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This interview in the Journal of Quality and Patient Safety highlights the career and motivations of Dr. Gordon Schiff, a leader in patient safety whose has focused his efforts on improving medication safety, diagnostic safety and the role of information technology in enhancing care.

This month’s Letter from America looks at actions and strategies core to leading an organisation during unexpected enterprise-affecting crises. Letter from America is the latest in a Patient Safety Learning blog series highlighting new accomplishments in patient safety from the United States. “There's no such thing as the unknown—only things temporarily hidden, temporarily not understood.” James T. Kirk, Captain, Starship Enterprise. Star Trek, Season 1: The Corbomite Maneuver. 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 11th 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?

This article from Perlin et al. discusses how a 173-hospital system used technology as a strategy to reduce sepsis-related mortality system-wide by real-time dissemination of basic laboratory and clinical data to alert teams to patients exhibiting signs of sepsis risk.

This commentary from Michael Fraser 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.

The perspective of Megha Prasad, a New York cardiologist leading a COVID-19 infections disease service, discusses leadership qualities of being available, communication, adaptability, humility and gratitude as key to effective leadership during challenging times.

Leadership must nurture a robust safety culture to manage crisis. This article from Foy and Mallory highlights the importance of formal and informal communication mechanisms, management empowerment and responsibility, and dialogue across silos to enhance the safety of teams and patients.

Access to wide range of perspectives can bring creativity to solutions and the actions that implement them. This website presents materials that cover topics such as leading in critical times, building and supporting resilience, Leading to Innovate, change and adapt, teaming and working remotely, coaching peers and developing as a leader.

This regularly updated resource collection links to webinars, articles, and conversations that explore the role of leadership in crisis response. Topics covered include workforce, telehealth, operations and safety.

This month’s Letter from America looks at perspectives examining collective responses to the COVID-19 pandemic through a systems analysis lens. Letter from America is the latest in a Patient Safety Learning blog series highlighting new accomplishments in patient safety from the United States. Healthcare safety is complex every day – yet the emergence of the novel coronavirus has made holes in the Swiss cheese of the system more apparent. UK psychologist James Reason’s now famous “Swiss Cheese Model” serves as a metaphor for this month’s Letter from America. As more details on the coronavirus emerge, and time enables reflection on what has transpired, deeper analyses will no doubt materialise. Knowledge is developing in real time, helping us see gaps in our safety barriers and providing valuable insight to the challenge of reducing harm. 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.

Challenges to the status quo present leaders with the opportunity and responsibility to not only respond but to learn and transform the system. This article from Slotkin et al. shares the experience of leaders at a large health system to design an emerging COVID response to effectively innovate to sustain improvement.

Clinician well-being is known to play a role in error prevention. This perspective from Dzau et al., published in the New England Journal of Medicine, presents a five-part strategy comprised of organisational and national elements to ensure clinicians are situated to provide safe high-quality care during crisis, such as the coronavirus pandemic, and throughout the course of their careers.

This essay in The New Yorker summarises known weaknesses in US healthcare visible long before COVID-19—and discusses others more specific to the pandemic. The author suggests that efforts to change the system be informed by the COVID-19 experience. The work should not seek to return to the pre-pandemic state but instead aim to making changes based on what was revealed to improve health care delivery overall.  

Community-based workforce initiatives support vulnerable populations during uncertain times. This blog from Manchanda highlights the role community health workers, volunteers and nonprofit organisations play in COVID-19 testing and contact tracing strategy implementation, psychological support provision, and establishment of the infrastructure communities need to address challenges specific to their local challenges.  

This perspective published in the The New England Journal of Medicine examines the problem of racial disparities and the COVID-19 pandemic. The Chowkwanyun and Reed highlight the importance of viewing the data emerging from the crisis in the appropriate socioeconomic and deprivation contexts to protect against ineffective compartmentalisation of the populations being affected. 

System thinking encourages the consideration of the interacting forces contributing to problems to enable the design and implementation of strategies to address the underlying conditions that perpetuate those problems. This article from Bradley et al. in eClinical Medicine provides an illustration of the various forces to be resolved to effectively respond to COVID-19. Bradley DT, Mansouri MA, Kee F, Garcia LMT. A systems approach to preventing and responding to COVID-19. 

This data snapshot from Santoli et al. highlights the results of an examination of two data sets (Jan to April 2019 and Jan to April 2020) to assess the impact of the pandemic on pediatric vaccination in the United States. The authors found significant vaccination declines and highlight the importance of childhood vaccination to prevent future disease outbreaks.

This month’s Letter from America shares perspectives on innovation at a personal, team and organisational level in light of the COVID-19 pandemic. Letter from America is the latest in a Patient Safety Learning blog series highlighting new accomplishments in patient safety from the United States. The COVID-19 pandemic is creating an updraft to do something. Clinical, political, geographical, humanitarian, economical and logistical forces present recognisable pressures that either inspire or dissuade action ... but not for all. Innovators are energised when they see an urgent need to dismantle the status quo. They are well equipped to capitalise on the momentum generated by emergent situations to respond in a way that is collaborative, effective and safe. It is from this whirlwind that the April Letter from America is penned. 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.

This article from Zarzaur et al., in JAMA Surgery, shares 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. 

This commentary from Wu et al., in the Annals of Internal Medicine, summarises a triad of strategies used at one organisation to support healthcare workers in times of great stress. The authors suggest leadership focus on resilience, communication that informs and empowers staff, and a multi-component peer-support structure to provide a foundation for institutional wellness.

March’s Letter from America highlights insights from the field shared during Patient Safety Awareness Week earlier this month and touches on improving transitions, managing implicit bias and using evidence. Letter from America is the latest in a Patient Safety Learning blog series highlighting new accomplishments in patient safety from the United States. *Please note, this letter was written before WHO announced that COVID-19 was a pandemic, just a few short weeks ago. We acknowledge that the world has changed since then but we feel this content is still relevant to safer patient care, maybe even more so now. Each year in March, Patient Safety Awareness Week (PSAW) serves as a spark for increasing safety. Initiated in 2002, the concept of PSAW was formed by New York State-based founder of the Pulse Center for Patient Safety Education and Advocacy, Ilene Corina. In 2003, Ilene then collaborated with the Society to Improve Diagnosis in Medicine founder Dr. Mark L. Graber and the National Patient Safety Foundation to establish the annual event. PSAW triggers the sharing of resources and experiences to initiate partnerships that propel patient safety work forward. Many in the field take advantage of the opportunity to build awareness of their inventiveness and motivate collective action toward enhancing patient safety. 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.

Since To Err is Human was published in 1999, the patient safety evidence-base has expanded exponentially in alignment with continued maturity of the field. This publication is the 4th in a series of reports from the Agency for Healthcare Research and Quality (US-based), that reviews research supporting established patient safety practices to reduce patient harms. The current report is being published as updates are finalised to provide recommendation and share strategies highlighted in the literature to drive implementation of the practices discussed in areas such as:  opioid stewardship patient and family engagement telehealth implicit bias failure to rescue computerised decision support deprescribing.