These slides were created and shared by Dr. Michael Leonard and Dr. Allan Frankel of Safe and Reliable Healthcare in a webinar on November 7, 2018. All slide content is property of Safe & Reliable Healthcare and has been shared with their permission. -- To be successful, healthcare organizations are increasingly focused on how to deliver high quality healthcare in service of sustainable clinical value, all while also reducing avoidable patient harm. Despite increasingly sophisticated organizational effort, challenges abound: Patients are more complex, diagnoses more numerous, treatments more demanding in their precision, and there is a growing workload that can feel insurmountable. Organizations need an equally precise and diverse set of cultural tools to stay apace. Drs. Frankel and Leonard will provide a practical, sociotechnical framework that has evolved from their experience in training over 2,500 patient safety officers and working with numerous, world-class health systems over the last two decades. The framework focuses on effective leadership, a culture of safety and continuous learning. Watch this on-demand video to hear practical methods of assessment, engagement and implementation that can be readily applied in virtually any care setting. LESSONS LEARNED * Specific components necessary for the delivery of high value care. * The critical importance of psychological safety and how to achieve it. * How to assess any care environment for inherent strengths that can be utilized to enhance learning and mitigate risk. * Practical tools and behaviors that can be immediately applied in pursuit of habitual, operational excellence. PRESENTERS Drs. Frankel and Leonard have been leaders in patient safety and culture for over twenty years. They have held senior operational roles in complex healthcare systems and worked with hundreds of hospitals across the globe, gaining valuable insights that can be readily applied in your organization. Dr. Frankel is a Founding Partner at Safe & Reliable Healthcare and serves as Senior Faculty at the Institute for Healthcare Improvement. Dr. Leonard is a Managing Partner at Safe & Reliable Healthcare and Adjunct Professor of Medicine at the Duke University School of Medicine. Together they have worked extensively to develop practical, comprehensive models that enhance patient and family-centered care, effective leadership, a culture of safety, high reliability, and an environment of continuous learning and improvement.

1. A Systematic Framework
for the Delivery of Safety,
Highly Reliable Care and
Habitual Excellence
Allan Frankel, MD
Michael Leonard, MD
Proprietary and Confidential – Safe & Reliable Healthcare LLC 2018 ©

2. Culture HRO Transformation Partner:
Safe & Reliable Healthcare
IHI Affiliation Senior IHI [Institute of Healthcare Improvement] Faculty and Master Trainers for PSO Course
Contributions Contributors to TeamSTEPPS, Crew Resource Management, the IHI Improvement
Framework, the Global Trigger Tool, various surveys [SAQ and SCORE], WalkRounds,
Boards on Board, and LENS
Best Practice
Clients
Expertise Two decades of measuring and improving culture and reliability across > 1,300 hospitals
Core HRO
Transformation Team
Dr. Michael Leonard Dr. Allan Frankel Terri Christensen, RN Maureen Frye, RN Jean-Ann Wurtz, MPSL Josh Proulx, PEng
Contact: kaitlyn@safeandreliablecare.com | 508.981.8156

3. Our Goal
 Provide a practical, systematic framework that can be applied in
virtually any care setting
 Understand the key components of High Reliability Organizations
– effective leadership, a culture of safety and continuous learning
and improvement
 Offer practical tools and insights that enhance the ability to
deliver optimal patient care in an environment of continuous
learning and improvement

4. Framework for Safe &
Reliable Care
Source: https://www.safeandreliablecare.com/blog/2016/11/29/s-r-sociotechnical-
framework-ihi-minicourse
Framework is Anchored in 23 Years
of Experience Across > 1,300 Hospitals
Transparency
Leadership
Psychological
Safety
Negotiation
Teamwork &
Communication
Accountability
Reliability
Improvement
and
Measurement
Continuous
Learning
Engagement of
Patients &
Family
Leadership
Culture
Learning
System

5. Safe & Reliable Culture Maturity Model
UNMINDFUL
Who cares as long as we’re not caught.
Chronically Complacent
REACTIVE
Safety is important. We do a lot
every time we have an accident.
SYSTEMATIC
We have systems in place to
manage all hazards.
PROACTIVE
Anticipating and preventing
problems before they occur;
Comfort speaking up
GENERATIVE
Safety is how we do
business around here.
Constantly Vigilant and
Transparent
Tipping Point =
Psychological
Safety
Value
©S&R 2018

6. Poll Slide #1 – Where do you think your
organization is on this maturity curve?
5 –Generative
4 - Proactive
3 - Systematic
2 - Reactive
1 - Unmindful
Safe & Reliable Culture Maturity Model
UNMINDFUL
Who cares as long as we’re not caught.
Chronically Complacent
REACTIVE
Safety is important. We do a lot
every time we have an accident.
SYSTEMATIC
We have systems in place to
manage all hazards.
PROACTIVE
Anticipating and preventing
problems before they occur;
Comfort speaking up
GENERATIVE
Safety is how we do
business around here.
Constantly Vigilant and
Transparent
Tipping Point =
Psychological
Safety
Value
©S&R 2018

