 Hi everybody, I'm Donna Prosser, Chief Clinical Officer at the Patient Safety MIMA Foundation. Today we're joined by Chuck Stokes, former president and CEO of Memorial Hermann Health System. He's also the founding partner of Relia Healthcare Advisors and was the past chairman of the American College of Healthcare Executives. He's here today to talk to us about high reliability in healthcare. Welcome Chuck. Thank you. Great to be here. Can you tell us just a little bit about your background? Well, sure. I started my healthcare background as a critical care nurse and I thought I was going to become a CRNA and I kind of started down that road training to be a CRNA working in critical care but got sidetracked into nursing administration and then decided that I probably would like to understand a little bit more about how the entire health system worked. So I went back to graduate school at the University of Alabama in Birmingham and got a master's in hospital and healthcare administration and then left the bedside, never went back into the clinical area and stayed in administration for the last 40 years and I've been the COO of four different organizations and the president and CEO of one. And so I have in December of 2019, I retired after 40 years of being in the trenches of healthcare. Excellent. Well, thank you so much for joining us here today. I'm really interested to hear what your thoughts are on high reliability. What does high reliability in healthcare mean to you? Well high reliability to me means the elimination or prevention of patient harm and also harm to the workforce and that's including your nurses and caregivers and your physicians. And it's such an important issue that the public has kind of been a little bit sheltered from over the many over the past decades. And the public has very little idea about how much patient harm actually happens on a daily basis in our industry and if they did, they would be scared to death and some of the frequently quoted numbers which are probably understated was that on an annual basis, there's over 240,000 deaths that occur every year as a result of medical error. And so when you think about that, the metaphor that we have always used using talking about that number is it is the equivalent of somewhere between four and seven fully loaded 737 airplanes crashing every five to seven hours in this country. Now we know that if that were the case and that that was actually happening, there would be no airplanes flying until basically a root cause analysis was done to figure out why airplanes are dropping out of the sky every four to seven hours in the United States. And so until COVID-19, death from medical error was the third leading cause of death in the United States and the public, very few of the public have very little awareness of that. And so I think that when I talk about high reliability, I only talk about zero patient harm. That's what high reliability means to me. It does not mean about I'm making a 50% improvement in my error rate or patient harm. It is only about getting to zero. That is the only acceptable number for high reliability. And that's really what I've spent probably the last 20, 25 years of my career was doing focusing on that. And as a critical care nurse, as an old critical care nurse, of course, we were always cognizant of about patient safety. I mean, it was at the top of our mind all the time. But most of the organizations that experience patient harm, it's not because of bad employees. It is because of broken processes. And that is really what we have to focus on in the industry is fixing broken processes and putting stop gaps in place so that you can't move from one part of the process to the next without going through a step of patient safety. Very well said. Now, we know Memorial Herman is a leader in high reliability. Can you tell us when did you embark on this journey at Memorial Herman and why? Yeah. So I arrived in 2008 at Memorial Herman and they had really started. Dan Walderman was the president and CEO at the time. And they had really already embarked on the journey because the primary reason was in 2007, we had the organization had a series of patient safety events. And it had to do with administering the wrong blood product to the wrong patient. And so anyway, that and we caused patient harm. I mean, there was harm that resulted from that. And it happened within like a period of a few weeks and everybody was kind of dumbfounded. It's like, how can that happen? Because when you think about blood administration, it's always two provider check. You double check the numbers. You double check the blood product. I mean, there were so many checks and balances, but this happened multiple times and a very short period of time. And Dan said, hey, we can't allow this to happen. This can, we have to fix this process. There's something broken about the process and we can't allow this in our organization. And so the organization got very busy pulling apart, basically doing a root cause analysis of the process. How did this happen? And we fixed the process. And so I can say that from 2007 until I left in 2019, when I retired in December of 2019, we had administered over 1.5 million transfusions of blood products during