In many ways, the children’s hospital safety movement borrows from characteristics exemplified by children and can be a model for safety improvement across the health care industry. This session explores the history, philosophy, results, challenges, and future strategy of the Children’s Hospital’s Solutions for Patient Safety Network.
So next up to introduce our next speaker is symposium committee member Joan Smith, director of Quality Safety and Practice excellence at Saint Louis Children's Hospital. Uh, thank you all and again thank you all for being here today and Clay, that was tremendous. So first I wanna thank you and since Denise is here also, you and Denise for really, um, being the pioneers in quality and safety here at BJC and for the legacy you look behind. So this is a testament to both of you. So thank you. OK, so I have the distinct honor and pleasure to introduce to you, um, somebody who's very special to us at Saint Louis Children's Hospital. So Anne Lyron is the chief medical and strategy officer of the Children's Hospital Solutions for Patient Safety National Network, also what we call SPS. Doctor Lyon is an associate professor of pediatrics and bioethics at Case Western Reserve University School of Medicine and a pediatrician associated with UH Rainbow Babies and Children's Hospital. Her service at Rainbow is extensive, including positions of clinical. Service attending and director of Rainbow Center for Pediatric Ethics, vice chair of Quality and ethics, and interim co-chair of pediatrics. In 2010, she became co-clinical director of the SPS first in Ohio and then across the nation. In 2016, she assumed full clinical directorship for SPS where she leads the development and implementation of clinical and operational strategies related to quality improvement, research and innovation designed to eliminate healthcare acquired conditions as well as address cultural barriers to consistently performing practices that keep patients and the healthcare workforce safe. Anne is going to be, um, talking to us today. Her title is Act Like a Child Learning from Pediatric Patient Safety. The Children's Hospital Solutions for Patient Safety Network is a network of the United States and Canadian Children's Hospital that has achieved exceptional results in patient and employee safety using both time-honored and innovative approaches to eliminating healthcare harm. In many ways, the children's hospital safety movement borrows from characteristics exemplified by children and can be a model for safety improvement across the healthcare industry. And Clay gave a great example of that with his son at the end of his presentation. This session will explore the history, philosophy, results, challenges, and future strategies for the SPS network. And, uh, while she has an impressive resume, um, I just want to say that Anne is also a very kind human. So welcome, Anne. Good morning. It's really a privilege to be here and honor the transformative work of Doctor Dunnigan, um, but maybe, with all due respect, even more importantly, the work that you are all doing in this hospital to improve the lives of other humans. I am also delighted to represent work in healthcare safety that you might not be all that familiar with. So, as you know, children are used to following, um, the rules that adults make for them and being led around by adults, but I'd like to suggest that in healthcare safety, that the children's hospitals have a lot to say. I have a very boring financial life, so certainly have nothing relevant to disclose. Hopefully, my objectives are a little bit more interesting and will come through in my talk. But children are this unique form of human beings who simultaneously have very loud voices and no voice at all. Their loud voices can be extremely effective at, um, securing themselves, maybe a nap or, um, something else to eat, but they're mute when it comes to advocating for the rights and resources that they need to fully actualize. For this, they need champions and campaigners and lobbyists. And it, when it comes to pediatric healthcare safety in the United States and Canada, that's us. The organization that Joan introduced at the SPS or the Solutions for Patient Safety. And notice I said us, and that includes you, because you're a part of this too. Actually, St. Louis Children's Hospital has been a part of SPS since 2012. And Saint Louis Children's Hospitals has some absolute superstars. Joan being one of them who actually also has served as the Midwest Regional champion, and someone I know who couldn't be here today, but Heidi Fields is a co-leader of our network's serious falls leadership team and has guided our work to an 82% reduction in serious falls across the children's hospitals. So you can thank her when she comes back from vacation. About 2/3 of the participants of the SPS network are actually children's hospitals within larger hospitals or hospital systems. And I have to say that those hospitals are acutely aware that part of the challenge of helping others is helping others recognize that children are not little adults. And pediatric safety is not little adult safety. So what I want to do is talk a little bit about the history and work of SPS, the results that we've achieved, the challenges we still face, and the progressive way that we're evolving. And I hope that you are able to see the parts that are translatable beyond the children's hospital world. So let's get back to the idea that children's, um, pediatric safety is not little adult safety. To make it relatable and a little bit of fun, you maybe heard about the way that people start to look like their dog. They even maybe take on some of their characteristics, their personality characteristics, their physical characteristics. So as part