex series of things.

We call it the Swiss cheese model that a whole bunch of things go wrong. And psychologically, we tend to try to blame the last thing that happened, but that's just intellectually bankrupt. It isn't true. So we can live with error. We live with harm. Patients sort of know it. I think I don't think it's been a secret from them, but actually they're so forgiving and so respectful of their clinicians almost all the time that they don't speak up and say this. It doesn't seem right. Now we've learned that that has to change, that we need partnership with patients around that.

The human side is the side of feeling guilty when guilt is the least useful emotion. It's all about learning. And another useless emotion is blame. We seem addicted to finger pointing and incentives, you know, as if that would make a difference. It makes no difference. We need to design care so good people can do the job they want to do.

And some of the data has suggested that there's far too much preventable harm that is occurring. Yet we also know that when things go wrong, lots of times we're not reporting the true extent of some of the things that do go wrong. And we don't always have a measurable sense of the impact on that. But as we think about this notion of harm over time, I think what we're seeing is a much more

clear realization that harm is multidimensional, that it can be very longitudinal, and it can impact so many people. And it bears an incredible cost to society. Yeah, I mean, there have been attempts to develop metrics that say, well, how frequent is harm or how many patients die from errors? It's almost an empty question.

uh search because it depends on how you define harm how you define error and we tried to stabilize those my own opinion is we put far too much energy into coming up with a number and then debate the number instead of going back to the roots which is saying are we able to produce help every single time did this deed meet the need of the patient

or family or community that we intended to meet or did it miss it? And all of those are forms of, I guess I'd have to say, I'd have to say harm. Human error itself is very complicated, but, um,

My own view is that some of the, you would call them philosophical, the cultural side of this is do we sense what's happening around us? Are we able to help patients and families talk back to us to tell us what their experience really is? Did we help? Did we not help? That narrative exploration is, to me, every bit as important as trying to attach a number to this very, very crucial problem. We're really at a turning point in healthcare about how we think about harm.

Classically, what we've defined as harm has been stuff that we either get paid for or penalized for. It's stuff that is chartered in the reimbursement policies and other things. And those are things like urinary catheter infections and other very explicit types of harms. And I think those are super, super important and I'm not discounting them.

If we think about harm more broadly, and we think about not only the patient, but we think about the workforce, and we think about the family caregivers and others, we've got harms that are of a physical nature, harms that are of a psychosocial nature, a financial nature, and more. And what a lot of the public perceives and experiences as harm are incidences of disrespect.

And so what we're starting to see now are organizations that are really tracking and classifying reports of disrespect to patients and to the workforce. A lot of this learning has come from patients and family members and the partnership that we've had with them that has embraced what matters to them in their experiences of safety. Another key and complex area to consider in our conversation about what constitutes safety and harm is waste management.

Back in 2012, I wrote a paper with a colleague at the Rand Corporation on waste and healthcare. At that time, we worked with six categories of waste. One was safety problems, injuries to patients, but there were others like excess administrative costs and bureaucracy.

The waste of dropped balls, like a patient gets handed off between two clinical sites and continuity doesn't exist sufficiently. There's waste and fraud. When we added up all those numbers from the literature, our estimate in our RAND Corporation published paper was about 34% of all the costs could be attributed to those forms of absolutely not helping patients at all.

Now, is that safety? In my view, it's all safety. I sometimes provoke my friends from the safety world saying, I don't particularly distinguish between what people call quality and what people call safety. The definition of the term quality is meeting the need you intended to meet. If I do something that helps the way I wanted, that's quality. If I do something that doesn't help, that's poor quality, whether you call it an error or

waste. But we're up in that level. Many of our friends from industry, the petition I've worked with through the many years, would make the estimate a lot higher, 50%, 60%. I've even had a colleague at University of Chicago who observed healthcare and thought that 95% of what we do doesn't help

95% is staggering. But let's take a look at that 34% of healthcare spending that Don referenced. That 34% is the equivalent of about $910 billion a year. Fast forward to today, and according to a 2019 study published in JAMA, that number hasn't changed much. Eliminating waste is essential and goes hand in hand with ensuring safety, and not just in healthcare.

One of the co-founders of the Luce Leap Institute was the late Paul O'Neill, who was president of Alcoa and secretary of the treasury. I think Patricia will agree with me. He was one of the beacons in this field. And he made Alcoa, which is a very risky environment. You're producing metals at high temperatures, for example. It became one of the safest manufacturing companies in the entire world. And he knew it because he measured injuries to workers.

