Today, I released Podcast #124, an interview with former Alcoa CEO and Treasury Secretary Paul O’Neill on patient safety and leadership. You can download or listen to the audio here.
For this special podcast, I wanted to share some transcripts and quotes from what O’Neill had to say, as it’s interesting, insightful, provocative, and sometimes controversial.
In summary, O’Neill talks about:
- Leadership mindsets required for dramatic workplace safety and patient safety improvement, including a near 100% reduction in hospital acquired infections at Pittsburgh’s Allegheny General Hospital
- Why the United States has accomplished “practically nothing” nationally since the famed 1999 Institute of Medicine report “To Err Is Human“
- Why society’s most lacking skill is “leadership”
- Alternative ways of compensating patients who are harmed by the healthcare system while ensuring real improvements are made by learning from each problem
- Why Rep. Paul Ryan (R-WI) needs to shift his focus from “financial engineering” to visiting ThedaCare to learn about “the real way” we should improve health care.
In the podcast, O’Neill was first asked about the workplace safety improvements that took place during his CEO tenure at Alcoa. When this idea of safety improvement was initiated, Alcoa was already in the top 1/3 of U.S. companies for avoiding injuries and their injury rates (as found on the Alcoa health & safety website) are now 30x lower than hospitals, says O’Neill. O’Neill argues this 30x improvement can be achieved in healthcare organizations, but it requires the right leadership and the articulation of goals at the “theoretical limit” (zero harm and zero injuries).
O’Neill then talks about Dr. Richard Shannon, now at the University of Pennsylvania, and how he got interested in this “theoretical limits” approach to improvement from an Alcoa University course that he attended. O’Neill recounts how Dr. Shannon had 39 patients who got infections in 3 ICUs in the 12-month period before the course, with 19 of those patients dying.
Allegheny General Hospital started their infection prevention efforts using these principles:
- get people involved
- get them observing how the care is done
- come to agreement with all about how they would do the work
- do it the same way everyday,
With this approach, if there was an infection, they could more easily understand why that happened.
Over 18 months, they worked in this, and then started measuring for a 12 period. They had 100 more patients than the comparable 12 months, but just 1 infection (not 39) and nobody died. O’Neill said, “Dr. Shannon’s experiences were very consistent with my own at Alcoa, that when we got people to practice good ideas and to learn from every instance of anything going wrong, that the process (whatever it was) got better and better and better. And so, even today, Alcoa has maintained the safety culture.”
O’Neill said, “Since 1999, when the Institute of Medicine’s famous study was published, called “To Err Is Human,” we’ve accomplished, on a national basis, practically nothing in terms of reducing things gone wrong in the delivery of health and medical care.”
After mentioning some of the success stories (UPenn, ThedaCare, Virginia Mason), O’Neill continued, “The tragedy is, as straightforward as these ideas are, leadership in health and medical care institutions around the country have not grabbed these ideas and implemented them, which is, frankly, unbelievable when it’s so clear that the benefits are not only to significantly better outcomes for health and medical care, but significant cost reductions at the same time.”
The rest of story is best told in O’Neill’s own words, edited in some instances for clarity:
“So, I believe, having observed the practice of care giving around the country, in a lot of different venues, that if we can get these ideas practiced every day in every care giving institution in the U.S., we could have an enormous improvement in the outcomes for patients and we could save $1 trillion a year out of the $2.7 trillion we’re spending on health and medical care. And that would be unbelievably positive for our society.”
What is getting in the way these ideas and results spreading more quickly?
“I honestly think the skill shortage in our society, maybe in the world of civilized people, is real leadership. There are a whole lot of people who I suppose are leaders by designation, but I don’t honestly know a lot of people who are leaders in the sense that they will articulate goals at what I call the theoretical limit and then help their people to acquire and practice the skills that are necessary to what I call habitual excellence. It’s really hard to find leaders who understand the concept of habitual excellence, which means a leader should expect every aspect of his organization to perform at the known level of possibility. Having that kind of leadership and a leadership that is not about punishing or blaming people, but about using every single instance of anything gone wrong as a basis for organizational learning is really critical to this. There are a lot of people working on pieces of these ideas but, unfortunately, there isn’t a national movement yet. Hopefully, soon there will be.”