of my presentation today, I'd like to make the argument that we leaders in children's hospital safety have taken on some of the key characteristics of children in the last few years that we've been focusing on the work together. And there are 4 characteristics that I'll highlight today. So I want to start with, um, our rate of growth. I know you know all this, but children are really amazing creatures in that regard. If you think about it, an entire living, breathing baby forms in a little less than a year from a single cell. And then to continue the marvel, in their first year of life, a baby's brain doubles in size, their body weight triples, and they grow about 10 inches in length. The mind-blowing linear growth continues again in adolescence when our teenage friends grow several inches in a matter of months. I mean, come on, when's the last time you did that? Maybe your waistline or the width of your foot or something like that, but. In 2009, the Children's Hospital Solutions for Patient Safety Network was born. And our conception came after the government of the state of Ohio announced that it would publicly require safety measures, none of which was relevant to pediatrics. So the CEOs of the 8 Ohio Children's Hospitals, and yes, there are 8, negotiated with the government of the state of Ohio to allow the children's hospitals to report pediatric appropriate measures, and in return, the children's hospitals agreed to do something that had never been done before. And that was to work together to eliminate serious harm relevant relevant to those, um, those metrics. We were absolutely in new territory here. In a city like the one I live in in Cleveland, there are 2 children's hospitals, they're 400 yards apart. They compete voraciously for market share and talent. How is this going to work? I know the executives were extremely nervous and the lawyers were probably shaking in their boots, but what was interesting is when you got the people together who actually care for the patients and are actually working to improve safety on a day to day basis, all those imagined barriers disappeared. And honestly, a kind of magic happened that I don't think any of us anticipated. Within just 2 years of starting the Ohio Collaborative, we reduced surgical site infections and adverse drug events in children by more than 50% each, and then we're inspired by a CMS contract to expand the network beyond Ohio. Then year after year we attracted dozens of committed hospitals to our work. Currently, the Solutions for Patient Safety Network is comprised of 153 children's hospitals in the United States and Canada that work together with the mission of eliminating serious harm that happens to both patients and employees. OK, the 2nd way that children's hospital leaders are similar to children is our activity level. Children are natural high energy machines. We all, many of us, I presume, watched a bit of the Olympics, and there have been studies that show that children have energy bursts comparable to elite athletes. You might have noticed that certain age children have no gear called walk. They are in constant motion and it's exclusively in the form of a run. In fact, children do move constantly when we don't plug them in, except when they're asleep. Many young children engage in over 180 minutes of moderate to strenuous physical activity every day, while most of us adults struggle to meet the recommended 180 minutes during a whole week. SPS has been moving at a run since we were born, and I'd like to share with you some of what we've done and accomplished as, um, since we began our work together. We've been guided by a set of principles that continue to serve as our foundation. The first one is I teach, I'll learn. And that's the idea that no matter how big or small a hospital is or how old or new they are to our network, that every children's hospital has something to teach and something to learn. We've organized innumerable webinars and work groups and research cohorts and improvement cohorts. We've laid down improvement challenges. Using our own data, we've developed 11 evidence-based harm prevention bundles that took us from a situation where care processes were conducted in a highly variable, one could say arbitrary manner across children's hospitals to standard best practices. So in 2026, if you take your child to a children's hospital in Toronto, San Diego, New York City, Baton Rouge, or St. Louis, you can expect the same high quality and safe care. We created an ethos that extends beyond presenting on a webinar to include more academic output with multiple peer-reviewed publications describing our results. Over the last years, we've had 20 publications and 40 abstracts in peer-reviewed journals and another 10 that are in the works. Every few years, we publish our, our overall impact. And about a year ago in JAMA Pedes, we had a publication that described our results to date. One recent example of the vigorous work that's happening in pediatric safety is for our last meeting, we had 188 abstracts related to children's hospital safety that were submitted. That's reflected how we've evolved the way we work together. When we first started our network, we often used the phrase steal shamelessly. I really don't use or even like that phrase anymore because stealing implies something devious and reinforces the idea that we're competing instead of working together. We don't steal. We share generously and receive graciously. And that, as it turns out, has been an amazingly powerful model that has accelerated safety improvement and it's been a certain key to the success of our network. If you were to join any webinar that happens across our network, you would see incredible examples of people offering to share documents and tools