that period of time. And we had zero patient events and no one got the wrong blood product. And so one of the things why that's such an important point is because when you start talking about getting to zero, a lot of times clinical people say, well, look, things are going to happen. You know, you can't prevent everything. This is a very complex world and sometimes things are going to happen. But that is an example of how if you put the right processes in place and you hardwire those processes, you really can get to zero. So when we think about patient harm from things that happen all the time, wrong site surgeries, why did we start marking the site back in 2002? Because there were so many wrong site surgeries across the country. And I think the Society of Orthopedic Surgery, they were the ones first group that said, hey, it would be a safe thing to do to just mark which arm, which leg, which knee, which hip you're going to be operating on from an orthopedic standpoint. And then other specialties where there was laterality involved said, no, this is really a good thing to do for everybody. And of course, over time, it didn't happen overnight. It happened over many years. Organizations said, hey, you know what? You got to mark the site. We, a wrong site surgery is a preventable event. Leaving a retained foreign body, a needle, a sponge, an instrument in somebody's body is a preventable event. We have to take measures to make sure that that does not happen. And so we started doing that. And then we started holding people accountable and holding leaders and holding clinicians, physicians and nurses and other healthcare allied health professionals accountable for making sure that those things were done every patient, every time, timeouts before surgery. When you mark a site, you're doing a right knee surgery, patient comes into the OR. Why do we do a timeout? We want to make sure we've got the right patient on the table. We know what surgical procedure that we're going to do. And we've got that site marked. And then the timeout is we validate that information. We introduce everybody in the room to make sure the doctor, the surgeon knows who's in the room, who's part of the team, and then we move forward. And when you think about this, it really only takes just a minute or two. This isn't a 15 minute procedure. This is just a couple of minute event. But it's say thousands and thousands and thousands of wrong site surgeries and retained foreign bodies. Just before you whip that last stitch and close that incision site, do you have a correct sponge count? Do you have a correct instrument count? And if you don't, let's get an x-ray machine in here and take a quick x-ray just to make sure that we didn't leave something in and we didn't just miscount the sponges. And so those are things that, but the journey of getting there is not an easy journey and it's not a journey for the plane of heart. You're right. It is definitely not an easy journey. So can you share with our audience what challenges you faced at Memorial Hermann and getting this off the ground? Yeah. So I think that there were many. And so let me just start with where high reliability has to start. It has to start in the board room. It has to start with governance. You can't just go out and roll it out to your employees and your physicians. It has to start with the leadership. Governance is the ultimate fiduciary for quality in the organization. And so when you think about it, board meetings for many, many years in healthcare, these kind of things were not discussed in board meetings. Nobody came in. No CEO came in and told their board. Let me tell you what happened since the last board meeting. We killed three people in our healthcare system. Nobody ever said that. And the only way that you can get to higher reliability is being totally transparent and totally honest and starting with the board. You have to do it with the entire organization, but you have to start with the board. And I can tell you when you start that process with governance and if they have never heard of it and they've never heard those kind of discussions in the board room, it's a shocker. And I can tell you that from personal experience when we started that, Ed Memorial-Hurman, Dr. Michael Shabbat, who was our chief medical officer at the time, Michael would stand up and we had the IHI's format about presenting patient harm. So what it was was it was on the big screen. There was a slide that had all the patients with fictitious names. But what actually happened to them from a harm standpoint was underneath their name. And so their names were up there on a slide. And Dr. Shabbat would say, this is what happened since our last board meeting in harm events. And then the next click of the slide was if the name turned red, that means that the patient expired. And so the first time that that was presented was very shocking to the board. And then I, as the chief operating officer, had to stand up in front of the board and say, here's Michael with Dr. Shabbat would say, here's what clinically happened to the board, I mean to the patient, but here's what we're going to do about it from an operational standpoint. And I had to describe what would happen, what we did to mitigate