There also has been hesitancy in healthcare to fully embrace communication technologies that can optimise and energise processes. Uncertainty and optimism are certainly warranted in the use of electronic mobile connections in healthcare and the devices that support it. These new approaches touch facets of training, appointments, personal health monitoring and overall system reliability. Beyond the changes necessitated by the pandemic, the need to embrace new technologies in healthcare is now essential and will be for the future despite expected challenges to universal adoption.

The covid pandemic has motivated healthcare to broaden its vision of the potential for remote technologies. Now telemedicine, telehealth, telecoaching, digital therapeutics and mobile patient outreach has become absolutely necessary. They are here to stay. Changes in reimbursement policies have provided coverage for telehealth services that, before the pandemic, was much more restrictive. While patients and physicians may appreciate the convenience of this “new normal”, there are quandaries associated with its uptake. At a time when relationships are so vital to our lives, having technology to either build them (granted in a new way), inform them (via a new set of communication tools) or damage them (dependent on the willingness, system robustness and comfort of the individuals involved) is worth considering. For example, worries about diagnostic accuracy, limitations of the virtual physical exam, concerns about privacy, usability and the loss of the person-focus of patient/physician communication.

The effectiveness of telemedicine and telehealth is also impacted by health literacy, access to reliable networks and patient comfort with using digital tools. Physicians and care organisations have to be creative and rely on partnerships and local resources, such as school district hot spots or public library broadband access, to make the system reliably work for all their patients. On another level, Dissent Magazine discusses a range of economic concerns stemming from the accelerated adoption of telehealth, including the primary worry that services have the potential to be structured as profit centres shifting the focus of decisions toward stakeholder and executive compensation rather than effective care.

Then there are questions surrounding the apps and tools patients are using to make decisions about their health. Dr. Google has known weaknesses. Patient-facing diagnostic apps, wearables and symptom trackers, while showing promise still require appropriate risk evaluation before patients should fully trust them to track and manage their health without clinician guidance, and protect against worry and overuse of health services. The Skeptical Cardiologist shares reasons to resist the temptation to rely on, for example, the blood oxygen monitoring accuracy of a much anticipated product for reasons that include lack of reference to primary data and cost. Use of symptom trackers could proliferate as patients remain hesitant to visit physicians due to covid concerns. One project from Georgetown University was forthcoming about its rapid development strategy when sharing the results of a covid symptom tracker pilot test. Areas covered included size of the beta test (48 students), use of unique identifiers to address privacy concerns for both patients and organisations involved, access to condition-relevant patient-centered educational information and instructions to seek medical care should symptoms indicate that necessary step. It is this sort of transparency that aids the healthcare community and patients to appropriately select and trust tools to manage symptoms and situations for public and personal health safety.

Voice activation technologies, so convenient for getting the latest news and listening to music, are seen as having great potential in healthcare monitoring as well. Voice characteristics are being explored as a diagnostic indicator. As covered recently in Nature, vocal biomarkers can track mental status, pulmonary function and coronary distress. But a myriad of factors could affect verbal characteristics reducing voice as a reliable mechanism for diagnosis. While promising, teasing out these differences in vocal diagnostics is still an emerging opportunity being explored in the US and around the world. Also, the use of voice-activated technologies in certain care settings can impact the privacy of the patient and may therefore not be suitable.

On a systemic scale, the growing dependance on technologies leave patients, clinicians and organisations vulnerable to purposeful or accidental incidents or outtages, such as cyberattacks, that create disruptions and compromise patient safety. Recently a large health system in the US was crippled due to a ransomware attack. Patients needed to be rapidly moved to another out of system facility to ensure their safety. Experts caution that this is not the last of these situations and advise systems to train their staff and create awareness to recognise the early signals of a cyberattack to quickly reduce the extent of the damage and corresponding interruptions to healthcare services.

Mom is now expanding her use of technology to make life better. She is exploring her first streaming service and becoming comfortable with its capabilities to binge on popular programmes. Who knows if that will lead the way to virtual visits with her cardiologist, or being able to track her vital signs from across the country and her personal use of a smart watch to monitor her heart? Let’s hope for all moms and other patients the adoption of technologies in the health space can be folded into our daily lives with minimal harm and negative disruption.

Hill distributes music and instruments to his students with instructions to practice on their own and they come together to play for the town. Let’s just say it doesn’t go so well. Although committed to the goal, the kids can’t play the music without solid instruction, synchronised development, collective practice and effective leadership. A band needs to follow the same score of the same tune in order to MAKE music that works.

The COVID response in the US seems to have put patients, the public and clinicians in a situation similar to that of the River City kids. States, schools and cities seem to be playing from different arrangements of the same tune resulting in a lack of coordination and consistency across the country. The result is not just noise but profound failure. Ed Yong in The Atlantic summarises the systemic discord that has contributed to an estimated 183,000 deaths in the US. He highlights how despite ample warnings the country was unprepared for a pandemic, and suggests it remains unprepared for the next one. Weaknesses in leadership, testing, state policies, data capture and dissemination, public health infrastructure and information inaccuracies set the stage for the spread of COVID. Lack of respect for science, ingrained bias against people of colour and an ineffective health system perpetuated much of what could have been prevented.

The situation Yong describes in his article has led the USA to a patchwork response to the pandemic. Across the country a variety of populations are being put at risk. For example, students and teachers at colleges and universities are having to navigate their way through the crisis – sorting through local concerns and statistics to devise a course that will serve their communities best while serving a mobile population of students who come from home to learn while potentially carrying or picking up the virus to take home or to their dorms. As examined in Kaiser Health News students arriving for classes are experiencing varying approaches to testing, hybrid online/in person class models and stay-at-home and masking orders. And should students become ill, universities may not be well equipped to keep those patients safe.