with no direct benefit beyond the opportunity to be on the receiving end another day. So another of our core principles is we don't compete on safety. As I said, market share and talent, absolutely, but safety, no. And what that means is sharing real data and sharing process data like how the nurses in your ICU maintain the central line and whether it's per protocol. Sharing that kind of data is good, but it's not really that triggering. What takes more organizational courage is sharing outcome data. We pressed for this not because we wanted to start competing, but for the purposes of identifying who does it the best and how can we learn from them and where are our opportunities. At the end of last year, we published our annual Shine transparency report. And for every work stream that we tackle, we list the hospitals with the top rates. We give their names, their rates, descriptions of their hospitals and other demographic data. We give the name and contact information of the appropriate people in the organizations in case people want to reach out, which they do. At the beginning of our network, was it embarrassing and scary for to share outcome data that we weren't proud of? Heck yeah. But once we realized that everyone is in the same boat, we could settle down and trust our peers, and it really became easy. And you know what? The world did not explode and we're off and running. And we've made remarkable progress in developing a culture of non-competition. When we first started our work, no one shared their outcomes on their public websites, and most of those who did so on their internal websites put them in rarely viewed locations. But if you were to log on to the websites of SPS hospitals now, you would find that dozens and dozens of them share their outcomes publicly, and almost all of them have improved their internal transparency. A 3rd core principle of our network relates to leadership. First, the idea that active leadership from the top is essential. And that it's not about signing a check or giving a thumbs up to our work. So twice a year, we, we host a CEO learning opportunity that is required for our leaders. We've also trained over 2700 Children's Hospital Board members in the essentials of safety governance. We started the SPS network with about 20 devoted, passionate safety leaders. But in an organization with its mission as audacious as ours to eliminate serious harm, I figure it's really not possible to have too many leaders out there in the world. And we now have 250 SPS leaders. In my role in the network, I've had countless one on one phone calls with these people because I believe it's critical for sustainable results. I try to create an environment that invites their engagement and innovation. I encourage them to text and call me directly whenever they have an idea or a concern. My colleagues and I send personal thank you notes to each one of them every year to acknowledge their importance. Why? Because I think it's akin to offering these leaders stock options in the work that we're doing. I want them to see and feel what I believe is also true, that they own this network. And what I've seen is that as owners, they then care for it, they're proud of it. They're all volunteers, but I'm continually awed by the observation that these people lead SPS like it's their primary responsibility and they love it. Many tell me that the work they do with our network is the most rewarding part of their job. And of course, these leaders can influence others I couldn't reach with an email or a webinar. These are the people at the front line who are the ones that actually make the hospital safer. So as a result, we have more than 8000 people who have requested to access our SharePoint resources and be a part of our hospital contact database. The last principle I want to talk about is one Clay mentioned as well, is to focus on the culture of safety. We love our QI and process improvement is definitely our jam. But from the beginning, we have appreciated the need to intentionally and systematically improve the culture of safety in the, in our hospitals. So as one example, we've trained 3/4 of a million people in the basics of optimal safety behavior, so that we can all use the same language and have the same expectations. More recently, we've begun to fully embrace innovation. We started by defining our needs. Where do we need to invent and think outside the box in pediatric healthcare. We've established partnerships with pediatric device consortia to find and develop, uh, devices that are much needed to keep children safe. Now we're evaluating which of these will have the greatest safety benefit so that our network can serve as the test engine for these critical projects. And we're doing something very similar in, uh, with the digital innovation accelerator. So, like children, we've been busybodies, but it's worked. Since our network began, we have spared harm to over 33,000 children. These are our children, our grandchildren. Our nieces and nephews and friends and neighbors, and the little one who gives you a smile from the grocery store cart. Shown here are the key hospital-acquired conditions that have been the focus of our work and our results. These results include a 12% decrease in serious peripheral IV infiltrates, a 23% reduction in lapses. I mentioned the 82% reduction in falls, which are frankly now very rare events in children's hospitals. One of our most compelling improvements has been unplanned excavations. This is when the endotracheal tube of an intubated child is inadvertently dislodged, leading to a considerable risk of respiratory and cardiac arrest. We started this work in late 2016 when a couple of dozen brave hospitals agreed to test interventions to reduce this type of harm. At