that from ever happening again. A lot of times in board meetings, you can imagine 10 years ago, boards were not, however liability was not a big topic at the board meeting. What do you think boards were most interested in? They were interested in financials, what kind of big project they had, what kind of big capital equipment, what they were going to build. It was about bricks and mortar, how they were going to grow, who they were going to merge with, who they were going to buy. And so one of the things with governance is total transparency, total honesty. And then you have to have time at the board meeting to discuss these events because you're going to be asking the board to submit, to give you resources in order to mitigate some of these harm events. And then you have to educate your board. You have to bring experts in that are from, it's always good to bring outside experts in from a governance standpoint to remind the governance of the organization. What is their fiduciary as it relates to quality and safety? And then you bring people in like physicians that are experts in quality and safety and say, here's what you have to put in place in order to mitigate harm among your physicians, your hospital staff, and your patients. And at Memorial Hermann, what we used to do is we would bring patients and family members into the board meetings and let them tell the story if their family member was harmed. And that's very powerful for governance to actually hear about a harm event from a patient or a patient's family member, what that did to the family. And then we would also, when we had staff that stepped in and did heroic things about saying, we stopped the surgical procedure because the surgeon wouldn't do a time out or mark a site or we did a safety, a double safety check on like a blood administration or something like that, we prevented harm. We would present them at the board meeting and let them tell their stories to reinforce to governance. We are doing the things to keep our patients and our workforce safe in this organization. So that's the first thing, I mean, that's starting with governance. That is the first thing. The second thing you have to then as senior leadership have to declare, we're not going to have harm events and everybody is accountable. Starts with the CEO and it goes right on down to the employee and the organization. And it's not just, how reliability is, we always think about the patient and something bad happening to the patient. But it permeates the culture to the point where you could have a registration clerk sitting in a registration booth registering patients and see somebody spill their coffee in the lobby. That person has a responsibility to stop what they're doing, go over there, and either clean the coffee spill up off the floor to keep another visitor from slipping and falling on the floor, or call housekeeping and go stand by the spill until housekeeping gets there and cleans that up. So the culture, it's about creating a culture of accountability where everybody is responsible for safety of everybody, of visitors, staff, patients, etc. And so senior leadership has to be the next rung down that you're responsible for it. I'm holding you accountable for it and it's no excuses accountability. We don't make excuses when things happen. We make action plans about what we're going to do to mitigate, okay? No excuses, action plans. And then you start tying incentives. You tie your financial incentives for your executive team to quality and safety in the organization. You send a message to the organization that the only way that you get promoted and that you move upward in this organization, is that you have a commitment to quality and safety. And you demonstrate that time and time again and you demonstrate it over time. So that's kind of the second rung and then to your medical staff. And this is, it's no easy feat. And you have to hold the line with the medical staff to say, you know what, if you don't mark a site and you don't do safety procedures here, you can't stay here. And that's very difficult. And it's especially difficult in small hospitals across the country. If you are the only general surgeon in a 150 bed community hospital says, I'm not doing a timeout, are you going to get rid of that general surgeon? You might discipline, but are you going to say you can't really operate here? Now, when you're in a big metropolitan area and you've got thousands of physicians on your staff, people might say, well, if you're not going to do that, there's another one that will come out and take your place. That's not the culture. The culture is we do this for everybody's safety. We're doing it for your patient's safety. You're not trying to do this to be punitive. You're trying to establish the culture of safety for everybody. And you're actually sending the message to the physician, I care about you, but I care about your patients as well. And we're going to do everything we can to keep you safe and to keep you from having a bad outcome as well as your patient. And so the medical staff is, and the thing that I found with the medical staff is 95% of them will always do the right thing. They will always do the right thing. You give them good information, you're honest with them. You're very straightforward. You show them information, you're transparent. You're not spinning anything. There's no spin here. It's about the truth. It is only about getting to the truth. 