Thank You, Employees!

Today, I was able to do one of the things I love most about my job – spend time with our wonderful faculty and staff!

I had a blast serving those of you who came to the Employee Appreciation Breakfast in the UH Cafeteria this morning, and I hope that all employees participated in the appreciation activities that took place across our Health System this month.

Thank you for the incredible work you do as stewards of our Health System. I encourage you to always take time to appreciate each other and yourselves for all of the important and meaningful things you do at work and at home every single day.

Supreme Court Hearing on Affordable Care Act

This morning, the Supreme Court will begin hearing arguments debating the constitutionality of the individual insurance mandate required by the Affordable Care Act.

When President Obama signed the ACA into law, it marked a historical moment in our nation. Today, two years and three days later, we are once again experiencing a pivotal moment in health care for our nation.

Recently, I read an article by Victor Fuchs, Ph.D., in the New England Journal of Medicine that explored trends in the U.S. health economy over the last 60 years. In it, Dr. Fuchs quoted Alexis de Tocqueville who said that in the United States, “events can move from the impossible to the inevitable without ever stopping at the probable.”

Improving our national health care system is not impossible, but it has become inevitable due to its immense strain on our economy and the well-being of our population. It is time to dedicate ourselves to the probable.

Regardless of the outcome of the Supreme Court hearing, our professional mandate remains the same – continue to discover and deliver high quality, safe and accessible health care to all citizens.

I hope you will join me in following the hearing as it progresses this week, and I encourage you to share your thoughts on Medicine That Speaks.

Follow up to “Enhancing Our Culture of Safety”

Your comments and feedback to my newsletter “Enhancing Our Culture of Safety” have been great! I love reading your perspectives and ideas, and Medicine That Speaks is meant to be a forum for this exact type of e-conversation. Keep the posts coming, and be sure to subscribe if you want to have my messages automatically sent to your e-mail.

I wanted to write a brief follow up to address some important points highlighted in your comments.

First, I want to speak to Joyce Wahr’s post. She said, “… could I ask you to perhaps clarify what is meant by ‘hold people accountable for their actions’ . . . to some this might mean a return to the blame and shame…”

First, let me tell you what I think about blame. Frankly, there is no place for blame and shame behavior in a maximally effective and safety-focused health care environment. In fact, I would like to see UMHS develop an exemplary culture of “disdain for blame,” where blaming is seen for what it is – a weak, demoralizing and counterproductive approach to problem-solving and improvement.

When it comes to accountability, intention is a factor. Many errors and mistakes are made by well-intended individuals. In these cases, accountability includes openly admitting mistakes in order to create an opportunity to address errors and learn how to prevent them in the future. However, accountability for willful violations of process or procedure is another story and requires definitive action appropriate for the offense.

The second thing I wanted to highlight is a point made by poster Lynn McCain who wrote “Only by instituting processes and systems that can catch errors before they can cause harm will we truly ensure patient safety. Every system produces exactly the result for which it is designed. If the results are errors, something in the system is flawed.”

This point is spot on. We to need to build systems that minimize the potential for human fallibility. I have long held the belief that if we keep doing what we have always done, we will continue to get the results we’ve always gotten. If we want a different result, we need to rethink the system producing the unwanted results. And we need to be creative, collaborative and communicative in our re-thinking.

In my January message “Putting Patients Above Politics,” I emphasized that if we want real change to happen in the American health care system that changes starts with us. Improving patient safety, cultivating a culture of “disdain for blame” and being proud to be accountable are real opportunities to shape the future of health care. Imagine what we can accomplish with the vast talent, expertise and compassion that abound at the University of Michigan Health System!

Enhancing Our Culture of Safety

Lately, I’ve been thinking a lot about what it means to have a culture of safety.

With a population of 22,000 employees and more than two million patients, visitors and guests coming through our doors each year, the University of Michigan Health System is a vibrant community unto itself. And in an organization of this size and complexity, things will go wrong, mistakes will be made and accidents will happen. What is most important is how we deal with and learn from our mistakes, problems and accidents to make sure we are always striving to create the safest environment possible.

When I was CEO at Riley Hospital for Children in Indianapolis, I had personal experience with a serious medical error. One night, when I was the Administrator on Call for Clarian (now known as IU Health), I had a chilling experience that forever changed my approach to patient safety.

