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We’re joined by Barbara L. Olson, a nurse and the chief clinical officer at The Just Culture Company. We dive into the recent report by the President’s Council of Advisors on Science and Technology (PCAST) titled “A Transformational Effort on Patient Safety.” Barbara shares insights on the report’s key findings and recommendations, particularly focusing on the concept of Just Culture and its role in improving patient and clinician safety in health care systems.

Barbara L. Olson is a nurse and chief clinical officer, The Just Culture Company. In this role, she supports health care clients in planning and sustaining Just Culture as a system of workplace justice. She can be reached on X @safetynurse.

She discusses the KevinMD article, “A shop teacher’s daughter on transforming patient safety.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Barbara Olson. She’s a nurse and chief clinical officer of The Just Culture Company. Today’s KevinMD article is titled “A shop teacher’s daughter on transforming patient safety.” Barbara, welcome back to the show.

Barbara L. Olson: Thanks for having me today, Kevin. I appreciate the opportunity to be here.

Kevin Pho: Now, for those who didn’t listen to our first episode together, I think it was a year and a half ago, just briefly remind viewers of your story and journey.

Barbara L. Olson: Thanks, Kevin. When you and I spoke about a year and a half ago, we were talking about a nurse who was being sentenced in the criminal courts for an on-the-job medication error. As for my background, if you looked at my social media feeds, they’d tell you I’m a nurse with an engineer’s mind, so that’s not a bad elevator speech for understanding who I am and how I look at the world. About 15 years ago, I turned my career to patient safety, which is the science of preventing people from being harmed as a result of care that is intended to help them. I’ve been privileged to serve on the executive oversight committee for the Certification Board for Professionals in Patient Safety, and I was a member of the working group that developed the first certification exam for professionals in this discipline.

I’m telling you these things, and I could tell you more about personal experiences supporting teams, driving measurable improvements and receiving awards, only because it’s important to understand that I bring deep subject matter expertise. I really have been deeply engaged in this work over the past two decades, and I relish the opportunity to talk more about where we are, and perhaps why we are where we are.

But thanks for mentioning that I work with The Just Culture Company. My current focus is really on helping organizations adopt systems of fair accountability: What do you recognize, what do you reward, what do you tolerate and what do you punish in the workplace, and how does that contribute to the outcomes we’re getting? Because we’re going to talk about the article I wrote, called “A shop teacher’s daughter on transforming patient safety,” I will tell you that, in addition to my professional credentials, I grew up in a house where people routinely said things like “Measure twice, cut once” and “Fail to plan, plan to fail.” It turns out, Kevin, that these things actually have a lot to do with how well we’re doing and what we need to do more of. The ultimate question is: Do we have a good plan to improve the safety of patients, or are we still executing against a plan that is not sufficient?

Kevin Pho: All right, so let’s talk about the article that you wrote on KevinMD, “A shop teacher’s daughter on transforming patient safety.” How did your article come together?

Barbara L. Olson: The impetus for the article was a report published in early September of this year called “Transforming Patient Safety,” and it came from the President’s Council of Advisors on Science and Technology. The first reports telling us that patients were not safe were published over 20 years ago. I’ve read them all, and when this one came out, I read it too. It wasn’t a surprise to those of us in the patient safety community, and frankly to patients and all stakeholders, that there is dialogue around this right now. In this decade, we can assume that approximately a quarter of Medicare beneficiaries who have to be hospitalized will experience an adverse event, and that upwards of 250,000 people in the U.S. each year die as a result of a medical error. It remains a serious problem. So when we ask, “We’ve been at this for two decades; how are we doing?” we know the answer is not what we would have expected.

The first thing that really impressed me about the new report is who it came from. The President’s Council of Advisors on Science and Technology is a 28-member group of national thought leaders who represent science, technology and marketplace innovation, and their goal is to optimize the well-being of the populace. It seems to me that our first-generation improvement work was informed by plans that traced back to the original IOM reports. These came from some of my peers, some of my mentors, some people I admire, and overall I would tell you they’re dedicated, educated, positively motivated people. They’re healers and academics, and they wisely invited others to the table. But I will say I think it has been largely a physician and health system approach. There have been many economic carrots, and a large number of economic sticks, that went along with those plans in order to drive change. Maybe this early work was important, necessary and foundational, but I don’t think you can argue, and I know my dad would not say, that we got what we wanted as a result of it.