And Paul used to say that he would stay in the room as executive for discussions of safety, but when finance came up, he would leave. It was his metaphor for saying, if we have quality, right, if we are doing everything the way we intended, the money will take care of itself. Paul became our teacher. I remember he simply had the firm view that you could not establish excellence in any organization without the workforce feeling absolutely safe.

We visited the Alcoa headquarters in Pittsburgh and I remember walking in, O'Neill's desk was out in the middle. I mean, he did not have a sequestered executive office. He was right with people. And on his desk was a monitor, which was his regular reporting from every Alcoa site about worker injuries.

He personally took responsibility for monitoring it, and if something happened, he expected an explanation, prevention, and resolution. And if you didn't do that, you couldn't work there. He had this theory that it was a precondition to excellence that the workforce feels safe. Now, that's in rolling aluminum sheets. Now, imagine that it's a nurse or a physician

Maureen Bisigliano, my successor's IHI CEO, taught me the phrase, "You cannot give what you do not have." So if we don't have a workforce that feels secure and cared for and safe, how can they possibly produce that experience for the people they care for?

You cannot have excellence of any form or safety or focus on patients from a workforce that feels vulnerable, unsafe, psychologically or physically at risk. It won't happen. I don't think it's just violence. It has become a focus of a workforce safety issue of these issues of violence

in care patients who for one reason or another lash out at the healthcare workforce. Let's not be reductionist about it. That does happen and it needs to be prevented and the workforce needs support as does the patient. But injuries to the workforce, psychological injuries, stress, are not rare at all.

So we pay a serious price if we don't attend to the overall vitality of the workforce at the same time, but they're focusing on the needs that they're trying to meet. They come arm in arm. And we have a highly resilient workforce. We know that from videotapes of operations. It was brilliant research done at Green Ormond Street Hospital on cardiac surgery in children where they videotaped the number of times a safety condition existed.

was a high multiple of the times that any kid got hurt. That's because the resilience of the staff, they're there saying, wait a minute, hold on, that's not right. And I think we way underestimate the heroism

of the healthcare workforce who are always on guard trying to stop these broken systems from actually causing harm. There's a lot of innovation. There's a lot of day-to-day adjustment that our colleagues working in healthcare are doing. So when we think about what constitutes safety or harm, it's also thinking about how we think about the workforce.

Yes, we want to minimize variation, particularly clinical variation where we know it's evidence-based, yet the adaptability of the workforce to be able to engineer in a moment, as John described, something that leads to better, safer care is exquisite. And that's what we want to really be able to harness. We need cultures that do that. I remember a number of years ago, I was on duty at night and I put a cast on a kid and

The next day, I got a call early in the morning from the physician's assistant. He said, I know you saw this kid last night. You did it wrong. That's not how you put on that cast. It could cause the following kind of problem. I was so grateful that that young guy spoke up and told me. And we need a culture that rewards that instead of that shuts that down. Secrecy and safety cannot coexist. There has to be an environment in which you can talk about it.

Boards of Trustees own safety. When a patient dies, needlessly, in your hospital, you did it. You did it. You own it. And workforce vitality is the board's job. And we can't mince our words about that. And it's not about accountability or metrics or rewards or punishments or incentives. It's about the board's leadership in creating a culture in which respect and dignity and psychological safety infuses the entire organization.

I couldn't agree more. The board owns it. The buck stops with the board ultimately and or beyond the healthcare systems, the most senior leadership ownership body of the small practice or whatever, the buck stops there.

Patricia and I and our colleagues in healthcare have learned a ton by looking outside the industry. Crew resource management, this is a very well-developed part, for example, of aviation safety. It was learned early on in the investigation of airplane crashes that the most common cause of a crash was miscommunication or poor communication, where somebody knew something that could have avoided the disaster, but that knowledge was not used. So the crew resource, the knowledge that

States sequestered. Why? Because of hierarchies, because of failure of attention to rules. So aviation made a major step forward when they developed this whole field of crew resource management or cockpit resource management, where everyone is taught how to mobilize the knowledge of the people, whether they're high status or not. We still have miles to go in healthcare, but you got to have that foundation of shared experience.