Strategies to address these problems from politicians, researchers and healthcare abound. There is a recognised need of a national policy that aligns efforts to manage the COVID situation. As noted in USA Today, countries that have had relative success in managing the virus, such as Germany and Denmark, have a collective approach to address the problem they have committed to. The article compares international responses to those of the US to illustrate gaps and highlight areas where coordination and collaboration are desperately needed to move the country’s effort forward.

Healthcare seems particularly suited to offer suggestions for improving the situation. The American Association of Medical Colleges recently published a guidance to set a direction for a safer future. The Way Forward on COVID-19: A Road Map to Reset the Nation’s Approach to the Pandemic outlines 11 recommendations to support and motivate the nation to adopt a systemic, collective plan to reset the country. Informed by expert insights from a variety of fields, the document shares actionable suggestions on topics such as testing improvement, national standards on face coverings and other safety protocols, and vaccine deployment planning. Suggestions include undertaking research to determine efficacy of face coverings to reduce transmission of COVID-19, distribution data to compare the impact of school reopening and designing a government-funded vaccine distribution and use process that involves a wide range of providers.

The Music Man ends with a rousing performance of “76 Trombones.” The kids in the band follow a course toward success, resplendent in full uniform, high stepping and proud, seamlessly working together. The families and townsfolk people beam with accomplishment and join in on the celebration of collective achievement. When will we be ready to take up our instruments and perform cohesively together with no one left behind due to having a different COVID-19 score? 

In some ways, it sounds like healthcare in the era of COVID-19.

While months of the coronavirus pandemic are behind us, the uncertainties caused by the pace of change and the expected surge of further infection spread bring continued stress, fear and frustration. Disruptions to services, processes and relationships are rampant. They demand continued experimentation across healthcare to address concerns to keep patients, communities and healthcare workers safe. And the lack of a coordinated collective policy response to the crisis only perpetuates discomfort about the unreliability of actions to improve safety and the substantial costs the future holds in store.

Ambiguities and dread due to the pandemic are problematic and will be for some time. Continued patient avoidance of care is evident and could be contributing to lack of timely care and diagnosis. An ImproveDx article summarises how fear is keeping patients from getting the care they need, and highlights the importance of recognising that rebuilding trust will take time. To anchor this effort, leaders must view risk as individuals see it rather than just an academic exercise to inform reentry strategies in the months to come.

The unsettled nature of care and access to loved ones during COVID can make end-of-life planning particularly fraught with uncertainty. Stanford University School of Medicine has developed the GOOD framework for clarifying steps forward when working with patients and families facing palliative care decisions during the pandemic. Its four elements – Goals, Options, Opinions and Documentation – provide an effective structure for clinicians to have conversations with patients and families to address care management when the path forward is unclear.

Prolonged uncertainty can degrade healthcare staff mental and physical health. In Hawaii, one health system sought to make antibody testing available to staff as a strategy to decrease anxiety and improve sensemaking around the crisis. Hawai`i Pacific Health in NEJM Catalyst explores the reasons why those who were tested opted into the programme. The authors found “curiosity” to be a primary motivator. Knowing something – whether positive or not – can reduce one aspect of uncertainty, which the article posits will help clinicians and their community think beyond the doubt to achieve a modicum of control. This single piece of stability will enable a willingness to gather information, to plan and to act.

Despite the challenge uncertainty brings, there are individuals who consistently believe the future holds promise. People who are able to act and make a difference despite uncertainty. Much has been said about those in the midst of the COVID-19 crisis, but others continue to address persistent uncertainties and unreliableness of care – beyond the pressures of the pandemic. There are many whose tenacity shores up the foundations of the healthcare system to improve its safety. One such leader from the US, John Eisenberg MD, is celebrated every year through an award programme in his name. John was a founding father of patient safety in the US. Through his leadership, national research and improvement programmes were developed and funded to lead government efforts to improve quality and safety. In July for the first time, the John Eisenberg Patient Safety and Quality Awards were bestowed virtually. These awards recognise individuals, local efforts and national programmes whose work provides evidence of the value and commitment to engage in work to improve safety.

This year’s recipients demonstrated values core to improvement and perseverance in their work toward achieving healthcare that is safe. The awardees have accomplishments that focused on diagnostic error and sepsis reduction. Each of these stories started in tests and trials motivated by commitment to getting healthcare to a better place. For example, Tennessee-headquartered HCA Healthcare was recognised for its SPOT (Sepsis Prediction and Optimization of Therapy) algorithm as a mechanism to identify sepsis quickly to enhance quality and patient safety. Through this enhanced use of technology, SPOT uses basic laboratory and clinical data in real time to provide teams with the information they needed to reduce sepsis mortality across their 173-hospital system. Data triggered alerts that initiated actions to decrease response times by approximately 6 hours rather than relying on shift change as the information sharing mechanism. The SPOT algorithm enhancement to the electronic medical record partnered well with existing sepsis management processes to arrive at improvements.

In the climax of Hamilton’s first act, the battle of Yorktown culminates in a chorus of “the world turned upside down”, with the hope that the cacophony will ultimately result in a new country with new freedoms only imagined prior to crisis. It is certain that COVID disruptions will continue to test us all worldwide. Can we challenge ourselves, our peers and our leaders to experiment as necessary to confront COVID-19 while guaranteeing that what was learned will be used to create something better?  

Leading a large enterprise isn’t easy. Vision, compassion, humility, curiosity and adaptability are required attributes for those in charge to keep moving forward during times of relative calm or uncertainty. The stress and tragedy that accompanies catastrophic events can reduce the resolve and effectiveness of even the most accomplished leaders. Unprecedented large-scale situations, such as the Hurricane Katrina landfall or the September 11^th terrorist attacks, reveal gaps in understanding that may not have been apparent before the disaster. These blind spots can dismantle the reserve of a leader and their team to culminate in poor decisions, inaction and organisational dysfunction.

