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FOR FURTHER READING
"ROI: Calculating Your Financial
Return on Patient Safety"
by Steve
Harden
It's no big
secret . . .
Patient
safety and quality
improvement efforts
contribute directly
and permanently to
an organization's
bottom line.
Read how facilities
implementing
LifeWings Patient
Safety Programs are
able to realize an
average ROI of 450%,
and sustain these
financial gains year
over year.
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NEWS TO USE
In implementing a
CRM-based Safety and Quality
Improvement Program
The Joint Commission
OR Manager Inc.
Vol. 25, No. 4
April 2009
"Getting surgical
teams on board
for OR
checklists and
briefings"
An interview
with Steve
Harden and Steve
Montague.
U.S. Airways Accidents -
Then and Now:
Read David
Paulin's compelling
comparison between the
recent US Airways Flight
1549, the "Hudson
Miracle," and US Airways
Flight 5050 that
occurred 20 years ago.
NBC's ER:
Watch the 4th segment of
NBC's ER,
Episode 1519
(March 12th) to see
the use of a Surgical
Check List.
The Oprah
Show:
Dennis Quaid re-visits
Oprah and talks about
his family's ordeal
resulting from a medical
mistake and the changes
that have been made to
prevent similar errors.
Dr. Oz discusses the
valuable use of
checklists.
(March 10, 2009)
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LIFEWINGS HEALTHCARE
SPEAKERS & CONFERENCES
April 4-8, 2009
McCormick
Place, Chicago, IL
LifeWings President
Steve
Harden
will present at the
Karlstorz Breakfast
Workshop on April
4th. Please
e-mail
Steve if you
would like to
schedule a time to
meet with him during
this event.
May 20-22,
2009
Gaylord
National
Resort &
Convention
Center,
Washington,
DC
LifeWings
Vice
President
Steve
Montague
will be
attending
this
conference.
Please
e-mail Steve
if you would
like to
schedule a
time to meet
with him
during this
event.
40th Annual AST
National Conference
May 28-29, 2009
Caesar's
Palace, Las
Vegas, NV
LifeWings
President
Steve Harden
will present "Soaring over
the Quality Chasm" on May
29th. Please
e-mail Steve
if you would like to
schedule a time to meet with
him during this event.
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STREAMS IN THE DESERT
Thoughts and Stories to
Inspire
Lessons from the
Hudson River
by: Steve
Montague
On
January 15th, 2009, the
crew of USAir 1549
successfully landed and
evacuated a commercial
airliner in the Hudson
River. Dubbed the "Miracle
on the Hudson," it
was a validation of the
resilient systems that
have made commercial
aviation as safe as it
is today.
"Sully"
and his crew relied upon
system standardization,
communication protocols,
and coordination of
tasks that have been
honed through years of
refinement, practice,
and discipline. It's
these same techniques,
and systems to ensure
their use, that are an
integral part of
improving patient safety
and quality of care. [Read
More]
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SHARPENING THE SAW:
A Message from Steve
Harden, President of
LifeWings Partners LLC |
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Disaster
Planning in Uncertain
Economic Times:
How to insure
organizational success
in a rapidly changing
world.
I do a
lot of traveling and
speaking to different
hospitals and healthcare
conferences around the
country. Because of my
exposure to so many
varied types of
organizations I am often
asked, "What do you
think the future holds
for healthcare?"
A year ago, I could
have given a much
more definitive
answer to this
question. Now, with
a new President and
his interest in
expanding access to
care and
establishing EMRs,
in addition to the
economic crisis and
the recent stimulus
package, I don't
think anyone knows
for sure what's in
the future for
healthcare. Despite
the uncertainty,
there are a few key
principles that will
transcend all of the
current chaos. Those
hospitals that
survive will be the
ones that harness
these principles of
success. Those that
ignore them will
fail.
1st
Principle:
All
organizations are
going to see vastly
increased government
regulation and
scrutiny of their
safety statistics
and quality
outcomes.
This
increased scrutiny
is going to affect
reimbursement rates
and thus the
economic model of
the organization.
Think about the
public furor over
the bonuses paid to
the executives of
AIG after their
government bailout.
Now think about the
number of government
dollars being poured
into healthcare
reform. The urge to
make sure money from
the public coffers
is being used well
will only intensify
in the future. Be
sure of this, your
safety and quality
performance will be
less and less of a
secret and that
performance will
drive your
reimbursement. [ Read
More]
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LEADERSHIP TOOLKIT:
Skills for Sustaining an
Enduring Culture Change |
 Do
No Harm: Best
Practices of Safety
Cultures
by: Steve Montague
The
commitment to "always
doing the right thing"
and the dedication to
actively preventing
"wrong things" are
necessary in safety
cultures. The following
article discusses best
practices used by safety
cultures founded upon
the principal of "first,
do no harm."
Many
Americans might consider
2008 a less than stellar
year. Aside from the
down-turned economy and
geopolitical events, we
can't ignore the
alarming fact that our
healthcare system is
failing to keep patients
safe. The Joint
Commission reports that
815 individual sentinel
events occurred in 2008,
with approximately 70%
resulting in patient
deaths. Each of these
events was unique, with
its own set of
circumstances, its own
clinical setting, and
its own clinicians.