The anger, the guilt, the shame, the secrecy, they come from a sense of helplessness. I get trapped in a situation in which I feel terrible or something really went wrong and the world is going to make me defensive, blame me. The way out of that is learning. The way out of that is saying, wait a minute, wait a minute. There is a different way here. I can get involved. I can become an agent of change. And it's not going to happen through blame. Blame is...

It's just useless. Competence is not. And I think what Patricia does with her brilliant work is help us learn. So it's awareness and then method. What we're talking about here is far more than sentimental notions. These are essential realities for a workforce to be able to perform their best and optimize care for patients.

So how do we move from theory to practice? From isolated improvements to lasting change? How do we take what's working in one hospital or one unit and make it work everywhere? It's not just about setting goals. It's about creating the structures, supports, and shared language to get there. Building safety into every level of the system. So now the National Action Plan emerges. My skepticism was with Patricia's ambitious vision

A lot of people came to that table, public sector, private sector, you know, government, commercial. And I never thought they'd all be able to work together to produce a common plan. I doubted it from the start. I was dead wrong.

It was a rather ambitious vision. I'm going to give a lot of credit to Don and the members of the IHI Board of Directors who got behind this idea, this bold vision that we would be able to collaborate with parties that had never collaborated before to develop a national action plan. And we brought together 27 diverse parties.

from federal agencies, major national associations, creditors, and very importantly, patient and family partners among them to be able to step up to the plate. The board charted us with the creation of the first public-private national action plan in this country. And we didn't jump into what we were going to do right away. We had to spend that front-end time

defining the guiding principles for how we would work. We were coming together to not compete on safety. We checked our respective hats at the door and said, what is it that we as healthcare leaders across this country can and should be doing to improve

realize and transform safety. We were going to ensure that we had an equity lens, that we were recognizing that inequities were harms, and that would also be threaded deeply through our work. We also agreed that we've spent so much time talking about what we call the whack-a-mole challenges that keep popping up, setbacks, for example, in ventilator-associated pneumonia or CAUTIs or other things. Those are some of the

challenges that have well-established evidence-based bundles. But what we were looking at was what's the bundle to architect total system safety, to create the conditions under which safety can be realized. In healthcare, we keep building a lot of rooms onto the house of healthcare, but what we were trying to do was understand what we needed to fortify the foundation.

Let's take a step back to appreciate the significance of this mission. To come together, public and private partners, patients and clinicians, nurses, community, healthcare and industry leaders to, as Patricia says, not compete on safety. To put a fine point on that, we can look at the difference between the airline and the automotive industries.

Car commercials often compete by claiming one model is safer than the other. That's competing on safety. In contrast, the airline industry prioritizes safety across the entire system, focusing on making the whole industry safer rather than comparing individual planes. This is the approach needed to build that architecture of safety, that total systems safety into healthcare.

creating the conditions where safety can truly be realized throughout. So what are the building blocks for this foundation? And what is that plan?

Safer Together, a national action plan to advance patient safety, is a package that is designed for any healthcare organization across the continuum of care. The package includes evidence-based recommendations across four foundational areas, culture, leadership, and governance, workforce safety and well-being, the learning system, and patient and family engagement,

Another component of the Safer Together National Action Plan is an organizational assessment tool that helps organizations convene assessment teams to assess the current state of their organization across those four foundational areas and to identify the opportunities for improvement and opportunities to also reinforce the areas where they're performing well.

This is a tool that's intended for healthcare leaders to use to help guide

and align with their safety strategies to be able to emphasize more focus on improving those foundational areas. The National Action Plan Package has a third component to it, which is the Implementation Resource Guide, which provides an array of resources across those four foundational areas that organizations can tap into to augment and to support their improvement priorities.

Assessment tools, supports and resources under four foundational areas that all hinge on leadership. There are some foundational reasons why this is one of the foundational areas of the National Action Plan. And quite frankly, even though all four areas are interdependent, without this area, the other three areas do not get realized.