7. Avoidable Patient Harm
• 30% of hospitalized patients
have something happen to
them you and I wouldn’t want
to happen to us
• 10% are harmed seriously
enough to stay in the hospital
longer and go home with a
disability

8. Senior Leadership
Cyclic flow of information with
feedback and organizational learning
UNMINDFUL
No awareness of safety culture
REACTIVE
Playing defense – reacting to events
SYSTEMATIC
Systems in place to manage hazards
PROACTIVE
Playing offense – thinking ahead,
anticipating, solving problems
GENERATIVE
Organization wired for safety and
improvement
Systematic engagement with dialogue,
support and learning
Process for interaction between senior
leaders and frontline staff
They’re here – something bad must
have happened
We don’t know or see them

9. Aligning Leadership with
Front line Caregivers is
Essential for success
Question: The values of facility
leadership are the same values that
people in the work setting think are
important.
Benchmarks: 2018 Q1 US Hosp.
25th: 44% 50th: 60% 75th: 74%
Percent Positive Percentile(s)
n = 149883 responses
From 6070 units/department
Source Data: Sep 2018
Positive + Neutral = Negative -
44 60 74
0 20 40 60 80 100

10. Published Tie-Together
Cultures that visibly “close the loop” with frontline teams
have > 20% better culture, burnout and engagement
Source: http://qualitysafety.bmj.com/content/early/2017/10/09/bmjqs-2016-006399
Michigan SCORE survey data with and without closing the
loop on ideas and concerns from the frontline
Better culture,
burnout and
engagement measures
when WalkRounds
feedback is provided

11. Local Leadership
Leaders create high degrees of psych
safety and accountability
UNMINDFUL
No awareness of safety culture
REACTIVE
Playing defense – reacting to events
SYSTEMATIC
Systems in place to manage hazards
PROACTIVE
Playing offense – thinking ahead,
anticipating, solving problems
GENERATIVE
Organization wired for safety and
improvement
Leaders model the desired behaviors
to drive culture safety
Training and support exists for building
clinical leadership
Episodic, completely dependent on
the individual clinician
Absent for the most part

12. Reliable feedback is
essential for a healthy
unit culture
Question: In this work setting, local
leadership regularly makes time to
provide positive feedback to me
about how I am doing.
Benchmarks: 2018 Q1 US Hosp.
25th: 59% 50th: 73% 75th: 85%
Percent Positive Percentile(s)
n = 150952 responses
From 6069 units/department
Source Data: Sep 2018
59 73 85
0 20 40 60 80 100
Positive + Neutral = Negative -

13. A Wide Variety of Skill Among
Local Leaders
Absent Burned Out
Socially Inept
Disinterested
Source: Bohmer R, Leading Clinicians and Clinicians Leading, New Eng J Med, April 2013
10% 10%80%
Clinically Excellent
Well Meaning
Socially Adept
Inadequately Trained
Engaged Knowledgeable In:
- Organizational development
- Whole system change
- Measurement to manage
- Relentlessly focused on process
- Know culture IS a process

14. Psychological Safety
Primary responsibility of leaders,
continuously modeled everywhere
UNMINDFUL
No awareness of safety culture
REACTIVE
Playing defense – reacting to events
SYSTEMATIC
Systems in place to manage hazards
PROACTIVE
Playing offense –anticipating
GENERATIVE
HRO – wired for safety and learning
Leaders model expect the behaviors
that promote psychological safety
In some units it feels safe to speak up
and voice a concern
Personality dependent – it depends
who I’m working with
Fear based – keep your head down
and stay out of trouble

15. Poll Slide #2 – Do you know of a patient
who has experienced serious avoidable
harm because someone was hesitant to
speak up?
1 - Yes
2 - No

16. Safe, Optimal Care
Requires Psychological
Safety
Question: In this work setting, it is not
difficult to speak up if I perceive a
problem with patient care
Benchmarks: 2018 Q1 US Hosp.
25th: 58% 50th: 69% 75th: 80%
Percent Positive Percentile(s)
n = 145455 responses
From 5911 units/department
Source Data: Sep 2018
58 69 80
0 20 40 60 80 100
Positive + Neutral = Negative -

17. SCORE Survey Data to Predict & Proactively
Avoid Wrong Site Surgeries and Retained
Foreign Bodies Across 13-Hospital System
Source: SAQ/SCORE Survey data from 13 hospital with 92% overall response rate
Insight
1. Surgical Never Events occur
when Nurses and Surgeons
have different perceptions
of Safety Climate
2. > 92% response rates =
“I believe this data”
3. Baylor study: in 70% of
RFOs, someone felt
something but didn’t feel
comfortable saying
something

18. SCORE Survey Measures Correlate to
Patient & Personnel Safety
Insight
1. Unit levels cultures often vary > 4x
within a site
2. Healthier cultures produce better
outcomes for patients and
personnel. 60% positive responses
are “tipping point”
3. Linkage to outcomes and 88%
response rate = “I believe this data”
4. AHRQ did not correlate to outcomes
across > 1,000 hospitals [paper here]
Source: Teamwork Climate Domain from SAQ/SCORE Survey from > 400 bed hospital with 88% overall response rate
Where would you want to be a
patient? A staff member? A manager?Real example from 400-bed hospital

