Skip Navigation Archive: U.S. Department of Health and Human Services www.hhs.gov
Archive: Agency for Healthcare Research Quality www.ahrq.gov
Archive print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to www.ahrq.gov for current information.

Can You Minimize Health Care Costs by Improving Patient Safety?

Session 2: How Can States and Institutions Work To Create a Culture of Safety?

Presentation by Julie Morath


Via the World Wide Web and telephone, the second session of a Web-assisted audio teleconference series occurred on September 30, 2002. The User Liaison Program (ULP) of the Agency for Healthcare Research and Quality (AHRQ) developed and sponsored the program.

This is the text version of the slide presentation.


Slide 1

Cover slide with image of Julie Morath, M.S., R.N., Chief Operating Officer and Chief Executive Nurse, Children's Hospital and Clinics, Minneapolis/St. Paul, MN.

Slide 2

The Leader's Role

Creating and Leading a Patient Safety Manifesto.

A Public Declaration of Intent for Action.

Slide 3

Patient Safety Manifesto

  1. Declaring an Urgent Problem.
  2. Accepting Leadership Responsibility.
  3. Gaining Knowledge and Tools.
  4. Ensuring Accountability.
  5. Confronting Myths.
  6. Aligning External Controls.
  7. Accelerating Change.

Slide 4

What We Learned

  • Myths and expectation of perfection are deeply rooted.
  • Fear of failure, blame, and sanction permeate health care.
  • Learning and understanding complexity is critical to creating safety.
  • Stories and conversations create safety.
  • Keep the cases alive: revisit issues.
    • "I don't know what it means now."
    • "It is disturbing."
    • "It is not concluded."
    • "Friction-less dissemination."

Slide 5

What We Learned

  • "Accounting" or reporting that loses the story is a waste.
  • Errors are sources of learning and resiliency.
  • Errors define margins of safety.
  • Follow and break rules.
  • Prioritize on themes/archetypes.
  • Safety requires a team.
  • Safety is as much about recovery as prevention.

Slide 6

"Reciprocal Accountability"

This is not about telling people to be more careful.

Slide 7

A few Simple Rules to Remember (image of Swiss cheese slice)

  • Fix what you can.
  • Tell what you fixed.
  • Find someone who can fix what you cannot.

Slide 8

Black and white image of woman holding an African-American child

  • "Nothing about me without me."
  • "If it looks wrong, it is wrong."
  • Disclosure and truth-telling.

Slide 9

"Over-learn" the Key Concepts

  • Swiss cheese model.
  • Blunt and sharp end.
  • Hindsight bias.
  • High Reliability Organization (HRO).

Slide 10

Executive Session

  • Three levels of success.
    • In the ideas and behavior of members.
    • In challenging professionals outside the confines of the group.
    • In changing conventional wisdom.

"Who loses sleep over this problem of patient safety?"

Slide 11

Engagement of State Officials and Hospital Leaders

  • Start the dialogue.
  • Educate.
  • Review the regulatory experience.
  • Identify common ground.
  • Work to close gaps.

Slide 12

Hospital leaders

  • Positional leaders.
  • Leaders in medical/professional staff.
  • Attitude/informed leaders.

Slide 13

Patient Safety Improvement Corps

  • Structure to represent "ideas."
  • Methods to evaluate effectiveness on interventions.
  • Deployment/dissemination strategies within and across the organization.

Slide 14

State official potential pitfalls

  • Individual and isolated problem focused response.
  • Protection of the public versus improvement of the system, e.g., "heads must roll."
  • Public accountability and expectations versus space for improvement.

Slide 15

State official potential pitfalls.

  • "Watchdog" relationship versus partnership relationships.
  • Distance from real world issues.

Current as of March 2003


Internet Citation:

Text Version of Presentation by Julie Morath. Can You Minimize Health Care Costs by Improving Patient Safety? Session 2: How Can States and Institutions Work To Create a Culture of Safety?. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ulp/costsafetele/sess2/morathtxt.htm


Return to Teleconference Sessions>

The information on this page is archived and provided for reference purposes only.

AHRQ Advancing Excellence in Health Care