My husband, Mark and I were at a black tie event when my Blackberry buzzed. The message said: CALL – EMERGENCY. I learned that five vulnerable premature babies in the Methodist Hospital NICU had received a terrible overdose – adult dosages of heparin, a blood-thinner to prevent clotting. The drug’s manufacturer had streamlined packaging to simplify its use, but this caused confusion as to which vials contained adult doses and which contained the much smaller pediatric doses.

I left my husband at the concert and told him to find his own way home, and I rushed to Methodist. On the way, I called the NICU and learned that medication to counteract the heparin had already been given without any noticeable improvement. I knew that meant the situation was terribly serious. I contacted Clarian’s Chief Operating Officer and the system’s Chief Nursing Officer who were attending another black tie event and I told them to meet me at the hospital. Within minutes, the three of us arrived on the unit – all of us dressed in formal evening wear. That alone signaled to staff who saw us running into the hospital that something was terribly wrong.

I entered the NICU. The unit was nearly full of babies – 26 of them with only one crib unused. Babies were crying. Frantic parents were crying. One mother demanded the names and addresses of specific nurses and vowed revenge on those she believed were in the process of killing her infant. No, I thought, that’s not what happened. This was a medical error, a very serious error, the most serious one I had ever seen.

Questions had to be answered: What exactly had happened? Who was involved? Where were they? How would order and control be restored? What was the best path to care for the affected babies and others in the unit? What about the families? What should I do? What could I do?

Though it was late Saturday night, I called additional neonatology staff at home and asked them to please come in to assist with the crisis. They did so willingly. I spoke with the many chaplains who had arrived to provide support and comfort, and I helped direct them to the frightened and grieving parents and terrified staff. In addition, I asked for a summary of events from the unit’s nurse practitioner and neonatologist. After reviewing the number of adult heparin vials that were missing, contemplating the chaos of the situation and hearing the reports, I had a sudden realization that there must have been a sixth baby who was given a heparin overdose. During the next several minutes, we identified a sixth baby. Care to this child was initiated immediately.

In the end, two babies died within the first 24 hours and a third baby died a few days later; three babies lived, including the sixth one we had identified. The entire institution was changed in perpetuity as a result of this calamity.

Patient safety became the mantra across every unit at every Clarian/IU Health and I was reminded why it is so important to never be content and to always be improving. No matter how good we think we are, we can always be better.

Creating a culture of safety means many things, including:

  • Admitting our own errors and mistakes when they occur, and feeling empowered and supported to speak up when we see another’s;
  • Respecting each other’s professional input and checking our egos at the door so  that we always remain focused on our number one priority – patient safety;
  • Continuously evaluating our processes and procedures to identify areas for improvement and then implementing these improvements;
  • Engaging patients and families in health care decisions and keeping them informed throughout the course of care;
  • Holding people accountable for their work and their actions;
  • Learning from errors so that we don’t repeat them.

Health care is a human system, and humans are fallible. There is not and never will be a perfect person or a perfect hospital. The most educated, experienced and well-intended people make mistakes, and the most prestigious health care organizations make medical errors. That is why a culture of safety requires processes and systems that minimize human error.

In his book “Complications: A Surgeon’s Notes on an Imperfect Science” Atul Gawande says: … not only do all human beings err, but they err frequently and in predictable, patterned ways. And systems that do not adjust for these realities can end up exacerbating rather than eliminating error.

While it may be impossible to be perfect, we most certainly can be exemplary.

I am proud of the University of Michigan Health System. But, to be a leader in safety, we must demand excellence from ourselves every single day. Because we can never be perfect, we must be resolute in our commitment to continuous improvement. I know that this Health System has what it takes to be the safest hospital in the nation. I call on all of you to engage, to recognize the important role you play and to be more diligent than ever in pursuit of this foremost goal.


A Step in the Right Direction for Patients: Trinity Health-Michigan Affiliation

Our new master affiliation agreement with Trinity Health-Michigan is cause for celebration. It begins a new effort to further benefit patients around the state, and it provides new opportunities in clinical care, research, physician training and other areas.

This is the kind of work that fulfills our mission to be a statewide resource, and we are very fortunate to engage in this effort with a strong and successful partner.

Read the press release for more information.