- Email: [email protected]
An Interview with Paul O’Neill
The Joint Commission Journal on Quality and Patient Safety Interview
An Interview with Paul O’Neill Interviewed by Meghan Pillow, RN, CCRN Paul H. O’Neill is a founder and Non-executive Chairman of Value Capture, LLC, Pittsburgh. Mr. O’Neill served as the deputy director of the US Office of Management and Budget from 1974 to 1977, where he served on staff beginning in 1967. He worked as a computer systems analyst with the US Veterans Administration from 1961 to 1966. Mr. O’Neill was the 72nd Secretary of the US Treasury, serving from 2001 to 2002, and chairman and CEO of Alcoa from 1987 to 1999. During his government service, Mr. O’Neill helped to shape many of the policies which define the American health care system today. Please address correspondence to Mr. O’Neill’s assistant, Janice Celedonia, at [email protected].
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hat led to your interest in quality and safety in health care? I have been involved in health care in a lot of different ways since 1961, so this is by no means a recent interest. In 1961, after graduate school, I was recruited as a management intern at the Veterans Administration (VA) because my background was in economics and operations research. The VA had 212 hospitals at that time, and that was my first encounter with health care. Then, I became a cochair of the Pittsburgh Regional Health Initiative in 1998, a regional collaborative of medical, business, and civic leaders that was organized to address improvement in health care quality and safety.1 What has motivated me all along is my belief in the potential for improvement of health care, the single largest economic sector in the United States. We are spending 2.8 trillion dollars a year and could realize a vast improvement in patient outcomes and still save a trillion dollars a year. I think of all the things we could do with a trillion dollars. I have also continued to contribute to worker safety on the basis of a set of ideas about what makes an organization habitually excellent. There are not many organizations that are habitually excellent. If any industry claims that it is habitually excellent, then there must be zero injuries for the people who do the work. I don’t think you can be habitually excellent at everything unless you begin with caring about your workers. According to the Occupational Safety and Health Administration data on recordable incidents, health care is the most dangerous industry in the United States.2 It’s unbelievable how awful and how numerous worker injuries are in health care— and I don’t consider this to be a separate subject. If you don’t have a process to learn from every single thing gone wrong in real time to ensure that people don’t get hurt, then I don’t think you’re habitually excellent in anything you do on a regular 428
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basis—whether it is transplants or knee replacements. If your workers are hurt at rates that are unconscionable, you’re not excellent. Being a leader of a safety culture takes courage. What gave you the courage to make worker safety the top goal of Alcoa in 1987? I don’t believe it takes courage to do the right thing. In more than 50 years I’ve observed many organizations say that their workers were their most important asset when there was no evidence that this was really true. When I went to Alcoa, I decided that I was going to make the workers the most important asset of the organization by creating an environment where people are never hurt at work. Why would you organize in such a way that people can be hurt? Workplace safety should be a precondition, which means it’s like breathing. Safety should never be a priority because the connotation of priority is to change. Alcoa is an organization where people not getting hurt is the first requirement every day for every person in its worldwide operations. Now, if I could wave a magic wand, I would have every health care organization adopt the idea of a worker injury–free workplace as a precondition. That would lead to great changes in health care. I have stated these ideas in speeches to tens of thousands of health care professionals, and they still haven’t gotten worker safety on their dashboard. People say they care about patient safety, but by evidence it’s simply not true. Did you face any resistance at Alcoa for making worker safety a precondition from board members, managers, or frontline employees? The board was great, and they hired me knowing that I beVolume 40 Number 9
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The Joint Commission Journal on Quality and Patient Safety lieved in being part of a values-based organization. So they weren’t surprised when I declared on my first day at Alcoa that it was to be an injury-free workplace. There were many managers and frontline employees who believed that accidents were inevitable or that it would cost too much money to be injury free. Leaders need to articulate nonarguable goals. There may be disbelief that you can achieve an injury-free workplace, but it’s hard to find anyone who will say that it isn’t a good goal. Then, leaders need to take away all the excuses of why we can’t do something. One excuse was that we couldn’t afford to get to zero worker injuries. So I said, “We are not going to budget for safety ever again.” We spent whatever money was necessary to achieve an injury-free workplace. If anyone in the organization—from the lowest level to the highest level—identifies a risk, we will fix it within 24 hours. And we held this standard to all of Alcoa’s operations throughout the world—at 340 locations in 43 countries. If an injury still occurred, it was a requirement to post the name of the person injured (to keep it personal so that it was not about numbers), the nature of the injury, the analysis of the contributing causes to the injury, and an indication of changes that were made to equipment, process, or training to ensure that it never happened again. This information was distributed to every employee in real time via a real-time safety-reporting system, which we called the Real-Time Safety Data System. So if we had an injury in Russia, the people in Davenport, Iowa, could learn from it and be able to prevent a similar occurrence. Most people used the Real-Time Safety Data System as a screensaver on their computer. A leader needs to be a steward of resources. When everyone battles with tight budgets, how did you