It has to be the purpose of the organization. Unless we have habitual excellence and constancy of purpose and safety, we do not have the basic ingredient for it to be realized. The second area was making sure that we're able to assess the capabilities of the organization and commit the right resources to safety. And those capabilities are often thought of, I think, traditionally as, let's make sure the people at the

what we call the sharp end of care, are doing the perfect job every day. But we know that because safety is a system property, that the leaders who are running the system have this utmost obligation to intentionally engineer safety into the daily work of the organization and make sure that the resources are there for it to be a part of the daily work and not just thrown at it if something goes wrong.

after a crisis has occurred. Widely sharing information about safety was another one of the four key recommendations to promote transparency. And we saw this with Paul O'Neill with Workforce Safety, having that real-time dashboard of what's happening in my organization and being able to be very transparent about

exploring where the system breakdowns might have been that led to those realities and also being very transparent about engaging those who have the best expertise possible to help design solutions to ideally prevent that from happening in the future.

And then making sure that we've got competency-based governance and leadership. And we've got a lot of folks who have historically been sitting in boardrooms and on leadership teams that haven't had the foundational education around what safety is and have not necessarily had some of the reinforcements of accountability.

accountability in their job description and how they're evaluated. And those are some of the threads that ultimately take us through to the National Action Plan Assessment Guide. Before we move on to the next pillar, let's briefly consider what that assessment looks like.

In the National Action Plan, what we're doing ideally is having senior sponsors for all of the goals because that's what kind of keeps this work in check and measurement and monitoring strategies that enable us to be able to adapt in real time. Conducting PDSAs, Plan, Do, Study Acts, they're small tests of change that enable us to understand if the changes that we're making are going to result in improvement.

In the model for improvement, the key questions are, what am I trying to accomplish? By a year from now, when I conduct my survey of patient safety culture, I would like to see that my workforce is feeling more comfortable reporting

safety events by X percent. That is a key indicator of the psychological safety that's present in the workforce. It's also a really important indicator of whether and how the workforce is actually responding to feedback and reports from the organization. A lot of folks will drop out of that whole reporting cycle and lose momentum and lose trust in the organization if when they report

They don't have closure on what they're reporting and they don't see any changes. The next pillar they focus on in the National Action Plan is workforce safety and well-being. Do health care workers feel valued and cared for? Do they have the resources they need to do their jobs? The staff, the support? Do they feel psychologically and physically safe?

You can't have patient safety and the best outcomes if you don't have a safe workforce and a workforce that feels good about themselves and has a sense of well-being. It really goes back to that first pillar, the leadership and governance pillar and the understanding there. A culture of fear, a culture of blame is poison for safety. It's toxic to safety.

And that's not like a high-minded moral position about being a nice person. That's the science. So if you're an executive and you really want safer care and safer workplaces, you have to do away with fear. Do away with blame. It's so much easier...

to do the opposite. Point your finger and say you messed up and don't do that again. A, you're not understanding the nature of safety as a system property. B, you are definitely assuring that you will never speak up again when something's wrong, which means you will lose the information on the basis of which you obey things better. And so instead of harnessing the wisdom of a workforce, you have simply squandered it. And frankly, we see that all the time.

You'd think by now, nearly 30 years into the healthcare safety movement, it would have dawned on the entire executive and governance structure that blame and fear are not pathways to excellence. They're simply lazy shortcuts to the real job of re-engineering systems so the good people we have can be guaranteed that they can get their work done well. I wish we could make that happen. The National Action Plan is a very clear articulation of that.

And now I guess it falls to executive suites as to whether you actually take this seriously. We do hear people that say, I feel comfortable speaking up. We've seen organizations that have worked on this move the needle on their surveys of patient safety culture scores in this domain.

And it is possible. And that's where the whole wheel keeps flying back to what happens with leaders who are setting the tone, who are setting the expectations and holding people accountable and recognizing and rewarding speaking up. It doesn't mean that every pebble or boulder in people's shoes is necessarily addressable.

But being able to acknowledge and recognize that feedback and to bring the workforce into the co-creation of solutions can go a long way. I don't know who the leadership teacher is who said this, but I've heard it many times that the currency of leadership is attention. It's what you pay attention to. That's why Paul O'Neill had leadership.

an injury report on his desk in the morning on his monitor every day and everybody knew it. The currency of leadership is attention. Well, think about what it's like to lead a hospital today. Everyone shows up and says, my issue is the most important issue. Equity is the most important issue or the balance sheet is the most important issue or

or carbon emissions are. Everyone wants the attention of the leader. And everyone's right. They're all important things. And we have, as a safety community, I think we have a job to have a respectful way to deal with that. How do we help our leaders move safety where it needs to be, at the center of attention, without being insensitive to the complexity of the jobs they have? And that's a really interesting enterprise. And I think it's time to take that really seriously.