The COVID-19 pandemic is such an event. Rules are being mindfully adjusted to respond to the litany of process, clinical, financial and political disruptions healthcare workers must grapple with as they face the uncertain conditions of their patients, communities and themselves. It is incumbent on leaders to create stability by addressing these unknowns. Leaders within hospitals, social care organisations and within the public health spectra need to make immediate process adjustments to optimise effort, realise opportunities for improvement and learn to be resilient. They need to arrive at understanding while simultaneously managing challenges that emerge from the strained system to keep their enterprise on track. They need to do this by paying attention to safety culture, transformation and innovation, and will need tools and resources to do so.

Leadership must build a culture to keep patients and workers safe. Leader’s communications and actions are core to the implementation of safe working conditions to provide the best care possible during a crisis. Yet, a Gallup poll of US healthcare workers found a lack of understanding of their organisation’s COVID-19 plan and lack of belief that safety policies in place will support their safe return to work. To address this gap, experts recommend leaders three steps to a better safety culture:

• use formal and informal mechanisms to explicitly communicate what the organisation is doing to keep staff informed and safe during the pandemic
• enlist their managers to implement policies, create opportunities to align the work of management and hold managers accountable to implement and sustain current practice and procedure
• talk to their people. Keeping an open dialogue through the use of established mechanisms such as ‘rounding’ can solicit insights and raise concerns to enhance the safety of teams and patients.

Leadership must see opportunities to transform systems: COVID-19 has presented leaders with immense responsibility to act, adjust quickly as required and use those process changes to improve the overall system of care post-pandemic in preparation for the next unprecedented challenge. Geisinger Health System leaders in their article, 'How one health system is transforming in response to Covid-19' share the experience of designing their emerging COVID response to reliably innovate rather than only react. Leaders examined core system business concerns such as pharmacy and information technology by bringing together multidisciplinary groups that dismantled silos. Teams worked together using scenario planning to fully consider how restoring care processes, entering new work phases, preparing for the second wave and restoring financial viability would affect patients and employees.

Leadership must use evidence and collective knowledge to adapt: The Journal of Public Health and Management Practice shares recommendations for leaders to meet COVID-19 stressors successfully. The article suggests leaders communicate well, be decisive, lead without hierarchy, remain proactive and take care of themselves to protect others. For example, to lead across a system seek expertise from a variety of organisational and environmental elements. Working with government officials, staff and peers can form collaborations, solidify shared purpose and distribute responsibility to serve a community well in crisis. Public health is a core partner in understanding how to guide, motivate and inspire change to enhance a collective response to COVID-19 and upcoming health threats.

Clinicians in patient-facing leadership roles also exhibit these behaviours as their roles shift to manage crisis. The perspective of a New York cardiologist leading a COVID-19 infections disease service illustrates how the transfer of tacit knowledge around deliberate leadership observed daily while coordinating the service shaped his views on leadership and his ability to lead. Being emotionally available was a core characteristic that helped to express grief, exhibit vulnerability and openly share concerns, giving the experience the humanness it needed. This was important not only in his ability to mature as a leader but to demonstrate the empathy needed to get his team through the challenges at hand.

James T Kirk knew how to lead. He sought consensus, learned from mistakes, yet acted as necessary to keep his crew safe, engaged and aligned with the organisational mission. He sought partners across the federation as needed. Kirk could be firm, decisive, yet empathetic. Have health leaders done similarly to protect staff, patients and the community, while gaining experience during COVID-19 to apply over time to enrich the care system at large and boldly go to a better, safer future?

The Swiss Cheese model illustrates how latent weaknesses in the protective barriers that systems build exist and become more apparent after failures occur – if we look for them. COVID-19 is just such a test; it is amplifying the holes in today’s healthcare system. A recent New Yorker essay highlights the known weaknesses in healthcare visible long before COVID-19 – racial inequities, bureaucratic inefficiencies, drug shortages, under resourced public health initiatives and fiscal prioritisation to the detriment of preparedness. Others are more specific to the pandemic: lack of access to personal protective equipment and medical devices, supply chain disruptions, hording behaviours, misinformation and patients not seeking chronic, emergency or preventive care. The essay suggests that we should not seek to return to this “normal”, but to learn, revise and improve. 

Holes in processes to keep patients and workers safe are also expanding as the cheese melts. Healthcare worker illness, psychological strain and suicide are revealing fractures across US healthcare delivery that undermine the ability of clinicians to provide care as they work to keep patients and themselves safe. The US National Academies of Medicine has outlined an approach to protect clinicians’ wellbeing. Through a focus on organisational and national priorities, it aims to help sideline the negative after-effects that first responders to the COVID-19 crisis may experience through a call for funding, epidemiology and real-time support for providers.

Efforts to diagnose COVID-19 are thick slices of cheese with a myriad of holes that affect both clinical and policy responses. As summarised in a recent commentary, the system response is a fundamental challenge: measurement is a mess, data are inconclusive, testing processes are inconsistent and results in some cases unreliable. While this state of affairs is rapidly changing, foundational concerns are likely to remain. Economic support for organisations and States rests on the data that are apt to be skewed, ineffective and counterproductive. The international disease codes used to document COVID-19 cases are being imprecisely applied. The authors of the commentary provide suggestions to impove the use of the diagnostic codes and thus the quality of the data collected.  Actions in this area are needed to inform the research so we can understand what has happened and fund and design public health initiatives and reopening strategies that enable containment, testing and equitable treatment. 

As time passes, suggestions for improvement informed by national and local experience appear. Communities are painfully aware of the situation COVID-19 places them in. Experts there are contextually situated to address local challenges such as population instability due to unemployment, homelessness and food insecurity. A Health Affairs blog calls for strengthening the community-based workforce to assist in propping up vulnerable populations after disaster of any kind strikes, including COVID-19. Community health workers, volunteers and nonprofit organisations are highlighted as important players in testing and contact tracing strategy implementation, psychological support provision and establishment of the infrastructure communities need to face their specific challenges. It will take resources, tenacity and courage to facilitate and sustain community level COVID-19 response.  