So when you think about all of the thousands of ways in health care that things both go right and go wrong, it is important to me to see that this report is coming from outside of health care, that it is respectful of health care knowledge and professionalism, but that it is saying that in order to fix this, we need to bring everyone to the table. That’s the first thing I loved when I saw the report.

The second thing I really liked was that the health care workforce is included. The report covers both patient safety and the safety and well-being of the people who care for the patients, and I think that’s really wise. Relative to that kind of all-in, holistic approach, I liked that there is a clear recognition of the need to partner with patients, not to satisfy patients or engage patients, but to truly come at this in a way that fully includes patients. The other piece of that inclusive nature that I thought was noteworthy is that the report clearly calls out disparities and recognizes that there are members of patient populations who have experienced harm at disproportionate rates, and that their engagement, their participation and their seeing the world through different lenses is really important. If I were going to put my shop teacher’s daughter hat back on, I’d say I think the original plan, Kevin, was that a rising tide will lift all boats, and when you look at the data now, that was not a good plan. We have left many pockets untouched. So I think there’s an opportunity, and it is reflected in the recommendations from this report, that will help us get to a better place.

The third thing that I would call out, that I loved seeing in the report, is the recognition of workplace justice: that what you recognize, reward, tolerate and punish will inform what happens in the workplace. I’d also say, because I have been in the just culture space for many years now, that it can be a confusing term. Sometimes it’s tossed around kind of like Kleenex or Windex, where we all have a reasonable understanding of what’s in that bottle or what’s in that box. But just culture is really not like that. If an organization is going to benefit from having a workplace culture that performs in a certain way, it’s really important to say specifically what that looks like.

Just culture is really about shared accountability. People are judged by the quality of their choices, not the luck of the outcome, and organizations are accountable for the systems that people use to deliver care. What is intrinsic to the just culture model of workplace justice is recognition of human fallibility. I think our first generation of work helped a great deal. Twenty-five years ago, it was really hard to say that a smart physician or a caring nurse could err, and that has been addressed and somewhat tamped down. The key, though, is to recognize what you do with that knowledge, and it is only going to result in something good if the fact of our fallibility is countered by systems that can reasonably anticipate both human error and what I would call, in a very unscientific way, a sketchy choice. Some choices are made because they’re the best a person can do at the time, and sometimes they’re not an ideal choice, but they actually represent a choice. So our systems of workplace justice have to deal with the fact that people of free will make choices that may or may not align, and we have to have systems that can reliably produce the desired outcome despite the fact that those things are happening all the time.

The other thing I would tell you about what I saw in that report, and it’s important to recognize at scale, concerns who designs these systems. You can look and say, “Wow, it is really important for General Hospital to have good systems of care,” but a general hospital does not have unlimited resources. We also have to ask how well EHRs are designed, how well medical devices are designed and how well pharmaceuticals are designed to help people do the right things and not step in the wrong hole. So this whole notion that this is all-in is really important to me, and I think it is really a differentiator as we look at what should come from this next call to action.

Kevin Pho: Now tell me, how far are we from your ideal world of just culture? And if we’re not quite there yet, tell us some of the immediate steps that hospitals and medical institutions should take in order to get us there.

Barbara L. Olson: I think it’s really important to recognize that just culture, as a system of workplace justice, is not one tool in a high-reliability toolkit that you pull out when you’re going to judge conduct in the aftermath of an event. For many people in health care, it came to us that way. That’s how we came to know that there is such a thing, and for many people it resonated. But just culture is really about what you choose to recognize, reward, tolerate and punish all day, every day, from the days when you don’t think anything has come even close to jumping the tracks to the days when it seems like everything lined up and the whole thing fell off the rails. Because the difference between a catastrophic event and business as usual lives in what business as usual is.