The third pillar is learning systems. And at first, that might sound like a teaching strategy, like a new way to train staff or run a classroom, but that's not it. It's actually about something much bigger. It's about building a culture where the system learns from mistakes, near misses, and even from the things that go right.

It means creating space where nurses, doctors, aides, administrators, and even patients and families have space, opportunity, and time, and are asked to speak up about what they see, what they know, and what they've lived through. A lot of how we're operating falls under this notion of safety one, where we're reacting to things after they go wrong. And very commonly in the process of doing that, there's a lot of finger pointing at what the humans did wrong.

And that is creating this vicious cycle of a sense of blame and human failure. And there's a lot of energy around constraining humans in that process. It's like, okay, if Patricia made a mistake, then Patricia is going to go right back to reeducation and she's going to be told to reread the policy and that's going to constrain Patricia to do the things that are necessary for safety.

under the safety to notion, what we're really looking at is learning from what goes well. And we're also really studying how the humans that are in healthcare are really adapting to and have the ability to respond in real time to ensure that things do go well. So it's a very different perspective. And that's an example of

Something that's not built into the everyday knowledge of leaders in healthcare. Very often if we try to address strategic and operational variation, along with clinical variation where it's appropriate, then we've got that systems perspective with alignment and the ability for people to do their job better. The fourth pillar of the updated National Action Plan is patient and family caregiver engagement.

It's built on a simple but powerful idea that patients and families aren't just recipients of care, they're partners in safety. And more often than not, the person they're partnering with is a nurse. Nurses are the ones building trust, translating medical jargon, noticing what others might miss. Their communication and assessment skills are what make this kind of connection possible. Allow the system to listen from the outside in.

But here's the thing. Those relationships happen when empathy is valued, when listening is rewarded, and when this kind of engagement is not just allowed, but celebrated.

One of the ways that we celebrate this is that IHI has a DAISY award for extraordinary nurses in the patient and workforce safety realm. We are now in our 11th year of that award, and nurses, both as individuals and teams, have really done some remarkable things in the terms of safety. A healthcare system in the Boston area was experiencing some infusion pump alarms in the ICU.

Turns out it led to a class one FDA recall nationally of the infusion pumps. But it was because the team and the system worked together, not only with nurses, but with the biomedical engineers and others, the safety and the risk colleagues, to be able to deeply understand what was happening and what the risks were. And they took action to make sure that it was elevated outside of their organization. And that was one of our

more remarkable team contributions to safety.

Doesn't have to be big awards, though, that necessarily are important. And Paul O'Neill said there are three things that he wants every employee every day to be able to affirmatively answer to. One is, am I respected every day in every interaction that I have with every individual? Do I have the resources that I need to be able to do my job and do it well? And M, I recognize that third R of the

three R components in a way that is meaningful to me and helps me realize that I'm contributing value to the work of the organization.

There's a kind of celebration in just being able to talk about it. One of the turning points for me and my understanding of this was many years ago, we were working on infections in intensive care units, ventilator infections from people who got on respirators and infections from central venous lines. By then, we knew what to do about it. There was great science and we knew how to prevent central line infections, CLABSIs.

And one of the things that happened was there was a hospital that we were working with that had successfully eliminated them. There was a whole year in which there was not a single person in that ICU got a central line infection because they were religiously following the science-based program. And they were so, I mean, my goodness, they were so proud of themselves. And we touted them. And then I heard that they had an infection. And so I called the

the executive in the intensive care unit just to say, "Well, I'm sorry to hear about that. What happened? What did you do?" And he said, "Well, first, we gathered and sat around and we cried." You understand how valuable that is, how important that is, that it's open, we know what happened, we know we have the goal, we know we're human, we're not going to give up, but we care so deeply. What kind of building of the culture that Patricia is talking about must that affect?

The other thing is, it's what to celebrate. Yes, the search for goals is key like that, you know, no central line infections. But there really are two levels of celebration. One is that we set this goal and we achieved it. But remember the cultural change, the idea we are now a different place to be able to recognize and celebrate that. And that leads to the voice of patients.

There is very, very strong and I must say extremely welcome leadership now coming from the patient community, patients, families, carers, communities who have experienced injuries or have learned about it. And they are unbelievably important in this movement. Their energy, their soul, their impatience.