the time, the prevailing opinion was that unplanned extations, while common and serious and unfortunate, were not preventable. I had many people, despite the fact that I am indeed a trained pediatrician, explain to me that there are only a few millimeters difference between a position that's squarely right and dramatically wrong in a premature baby. At any rate, that volunteer cohort worked together to develop an evidence-based standard that has now been adopted and refined, uh, in the subsequent years by SPS hospitals. What you see here is the statistical process control chart with time along the X axis and our network's unplanned extubation rate on the Y axis. We started with a rate of 1.1 unplanned extubations per 100 ventilator days. Through our work together, we've now received, we've now achieved a rate of around 0.4. This harm, which was strongly felt to be unpreventable, has now been reduced by 61%. As part of the project, we designed, implemented and published a novel QI approach to reducing unplanned excavations and have published several articles on this approach, um, and results with another one on the way. Of course, these improvements translate to dollars too. An estimated $776 million US dollars of costs have been averted due to the work of the SPS network. And while we had a lot of success early in our network, when low hanging fruit was abounding, we're not slowing down as we approach our adolescence. As we made a transition to a new strategy, we had one year goal period for 2025, and you can see those goals and our actual results on this slide. We continue to make steady progress. In some cases, we exceed our own expectations, and in other cases like patient behavioral events, that makes us appreciate the need to better understand the problem and test solutions. So you can appreciate the patient behavioral events are now a major focus for us. For our next, um, several years, we've identified seven areas where we're hoping to make breakthroughs between now and 2030 as part of our new strategy, and you can see our goals here. OK, so back to the ways we emulate children. We've grown fast. We move at a run. Another characteristic of children that we in pediatric safety model is their adaptability, their flexibility, and their fearlessness of change. Their physical flexibility is amazing and is attributable to softer and more porous bones and a higher percentage of cartilage and lax ligaments. Children's brains have a high degree of neuroplasticity, which makes them more capable of learning new skills and absorbing information efficiently. This is why they can learn a language more effectively than adults. Children also approach learning without the cognitive biases and fears that adults develop. They're more open to new ideas and less self-conscious about making mistakes, which allows them to experiment and learn faster. So these characteristics, flexibility, curiosity, adaptability, are also hallmarks we admire in the SPS network. The SPS networks is defined by testing, trying, adapting, and considers its ability to be nimble and take reasonable risks as a critical asset for improvement. Importantly, the SPS network is also humble and honest about its shortcomings and open to evolving and trying new approaches, rather than clinging to a single theory that we continue to double down on. And this is very important. So for those of you who are not safety scientists entrenched in these approaches, I want to give you a whirlwind tour of the major approaches to safety for the last 30 years. The first is compliance. Compliance was born in the industrial revolution and is an age-old method focused on worker obedience to standards. In order to create the product we want or get the result we desire, we're going to write down exactly what we want the worker to do. We're going to have them sit in a room and teach it to them, and then we're going to expect them to do exactly what's on that paper. Standardization and compliance are vital foundations. This and the next few approaches that I'm going to describe moved us from a place where key processes were conducted in an arbitrary manner to a standard better way. And this has been an important part of how we in the SPS network have spared harm to 33,000 children. But while it's a vital foundation, it doesn't completely work in large part because it doesn't, by definition, promote innovation. Innovation and standardization are strange bedfellows, you might say. Next is behavioral-based safety. And these programs engaged workers for the first time by auditing and correcting their behavior to prevent harm. A drawback of this is the reinforcement of the blame culture because it assumes that people make bad choices instead of people have bad choices, a concept that I'm going to come back to. Then we started doing more process design and this introduced a new perspective, inviting engineers to design errors out of systems and acknowledging that humans have always continued to and will always err. So let me give you an example. Think of a patient that has multiple lines and tubes, an IV line for medication, an enteral line for nutrition. In the past, and maybe some of you can remember that this, both types of tubing used a standard lure connection, which meant it was actually physically possible to connect the IV tube to the feeding tube and vice versa. And tragically, that happened on many occasions. So as part of process design, human factors engineers redesigned connectors for rail feeds to make them incompatible with the IV tubing. But this approach can be slow and inexpensive, and it also may not account for unexpected events. And finally, I want to talk about the approach that Clay mentioned, approach that has been an intense effort at BJC and that