Each tragedy had its own
victims, including the
families, loved ones,
and "secondary victims,"
the clinicians
involved. Moreover,
millions of dollars were
paid out by hospitals
for these mistakes;
dollars that could have
been spent on error
prevention. [Read
More]
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SKILLS AND TOOLS:
Get Better Today |
Essentials for
Checklist
Implementation
The success of
the World Health
Organization
(WHO) surgical
safety checklist
(NEJM, January
29, 2009) is the
latest in a
growing list of
low-tech, low
cost best
practices that
are dramatically
improving
patient safety
and quality.
While adopting
these best
practices is
simply doing
"the right
thing," there's
also a strong
business case to
be made.
CMS
suggests that the
cost of a single
surgical site
infection represents
between $63,000 and
$180,000. If one
were to average the
results of the four
hospitals in
high-income
countries as
reported in the NEJM
article,
implementation of
this simple and
mundane protocol
represents two less
infections per 1000
surgeries. Now do
the same math for
other complications
such as retained
foreign objects
($63,000), or
infection after CABG
($299,000) and the
picture is quite
compelling. In
today's austere
financial climate
doing the right
thing is also good
business.
"Regardless of
whether it's a
"bundle," a
checklist, or a
protocol, not
every healthcare
facility that
tries to
implement these
standardized
practices
succeeds, and
they seem very
surprised when
they don't."
 Checklists
often appear
intuitively easy -
in fact many of us
used two common
checklists as we
prepared to feast
during the holiday
season. A grocery
list is a great
example of a
"read-and-verify"
checklist, while a
recipe is a
"read-and-do"
checklist. If you
want to ensure that
your meal will be a
success, and save
time and money by
avoiding additional
trips to the store,
you use the
checklists. [Read
More]
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SUCCESS STORIES:
Reported Results from
Organizations Implementing
LifeWings Patient Safety and
Quality Programs |
 Oakwood
Healthcare System
Captures Success on
Video
Oakwood
Healthcare
System (OHS) recently
produced an
innovative
educational video capturing
their successes
during a
system-wide Crew
Resource
Management (CRM)
implementation.
Universal
Protocol - A
Guide for the
Oakwood Surgical
Team,
is a 10-minute
training video
used to promote
and sustain the
standardization
of communication
and skills among
OHS team
members, as well
as educate
patients about
their role in
the healthcare
process.
"The CRM
Steering
Committee
was looking
for
innovative
ways to
spread the
word about
our
LifeWings
program.
The
Universal
Protocol
video has
been very
effective in
demonstrating
CRM skills
and
techniques
while
training
physicians
and staff
across Oakwood
Healthcare
system on
the concepts
of teamwork,
communication
and hand
offs while
performing
patient
identification,
site
verification
and the time
out process
in the
operative
areas."
-
Sara Atwell,
Chief
Quality
Officer
Oakwood
Healthcare
System
The
video reinforces the
necessary use of CRM
behaviors and skills
by clearly noting
critical points at
which complete
communications and
teamwork are
essential.
Identifying the
people involved in
each step and
describing the
Hardwired Safety
Tools is also an
effective measure in
standardizing these
behaviors across
multiple system
hospitals.
With less than a
10-minute running
time, the video also
serves as an
introduction for new
personnel's training
and a refresher for
recurrent training
requirements. Edited
selections of the
video involving
patient
communication are
also used to promote
patient awareness
and understanding of
the procedural steps
involved in their
care.
Overall, the effect
of this effort has
succeeded in OHS
securing increased
CRM skills
acceptance,
awareness and
understanding across
the Oakwood system
and corresponding
improvements in
patient safety.
We applaud the
healthcare
professionals at
Oakwood for sharing
this great example
of teamwork and
going the extra mile
to innovate for
patient safety.
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LIFEWINGS CRM/PATIENT SAFETY
USERS GROUP |
Would you like to
connect with other
members of LifeWings
Partners CRM/Patient
Safety Users Group?
Membership benefits
include
opportunities to
network and
collaborate with
your peers, to unite
in such a way as to
share experiences
and challenges, as
well as meet other
members with similar
interests and work
focus. Designed to
provide improved
healthcare quality,
communication,
education, and
collaboration,
LifeWings Partners
CRM/Patient Safety
Users Group needs
your help!
As a current or
prospective client,
we value your
feedback. Please
consider giving 5
minutes of your time
to complete our
on-line survey.
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 About
Us
LifeWings
Partners LLC was founded by
a former U.S. Navy Top Gun
Instructor and commercial
airline pilot. The firm
specializes in applying Crew
Resource Management (CRM)
based teamwork training and
safety tools to help
healthcare facilities save
patients' lives and reduce
costs. LifeWings has helped
over 85 facilities
nationwide provide better
quality care to their
patients.
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phone: 800.290.9314
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2009
John M.
Eisenberg
Patient
Safety and
Quality
Awards