When it comes to creating a culture of safety, physicians play the leading role on their medical teams, whether they want to or not, said this year’s presenter of the Anna Maria D’Amico Lecture.
C.M.A. Max Rogers IV, MD, FACOG, presented “Leading a High Performing Women’s Healthcare Team: Your ‘How To’ Checklist” Saturday as part of the annual Presidential Program.
Dr. Rogers, who described himself as a “boots on the ground” obstetrician and gynecologist, came to medicine after years as a Marine fighter pilot. His interest in patient safety and quality improvement in health care has led him to use his military background to create steps to reduce medical errors.
“Culture is what we do when nobody is around,” said Dr. Rogers early in the presentation, quoting retired Navy Adm. Harold W. Gehman.
Dr. Rogers closed his presentation by talking about his fellow pilot and good friend Navy Cmd. William McCool, who later became an astronaut and was one of the crew members of the Space Shuttle Columbia who died in 2003 during re-entry. The review of the accident — led by Adm. Gehman — found that the disaster was a direct result of NASA leadership failing to create an effective culture of safety.
“Ladies and gentlemen, I submit to you that the consequences to our patients, and the consequences to our teams, of us failing to lead those teams are no different than the consequences of the leadership at NASA failing to lead their teams,” Dr. Rogers said.
Culture is like an iceberg, Dr. Rogers said, with the top 10 percent being the observable, visible behaviors. Teams look to their leaders in that top 10 percent. He cited a study that showed leaders who improve their visible behaviors reduce adverse events in a practice by 80 percent over two years.
Four of the six items on Dr. Rogers’ checklist concerned communication. He said it was the most important tool that a high-reliability practice has at its disposal.
“If communication is so vitally important to your mission, you cannot afford to leave anything to chance. Nothing,” he said.
The checklist includes:
- “SBAR” Say the Word — Situation, Background, Assessment, Recommendation technique. Nursing units are being taught this, he said, so physicians need to ask nurses directly.
- Read-backs: Ask for it First — Every time Dr. Rogers leaves a verbal order, before anybody can say anything, he tells the team member to read the order back to him. This prepares the physician to understand that the conversation is not over, gives the team member a sense of relief, and identifies the physician as a player in the culture of safety.
- Clarifying Questions: Encourage & Invite — After any explanation, leaders should reach out and ask their teams if there are any questions. Ask the most junior member first, which has a positive impact on the whole team. “In almost every serious event, somebody on the team knows that something’s not right, but for whatever reason hasn’t been empowered to speak up,” Dr. Rogers said.
- Critical Language: Use it — At his hospital, the phrase, “Before we go any further, doctor, could I get some clarity,” is a signal to everybody about something that could be a safety concern.
- Lead Your “Time Out” — If physicians in their role as team are indifferent to the time out, then the entire team will be. Make every time out purposeful.
- Debrief — If more debriefings take place, then everybody becomes more comfortable. Debriefings also need to take place after positive outcomes.
Dr. Rogers also gave the audience three foundations for any culture of safety. First, he encouraged leaders to do whatever they can to send multiple physicians to the ACOG Postgraduate Course on Quality and Safety for Leaders in Women’s Health Care. Second, leaders need to establish meaningful peer review, upgrading from just grading charts of colleagues. Finally, practice simulation, and a lot of it, must take place.