is high reliability organizing. So this approach really revolutionized safety because for the first time, we weren't just talking about the individual, we were talking about the organization and how the organization can improve. And it distinguished between complicated systems and complex systems. So let me take a brief diversion here to talk about the differences of types of systems. The first type is a simple system. Here it's cause and effect, straightforward and simple. You think you flip the switch, the light comes on. That's not healthcare. Complicated systems are like a mechanical watch or maybe a combustible engine. They're predictable, they can be broken down into their parts and analyzed. You could likely draw a linear diagram to explain how it works. Complex systems are things like the financial markets. The public health system. Healthcare These these types of systems are unpredictable due to the interactions of their components, and the solution to them doesn't lie in breaking them down into their parts, but rather understanding the interdependence of the work that's being done. So HRO theory is a major step in the right direction in that it recognized the complexity that exists within healthcare. All of these approaches have given us critical insights in our journey, all added value and work to some extent. But we're not done in safety. We're continuing to evolve, and like children, we need to be nimble and allow ourselves to learn. The approach that we're evolving to now is largely informed by research in other disciplines like resilience engineering and organizational psychology. And other industries like oil and gas that have heavily transformed safety. This approach is called socio-technical safety or human and organizational performance. This approach recognizes the interconnectedness of social and technical factors in understanding and improving safety within complex systems, the interactions between people, structures, and technology. I understand that you all just implemented some new pumps. It's not simple, is it? It's not even complicated. It's complex. So this approach focuses on learning in ways that we've never done before, and particularly learning from the front line. It emphasizes the critical importance of leadership and reinforces that error is actually normal. This approach nails the concept of complexity and presents a new operational definition of safety, not as the absence of errors, but as the presence of safeguards that prevent harm. And this shift is particularly profound as it moves us from thinking of safety, not as something we achieve, but something that we do. And what we do is facilitate organizational learning to build those safeguards. The words come out easily, but the transition is not subtle. In the old way, we focused on bundled reliability and standards as the North Star, and we let auditing data and event analysis drive our efforts that were mainly focused on influencing the front line to adhere to the standards. The new way heavily emphasizes learning in deeper ways, especially from the front line. It's about engaging the entire organization in improvement and teaching new tools that help us build safeguards instead of playing whack a mole all the time. These tools are things like learning teams and walk-through talk-through and proactive safety huddles, and involve adopting a new language that reflects this new approach. I want to talk, go back to my unplanned excavations and mention a project that was very recently done. And employed the proactive safety huddle approach. What we did is we opened to our network the opportunity to participate in an improvement cohort where we were going to test a structured proactive safety huddle to prevent unplanned extubations in the NICU. This after we'd already seen tremendous reduction in the NICU of our unplanned extubations as I recommended. And what I hope you can see here from the red center line. It worked. In fact, we realized another 20% of reduction in unplanned extubavations in the NICU applying this proactive approach. We're doing this similarly in other areas that we work. We're doing walk-through talk-throughs in central line care outside of the ICUs. We're employing learning teams in behavioral health units, and as we, uh, in intensive care units to consider how we can prevent delirium. These approaches more successfully consider the system issues and their interactions to proactively incorporate those safeguards. So we've adopted modernized safety concepts. We're moving away from the idea that we can engineer out air and thinking of air as just being normal. And safety not as the absence of errors or events, but the presence of safeguards. We're moving from a place where we had the, the, the, the, the top of the line was rigid adherence to standards. To cultivating adaptive capacity. Adaptive capacity is the measure of the system's ability to absorb variability, including that introduced by human error and adaptation before it impacts system performance and outcomes. We loved our Swiss cheese models, we could explain those to our dogs, but it's more complicated than that. And we investigate, we've gone from just learning from investigating events to with the hair of their lives to deepening our learning in other places. And instead of just a wholehearted effort to influence the front line to do it the way we want them to do it, our purpose is now maximizing the ability to do the work they signed up to do. And in all of this, leaders are essential. So for the last few minutes that I have with you, I want to dig deeper into a few of these concepts, namely honoring complexity, learning, and thinking about how leaders respond. For a talk that I recently gave to the SPS network leaders, I did a lot of