Watching media coverage can be overwhelming but can also illustrate the complexity of addressing the disruptive tendencies of the coronavirus pandemic. Newspapers and healthcare media services can provide insight into the system-level complexity of the pandemic. These services are flagging and providing access to articles from the press or literature to provide a well-rounded collection of materials to track what is happening. It’s one way to remain keep abreast of the issues: who from racial, ethnic and socioeconomic groups are impacted, what programmes and industries are being altered, where specifically in the US the virus touches, when the threat emerged to affect a particular segment of the population or workforce and why the connections between them all are important to consider. This is highlighted in a recent commentary in the Lancet, which illustrated some of the interacting components in a society responding to the threat of COVID.  Tools such as these can assist in keeping us informed to combat weaknesses in failure barriers that emerge due to bias from listening to one outlet or seeking only one point of view.

No matter what slice of the COVID-19 Swiss cheese sits on the plate in front of us – its holes are apparent. Experts are calling for coordinated system-wide action to prevent further loss of life and economic hardships.  Other challenges are likely to emerge the longer COVID-19 influences lives. We all need to learn from the lack of success during the current response manifestation and use those insights to inform actions to prepare for the next virus wave. It will help to navigate future choppy, uncharted waters. To prepare for the 'new normal', courage to see value in failure is paramount. We should also proactively apply learnings based on what went well to better prepare organisations, systems and governments to close holes in the global approach before the next wave. 

Innovators can be challenging to be around. They see the world differently and can ruffle feathers with ideas that don’t stay on the well-trodden path. But when there is no normalcy, free thinking presents opportunities, necessitates unique partnerships and motivates organisational willingness to recalibrate. It is the responsibility of leaders and peers to appropriately harness this energy to make the most of opportunities that innovators present as they directly interface with patients.

The willingness to innovate to address the COVID-19 pandemic is inspiring. An impressive range of solutions have been devised to meet equipment and care service access challenges. Social media is a robust and widely accessible mechanism to stimulate conversations about these ideas. #MacGyverCare is one of several Twitter streams devoted to sharing unconventional solutions. MacGyver, hub members may know, is an American TV character known to improvise to get things done in difficult circumstances. Similar to the hub's own Coronavirus Share your Tips page,  people are using #MacGyverCare for sharing ideas and innovative solutions to help those on the frontline manage the demands of the crisis. Examples include creative solutions to the personal protective equipment shortage across the country.

While acting to devise a new “as needed” approach may not be something everyone working directly with patients can do, there are other avenues for supporting clinicians to help them provide safe care and find comfort, resilience and even joy in that commitment. People are coming together to ‘MacGyver’ with peers during the pandemic. For example, unique partnerships with libraries are cropping up  provide access to the literature, open WiFi hotspots to provide children access to school programmes and even to produce PPE. Is that a MacGyverism? At Columbia University in New York, a Research and Learning Technologies librarian partnered with a cardiology fellow to modify a freely available pattern to create face shields. Using 3D printer skills, assembly line know-how and teamwork they brought together a team to produce and distribute the equipment to staff at New York Presbyterian Hospitals. The Columbia University library shared their process to spread the innovation and encourage the wide use of their concept.

At an organisational level, agile information sharing is the bedrock of crisis management. Flexible, enterprise-wide and individualised communication strategies must be in place to respond to rapidly changing circumstances and keep those touched by the situation healthy and safe. The Johns Hopkins University in Baltimore are using peer support and crisis communication strategies to promote institutional resilience. Leadership commitment to resilience, information sharing to reduce anxiety and support network development all buttress system efforts to assure its workforce and community remain safe and healthy both during and after a crisis. The Hopkins process brings the skills of employee assistance, chaplaincy, workplace wellness and psychiatry to the fore in a multidisciplinary team-based approach to assure staff are well situated to provide safe care while staying safe themselves.

In light of the shift of resources to patients with COVID-19, delivery of services to patients with non-COVID-19 conditions must also be redesigned. The University of Wisconsin has used an administrative restructuring approach, building on military and emergency management experiences to make adjustments in surgery workforce and expertise availability to address complex shifts in care processes in response to the COVID-19 pandemic.  Adjustments were made to synchronise work cycles to assure clinical expertise was reliably available, develop a single clinical pool to staff from rather than coordinating assignments based on speciality or educational level, and form strike teams to engage highly experienced clinicians as needed. These tactics invigorated information transfer, provided role clarity as situations changed and strengthened process sustainability. Team leaders anchored their work by remaining focused on a declared mission and guiding principles to support that mission.  

While the uptake of new knowledge and science into healthcare practice is often shrouded under the oft-stated “17-year lag” , it is obvious through these and other examples that care innovations can be recognised, applied and improved upon quickly. Granted, it is important for innovators and the organisations they engage with to seek the advice and council of experts from the human factors, process improvement and safety domains to ensure their new ideas are developed and flow into daily work in the safest way possible. However, after this current crisis, let one of the lessons we learn from the COVID-19 pandemic be to make patient safety progress more rapidly through the use of innovative thinking, partnerships and organisation ingenuity. 

PSAW uses a wide range of communication methods to create energy and rejuvenate effort through the sharing of lessons learned and common goals. Buttons, posters, in-house newsletter articles, blogs, webinars, employee recognition awards, and poster presentations are all used to increase awareness. Earlier this month, The Institute for Healthcare Improvement (IHI) partnered with the Agency for Healthcare Research and Quality (AHRQ) to host a Twitter chat that surveyed the experiences of participants on transitions, challenges and successes. Programmes highlighted during the discussion include the bundled handoff method I-PASS developed by a team at Boston Children's Hospital and Harvard Medical School to enhance team communication. Twitter chat participants noted the importance of being able to adapt transitions tool to their environments. I-PASS leaders noted efforts to develop local champions to assist with the application of the bundle for use in the variety of situations patients and providers encounter throughout the care journey.