95% will do the right thing every single time. And sometimes you can say, well, there's few, sometimes physicians, they're scientists. So they're a little skeptical by nature because that's their job to be skeptical. And what I tell people a lot of times is if you ever convert a skeptic, you get an evangelist, right? And so what you want to do is you want to create a lot of evangelists within your organization. They will go out and they will be the ones that will tell their peers, do this because it's the right thing to do. When their peers don't do that, it's not administration coming down on the medical staff. It's the medical staff doing their job of governance from their standpoint of taking care of their own medical staff peers in terms of safety. And then from the medical staff, you get to your employees. So again, everybody is responsible and accountable for high reliability in the organization. So at every leadership meeting on your CEO newsletters, your all communication forms, you have your organizational safety scoreboard out there. You have that thing stuck up on every nursing unit in the hospital and every department in the hospital. So everybody knows every day where you are on quality and safety. Totally transparent. You can't hide anything. That gets a little hairy for a lot of people because they are scared that, oh, legally that might expose us, et cetera. There are legal considerations and I'm not trying to minimize that. But the overwhelming majority of stuff that we have to discuss can be transparent. And if you want to get to high reliability, you're going to have to get there about transparency and honesty and straightforward and candor about things. Wow. Well, you mentioned that Memorial Herman, you went on this journey in 2007. Where is Memorial Herman now on the high reliability journey? Yeah, so they're still recognized as one of the leading health care systems in this country for high reliability because I think we paved the way for a lot of other organizations to start doing that. But we also had a lot of other organizations like ACHE and IHI and other quality-related organizations come together because they actually saw how much harm was being done in the country. And so, for example, when I was chair of ACHE, ACHE and IHI came together and Dr. Gary Kaplan with Aleutian Leap Institute was chair of Aleutian Leap Institute at the time. The chair of ACHE, well, Deborah Bowen and Dr. Tejal Gandhi from IHI, we all came together and said, this is such a national issue. Let's come together and come up with a white paper that we can give and present to the industry about how to become high reliability in health care. And so we interviewed over a year. We got together, there was a group of us. We interviewed like 50 different leading health care organizations, all big name organizations you would recognize them all. We interviewed oil and gas people, aviation, nuclear power, military folks. And we asked them, these are all high reliability organizations. We said, how did you get there? How did you train your people and what was that journey like? And we put that together in a 47-page paper called Blueprint for Safety. And it's free and we gifted that to the country. We gifted it to every health care organization in the country. And I think I can't remember what the latest is, but the last time I heard that document had been downloaded over 18,000 times. And so you can go on IHI's website and ACHE's website and get that document. And it basically breaks it down into six domains of what are the domains of a high reliability organization. And then ACHE and IHI, what we have spent time doing is developing curricula around those six domains. Because one is like I just said, is governments. The second one is senior leadership, diversity and inclusion. How do you embrace diversity and inclusion in order to come up with a safe environment? And so it goes through the six domains and we put together curricula about teaching organizations. If they're having trouble in one of those domains, how do they get help to get there? And so when I was president and CEO of Memorial Hermann, our chairman, Deborah Cannon, she was the CEO for the Houston Zoo. And you think about, that's a pretty high reliability organization. Because I'll tell you, if the tiger gets out of the cage on Saturday afternoon, that's a bad day at the zoo, you know? And so there are a lot of high reliability organizations that you can learn from. It's not that we have it all under control and everything, but it's kind of the journey that just never ends. It just, it just, it's, as I think we were talking earlier, the high reliability environment will get redefined because of changes in technology and in technique. And so when you think about what we've been experiencing for the past year now with the pandemic, with COVID-19, think about the high reliability environment now of telemedicine and telehealth. And how we're going to ensure that patients are not harmed via telemedicine and telehealth where you don't