reading about the concept that cognitive scientists call goal conflicts. In various places in life, both professional and personal, our brains are engaged in strategic processing during which we assess and compare different courses of action. Should I let my teenager go to this party? On the one hand, I want to give her autonomy and some freedom. On the other hand, I want her to be safe. Key goals in raising teenagers and making decisions about their actions are encouraging their autonomy and keeping them safe. But these two goals can conflict. So when we have multiple simultaneous and active goals that suggest different courses of action, these are goal conflicts. And goal conflicts are ubiquitous in healthcare, particularly for the frontline provider. Consider that as part of their routine strategic processing, they have to account for different but interacting goals, patient safety, employee safety, patient satisfaction, throughput, ideal clinical outcomes. They have to account for different risk profiles, and there's no such thing as absent risk. Different consequences of failing and succeeding, how their leadership will respond. And all the while they're faced not just with uncertainty, but with distraction and time pressure. Think of a busy OR on the weekend and imagine that you are the anesthesiologist in charge. You have a couple of rooms and a couple of residents, and you're the attending. And what you know is that there's a trauma coming that requires vascular surgery. There's an appendectomy in the ER. There's a perforated bowel in the NICU. There's an intracranial bleed in the PICU that's being considered. You had a regular OR schedule and the surgeons are getting restless. The staff are tired and Snowmageddon has come again to St. Louis. You have resident supervisory issues, and always the looming possibility of an emergent call for intubation assistance or an unexpected trauma. How to make decisions about what, when, where, in what order. With limited resources, staff members in this situation have to take gambles all the time. And when they work out, as they most often do, no one even notices. So frequently, frontline providers have to act decisively and in the midst of competing demands in an environment rife with uncertainty and risk. It's so common, implicit and unstated that it's almost invisible. In fact, goal conflicts are the rule, rather the exception for frontline providers. So people have to cope with these goals and shift between them and weigh them and choose to pursue one over the other and abandon some altogether. But these goal conflicts are much easier to see at the sharp end as the anesthesiologist than the blunt end as the CEO. It's common for the complexity of these conflicting pressures to be underestimated so that it just looks like it was a bad decision when an event happens. But organizational decisions at the blunt end affect sharp end goal conflicts. Of course, they're derived from important things like the need to anticipate legal liability and regulatory guidelines and economic factors. The goals the front line perceives are not necessarily the written policies and procedures and may be quite different from what the leadership perceives. The front line cope with goal conflicts either by trying to balance competing demands or just by following the policy. And as I said, either way, it generally works. And spending more energy trying to understand why it generally works is a key hallmark of this modern safety approach. Spoiler alert, it's the adaptive, resilient thinking of human beings that are typically responsible for that success. Although no awards are given out 99% of the time, the OR scenario plays out just fine. Until one day it doesn't. NASA in the late 90s. Had an organizational philosophy that was 3 words faster, better, cheaper. And it epitomized how multiple contradictory goals are simultaneously present and active in complex systems. The Mars Climate Orbiter was a NASA spacecraft that was lost in 1999 when it burned up entering the Martian atmosphere because of a navigation error ostensibly caused by a failure to convert between English and metric units. That same year, the Mars polar lander crashed into the surface of Mars due to a failure to anticipate vibrations of its landing legs. After these events, some organizational critics argued that the influence of the faster, better, cheaper philosophy was the problem and suggested that NASA limit itself to maybe two of the three. You could be faster and better, but not cheaper or better and cheaper, but not faster or cheaper and faster but not better. But the reality is that NASA is actually trying to do all three of those things. You can bet that the decision of many individuals came under scrutiny when these two expensive spacecraft failed. Despite the fact that the strategic goals that highly influenced their decisions were set by people many pay grades above them. Which brings me to the responsibility authority double bind. This is situations in which frontline have the responsibility for the outcome, but lack the authority to take the actions they see as necessary. And research related to the responsibility authority double bind are limited but consistent. Splitting authority and responsibility appears to have poor consequences for the ability of the operational system to handle variability and surprises that go beyond the pre-planned routine. Our historical tendency when events happen though, is to actually strengthen the double bind, lock humans down with more procedures, more policies, more standards, more auditing, etc. Example of that outside of healthcare was one consequence of the Three Mile Island nuclear reactor accident. When the Nuclear Regulatory Commission pushed for utility companies