The California Patient Safety Organization (CHPSO) hosted five free webinars during PSAW on a range of topics.  One webinar focused on mitigating unconscious influences, or cognitive biases, that degrade relationships, decision making and care delivery. The speaker, Michelle van Ryn, President and Founder of the Institute for Equity & Inclusion Science, highlighted specific tactics, tools and educational programming to combat unconscious biases generated by gender and racial differences. She reviewed organisational conditions that facilitate biased interaction such as unsafe psychological culture and overwork. Dr van Ryn discussed valuable skill development tactics for increasing an individual’s management of their potential for implicit bias that focused on mindfulness, empathy, inclusion and partnership-building behaviours.

Another high point of the week was the release of AHRQ’s Making Health Care Safer III report. This publication summarises the current evidence base on 47 patient safety practices targeting 17 areas of concern. For example, the  chapter on sepsis discusses the evidence on manual or electronic screening tools for sepsis. The authors discuss the performance of currently used methods to determine patient susceptibility to sepsis to help ensure timely treatment initiation. While they concluded more evidence is required to determine outcome measures associated with screening methods, the authors shared links to examples of robust tools currently being used in US hospitals. Another focuses on infections due to multi-drug resistant organisms. One distinct practice review discusses hand hygiene, of particular relevance due to the COVID-19 outbreak. The authors discuss the persistent weakness in hand-hygiene practice due to workload, lack of education and easily accessible supplies. The World Health Organization’s My Five Moments for Hand Hygiene programme is highlighted in this evidence covered as an important approach for implementing hand hygiene completeness into frontline care. Thirdly, patient and family engagement is covered as a patient safety practice relevant across the spectrum of care delivery. The authors discuss difficulties in tracking the evidence on engagement as a distinct element of patient safety. They highlight several studies on the topic and share resources to encourage adoption of activities that encourage patient involvement in their care.

hub members should refer to the search strategies in the report (included as an appendix in each chapter) designed to review each discussed best practice. Leaders can use these vetted search strategies to keep current on the emerging evidence related to the initiatives they are implementing in their own organisations, targeting the specific challenges they are confronting in their own improvement work.

 Connecting with experts and recognising their contribution to change can motivate action. By providing stimuli, Patient Safety Awareness Week re-energises those on the front-line of safety. It facilitates expert conversation, knowledge sharing and evidence identification to keep our patient safety efforts and our patient safety leaders moving forward.

Patient safety leaders are apt to feel like weatherman Phil. Repetitiveness – the feeling that something been done over and over again without change – can decrease engagement but it can also lead to experiential knowledge that can be applied to future efforts.

Community engagement is paramount to patient safety success but it can be challenging if people feel like they wake to the same problem every day despite efforts to make a difference. The Boston-based Betsy Lehman Center has developed Including the Patient Voice: A Guide to Engaging the Public in Programmes and Policy Development.  The Guide shares a six-element approach to involving members of the public as partners to reduce reoccurrence of poor care. Strategies focus on enabling community members to succeed as partners and contribute as experts to designing health services that are evidence based and accessible to all. This includes leadership-led mini-workshops for staff to inform their engagement programmes and patient correspondence reviews to identify the right consumers to invite as participants.

Similarly lessons have been shared by MedStar Health, a large regional healthcare system that sought to engage patients and design strategies that engage patients and families in safety improvement. Organisational structures such as Patient and Family Advisory Councils (PFAC) served as the focal point of the shared learning effort. The system developed a network of courses that shared best practices to foster innovation and sustain realised improvements in event reporting, disclosure (the CANDOR Toolkit), after-incident support and sepsis reduction. The tactics used include board and leadership activation activities, a mentorship programme for new community leaders and public awareness campaigns. For example, the system launched a collaborative to share information to improve early detection of sepsis. Patients who had contracted sepsis along with PFAC members and in-house quality experts were brought together to design an educational video to reduce sepsis that highlighted symptom identification and response. The programme contributed to marked sepsis treatment improvement.

The City of Philadelphia recently launched a prescription monitoring strategy to curtail the overprescribing of opioids in their region. Because this programme identifies by name the 10% of physician that overprescribe, these individuals can be offered targeted training and, if necessary, legal interventions to address their behaviour. Home-grown programmes can also be proactive to prevent overprescribing. One Boston-based family medicine clinic described their five-year change management effort to reduce opioid overuse. The authors reported their focus on developing “shared general principles”; communication mechanisms to connect clinicians with in-house addiction experts, patient registries, targeted training, certification opportunities and centralised leadership were all instrumental in embedding improved prescribing practices throughout the organisation.  

Consistent unremitting workload pressure perpetuates stress and fatigue. Its presence degrades staff relations, performance and the safety of care delivery. It’s a common problem that medical residents are burnt out: no news there. What conveys great promise are programmes like what the Virginia Mason Medical Center in Kirkland Washington has done to address burnout by implementing workflow changes and fostering a culture of “collegiality, respect and innovation”. The Center changed workflow by standardising clinical tasks, defining staff roles and carving out protected time for staff to recharge, self-educate and participate in improvement efforts. The Center has enhanced its culture and improved staff morale through leadership efforts to lower hierarchy, welcome and respond to feedback, and address inefficiencies that can discourage staff and derail efforts.  Ninety percent of staff at Kirkland reported in a 2018 internal survey feeling content and engaged about their work.

Medical residents can also find support through programmes like the ACGME Aware initiative. This set of tools targets strategies that junior doctors can use to build resilience and embrace their professional community through a mobile phone app to find support as they need it. Personal tactics to protect against burnout for more experienced healthcare professionals are also in demand. A news story in Medical Economics highlights what doctors and hospital administrators can do to minimise burnout, such as making time to socialise with peers and using the opportunity to share stories, rethinking their roles to bring joy back to medicine, and to listen.