make sure there was always enough money for safety? I told all the leaders this is what we are going to do. We never had trouble finding the money for these safety expenses. Most of it is not about spending a lot of money. First of all, I had to get all employees to understand that they are important and that we couldn’t achieve an injury-free workplace unless they all accepted responsibility for their own behavior. You can’t do this by order, edict, financial incentives, or anything else. You can only do it by persuading people that they really do matter to you and that the only important measure is that people don’t get hurt. People need to be trained and fanatical about doing things that we know are consistent with avoiding injury. It’s not optional to wear a hard hat in factories with overhead cranes and dangerous things falling from above—it’s a condition of employment. Once you’ve been trained in the right thing to do, you have to do it. Even if it’s 120 degrees outside, it’s not September 2014
okay to take your hard hat off. It’s not okay for visitors to come into a plant and ignore the rules for steel-toed safety shoes, hard hats, and hearing protection. Once you let anyone—even the president of the United States—come in the facility and not observe the safety requirements, then the safety requirements don’t exist. The rules are the rules, and no one is excepted from them. How did you empower your employees to feel safe enough to report potentially injurious conditions? It’s first by saying so, and then it is by using events and observations about experiences. Three weeks after I was at Alcoa, I traveled to an Alcoa plant in Tennessee outside of Knoxville that had three to four thousand employees. I spent the morning walking through the plant and talking to the people and asking about their families. I had a luncheon with many people from the union ranks and supervisors. They asked if I wanted to talk, so I got up and said, “In all the organizations I’ve worked in, there’s a tom-tom network—it works better than the Internet. People know things right away if your tom-tom system is working. So I assume you know already that I believe we should be an injury-free workplace, but I want you to know that I really mean it. I told the supervisors we are not going to budget for safety. If anyone identifies anything that needs to be fixed for safety, I want you to fix it. Here’s my home phone number. If your managers don’t do what I just said, you call me up any time of the night or day and let me know.” Three weeks later, I got a phone call from Tony at Alcoa in Tennessee. He said, “You said all this hot stuff about worker safety, and I’m calling to tell you that for the last three days that hasn’t been true. I’ve been working with a 20-foot broken section of the conveyor system that takes a 600-pound ingot across the plant to the rolling machine. So we have been lifting the ingot from where the system is working across the broken part to the next working part, and we’re really worried we’re going to drop this and hurt our feet or our backs.” I called the plant manager at home and woke him up, saying that I just heard this report and that I wanted him to get that conveyor system fixed and to then call me. At about 4 a.m., my phone rang and the manager said, “I’m really sorry they bothered you. We fixed the conveyor and it will never happen again.” I said, “It needs to never happen again. I don’t ever want to get another phone call like this. What I said to you, I meant.” People all over Alcoa learned about that story, so I didn’t have to go to every plant and do the same thing. The organization began to understand that I really meant what I said.
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The Joint Commission Journal on Quality and Patient Safety Every year in the 13 years that I was at Alcoa, our lost-workday (days away) rate was lower than it had been the previous year. When I left, in December 2000, the lost workday rate was about 0.20, while the national rate was still around 5. Today, the lost-workday rate, which is posted daily, is 0.095.3 After I left, Alcoa didn’t stop caring about worker safety. When your board, managers, and frontline staff bought into the worker safety goal and mastered it, did this mastery spill over to other parts of the business? There is a spillover effect. Once you get the rhythm of understanding how to learn from everything gone wrong and do it in real time and engage every employee in the process of the pursuit of excellence, it affects everything you do. From 1987 to 2000, we became the preeminent aluminum company in the world. We went from earning revenue of $4.5 billion in 1987 to $28 billion in 2000. And the value of our company improved by 900%. So being excellent in everything you do is consistent with economic excellence as well. How does your work with worker safety at Alcoa translate to health care? All these ideas are perfectly applicable to health care, but it’s a direct function of real leadership and engaging every employee in a quest to be better tomorrow than we are today. If you don’t have a dedication to making your processes better every day, it doesn’t get better. People need to understand that transparency and ownership are critical to habitual excellence. You can’t find an infection and give the report to the Infection Control Committee that meets three weeks later and expect the hospital to ever do anything that systematically eliminates infections. Early on, we created Alcoa University to teach employees concepts of continuous learning and improvement. Through the Pittsburgh Regional Health Initiative, I made it available to the people in the community. For example, Richard Shannon, MD,* and physicians, nurses, and infection control practitioners at Allegheny General Hospital, received five days of intensive training in the improvement system called Perfecting Patient Care and then applied those principles in clinical practice. Rick was responsible for three ICUs at Allegheny General Hospital in Pittsburgh. We used the ideas from Alcoa to eliminate central line–associated bloodstream infections (CLABSIs), * Richard P. Shannon, MD, was the Frank Wister Thomas Professor of Medicine at the University of Pennsylvania Perelman School of Medicine and chairman of the Department of Medicine of the University of Pennsylvania Health System before his appointment in August 2013 as the executive vice president for health affairs at the University of Virginia, Charlottesville.
