TSB Transportation Safety Summit

"Disciplinary" case study from health care

Jack Davis
Chairman and CEO, Mobile Inc.
Ottawa, Ontario, 21 April, 2016

Check against delivery.

Slide 1: "Disciplinary" case study from health care

• Jack Davis
• Chairman, CEO.Mobile Inc.
• (former President & CEO, Calgary Health Region)
• TSB Transportation Safety Summit 2016

Slide 2: Preamble

• (former) Calgary Health Region (2004)
  • geographic area
    • 39,260 sq km
  • 14 communities
    • 12 acute care sites
    • 40 care centres
    • 7,836 beds/spaces
  • healthcare providers
    • 24,000 employees
    • 2,150 doctors
    • 3,917 volunteers
  • Map of Calgary Health Region

Slide 3: Outline

• Part 1
  • Events of 2004
• Part 2
  • What did I do?
  • What was the outcome?
  • What effect did it have on the organization?
• Summary

Slide 4: Part 1: Events of 2004

• Unexpected deaths of two ICU patients.
  • undergoing continuous renal replacement therapy
  • potassium chloride (KCl) used instead of intended sodium chloride (NaCl)
• We could have had 34 deaths!.
• Pictures of boxes and vials of potassium chloride

Slide 5: Part 1: 2004

Front page of Calgary Herald, March 19, 2004

Slide 6: Part 1: 2004

News article in the Calgary Herald.

Slide 7: Initial reaction: Shame & Blame

Dialysis drug mix-up demands fatality probe news article

Slide 8: Part 1: 2004

Pharmacy staff to answer for deaths news article

Slide 9: Part 2: What did I do

Photo still of CBC news interview

Slide 10: Part 2: What did I do

Facing up to double jeopardy new article

Slide 11: What I started to do

• Considered disciplining in accordance with expectations
  • To calm the noise in the media
• Listened to advice
  • Legal
  • Insurance
  • Medical professionals
  • Safety experts

Slide 12: A fork in the road

• The press was calling for ‘blood”
• My rethinking
  • ‘You can't run your life by catering to the media.”
• My experts were saying
  • “This has happened before; there are methodologies to sort this out. Let's get going!”
• My thought
  • They had science and insight behind what they were saying − not making it up.

Slide 13: A cold weekend day in the spring

• A walk in the snow led to a decision
  • “Somebody else could be making the same error elsewhere….”
• What should we do?
  • What would make the system better?
  • What would save lives?
  • What would alleviate pain & suffering
• What you line it up that way
  • There are no other options!

Slide 14: What we'd done well by that time

• Full disclosure with family
  • Explained all the facts
  • Rare at that time
• Shared problem with other HC systems
  • To avoid other deaths
  • Also rare at that time
• Went public: held news conference
  • Were open, honest & transparent

Slide 15: What I did

• Dealt with Pharmacy Technicians
  • Off with pay during the 3 investigations
  • Given counselling
  • Not disciplined or blamed.

Slide 16: Part 2: What was the outcome

Photo still of new press interview

Slide 17: Allocation of resources

• An individual at the Executive Level
  • With appropriate authority
  • Responsible & accountable
• $ 5M CAD od $5B CAD budget
  • HAVE budget for safety!
  • Relatively modest investments
  • Most good things relatively inexpensive

Slide 18: Some of ‘WHAT' we did

• Board Committee for Safety
• Safety Department, with a VP & $
• Code of Conduct
• 4 related policies
  • Disclosure
  • Reporting
  • Informing
  • Just & Trusting Culture
• Safety briefings before meetings
• Reporting software
• Patient Family Advisory Council
  • Active member of Region's Safety Committee

Slide 19: Our culture was the problem

• Hierarchical
• Individual responsability
• No sense of system
• Organised for failure
• Shame & blame
• Picutre of ruins

Slide 20: System needed to change

• If a system is inappropriately punitive
  • Takes energy to suppress negative feelings
  • Contributes to low morale & low energy
  • If your energy is low, you can't care
• Needed: appropriately non-punitive system
  • Just and trusting culture
  • More energy: Cross-over conversations
  • Focused on family centred care
• The whole system will improve!

 [Slide 21: Part 2: Effect on organization?

Photo of CEO

Slide 22: Blinding light of the obvious

We have the teams and the expertise to solve these problems!

Slide 23: From need to effect!

• Aim was to change the culture
  • Amended to Code of Conduct
  • Instituted Just & Trusting Culture Policy
  • Changed how we approached accountability
• People were
  • Happier & more engaged
  • Ready to improve the safety of the system

Slide 24: Deb Prouse & Steve Long

Photo os Deb Prouse & Steve Long.

Slide 25: Gave people confidence

• If something goes wrong
  • It's usually NOT about the individual being incompetent and / or needing punishment
  • Generally it's a failure in the system that needs to be addressed

Slide 26: Just & Trusting Culture Policy

• Picture of Just and Trusting Culture Policy
• Errors – when there has been failure in the provision of care to a patient and the health-care provider did not deviate from established policies, procedures, standards or guidelines, then the health-care provider will not be disciplined by the Region.

Slide 27: Summary 1

• The mission of healthcare
  • Saving lives
  • Avoiding unnecessary pain & suffering
  • Improving the quality of life
• Take everything back to these points
  • These are the reasons we work in healthcare
• Doing the right thing is easier than you think!

Slide 28: Summary 2

Leadership – a critical success factor cartoon.

Slide 29: Acknowledgements

• I would like to thank three people who have direct experience in the area & who have helped with this presentation
  • Ward Flemons MD FRCPC
  • Jan Davies MSc MD FRCPC FRAeS
  • Carmella Steinke RRT MPA.