Care Redesign

Halfway to Zero Serious Safety Events

Interview · March 5, 2018

Lee Sacks and Tom Lee

Thomas H. Lee, MD, interviews Lee Sacks, MD, Executive Vice President and Chief Medical Officer for Advocate Health Care.


Tom Lee:  This is Tom Lee from NEJM Catalyst, and we’re talking today with my good friend, and someone who I think is one of the best leaders in health care today, Lee Sacks, a physician who is the Executive Vice President and Chief Medical Officer for Advocate Health Care. Lee, I’ve been following Advocate’s safety journey for years now, and I gather that you have some good news to share. How’s it going?

Lee Sacks:  Tom, it’s going very well. As you know, our goal is to get to zero serious safety events by 2020. In 2017, we passed the halfway mark, which gave us a chance to stop and celebrate and help generate more momentum, because the second half of the journey is probably going to be more difficult. But we ended the year with about a 54–55% reduction from our baseline in serious safety events.

Lee:  It is one of my favorite stories in health care, and I know a good part of it already, but not everyone in our audience will know it. Can you describe for them how you and the Advocate management team decided to set your audacious goal in safety? How many years ago was it?

Sacks:  I think we set the goal back in 2013, but as I think back and reflect on it, we’ve been on a safety journey since To Err is Human came out in 1999. But the reality is, we struggled. We tried flavors of the month and different tactics, and we had some short-term success, but in 2013 we stepped back and said, we need to give some thought to how do we make a difference. And we spent a year creating a safety strategic plan trying to counter to my instincts of, do things as soon as you learn a best practice somewhere else and try to steal it and implement it.

But we were very deliberate, and at the time we set the audacious goal that by 2020 we wanted to get to zero serious safety events. The first part was really starting to be transparent and identifying events. We looked worse before we got better, but starting in 2015, we’ve seen a steady decrease leading to what I just mentioned, passing the halfway mark in 2017.

Lee:  How did you get started? I know that it’s one thing to set a goal, but then you had to get to work. What were your first major steps?

Sacks:  The first step was to look back at the things that we had tried since 1999, and it was following some of the IHI playbook, looking at other high-reliability industries — we had nuclear engineers come in, we had astronauts come in and gave inspiring keynote talks — but it really didn’t change what we were doing. So, we stepped back and put together a leadership group that included both front line and executives to put together a safety strategic plan.

We consulted with other industries, we tried to identify some best practices within health care, made some site visits, and put together a four-step safety strategic plan that was very deliberate and needed to be executed in sequence. At the same time, we got buy-in from the board and our CEO, who began to say that first and foremost we’re a safe clinical enterprise. He used to say we’re a clinical enterprise, but adding “safe” ahead of that started to capture the attention of the organization. It certainly resonated with our clinicians.

Lee:  I started paying attention when Advocate made 8 to 8:30 a.m. a meeting-free zone so that every unit of care could have safety huddles. Are you still doing that?

Sacks:  We are still doing it. The huddle varies from 8 or 8:30 depending upon which site. I’m out at one of our hospitals today, and the rest of the team is in their safety huddle, which started a few minutes ago. That was one of the first steps, but it paralleled leadership training.

Our senior leadership teams spent about 18 months going through a series of 2-hour modules related to high reliability, reading books and articles about it, and one of the first lessons was the value of a daily safety huddle. A chance where we start off with, we want to review all the events that occurred in the previous 24 hours, anticipate and plan for the same in the next 24 hours, and review and get updated on open items from previous huddles. In a hospital, it brings together the leaders of all the care units and the support services.

We started doing this 5 days a week and knowing that we would eventually expand it to 7 days, but after a month several of the sites said this is so valuable we’re starting to move to 7 days before you even tell us. We also do a system-wide huddle once a week on Wednesday to capture things that occur at more than one site and make sure that we’re transferring knowledge and solving problems — especially in the support services — that impact all of our sites. If we get into a special situation, like a couple years ago with Ebola or more recently with influenza, we’ll do the system huddle more than once a week if things need to be tended to more frequently.

Going back to your comment about the meeting-free zone: to support the huddle we put a ban on meetings between 8 and 9 a.m., the only exception being when there were physician meetings, recognizing that physicians need to start their days seeing patients. Most of those meetings are in the 7 a.m. hour but sometimes spill over past 8. But no meetings across the system except for the safety huddle, so we get 100% attendance and then can have a few minutes to debrief and follow up on items that need immediate action, and solve problems right then in real time.

Lee:  I know it’s tough to come down to three things that account for most of your progress, but because most people have trouble remembering more than three things, what would you say are the most critical three that account for your progress?

Sacks:  I’d start with our leadership buy-in — the board, the CEO, and everybody knowing that first and foremost we’re a safe clinical enterprise. Second would be the leadership training, because not only did we go through the didactics, but each of the leaders then was responsible for training the leadership team at their operating unit. If I’m a hospital president I needed to do the training for my senior team, and one of the things that I learned very quickly is when you have to teach something, you have to master the topic, and it makes it much more meaningful. The third is the a.m. huddle. Everybody in our organization would say that that’s played a huge role in transforming us and helping us reduce serious safety events.

Lee:  Any predictions on how low you can go? I know it’s been difficult to get to where you are, but you do have a real goal. Do you think it’s feasible to get to zero?

Sacks:  We’re going to get to zero. What that might mean is that a hospital or a medical group is at zero for a year or two. Will the stars align, and will we be able to say that the whole system is at zero for a year? I hope so. I look at commercial aviation, and in 2017 there were no fatalities anywhere in the world, and yet there probably was a little bit of luck, and just I think yesterday there was a fatal commercial crash in Russia. They’re not going to have the same streak in 2018. But if we can get close to that, we will have made a huge difference for the patients we serve. You can already count in the hundreds the lives saved that wouldn’t have been if we hadn’t started on this journey, and that’s what makes it so meaningful.

Lee:  You’re doing great work at Advocate, not just in safety, and I hope we’ll be talking to you sometime soon about some of the other remarkable things you’re doing around the value of care. Thanks for sharing your progress, and I know we’ll be talking to you about this and other things again soon. Thanks so much, Lee.

Sacks:  You’re welcome, Tom. Always look forward to talking with you.

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