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From July 2002 through June 2003, of the 1,787 patients flowing through the three ICUs, 1,067 patients had central lines, and 37 of those patients got an infection, 19 of whom died. And that was better than the national average. Rick articulated the goal of zero CLABSIs, and he got everyone to work together to figure out what caused them. Through investigation, we found that we didn’t have a protocol or a system for preventing the infections. Everyone knew you were supposed to wear a gown, gloves, and mask and prep the site for insertion, but they all did it different ways and they all thought they had the right way. There was so much variability in the process that you couldn’t figure out what was going on. First, we got the ICUs sterilized kits prepared so that you had what you needed and you didn’t have to chase around for things; everything needed was provided in the right size, with the gloves on top, for the surgeon, nurse, and every other care provider. Then they fixed the practice problem by reducing the variability of the procedure for inserting central lines. Finally, they gave everyone a pager so as soon as anyone detected what they thought was going to turn into a CLABSI, they came to talk to one another about where there was a break in the protocol and how it happened. New processes were implemented within 90 days. Within a year, the number of CLABSIs decreased from 49 to 6, despite an increase in the use of central lines. These results were sustained during a 34-month period. After a year to 18 months’ worth of improving and correcting the process, 1,830 patients had come through the ICUs, with only one infection—and no one died.4 So does it work? Yes. Have these practices been adopted at every health care organization? Unfortunately not. We have two million hospital infections every year, and every one of them is unnecessary. Do you think these patient safety projects can help construct a successful safety culture? Projects can be successful, but the results of projects can wither away over time unless an organization—from top to bottom and from side to side—is committed to the ideas of habitual excellence. If you do a project and show great results, but if everything around you is the same old stuff, your results will eventually regress to the mean. You need to have a commitment to inclusive organizational excellence. We have to create a culture where everyone is treated with the same level of dignity and respect without regard to their education, pay rank, title, degrees, race, gender, or ethnicity. The people who clean the rooms are given the same level of dignity and respect as the highly acclaimed neurosurgeon. Volume 40 Number 9
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The Joint Commission Journal on Quality and Patient Safety In health care, we still struggle to report our errors for various reasons. You once fired a top executive at Alcoa for not reporting a safety incident. Do you have any recommendations for increasing error reporting in health care? It wasn’t hard for me to fire that executive. It was an openand-shut case. Once it was clear that he had chosen not to report that people had been exposed to carbon monoxide poisoning, and he didn’t report it, I knew he had to be fired. And this was a guy who took a business and raised its revenue in 10 years and ran an organization with 30,000 people that was one of the safest parts of the organization, but he violated our value system because he didn’t report the error and did not let other people learn from the error. Once the rules are clear and known and retained by employees, they are not optional. You have to assure people that reporting things gone wrong is not dangerous to their career and that they won’t be blamed for reporting things gone wrong. If you have a retribution culture, managers might cut back on someone’s hours because they submitted an error and kept working to try to fix it. Unless people are appreciated and honored for identifying things to make the workplace better, they won’t do it. People on the floor know what’s true—all the fancy signs in the hallways make no difference at all—they know the reality of the work place. If you call out something that is wrong and you get penalized for it in whatever way, you aren’t going to do it again. Leaders need to establish a culture where people are honored for helping us get better. For example, people shouldn’t be asked to do things that put themselves at risk, like trying to move a 300-pound patient without a mechanical lift. Health care is perhaps the most disrespectful occupation in the United States. Until that problem is fixed, it’s difficult to get employees to believe that it is okay to identify things gone wrong. If you report it and nothing happens, why do it? People are not stupid. If they are not safe physically and psychologically, it’s not possible to be part of a culture of habitual excellence. As you are probably aware, The Joint Commission requires health care organizations to conduct root cause analyses whenever serious safety events—“sentinel events”—occur.* At Alcoa, you often pushed people to find the root causes of problems. To make sure you have a permanent fix for a problem, you need to identify the real root cause. A lot of times it’s not so obvious. Asking why five times is a really good idea. Let’s say you have an employee injury, and you want to know why it * The Joint Commission. Sentinel Event Policy and Procedures (Updated: Jun 10, 2013.) Accessed Jul 31, 2014. http://www.jointcommission.org/Sentinel_Event _Policy_and_Procedures/.