For 2020, Phil has told us that Spring is due to arrive early. Will the application of the successes reviewed in this month’s Letter reduce the recurrence of opioid overprescribing and staff burntout? We need more than a rodent to speculate on that for us. But given efforts by patient safety champions in the US and UK, improvements optimism is in the air. 

A renowned part of the franchise is the Tournament of the Roses parade. The 2020 parade theme was the ’Power of Hope‘. Volunteers, sponsors and organisations collaborate to produce a 5.5 mile spectacle involving over 40 floats, numerous marching bands and millions of flowers for viewer enjoyment. Collaboration is key to achieve medication safety too. In a recent study published in the Quality Management in Healthcare journal, a community health organisation’s successful method of frontline staff committee engagement generated process changes that culminated in reduced medication errors and increased near misses. Continuous quality improvement initiatives supported by these committees included technical handling and administration of medication, medication reconciliation, and enhancements to standardised treatment protocols.

Following the pomp and beauty of the parade comes the gridiron... the grit... the sweat... the teamwork. College teams are selected based on their performance during the year. Their individual and team competencies are what get them to Pasadena and give their fans hope for a win. Competencies are important for developing reliability no matter what field you play on. The Society to Improve Diagnosis in Medicine (SIDM) has identified key competencies that should be considered for inclusion in health professions education programmes to improve the quality and safety of diagnosis in clinical practice. They fill a noticeable gap in health professional education by embedding reasoning and partnering skill development into healthcare curricula. The SIDM approach emphasises individual, team and system level skills to hone clinician diagnostic abilities and orientation to diagnosis as a team.

In football and in healthcare, teams follow processes and plans but should be empowered to adapt when the situation calls for it. For example, TeamStepps is a US-government developed team training programme originally designed to enhance communication in acute care. A recent pilot study tested its application in mental health teams in schools to reduce staff burnout and turnover. This unique health environment adapted the TeamStepps method to improve organisational culture and provide support for the wide array of practitioners that provide care in schools. The success of the initiative improved team-based care delivery at the organisation.

Football holds for the teams, management and consumers the potential not only for spectacular performance but for mistakes that can result in injury. Fatigue and distractions can often be a factor in football injury on the pitch; so too can these factors result in injury in healthcare. The Pennsylvania Patient Safety Authority (PSA) released a 4-year analysis of newborn falls in the hospital following birth. Parental fatigue was a primary contributory factor that emerged from the investigation. The PSA describes educational tactics to help parents understand the potential risks for infant drops and encourages them to ask for nursing assistance in feeding if they feel overly tired to keep their babies safe.

Keeping track of disruptive behaviour is a relatively new effort for healthcare. Until recently, there was no way to raise a flag to indicate poor behaviour that can distract from team cohesion, coordination and communication. In a recent study, a large US health system devised a tool to evaluate disruptive behaviour among its ranks, measure its effect on teamwork, burnout and patient safety, and use that data to define improvement targets. In the sample, researchers found disruptive behaviour to exist in approximately 98% of work settings. The upside of this discouraging figure is that the tool effectively tracked disruptive behaviours so they can be addressed. There is hope for improvement – once a problem can be measured work can commence to fix it.

While not a strategy, hope motivates, as presented by Sidney Dekker in his movie: Safety Differently. Hope situates the future in possibility, instils learning from what goes array and sustains efforts to stay true to goals. Let’s keep hope alive as we work to score touchdowns for safety in 2020.

While recognising that certain characterisations in these movies haven’t aged well, the films have made an indelible mark on Hollywood history. The films of 1939 laid the groundwork for great things to come. They launched the careers of artists that have made a cultural mark worldwide: need I say more than John Wayne or Judy Garland? Another capstone to a productive year is the end of the 20th year post the publication of To Err in Human. The widely influential 1999 US publication showed us how to fight for patient safety – our Tara. It outlined approaches to address the seemingly reoccurring tornadoes in healthcare built to instead point toward home – a safe health system.

Scarlett’s tenacity, her force of personal will and sustained belief in Tara is what pulled her through the maelstroms of civil war Georgia. Clinicians, however, cannot rely on grit and willpower alone to address clinical and organisational threats to safety. The lack of control to minimise systemic pressures on their moral imperative to do a job well in non-supportive situations reduces a clinician’s ability to practice safely. Building on the To Err is Human legacy, The US National Academy of Medicine (NAM) is committed to understanding factors that contribute to unsafe care. A NAM recent report on burnout lays out a system-focus strategy for organisations to reduce conditions that degrade physician health and, thus, safe practice.

Dorothy’s quest to return home energised her instead to engage a multidisciplinary team. The skills of Scarecrow, Tin Man, Cowardly Lion and, yes, even Toto got them through the forest to safety. Without their individual commitment to the mission, humanness and competence the team would have never gotten to Oz. The American Association of Medical Colleges (AMMC) recently released a set of competencies expected in physicians to support quality practice. By suggesting what educators embed in their training efforts, the AAMC helps ensure learning opportunities that build competencies are embedded in programmes on the yellow brick road to safe care provision.

Transparency helps us to see situations as they really are. Peaking behind the curtain enables exploration that, if used appropriately, can drive improvement. Toto pulled back the curtain to expose a threat that, once clarified, launched a collaboration that got Dorothy back to Kansas. The US-based Leapfrog Group has also forged a partnership to look behind the curtain. The latest release of the Hospital Safety Score data has focused attention on what isn’t working to support safety while celebrating hospitals that demonstrate sustained safety and quality. The scores track weaknesses in hand hygiene, infection control, and patient falls as elements of whether a hospital is safe.

There have been challenges: wicked witches, budget constraints, refusal to accept change and conflicts. It has not been an easy road to Tara since Err is Human was released. Experts in the field have shared their dismay in the lack of progress. Yet stories of resilience, partnership and teamwork continue to motivate the resolve of Dorothy and Scarlett to keep going.