Their honesty is one of the most important changes in this whole field, I think, over the past couple of decades. And they can help us. They can help us by saying thank you, by saying attaboy, keep going. They can help us by saying you are wrong and let me show you how.

and we can celebrate that redirection. Yeah, and Don, I'm so glad you brought that up. It actually happens to be on average the lowest scoring of the four foundational areas. And what Don just described is not a nice to have, it's an essential ingredient for us to be able to engineer safety into the systems and to do it right. Because doing it technically right

is one thing, but doing it right so it services the unique needs of patients and family members, to me, is where the success lies.

We often talk about workflow and let's fix things so there's good workflow for all of us working in healthcare and I'm all for good workflow, but I care about care flow. I care about the outside in perspective of what a patient and family member is experiencing in their encounters in the healthcare systems and whether we deeply understand that and how we're co-producing safety so that

It meets the needs of those who are working in safety, but more importantly, unequivocally addresses what the needs of our patients and family members are. Nurse Patricia McGaffigan is Senior Advisor for Patient and Workforce Safety and President of the Certification Board for Professionals in Patient Safety at the Institute for Healthcare Improvement.

and she is senior sponsor for the National Steering Committee for Patient Safety. Dr. Dawn Berwick is president emeritus of IHI and former administrator of CMS,

He's one of the world's leading voices in healthcare equity and safety. He helped lead the creation of the Safer Together National Action Plan and continues to shape the future of safer, more compassionate care. Music for See You Now is composed by Sam Lippman. And special thanks to Shauna Butler for her vision and leadership on this episode. One of the biggest challenges we face when it comes to safety and healthcare is not knowledge or will,

it is in the effort to shift the paradigm. Look, we as a community have every reason to be concerned about the slow pace of safety improvement in the quarter century since "To Err is Human." But I think the story has changed. I think that we should be concerned, but not despair. There has been progress. By the way, we have the honest hope

that a new era of artificial intelligence and other technologies can bring new guardrails to our work. So the question I'm fretting about is this: I think back to that horrible night in the neonatal intensive care unit and my near miss in the NICU should have been known and studied by some patient safety authority in a high office.

Hopefully I would be asked for more information on the basis of which change in procedures could be designed. I wouldn't be blamed. I'd be recruited to help redesign a system with holes in that Swiss cheese, but I'm not naive about that. In some hospitals, I suspect today many hospitals, I would be blamed and reprimanded by others, not just guilty myself.

In a few, I might be prosecuted by an aggressive district attorney, or I might be counseled by the hospital's lawyers to shut up, remain silent. Faced with this dreadful error in the patient's care, will today's junior pediatric resident who almost kills a baby in the middle of the night have options that I did not have for safe and proper reporting?

options that I did not have or use. Will the hospital say, "Shh," or will it say, "Bring us everything you know so that we all can use your knowledge to help us improve?" Indeed, the illusion that safety is a matter of individual effort is one of the most toxic notions in the whole safety enterprise. It is we, not me, that makes the pursuit of safety a challenging sociologic endeavor.

And it also makes safety highly dependent on leaders who will understand that it is they who set in place the culture on which safety will either thrive or wither. As Don said, for a long time it seemed impossible getting dozens of major institutions to come together around a shared plan for safety.

But 27 organizations did come to the table. And with the leadership of Patricia McGaffigan, they listened, they collaborated, and together, they built something that can shape real change. The Safer Together National Action Plan is not just a document. It's a set of tools, recommendations, and resources built by people who understand that safety isn't competitive, it's collective.

And that's where the hope is, not in the idea that change is easy, but in the proof that it's possible when we choose to do it together. For CU Now, I'm Rebecca McEnroy. Thanks for listening. Nurses are transforming healthcare through innovation, compassion, and leadership. And Johnson & Johnson is proud to continue its 125-year commitment to champion nurses through recognition, skill building, leadership development, and more.

The American Nurses Association is dedicated to building a culture of innovation. Nurses improve the lives of patients and communities through innovative thinking, empathetic connection, scientific rigor, and sheer determination. ANA is proud to support and advocate for our nation's most valuable healthcare resource, our nurses.

For more information on See You Now, visit seeyounowpodcast.com and listen to any of the earlier episodes in our library, wherever you get podcasts.