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happened. The automatic first response is that Sally was not following the established protocol. If that is where the questioning stops, then you won’t ever fix the problem. Why wasn’t Sally paying attention or why wasn’t she following the standard procedure? And there are a whole bunch of questions that branch off from that question—for example, perhaps she was distracted because someone was talking to her when she was doing a procedure that required complete concentration. At least 1.5 million preventable adverse drug reactions—injuries caused by errors—occur every year in the United States.5 I was at a children’s hospital a few weeks ago. I arrived early for the morning conference with 15 people in the room and others on the phone going around giving reports for the last 24 hours. The third report was from a nurse who said that they had a four-year-old patient who had the wrong intravenous medication concentration, and they started infusing 2.5 mL before they realized it was a mistake. And they had smart pumps for this child. It was a problem with the decimal point, and that has been around forever. If health care didn’t have medication doses that were based in one-tenths, people wouldn’t get so confused. With the cases of wrong doses of heparin given to neonates, you can go to a medical facility within 10 miles of where you are and find that the adult doses and child doses of heparin are still stored next to each other, and it’s difficult to tell one from the other. We were able to get really good with safety at Alcoa because once we identified a root cause, we shared it with the rest of the organization. And it was not optional whether we adopted the practice. Why can’t we do this with heparin? It is a direct function of the lack of leadership. A lot of people are leaders by designation, but they are not leaders in my terms. They are presiders. I can’t tell you how many places I’ve been where the supposed leaders never go out on the floor and talk to the people who are doing the work and ask what is aggravating you today. In a good industrial factory where they have a shift change, they have a 10-to-15-minute meeting of people who work in the same area. They address anything new in our workplace today that could represent a risk, any change in equipment position that we need to be aware of, and so on. Then, they ask: “Does anyone have a personal problem that is nagging at you that could cause you to lose concentration? If you are worried about something at home, maybe we need to give you a half day off.” Do you know anyone who asks people, as a regular matter, if you are all okay? Health care providers are so busy trading information about patients’ conditions that the providers themselves become an afterthought or no thought at all.
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The Joint Commission Journal on Quality and Patient Safety What are the barriers to sustaining a safety culture in health care? It begins with a lack of leadership and corrosive culture. As I’ve just implied, it’s a lack of caring about the caregivers themselves and not being true to the idea that caregivers should never be hurt at work. The often-cited excuses of hospitals and other health care organizations as complex hierarchies or of physicians not being employees of hospitals are cop-outs. In a well-led place, if you are in our geography, you will follow our culture. If you’re disrespectful, we won’t let you work here. We will not tolerate you coming in here and treating people disrespectfully, and we don’t care if you bring in 30% of the patients. We will not put up with abusive behavior even if you are a profit generator. Once there are exceptions, there are no rules. An example of noncompliant behavior is the lack of adherence to the wellknown and often-repeated urgings to practice hand hygiene to prevent health care–associated infections. A median compliance rate for health care workers has been reported as 40%6— a tell-tale sign that for many organizations, “the rules don’t matter here.” People have excuses: I was too busy, I didn’t have time, I just did it a couple of minutes ago. Until we get this simple requirement right, it’s unlikely we will get the more complicated issues right. We need to create a real-time information system that captures everything gone wrong—not just worker safety, as we did at Alcoa, with a dedication that we are going to fix everything within 24 hours. Most organizations have a bookshelf at the nursing station with endless three-inch binders with all the rules, which are impossible for anyone to know. I believe they are all there to protect the lawyers—they are not there for guiding behavior. There’s so much written in obscure language in
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these binders that it can’t be understood. Rules need to be clear, straightforward, and few. Is high reliability an achievable goal for health care organizations? High reliability is an achievable goal for health care, but, on the evidence so far, there is a low probability we will ever get there. Why is that so? Because again, on the evidence, nominal “leaders” in health care don’t care about systemic excellence. If they did, they would demonstrate it by creating a system to eliminate injuries to their workers and then apply the system improvement principles to all they do—eliminating health care– associated infections, patient falls, medication errors, and all the other things that harm patients and cost enormous amounts of money. I apologize to the very few leaders who are doing this. Unfortunately, it is a small list. J
References
1. Pittsburgh Regional Health Initiative. Home page. Accessed Jul 31, 2014. http://www.prhi.org/. 2. McCarthy M. Injuries to health workers are common but safety checks are rare, report finds. BMJ. 2013 Jul 23;347:f4701. 3. Alcoa. Zero Is Possible. (Updated: Jul 31, 2014.) Accessed Jul 31, 2014. http://www.alcoa.com/sustainability/en/info_page/operations_soc_health _zip.asp. 4. Shannon RP, et al. Using real-time problem solving to eliminate central line infections. Jt Comm J Qual Patient Saf. 2006;32(9):479–487. 5. Institute of Medicine. Preventing Medication Errors. Report Brief. Jul 2006. Accessed Jul 31, 2014. http://www.iom.edu/~/media/Files/Report%20 Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medication errorsnew.pdf. 6. Erasmus V, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010;31 (3):283–294.