Goal-focused efforts can backfire and not live up to their expected purpose. The South didn’t win the Civil war though they believed it was their destiny to do so. Scarlett never won back Ashely no matter how hard she tried. A recent article published in Health Affairs highlights the lack of correlation between the US Medicare and Medicaid programme reimbursement initiative and direct impact on patient safety in the state of Michigan. Its impact is questionable—which for a large-scale solution embedded throughout the system—is humbling.

Questionable actions can be a human reaction to stress that needs to be called out and managed to reduce their presence and impact. While centering her as a force for action, Scarlett’s spoiled and selfish behaviour also destroyed her most meaningful relationship. Such destructive behaviours degrade relationships needed for the safety of care. A large US study published in NEJM found that harassment and inappropriate behaviours effect one-third of general surgery residents surveyed, particularly women. The mistreatment and bias generated by both patients/families and medical team members were identified as a key factor in burnout and physician suicide.

The stories from great films of 1939 illustrate the power of grit, resolve, focus and leadership as elements of achievement. They share with us memorable characters that live with us long after the movie theatre lights come up. Through the embodiment of the tenacity of Scarlett and the team-focus of Dorothy we can and will work through the known barriers to reduce patient harm due to medical care. We have not yet arrived at Tara, but we continue to work tomorrow toward getting over the rainbow.

You might think it’s all fun, funnel cakes and floating but—like any aviation activity—ballooning entails risk. Make no mistake, the balloonists and their
teams, the organisers, law enforcement, and even participants play a role in the safety of the event. Before sunrise each day, the “dawn patrol” of 8–10 hot air balloonists lift off. These experienced pilots gage the safety of the sky prior to the authorities giving the signal for the assent to begin. Only after that, does the wave after wave of multiple balloons unpack, gear up, inflate and take off from the field. Crews mull about, patiently navigating their designated space amongst onlookers and their cameras to get ready for flight. They implement standard procedures to safely gear-up for flight. Healthcare, too, prepares teams for complex situations to ensure safety through standardisation and practice. The US healthcare accreditation agency, the Joint Commission, shared insights on reducing maternal harm due to postpartum haemorrhaging that summarises best practices centered on readiness, recognition, response and reporting to support systems learning. Stanford Medicine in California recently held a series of “dress rehearsals” prior to opening a new hospital. The test of the space gave clinicians, administrators and patient advisors a chance to make sure conditions were right for a safe opening day.

The fiesta organisers also deploy tactics to learn from what doesn’t go well. They use technology to gather input from crews and the public to identify areas for improvement. Traffic into the 360-acre launch site creates ineffective and potentially dangerous situations given the swell of people arriving in town. Attendees almost double the size of the city for the 10-day event. Public input gathered online helped planners to redesign this year’s park and ride shuttle system after it failed in 2018 to reliably get people to the festival. Hospitals also use information technology to learn how to improve the safety of the care experience. Researchers in Washington State developed a 4-step model built on inpatient experiences with undesirable events. They used patient and family knowledge to design informatics solutions that engage patients as contributors to safety. The model supports raising awareness of problems, encouraging prevention actions, managing emotional harms and reducing barriers to reporting

.A rare situation stalled the festival this year: fog. Yes, fog is not something New Mexican’s encounter often but it shut down opening day morning—none of the balloonists could take off. This unique occurrence would have been all the more problematic had teams not heeded safety advice in this less-than-ideal situation. Practices and protocols keep patients safe too but only if they are followed. A unique set of circumstances led to the death of a patient awaiting care in a Pennsylvania emergency department. Protocols weren’t followed limiting situation awareness, communication and process completion. Balls were dropped and the results were tragic.

Complex systems can manifest unintended consequences from strategies designed to protect people. Balloon fiesta has its share of mishaps. Pilots end up in the Rio Grande, drift into powerlines, bones get broken and, rarely, lives are lost. The expert crews mean well but failures happen. A nurse in Tennessee who made a medication mistake that resulted in patient death was charged criminally. While lawmakers may feel this is a just approach, it is a threat to healthcare transparency. A series of incidents involving misdiagnosis of child abuse is raising concerns in the US. While specialised paediatricians can readily identify patient conditions that indicate abuse, sometimes those judgements are made in error. The decisions made to protect children instead accuse innocent parents or family members of harm. The safe flight of those families then tumbles to the ground.

The pace is back to normal in Albuquerque. Balloons still float above us in the morning and afternoon—'tis the season. They brighten the clear blue skies with the Sandia mountains as a backdrop. But you can bet that what did go wrong this year will be folded into the event planning so all that participate in the 2020 festival will be as safe as possible. 

It goes without saying that the place is gobsmacking: it literally takes your breath away. It is no easy feat to navigate the options for what can be done while you are there – the food, the views, the trails, the crowds, the mules! To make the trip really monumental however, visitors and staff need to keep safety in mind. Just as clinicians, patients and families do while they are in the hospital. They need to get informed, prioritise activities and trust judgment to manage risk.

Distributing good, freely available information

The Grand Canyon Visitor’s centres and trail heads provide a cornucopia of maps, pamphlets and booklets highlighting options for activities. Making information and data available is key to keeping a visitor to the Canyon free from harm. Similar to trail maps noting loose rocks, unmaintained walkways and mudslide potential, the US Pennsylvania Patient Safety Authority (PSA) models the important mission of transparency by sharing what they learn about threats to safety. The organisation has been collecting and analysing adverse event and other data for 15 years. The Authority disseminates it not only to generate action within their state, but throughout healthcare. Their new open access journal, Patient Safety, continues down a trail established by the PSA newsletter. This work will help all of us progress by providing insights to manage both unseen and known obstacles to safety.

Prioritising action

Grand Canyon National Park offers a wide array of choices for visitors. If you only have a day or two in the region, prioritising what hike to take and when to go takes some planning. Just as in safety where the options, tools and improvement goals can become overwhelming. It is crucial to have a method to sort things out. In both instances there is so much to do! Recently the US Veterans Administration (VA) health system published a paper on the process they use to prioritise efforts in their system. They summarised an approach that rests on a foundation of learning practices that could be helpful for all of us to consider in moving forward.