As organizations strive to align their workplace accountability systems, it’s really important to see that this is not something that’s in the patient safety toolkit. This is about how we respond to human conduct. Patient safety and worker safety, which we’re talking about today, are really my life, but I’ve also already mentioned things like: Are we equitable? Are we fair? Are we timely? Do we have good stewardship? These are all values that compete, and so for people to actually be able to make the right choices, organizations have to be really clear about what they value. In this space it’s really exciting, because the most important work happening right now is when interdisciplinary teams within hospitals and health systems come together. You have at the table organizational development, HR, clinical leadership, and yes, certainly patient safety and clinical quality, because they’re often looking at those metrics as a signal. But if you want to really change what’s recognized, rewarded, tolerated and punished, you’ve got to go to everybody.

Kevin Pho: Tell us the steps that a lot of hospitals still need to take in order to meet your ideal. What are you seeing from different hospitals in terms of the type of work they need to do next?

Barbara L. Olson: Like any notion that grabs attention and piques the imagination of people, you have organizations that have been at it for a long time. It made sense to them; the whole idea that this aligns with your values was easy to latch on to. Then you have those that are coming to it now because they are working from pretty strong national guidance and playbooks, responding to reports like the one we’re talking about today and saying, “OK, we’re not exactly sure what that is, but we want to explore it.” And then, as always, there are people who say, “I don’t think that’s the right way to approach justice.”

Because when we’re talking about what is recognized, rewarded and tolerated, many times what we have to recognize is that we’re not going to punish people for errors. We reset and say, “OK, what are we going to do if we’re not going to punish you?” Well, if you’re working in a system that’s way underdesigned for the task at hand, and you happen to be the person whose human error set something horrible in motion, we may need to console you. We may need to own, as an organization, that we had a system there that was a bomb, and it was just a matter of time until it went off. So as organizations learn to ask what this model means, and then think, act and resource what needs to change in order to live those values, there are quite a lot of shifts that will go on.

As for the other part of the model, there are many interesting facets of it. It’s not particularly complex, but it isn’t 100 percent aligned with American jurisprudence. Anybody who’s a hockey player knows that if you draw blood, your punishment is greater than if you didn’t, but drawing blood may just mean you hit the person in the wrong spot, right? So we’re peeling that off and asking what we give up if we’re not going to hold you individually accountable for a particular outcome. To really look beyond that means we have to be very sure of the quality of a choice that demands disciplinary sanction, and sometimes that does occur. There are times when individuals employed in an organization will do something deliberately to impugn the reputation of the organization, or they may choose to steal from a patient. Those are outlier behaviors, but they do occur. This is not a blame-free system of workplace justice. Rather, it says, let’s look at the quality of the choice and the circumstances under which these individuals are acting, in order to get to the place of saying what the correct response is and, from a system standpoint, what the replicable response is. Because we’re mammals, and like other mammals, we know what’s fair. We can immediately recognize when we don’t feel like we have been treated well. So it is both having a sound model of workplace justice and having the ability to make it teachable, learnable and replicable.

Kevin Pho: We’re talking to Barbara Olson. She’s a nurse and chief clinical officer of The Just Culture Company. Today’s KevinMD article is titled “A shop teacher’s daughter on transforming patient safety.” Barbara, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Barbara L. Olson: I thought about this a lot, Kevin. I think the most important thing, and it would have been true for me at probably any point in my career, is to really recognize that humans are fallible, and that our ability to deliver the results we want depends not only on knowing that but on doing something about it.

I would say that in health care, I think we under-ask, and perhaps under-demand, metrics and measures that tell us how safe something is. Your airline can tell you the likelihood that you will be harmed on a flight. It’s a very rare event, but they can tell you what they would project. They would never tell you it’s never going to happen; let’s just say it’s so rare that it likely won’t happen to you, and you probably will never know anybody it happened to. They can also tell you how safe your luggage is, and that’s not hard. Everybody has had lost luggage, or knows somebody who’s had lost luggage. But if I actually asked colleagues, “How safe do you think somebody is if they’re receiving an IV medication in an area where there’s no barcoding?” they would say, “Oh, I don’t know. Good question.” So my take-home here, as we think about what we need to do to improve, is to step up and get picky. These principles are in use in other industries all day, every day, and we need to invite them into ours.

Kevin Pho: Barbara, thank you so much for sharing your insight and perspective, and thanks again for coming back on the show.

Barbara L. Olson: Thanks for having me.