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An Interview with Paul O’Neill Interviewed by Meghan Pillow, RN, CCRN Paul H. O’Neill is a founder and Non-executive Chairman of Value Capture, LLC, Pittsburgh. Mr. O’Neill served as the deputy director of the US Office of Management and Budget from 1974 to 1977, where he served on staff beginning in 1967. He worked as a computer systems analyst with the US Veterans Administration from 1961 to 1966. Mr. O’Neill was the 72nd Secretary of the US Treasury, serving from 2001 to 2002, and chairman and CEO of Alcoa from 1987 to 1999. During his government service, Mr. O’Neill helped to shape many of the policies which define the American health care system today. Please address correspondence to Mr. O’Neill’s assistant, Janice Celedonia, at [email protected].
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hat led to your interest in quality and safety in health care? I have been involved in health care in a lot of different ways since 1961, so this is by no means a recent interest. In 1961, after graduate school, I was recruited as a management intern at the Veterans Administration (VA) because my background was in economics and operations research. The VA had 212 hospitals at that time, and that was my first encounter with health care. Then, I became a cochair of the Pittsburgh Regional Health Initiative in 1998, a regional collaborative of medical, business, and civic leaders that was organized to address improvement in health care quality and safety.1 What has motivated me all along is my belief in the potential for improvement of health care, the single largest economic sector in the United States. We are spending 2.8 trillion dollars a year and could realize a vast improvement in patient outcomes and still save a trillion dollars a year. I think of all the things we could do with a trillion dollars. I have also continued to contribute to worker safety on the basis of a set of ideas about what makes an organization habitually excellent. There are not many organizations that are habitually excellent. If any industry claims that it is habitually excellent, then there must be zero injuries for the people who do the work. I don’t think you can be habitually excellent at everything unless you begin with caring about your workers. According to the Occupational Safety and Health Administration data on recordable incidents, health care is the most dangerous industry in the United States.2 It’s unbelievable how awful and how numerous worker injuries are in health care— and I don’t consider this to be a separate subject. If you don’t have a process to learn from every single thing gone wrong in real time to ensure that people don’t get hurt, then I don’t think you’re habitually excellent in anything you do on a regular 428
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basis—whether it is transplants or knee replacements. If your workers are hurt at rates that are unconscionable, you’re not excellent. Being a leader of a safety culture takes courage. What gave you the courage to make worker safety the top goal of Alcoa in 1987? I don’t believe it takes courage to do the right thing. In more than 50 years I’ve observed many organizations say that their workers were their most important asset when there was no evidence that this was really true. When I went to Alcoa, I decided that I was going to make the workers the most important asset of the organization by creating an environment where people are never hurt at work. Why would you organize in such a way that people can be hurt? Workplace safety should be a precondition, which means it’s like breathing. Safety should never be a priority because the connotation of priority is to change. Alcoa is an organization where people not getting hurt is the first requirement every day for every person in its worldwide operations. Now, if I could wave a magic wand, I would have every health care organization adopt the idea of a worker injury–free workplace as a precondition. That would lead to great changes in health care. I have stated these ideas in speeches to tens of thousands of health care professionals, and they still haven’t gotten worker safety on their dashboard. People say they care about patient safety, but by evidence it’s simply not true. Did you face any resistance at Alcoa for making worker safety a precondition from board members, managers, or frontline employees? The board was great, and they hired me knowing that I beVolume 40 Number 9
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The Joint Commission Journal on Quality and Patient Safety lieved in being part of a values-based organization. So they weren’t surprised when I declared on my first day at Alcoa that it was to be an injury-free workplace. There were many managers and frontline employees who believed that accidents were inevitable or that it would cost too much money to be injury free. Leaders need to articulate nonarguable goals. There may be disbelief that you can achieve an injury-free workplace, but it’s hard to find anyone who will say that it isn’t a good goal. Then, leaders need to take away all the excuses of why we can’t do something. One excuse was that we couldn’t afford to get to zero worker injuries. So I said, “We are not going to budget for safety ever again.” We spent whatever money was necessary to achieve an injury-free workplace. If anyone in the organization—from the lowest level to the highest level—identifies a risk, we will fix it within 24 hours. And we held this standard to all of Alcoa’s operations throughout the world—at 340 locations in 43 countries. If an injury still occurred, it was a requirement to post the name of the person injured (to keep it personal so that it was not about numbers), the nature of the injury, the analysis of the contributing causes to the injury, and an indication of changes that were made to equipment, process, or training to ensure that it never happened again. This information was distributed to every employee in real time via a real-time safety-reporting system, which we called the Real-Time Safety Data System. So if we had an injury in Russia, the people in Davenport, Iowa, could learn from it and be able to prevent a similar occurrence. Most people used the Real-Time Safety Data System as a screensaver on their computer. A leader needs to be a steward of resources. When everyone battles with tight budgets, how did you make sure there was always enough money for safety? I told all the leaders this is what we are going to do. We never had trouble finding the money for these safety expenses. Most of it is not about spending a lot of money. First of all, I had to get all employees to understand that they are important and that we couldn’t achieve an injury-free workplace unless they all accepted responsibility for their own behavior. You can’t do this by order, edict, financial incentives, or anything else. You can only do it by persuading people that they really do matter to you and that the only important measure is that people don’t get hurt. People need to be trained and fanatical about doing things that we know are consistent with avoiding injury. It’s not optional to wear a hard hat in factories with overhead cranes and dangerous things falling from above—it’s a condition of employment. Once you’ve been trained in the right thing to do, you have to do it. Even if it’s 120 degrees outside, it’s not September 2014