to develop more detailed and comprehensive work procedures to ensure that operators followed these procedures exactly. It seemed reasonable. For the front line who actually did the things, strictly following procedures posed a lot of difficulties. The procedures were sometimes incomplete, they were contradictory. They were not able to accommodate novel circumstances that arose. So this led to the double bind because people would be wrong if they followed the procedure and that didn't fit the circumstance, and they would be wrong if they didn't follow the procedure, even though it might not fit the circumstance. Instructions, whether they be a bundle or a care path that potentially guide a person's behavior, however elaborate, and whether on paper or delivered via a machine, are inherently brittle when followed mechanically. Brittleness is a super cool word that resilience engineers use. Brittle processes do not have the ability to cope with novel situations. They can't adapt adapt to special conditions or contexts or recover from errors or manage system bugs or a pandemic. And in case it's not obvious, attempts to eliminate all sources of ambiguity and all possible scenarios are fundamentally misguided in complex systems such as healthcare. So let's think back to our OR scheduling case. There were millions of factors under consideration. How long will each case take? Will the arterial construction go well or will it be complicated? How should the residents be assigned given their training and expertise? Should the attending stay in the most complicated case, the shortest one, so she can circulate around? But then she'll be tied up for a long time if she goes in that case and things might slow down and she won't be available for supervision. What's the likelihood that a trauma will come in? It's snowing. Are people going to get in accidents, etc. etc. etc. Yet she needs to be decisive. Saying that safety should come first is instinctive, but it's naive. There's no way to measure risk when all of these paths are risky. To demonstrate the incredible complexity of healthcare compared to other industries, if we were an airline in that situation, we would just ground the plane. But that's not an option in healthcare. So the implications of this are many and I talked about the value of standardization, but endless retraining, auditing, and compliance, um, and blame of frontline care providers are not getting us where we need to be. We need to appreciate the gold mine of knowledge contained within the front line and begin to learn from them in earnest. Our our goal should not be to get them to always behave in a certain way, but to design systems that allow them to do what they passionately want to do and are supremely well qualified to do, and that is to take excellent and safe care of patients in complex situations. This is going to mean thinking and behaving differently. For example, when events occur, we need to remind ourselves that possessing knowledge of the outcome trivializes the situation confronting practitioners in real time and makes the correct choice seem crystal clear. During learning after an event, we need to expose the influence of competing goals and understand the strategic decision making of the people involved. When we find ourselves wanting to ask, how could that person have missed or not known or done that, we need to think about goal conflicts. And here in our heads, the mantra that I mentioned at the beginning, people don't make bad choices, they have bad choices. To try to understand how knowledge was brought to bear in context by people trying to solve an operational problem. A beautiful but sometimes painful characteristic of children that we try to emulate in our work is transparency and honesty. Children are Explicit and direct in their communications, more so than adults. They're more clear about what they need and want and observe and the challenges they face. And although I've shared with you some of the accomplishments of children's hospitals and safety, we remain very aware of our shortcomings. Way too much harm still happens. If you take our top 3 harms in children's hospitals, which are lapses, nephrotoxic medication associated acute kidney injury, and unplanned extubations, over 1000 children in our network hospitals experience one of those serious events every month, roughly 33 today. Our challenges we have in children's hospitals are external. Let's start with funding. 37 million children in this country rely on Medicaid for their healthcare. That's roughly 50, 55% of kids. However, in many locations, Medicaid coverage is seriously threatened. Sustainable, predictable, adequate healthcare for children is a critical investment in our, uh, country's future. Something else I have the unique, um, opportunity to observe. Safety improvement efforts in freestanding children's hospitals and hospitals within hospitals, which as I mentioned, actually constitute the majority of our network. And what I can tell you is that safety leaders in children's hospitals within systems have to walk to school uphill both ways in their efforts to improve pediatric safety. Not just because their resources are limited, but because their colleagues in adult hospitals and systems fail to recognize that children are not little adults, and that children's safety is not little adult safety. So children's hospitals can be stuck with the wrong resources, the wrong metrics, the wrong approach to improvement. I will tell you that this doesn't mean that children's hospitals within hospitals or systems don't achieve exceptional outcomes because they do, but the workarounds can be remarkable. A 3rd challenge for us are governmental and regulatory systems that similarly fail to accommodate the unique