have that direct contact between a caregiver and a patient. And how that information has to get moved back and forth between different kinds of medium. And so we've got a lot of challenges on this, a lot of challenges for us as we're moving forward. So what recommendations do you have for an organization who's just getting started on their journey? I would tell you that the first recommendation would be you just got to bite the bullet and go do it. I mean, it's, you have to do it. It's not a recommendation of, I think you ought to go do that. If you're going to be in healthcare today, you have to go do it. And what I would tell people is, don't, don't do a start, stop thing. I mean, when you get started, people in the organization most of the time and most organizations, they always see it as flavor of the month. Here, you know, we're, we've got a new initiative here to keep people safe and keep workforce safe. Flavor of the month, it'll, it'll pass. It'll go by and we'll lose interest in it. So when you get committed to this, you need to be all in. You got to get your board on, on board first. Governance has to be the first step. And the rest of it is a journey. It is a multiple year journey and you're not going to get there in one or two or three years. It is a multiple year journey. And you have to put resources. The other recommendation is you got to be willing to put forth resources. And, and so for an example of that was we came, we, we decided to be a high reliability organization if you were admitted to the hospital. If you were sick enough to get admitted to the hospital, you were sick enough to see a doctor in a timely manner. So we had a rule. We established a rule and concert with a medical staff and it was not easy. But we said, if you get admitted to any of our 17 hospitals, you had to see a doctor within four hours of being admitted. If you got admitted to the ICU from the emergency room, you had to see an intensivist within two hours of being admitted to the ICU. If you were sick enough to go to ICU, you must be pretty sick. Because all across the country, it happens, it happens every day that somebody gets admitted, but the doctor says, I'm admitting my patient. You know, Chuck, I know him well. Go ahead and admitting through the ER. I'll see him when I get through with my office practice this afternoon. Well, that doctor could be tied up all day seeing 30, 35 patients. And they, they come up at eight or nine, 10 o'clock at night. Well, if I have sepsis and I don't get treated for eight hours, you, I could be over the line of being, you know, taking cured from sepsis. I could be, it could be overwhelming sepsis and I could slide down the tubes and I could die. Okay, so we said, you have to have, you have to see a doctor within four hours or two hours if you're in the ICU. And when we said in order to make that happen, we have to put hospitalists in our, in our, in our facilities, all 17 facilities have to have a hospitalist 24 hours a day, seven days a week. We have to have intensivists in our ICUs to see a patient in two hours. And it was not popular at first with the medical staff because they didn't want another doctor seeing their patient. But they got used to it and it became the standard of care. It costs millions and millions and millions of dollars for our board to allocate the funds for us to provide staffing for hospitalists and intensivists in 17 hospitals for 24 hours a day, seven days a week, 365 days a year. But that's what it took in order for us to say high reliability that we wanted to get on that journey. So don't, you can't be tentative about it. You have to be all in to get started. There's a process and you can move that forward. I'm not just trying to say you have to get there overnight because you're not going to do that. I think you've got to be transparent. You've got to become a transparent organization with your data. You've got to be willing to share and share it throughout the organization and you've got to call it for what it is. And when you have bad outcomes, you deal with the bad outcomes. You have to be willing to do that. It's constant communication. You communicate. You start all meetings with high reliability stories about bad events, good events, good catches or something that, you know, prevented. It's not always about looking for the negative, but it's about looking for the positive. And we call, you know, we call that it's opening your kimono. Okay, it's like you got to be honest and you got to just say, here's who we are. This is where we are, but we're committed to getting better. And then the no excuses accountability, you got to say, we're not making excuses. We're going to make action plans. And that's how we're going to become a high reliability organization. Well, Chuck, this has been so wonderful. Thank you so much for joining us today and for sharing all of your wealth of knowledge on high reliability organizations. It's our goal here at the Patient Safety Movement Foundation that every healthcare organization across the globe will make a commitment to being highly reliable. So thank you for helping us get started. Absolutely. Thank you. Thank you for having me. I've enjoyed it. We'll have a wonderful day. You too. Bye-bye.