okay to take your hard hat off. It’s not okay for visitors to come into a plant and ignore the rules for steel-toed safety shoes, hard hats, and hearing protection. Once you let anyone—even the president of the United States—come in the facility and not observe the safety requirements, then the safety requirements don’t exist. The rules are the rules, and no one is excepted from them. How did you empower your employees to feel safe enough to report potentially injurious conditions? It’s first by saying so, and then it is by using events and observations about experiences. Three weeks after I was at Alcoa, I traveled to an Alcoa plant in Tennessee outside of Knoxville that had three to four thousand employees. I spent the morning walking through the plant and talking to the people and asking about their families. I had a luncheon with many people from the union ranks and supervisors. They asked if I wanted to talk, so I got up and said, “In all the organizations I’ve worked in, there’s a tom-tom network—it works better than the Internet. People know things right away if your tom-tom system is working. So I assume you know already that I believe we should be an injury-free workplace, but I want you to know that I really mean it. I told the supervisors we are not going to budget for safety. If anyone identifies anything that needs to be fixed for safety, I want you to fix it. Here’s my home phone number. If your managers don’t do what I just said, you call me up any time of the night or day and let me know.” Three weeks later, I got a phone call from Tony at Alcoa in Tennessee. He said, “You said all this hot stuff about worker safety, and I’m calling to tell you that for the last three days that hasn’t been true. I’ve been working with a 20-foot broken section of the conveyor system that takes a 600-pound ingot across the plant to the rolling machine. So we have been lifting the ingot from where the system is working across the broken part to the next working part, and we’re really worried we’re going to drop this and hurt our feet or our backs.” I called the plant manager at home and woke him up, saying that I just heard this report and that I wanted him to get that conveyor system fixed and to then call me. At about 4 a.m., my phone rang and the manager said, “I’m really sorry they bothered you. We fixed the conveyor and it will never happen again.” I said, “It needs to never happen again. I don’t ever want to get another phone call like this. What I said to you, I meant.” People all over Alcoa learned about that story, so I didn’t have to go to every plant and do the same thing. The organization began to understand that I really meant what I said.
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The Joint Commission Journal on Quality and Patient Safety Every year in the 13 years that I was at Alcoa, our lost-workday (days away) rate was lower than it had been the previous year. When I left, in December 2000, the lost workday rate was about 0.20, while the national rate was still around 5. Today, the lost-workday rate, which is posted daily, is 0.095.3 After I left, Alcoa didn’t stop caring about worker safety. When your board, managers, and frontline staff bought into the worker safety goal and mastered it, did this mastery spill over to other parts of the business? There is a spillover effect. Once you get the rhythm of understanding how to learn from everything gone wrong and do it in real time and engage every employee in the process of the pursuit of excellence, it affects everything you do. From 1987 to 2000, we became the preeminent aluminum company in the world. We went from earning revenue of $4.5 billion in 1987 to $28 billion in 2000. And the value of our company improved by 900%. So being excellent in everything you do is consistent with economic excellence as well. How does your work with worker safety at Alcoa translate to health care? All these ideas are perfectly applicable to health care, but it’s a direct function of real leadership and engaging every employee in a quest to be better tomorrow than we are today. If you don’t have a dedication to making your processes better every day, it doesn’t get better. People need to understand that transparency and ownership are critical to habitual excellence. You can’t find an infection and give the report to the Infection Control Committee that meets three weeks later and expect the hospital to ever do anything that systematically eliminates infections. Early on, we created Alcoa University to teach employees concepts of continuous learning and improvement. Through the Pittsburgh Regional Health Initiative, I made it available to the people in the community. For example, Richard Shannon, MD,* and physicians, nurses, and infection control practitioners at Allegheny General Hospital, received five days of intensive training in the improvement system called Perfecting Patient Care and then applied those principles in clinical practice. Rick was responsible for three ICUs at Allegheny General Hospital in Pittsburgh. We used the ideas from Alcoa to eliminate central line–associated bloodstream infections (CLABSIs), * Richard P. Shannon, MD, was the Frank Wister Thomas Professor of Medicine at the University of Pennsylvania Perelman School of Medicine and chairman of the Department of Medicine of the University of Pennsylvania Health System before his appointment in August 2013 as the executive vice president for health affairs at the University of Virginia, Charlottesville.