On alternatives to the existing medical malpractice system:
“There are several pushbacks to the idea of habitual excellence. One is to say “well, we can never be perfect and we don’t want to set goals we can’t achieve.” I found in my own early days at Alcoa when people told me that about workplace safety, then I said to them, ‘OK, if you don’t want to have a goal of zero, then let’s go around and find out who wants to volunteer to be hurt to make sure we reach our goal of somebody being hurt. And it’s so ridiculous on its face, it’s equivalent to people saying, “Oh, there’s no way we can eliminate all of the infections in the hospital,” – it’s a lie. It is simply not true. To aspire to less [improvement] than [reaching] zero is to excuse every single one that happens rather than learning from them and figuring out a way to introduce practices that take away the possibility [of infections].”
“In the secondary case of medical malpractice, they say ‘Oh my God, if we start reporting things gone wrong, we’re creating a roadmap for the lawyers to come and attack us with our own information. So, I believe there is a legitimate answer to that and it rests in this observation: if you go around the country and you try to find people who are malevolent malefactors who are intentionally hurting people, I would submit to you that, except for criminally insane people, you can’t find any examples of that. You find that people do get hurt in the practice of medicine in the United States… the answer is yes.
So, we need to combine that observation that people do get hurt with the idea that the way to avoid people getting hurt by the same set of circumstances over and over again is to learn from everything gone wrong. In order to do that, we need to have a transparent system where everything gone wrong is observed, documented, and shared on a real-time basis in every day in every healthcare giving institution.
In order to take away the excuse that they can’t have transparency because of the threat of lawsuits, we should abandon (it was already a bad notion of medical malpractice), and in its place create a system where when an individual is injured as a consequence of a medical intervention, we simply turn the case over to a board of experts to judge the economic loss associated with the injury, and award that individual that economic loss without any lawyers involved and without any trying to hide the fact that an individual was injured so that we can insist on transparency and there won’t be an economic cost associated to the individual events. I believe that this is sufficiently worthy that we ought to pay for it out of the general federal revenue stream of the federal government.
I would be willing to accept a step back from that with the medical care system producing the standby fund to service the economic cost of things gone wrong. I honestly believe, in a fairly short period of time, the costs would be sufficient that it wouldn’t matter.
I’ve been advocating to the government that they should implement a system where every care giving institution in the nation is required to hook up to the internet at 8 o’clock in the morning local time, wherever you are, and report on the internet every instance of a newly identified patient acquired infection, every case of a patient fall, and every case of a medication error. And I think the availability of that data – first of all, it would be shocking to the people and secondly, I think it would spur action to bring those numbers down quickly. It would cause the caregiving institutions to put their shoulder to the wheel of continuous learning and continuous improvement and we would stop this madness.”
“One hope that I’d have is that the Congressman from [John Toussaint and ThedaCare's] state who has become fairly famous for advocating financial medicine for health and medical care would go to ThedaCare, which exists in his own state, and see the real way we should deal with health and medical care instead of the financial engineering Paul Ryan is advocating these days in Washington.”
How others can help create and inspire the right kind of leadership to improve patient safety?
“I would urge Boards of Directors of health and medical care institutions, hospitals, and nursing homes to ensure the day-to-day operational leader is supportive of the idea of establishing theoretical limit goals for everything that goes on in their institutions. Because I think if Boards of Directors urge the people who are day-to-day responsible for care delivery, it might provide some stiffening of the backbone of those who are supposed to lead institutions to habitual excellence.”
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the Chief Improvement Officer for the technology company KaiNexus.