Trusting your gut

My husband in his college days hiked down the Canyon to the Colorado river and back up three separate times. Those treks gave him experience that enabled him to know when “worry” was worth listening to as we ventured down a rugged, steep, trail during our visit. We went down and came back up into the Canyon safely. A recent study from the US, published in JAMIA Open, looked at the accuracy of nursing judgement as a barometer for patient deterioration. The “Worry Factor” proved to be a darn good signal – over 75% of deterioration situations were correctly identified by nurses ahead of time.

Then there are the others

Do you ever wonder “what the ???” when you see people doing something in a park – there are signs everywhere NOT to do ... but they do it anyway? Scampering up rocks behind the safety railing, feeding squirrels, trudging down a rocky trail in flip flops! Safety messages are posted all over the park in an effort to keep Grand Canyon visitors safe. Of course, humans being human, don’t always follow the advice due to arrogance, language issues or a myriad of factors – the distraction caused by the beauty and awe of the place being one of them. Same goes for healthcare. Unintended consequences of process and environment complexity can derail efforts to keep patients safe. Bureaucracy can undermine efforts to keep large systems resourced to provide high quality care delivery, as we heard in a recent examination of the US Indian Health Service. Despite efforts to monitor opioid prescribing practices of physicians, the behaviours are notoriously persistent. Transparency and accountability for failure, while heralded as core attributes of safe care, are not always available to patients.

Patient safety and life are both grand adventures that we can navigate through the effective use of information, prioritisation and sound judgment. I hope you all have as good a partner in your journeys as I have had in mine.

50 years on – we all recognise this phrase that accompanied one of the most famous descents in history: Neil Armstrong’s emergence from the lunar module toward his first step on the moon.

The Apollo 11 moon landing represents an unparalleled accomplishment. Its characteristics resonate with patient safety professionals who look to space for inspiration. The Apollo programme experienced both triumphant achievement and catastrophic failure. The effort learned from mistakes, embraced teamwork, and considered human factors as part of its domain. Its workforce remained focused on a single goal. The effort embodied commitment, complicatedness and complexity. The 50^th anniversary of these victories provides compelling parallels for error reduction efforts active today in healthcare in the US:

Organisational learning systems

NASA (National Aeronautics and Space Administration) is a learning system. Learning systems are developed and nurtured through common goals, leadership commitment and resource sustainability. They thrive through action generated by the application of data, evidence and knowledge. Likewise, the US Agency for Healthcare Research and Quality (AHRQ) has partnered with the US-based hospital and healthcare accreditation organisation, The Joint Commission, to disseminate analysed evidence compiled by the Evidence-based Practice Center (EPC) programme. These organisations are working together to transfer what is known into an actionable form through a series of articles to enhance the use of better practice and learning on the frontline. This programme and the article series are introduced in a recent commentary on the project.

Coordinated action

The Keystone Center represents the culmination of the work of patient safety’s own Neil Armstrong – Dr Peter Pronovost, known for his otherworldly (at the time) commitment to the checklist intervention. The Keystone Center initially coordinated and collected data to guide the implementation of the checklist concept in 70 intensive care units across the state of Michigan. Now the Center serves as the state’s mission control for hospital patient safety and quality. Leaders there raise awareness of success through the Speak-Up! award programme that acknowledges frontline healthcare staff for voicing their concerns and making care safer. The Center enables sharing of concerns that result in cost savings due to harm avoidance.

A push in the right direction

The Apollo programme applied technical sophistication, engineering and know-how to land a man on the moon and return safely to Earth within a decade. No small feat! Despite that imperative, both the module and the space programme needed a little boost now and again to get out of Earth’s orbit to complete its momentous undertaking. Patient safety has a similar call motivating its work – zero preventable harm. Some aim for ‘zero harm’ but is this achievable? Healthcare is very complex with multiple machine/human/machine interfaces. Clinicians, leadership and organisations still need a boost to design and use technology and data to support the workforce to improve care at the bedside.

The mission-driven, Boston-based Betsy Lehman Center builds on a strong desire to prevent failures similar to those that took the life of its namesake – Betsy Lehman – the Boston Globe reporter who died in 1994 due to medication errors. The Center is a state agency that serves as mission control for its constituents. To help healthcare in Massachusetts move its safety work beyond the comfort of the status quo, they have recently convened a consortium to propel existing programmes towards new and aspirational achievement.

On the dark side of the moon

Of course, the Apollo programme suffered setback and tragedy. While I want to highlight successes in my Letter from America, I will also share stories of struggle to foster learning from what doesn’t work. News and narrative will often remind us of why continued work on safety improvement is fundamental.

Diagnostic error is prevalent. A recent analysis of closed US medical malpractice claims found that delayed or missed diagnoses in three primary clinical areas – vascular events (such as strokes), infections (like sepsis) and cancer – substantially resulted in disability or death. You can take that to your mission control to motivate data collection, teamwork and effort to focus on diagnostic improvement in practice.

Transparency is messy. The revelation of Neil Armstrong’s reported death in 2012 due to substandard medical care is sad for all kinds of reasons. It underscores persistent cultural influences that reduce the sharing of information related to poor care. This minimises our opportunity to learn from failure and support patients, families and clinicians involved in error. Organisational resistance to transparency about mistakes and the messiness of openness are challenges... even when the incident involves a patient with less name recognition.

The Apollo programme and the 1969 lunar landing remains inspirational to this day. It behooves all of us who dream of contributing to something we once felt was impossible to engender the right spirit, resources and commitment to help get it done. The learning required for such accomplishment takes time, a culture that supports discussion and recognition of success. If we embrace contribution, collaboration and community, our small steps have the potential to contribute to the “giant leap” forward – to help us take off, realise achievement and return our patients safely home.