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From July 2002 through June 2003, of the 1,787 patients flowing through the three ICUs, 1,067 patients had central lines, and 37 of those patients got an infection, 19 of whom died. And that was better than the national average. Rick articulated the goal of zero CLABSIs, and he got everyone to work together to figure out what caused them. Through investigation, we found that we didn’t have a protocol or a system for preventing the infections. Everyone knew you were supposed to wear a gown, gloves, and mask and prep the site for insertion, but they all did it different ways and they all thought they had the right way. There was so much variability in the process that you couldn’t figure out what was going on. First, we got the ICUs sterilized kits prepared so that you had what you needed and you didn’t have to chase around for things; everything needed was provided in the right size, with the gloves on top, for the surgeon, nurse, and every other care provider. Then they fixed the practice problem by reducing the variability of the procedure for inserting central lines. Finally, they gave everyone a pager so as soon as anyone detected what they thought was going to turn into a CLABSI, they came to talk to one another about where there was a break in the protocol and how it happened. New processes were implemented within 90 days. Within a year, the number of CLABSIs decreased from 49 to 6, despite an increase in the use of central lines. These results were sustained during a 34-month period. After a year to 18 months’ worth of improving and correcting the process, 1,830 patients had come through the ICUs, with only one infection—and no one died.4 So does it work? Yes. Have these practices been adopted at every health care organization? Unfortunately not. We have two million hospital infections every year, and every one of them is unnecessary. Do you think these patient safety projects can help construct a successful safety culture? Projects can be successful, but the results of projects can wither away over time unless an organization—from top to bottom and from side to side—is committed to the ideas of habitual excellence. If you do a project and show great results, but if everything around you is the same old stuff, your results will eventually regress to the mean. You need to have a commitment to inclusive organizational excellence. We have to create a culture where everyone is treated with the same level of dignity and respect without regard to their education, pay rank, title, degrees, race, gender, or ethnicity. The people who clean the rooms are given the same level of dignity and respect as the highly acclaimed neurosurgeon. Volume 40 Number 9
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The Joint Commission Journal on Quality and Patient Safety In health care, we still struggle to report our errors for various reasons. You once fired a top executive at Alcoa for not reporting a safety incident. Do you have any recommendations for increasing error reporting in health care? It wasn’t hard for me to fire that executive. It was an openand-shut case. Once it was clear that he had chosen not to report that people had been exposed to carbon monoxide poisoning, and he didn’t report it, I knew he had to be fired. And this was a guy who took a business and raised its revenue in 10 years and ran an organization with 30,000 people that was one of the safest parts of the organization, but he violated our value system because he didn’t report the error and did not let other people learn from the error. Once the rules are clear and known and retained by employees, they are not optional. You have to assure people that reporting things gone wrong is not dangerous to their career and that they won’t be blamed for reporting things gone wrong. If you have a retribution culture, managers might cut back on someone’s hours because they submitted an error and kept working to try to fix it. Unless people are appreciated and honored for identifying things to make the workplace better, they won’t do it. People on the floor know what’s true—all the fancy signs in the hallways make no difference at all—they know the reality of the work place. If you call out something that is wrong and you get penalized for it in whatever way, you aren’t going to do it again. Leaders need to establish a culture where people are honored for helping us get better. For example, people shouldn’t be asked to do things that put themselves at risk, like trying to move a 300-pound patient without a mechanical lift. Health care is perhaps the most disrespectful occupation in the United States. Until that problem is fixed, it’s difficult to get employees to believe that it is okay to identify things gone wrong. If you report it and nothing happens, why do it? People are not stupid. If they are not safe physically and psychologically, it’s not possible to be part of a culture of habitual excellence. As you are probably aware, The Joint Commission requires health care organizations to conduct root cause analyses whenever serious safety events—“sentinel events”—occur.* At Alcoa, you often pushed people to find the root causes of problems. To make sure you have a permanent fix for a problem, you need to identify the real root cause. A lot of times it’s not so obvious. Asking why five times is a really good idea. Let’s say you have an employee injury, and you want to know why it * The Joint Commission. Sentinel Event Policy and Procedures (Updated: Jun 10, 2013.) Accessed Jul 31, 2014. http://www.jointcommission.org/Sentinel_Event _Policy_and_Procedures/.