19. Teamwork Domain
Source Data: June 2016
• 31% hesitant to
speak up
• Dealing with
difficult
colleagues is
common
• Communication
failures within
units and
across units are
pervasive

20. Senior Leadership
Local Leadership
Psychological Safety
Effective Teamwork
Burnout & Resilience

21. Question: People in this work setting
are burned out from their work
Benchmarks: 2018 Q1 US Hosp.
25th: 60% 50th: 43% 75th: 27%
Percent Positive Percentile(s)
n = 151305 responses
From 6079 units/department
Source Data: Sep 2018
27 43 60
0 20 40 60 80 100
Positive + Neutral = Negative -

22. Influencing Factors in Burnout
and Resilience
• Do I feel valued by the organization?
• Do I have a voice?
• Do I feel supported in the work I do?
• Do I have the tools and resources to do my job?

23. The End In Mind:
Mayo Clinic Unit Culture
From a conversation with a Senior Trauma
Surgeon responsible for a Trauma Surgery Floor
and ICU regarding the application of the HRO
concepts in his Units:
“Before we started this program my biggest
concern when I went home in the evening was
that I didn’t know what I didn’t know. Now the
nurses and staff are comfortable about speaking
up about their concerns, and as a result, I know
what I need to know to help the services run
smoothly and safely. I go home in the evening
with greater assurance that we are on track.”
Physician Impact
1.5% ↓
Average Length of Stay
20% ↑
Psychological Safety
14% ↑
Culture Improvement
7% ↓
Burnout vs 11% ↑ across US
50% ↓
Adverse Events

24. Goal:
Self Reflecting
Improvement Capable
Transparency
Leadership
Psychological
Safety
Negotiation
Teamwork &
Communication
Accountability
Reliability
Improvement
and
Measurement
Continuous
Learning
Engagement of
Patients &
Family
Leadership
Culture
Learning
System
Pulling It All Together

25. Transparency
Leadership
Psychological
Safety
Negotiation
Teamwork &
Communication
Accountability
Reliability
Improvement
and
Measurement
Continuous
Learning
Engagement of
Patients &
Family
Leadership
Culture
Learning
System
Self Reflecting
Improvement Capable

26. Transparency
Leadership
Psychological
Safety
Negotiation
Teamwork &
Communication
Accountability
Reliability
Improvement
and
Measurement
Continuous
Learning
Engagement of
Patients &
Family
Leadership
Culture
Learning
System

27. Framework for Clinical and Operational
Excellence
Transparency
Leadership
Psychological
Safety
Negotiation
Teamwork &
Communication
Accountability
Reliability
Improvement
and
Measurement
Continuous
Learning
Engagement of
Patients &
Family
Leadership
Culture
Learning
System
Source: https://www.safeandreliablecare.com/blog/2016/11/29/s-
r-sociotechnical-framework-ihi-minicourse

28. Anatomy of Healthcare Systems
and Hospitals
• Each work setting’s capacity
is determined by the
strength of its framework
components
• Each healthcare system’s
capacity is determined by
the strengths of its serial
work settings

29. Operationalizing HRO Using
Real-Time Learning Boards
[LENS]

30. Why Real-Time Learning Boards?
Key Design Features:
1 – Psychological Safety
2 – Continuous Real Time Improvement
3 – Make Collaboration Fun!
4 – Efficient Intuitive Workflow
5 – Join By Video From Anywhere
6 – Full Data Analytics Suite to Measure
7 – Communicate Within and Across Units
Proprietary and Confidential – Safe & Reliable Healthcare LLC 2018 ©

31. Proprietary and Confidential – Safe & Reliable Healthcare LLC 2018 ©

32. Proprietary and Confidential – Safe
& Reliable Healthcare LLC 2018 ©

33. Proprietary and Confidential – Safe & Reliable Healthcare LLC 2018 ©

34. Issues and Good Ideas uploaded from staff
in real time since the last huddle……….
Proprietary and Confidential – Safe & Reliable Healthcare LLC 2018 ©

35. Connecting on key topics, during and between huddles
Proprietary and Confidential – Safe & Reliable Healthcare LLC 2018 ©

36. Teamwork:
Huddles
Proprietary and Confidential – Safe & Reliable Healthcare LLC 2018 ©

37. Participatory
and Effective
Communication
Proprietary and Confidential – Safe & Reliable Healthcare LLC 2018 ©

38. Proprietary and Confidential – Safe & Reliable Healthcare LLC 2018 ©

39. LENS Impact and User Feedback
• Increased efficiency – Nurse Managers spend ~ 75% less time
• 2-3x more engagement and completed projects [“Aims”]
• More consistent communication and transfer of info. Between shifts
• Facilitates conversations aimed at improving psychological safety
vs.

40. Summary
Questions & Comments

41. Poll Slide #3 – Would you like to learn
more about Health Catalyst products or
professional services?
1 - Yes
2 - No

42. Q&A

43. Thank You!