challenges of children's healthcare. And this is a place where we have more opportunity. We need to use our grown-up advocacy skills and encourage organizations outside of children's hospitals that influence our work to learn with us, including many of you in this room, our adult hospital colleagues. Let us continue to grow and run. Don't distract us with requirements and efforts that are nonsensical to children, but let us be your guinea pigs. Let us continue to be out front and figure out how to take giant steps forward, and we will happily share them with you and hope that you can benefit from them in the same way. Recently, I spent some time with my nephew, um, learning to tie his shoe. You know, there's the bunny ears method and the around the tree method. And I think sometimes when we were faced with problems, it is helped, helpful to break it down into steps. One of the things that safety leaders from across the SPS network have done is, as they've, um, focused on safety might be relevant to you, whether you lead in a unit or a program or across the organization. Firstly, you must prioritize. There has to be a thoughtful process, but where is it that you can maximize your safety benefit in terms of both the number and severity of patients who are harmed and their severity. And then you have to have an operational plan. And I hope I've made a strong case for moving away from engineering out of, out errors and process defects towards new concepts resulting in helping the front line do their work safely and effectively. Along with process improvement work, be mindful about integrating modern safety concepts in every project. Ask yourself, what do you need to learn? Don't assume you know. Use tools to learn, especially from the front line to help define the problem and create solutions that promote system optimizations and empower the healthcare team. Stop adding more without taking things away. Something else that safety leaders for sure across pediatrics, and I'm assuming adults are, are really good at, is something that we've come to know as accumulating safety clutter. We're working on this in pediatrics. It's definitely a fundamental part of traditional approaches to safety and safety management. In other words, we need to clean up our rooms. Procedures, paperwork, rules and data that accumulate and take people's time, but don't meaningfully contribute to safety. And these come from some of our favorite, favorite places, checklists, and redundant documenting. They exist to satisfy audits and legal requirements and organizational habits. We are terrible at removing anything that's ever been implemented. We like layering, more is better. But this leads to a burdened front line. And even worse, gives them and us the illusion of safety. The people who can best help you identify safety clutter are those that are most affected by it, the front line. Empower them to challenge ineffective practices. Ask them what is the silliest thing we're asking you to do. So it's a lot and it's hard, but here's another time that we need to act like a little kid. Little kids are good at figuring stuff out. If you give a 4 year old a phone in minutes, she'll be swiping through your photos and browsing TikTok like a pro. By the time she's 7, she'll be updating your LinkedIn profile. And not many years later, she'll be designing approaches and processes and technology that improves safety, healthcare, in our world. Thank you very much. OK, I'm happy to take some questions until, oh, maybe one question. OK. Are safety huddles unit-based or service line-based, leaders, frontline or both? Great question. All of the above. The safety huddle, and one thing that I want to tell you is that one of the challenges that we've had in implementing this is people say, huddles, oh, we do that. Proactive safety, oh, we do that. Learning from the front line, oh, we do that. And what I would encourage you to say is, what is it exactly you're doing? What does the safety huddle look like? To answer the specific question, I think that I, I'm a huge fan of huddles. I huddle with my team. And I think that can happen throughout the organization. So I don't think we're necessarily limited to that. The proactive safety huddles I mentioned specifically in the NICU and unplanned excavation had required attendees. That was the physician, the nurse, the charge nurse, the parent either had to be present or on the phone, the respiratory therapists. So it was really kind of the core team that was trying to figure out how they could prevent an unplanned extubation in a high-risk child. So should I keep going or I can do one more. OK. What is your advice for when there is significant reluctance to change? That's a great question. I actually have been thinking about this a lot. And what I tell you, uh, is that early in my career, I thought it was data. Data, data, data. Give people data and facts. I'm off that. We need those. They're coming later, but the first thing you must do is change the story. Change the story in their brain, use stories to change their stories. And if you don't believe me about the facts, just think briefly about the United States political system and how facts come into us and how the same people can receive facts and interpret them in very different ways depending on the story that they have in their mind. So the greatest. The method of influence that we have is our ability to change someone's story. So if you're really stuck with someone, throwing a bunch of facts at them will just frustrate you because it will, it will cause them to file them in the appropriate place in their story, which may be the wastebasket. But if you can manage to reframe their story, then you can have more success. So, thank you very much and congratulations.