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happened. The automatic first response is that Sally was not following the established protocol. If that is where the questioning stops, then you won’t ever fix the problem. Why wasn’t Sally paying attention or why wasn’t she following the standard procedure? And there are a whole bunch of questions that branch off from that question—for example, perhaps she was distracted because someone was talking to her when she was doing a procedure that required complete concentration. At least 1.5 million preventable adverse drug reactions—injuries caused by errors—occur every year in the United States.5 I was at a children’s hospital a few weeks ago. I arrived early for the morning conference with 15 people in the room and others on the phone going around giving reports for the last 24 hours. The third report was from a nurse who said that they had a four-year-old patient who had the wrong intravenous medication concentration, and they started infusing 2.5 mL before they realized it was a mistake. And they had smart pumps for this child. It was a problem with the decimal point, and that has been around forever. If health care didn’t have medication doses that were based in one-tenths, people wouldn’t get so confused. With the cases of wrong doses of heparin given to neonates, you can go to a medical facility within 10 miles of where you are and find that the adult doses and child doses of heparin are still stored next to each other, and it’s difficult to tell one from the other. We were able to get really good with safety at Alcoa because once we identified a root cause, we shared it with the rest of the organization. And it was not optional whether we adopted the practice. Why can’t we do this with heparin? It is a direct function of the lack of leadership. A lot of people are leaders by designation, but they are not leaders in my terms. They are presiders. I can’t tell you how many places I’ve been where the supposed leaders never go out on the floor and talk to the people who are doing the work and ask what is aggravating you today. In a good industrial factory where they have a shift change, they have a 10-to-15-minute meeting of people who work in the same area. They address anything new in our workplace today that could represent a risk, any change in equipment position that we need to be aware of, and so on. Then, they ask: “Does anyone have a personal problem that is nagging at you that could cause you to lose concentration? If you are worried about something at home, maybe we need to give you a half day off.” Do you know anyone who asks people, as a regular matter, if you are all okay? Health care providers are so busy trading information about patients’ conditions that the providers themselves become an afterthought or no thought at all.
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The Joint Commission Journal on Quality and Patient Safety What are the barriers to sustaining a safety culture in health care? It begins with a lack of leadership and corrosive culture. As I’ve just implied, it’s a lack of caring about the caregivers themselves and not being true to the idea that caregivers should never be hurt at work. The often-cited excuses of hospitals and other health care organizations as complex hierarchies or of physicians not being employees of hospitals are cop-outs. In a well-led place, if you are in our geography, you will follow our culture. If you’re disrespectful, we won’t let you work here. We will not tolerate you coming in here and treating people disrespectfully, and we don’t care if you bring in 30% of the patients. We will not put up with abusive behavior even if you are a profit generator. Once there are exceptions, there are no rules. An example of noncompliant behavior is the lack of adherence to the wellknown and often-repeated urgings to practice hand hygiene to prevent health care–associated infections. A median compliance rate for health care workers has been reported as 40%6— a tell-tale sign that for many organizations, “the rules don’t matter here.” People have excuses: I was too busy, I didn’t have time, I just did it a couple of minutes ago. Until we get this simple requirement right, it’s unlikely we will get the more complicated issues right. We need to create a real-time information system that captures everything gone wrong—not just worker safety, as we did at Alcoa, with a dedication that we are going to fix everything within 24 hours. Most organizations have a bookshelf at the nursing station with endless three-inch binders with all the rules, which are impossible for anyone to know. I believe they are all there to protect the lawyers—they are not there for guiding behavior. There’s so much written in obscure language in
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these binders that it can’t be understood. Rules need to be clear, straightforward, and few. Is high reliability an achievable goal for health care organizations? High reliability is an achievable goal for health care, but, on the evidence so far, there is a low probability we will ever get there. Why is that so? Because again, on the evidence, nominal “leaders” in health care don’t care about systemic excellence. If they did, they would demonstrate it by creating a system to eliminate injuries to their workers and then apply the system improvement principles to all they do—eliminating health care– associated infections, patient falls, medication errors, and all the other things that harm patients and cost enormous amounts of money. I apologize to the very few leaders who are doing this. Unfortunately, it is a small list. J
References
1. Pittsburgh Regional Health Initiative. Home page. Accessed Jul 31, 2014. http://www.prhi.org/. 2. McCarthy M. Injuries to health workers are common but safety checks are rare, report finds. BMJ. 2013 Jul 23;347:f4701. 3. Alcoa. Zero Is Possible. (Updated: Jul 31, 2014.) Accessed Jul 31, 2014. http://www.alcoa.com/sustainability/en/info_page/operations_soc_health _zip.asp. 4. Shannon RP, et al. Using real-time problem solving to eliminate central line infections. Jt Comm J Qual Patient Saf. 2006;32(9):479–487. 5. Institute of Medicine. Preventing Medication Errors. Report Brief. Jul 2006. Accessed Jul 31, 2014. http://www.iom.edu/~/media/Files/Report%20 Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medication errorsnew.pdf. 6. Erasmus V, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010;31 (3):283–294.
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