Value of Safety & Quality

Podcast Transcript

Michelle Lampton: Welcome to Learning to Lead, a leadership development podcast at Cleveland Clinic. I'm Michelle Lampton. One of Cleveland Clinic's six values is Safety & Quality. What we mean by safety and quality is that we ensure the highest standards and excellent outcomes through effective interactions, decision-making, and actions. We wanted to learn more about what Safety & Quality looks like in practice, so I sat down with Dr. Leslie Jurecko, Cleveland Clinic's Chief Safety and Quality Officer, to talk to her about what Safety & Quality means to her.

Michelle Lampton: So thank you so much for joining us today, Leslie. Can you share a little bit about your role at Cleveland Clinic and how you view it yourself?

Leslie Jurecko, MD: Sure. So my role is Chief Safety and Quality Officer. I'm a physician leader, I'm a pediatric hospitalist, and so I still see patients at Cleveland Clinic, I actually start seeing patients this spring. I'm new to my role, I started just about six months ago. The role of the Chief Safety and Quality Officer is to really define the strategy for the entire enterprise. It's all about how our enterprise comes together and becomes highly reliable, or that term, a high reliability organization. The goal is to provide the safest care to our patients. So in this role, I lead teams of experts and most of our teams are focused on preventing or detecting or correcting anything that could cause harm to a patient or to one of our caregivers or anything that causes hassles for the patient journey. So we try to improve everything about healthcare.

It's really inspiring to see all of our experts that I lead they're in safety, quality performance, accreditation or regulatory affairs, environmental safety experts, infection prevention experts, and clinical risk management. Our teams partner quite a bit with our institute leaders, our hospital leaders, the department and units, and we try to really define what best practice looks like, we share data around it, and we work as a team of teams. This team of teams extends across the globe, so Abu Dhabi, of course, we're working with our Florida campuses, our new London, we work with our Canada teams in Toronto, and also our Las Vegas team. So we all work together.

A really great example of us working together and why I love my role so much is we recently came together to improve what's called just culture in our organization. That's really around the fair process of how we treat our caregivers. If they are involved in a case or a time when care didn't go as expected, we're concerned of course that there was an error, but it's often not human error at all. That can be a component but it's often the system we put our caregivers in, the complexity of delivering healthcare. So what we did all of the teams from across the globe, the Cleveland Clinic family came together and said, "How do we want to care for our caregivers when they're involved in that? How do we want to treat them fairly?"

So we developed a decision tree that really talks about supporting them and it really focuses around improving the system they work in and not being punitive or placing blame on the individual caregiver. It's finding that balance of individual accountability for the caregiver, but more important leadership accountability and accountability for the Cleveland Clinic to design systems and environments for our caregivers to really work in and thrive in. So my job is amazing, it really just is awesome because I get to lead amazing people and teams and team of teams across the globe to just get better for our patients and then our caregivers.

Michelle Lampton: That's wonderful, thank you so much for sharing that. So today we're really talking about our value of safety and quality, so what do you want the organization to know about this value? How would you define it?

Leslie Jurecko, MD: The value of safety and quality is amazing. It's foundational to all we do, it is food, water, shelter for healthcare. Our patients expect that we deliver safe care and that we have the best outcomes at Cleveland Clinic. There is no doubt about it, they come in with that mindset and that expectation. Safety is what we define as really that zero preventable harm. We know that this is complicated, we treat some of the sickest patients and that they can absolutely be faced with complications in their care. But if there are things that we can prevent, and harm to our patients that we can prevent, our job is to do that and to have zero preventable harm, and that's really safety. Safety extends across the caregiver lens as well, we have 70,000 caregivers at the Cleveland Clinic. Healthcare is actually a very dangerous place to work, not only for the complexities around lifting patients and moving patients, but also there's quite a lot of violence, workplace violence in healthcare because patients are at their most vulnerable moments in their life. So our caregiver safety is very, very important to us. From the quality side, what I want everyone to know about quality is it's hard to define, it's like we say quality a lot but it's really, really hard to define. Probably the best definition of it, it's really the combination what they call STEEEP, that it's safe, timely, effective, efficient, equitable, and person-centered. It's about all the outcomes we deliver, the processes of care, and that patient experience. When you wrap that all up, can it be accessible and affordable for our patients? That's really the essence of quality of care.

I think it's really important to connect that to our vision. So if you think of our vision, to be the best place to receive care anywhere and the best place to work in healthcare, to be anointed the title the best, we have to be the safest, most reliable system. We can't even be in the game of being the best if we're not the safest, most reliable system with the highest quality care. So that's why this value is just really, really important for our caregivers to connect to each day.

Michelle Lampton: Wonderful. So you mentioned about safety and quality being important because our patients expect safe care and we want to be the best place to receive care in health care, for those of us non-patient facing, how can safety and quality relate to us?

 Leslie Jurecko, MD: At Cleveland Clinic, we call everyone a caregiver, all 70,000 of us are caregivers. The reason why is because it is absolutely their role is so important to actually the delivery of care at what we call the sharp end or that frontline, where the care is delivered. So when I think about non-patient facing caregivers, I think about the system they have to support, and you think about the operational excellence that's needed, I think about the technical systems that we need from our IT teams. We focus a lot in safety around both ways to prevent individual failures, but ways to prevent system failures. System failures are really, really important and in fact is most of our work around improvement and most of our area of opportunity.

It's all of those non-patient facing caregivers that work to create that system or that ecosystem that our patient facing caregivers are working in. And without them being highly reliable at what they do, we could create a system, a poorly designed system that really will defeat a good person every time. We all know that a poorly designed system defeats a good person every time. So we rely on our non-patient facing caregivers to develop the system around so our patient facing caregivers could show up and perform each and every day.

One of the models I'd like to put in your vision while you're thinking about this is what's called the sharp end blunt end model. Reason why that's important is because I think we talk a lot about the sharp end of the frontline, what our frontline caregivers are doing, how we provide care to that specific patient and that family. But the blunt end of the organization is really, really important. It's those systems I mentioned, it's those systems I talked about that support the sharp end of our organization. If there isn't reliability in those systems, our sharp end is what really suffers. So we have to think about everything we do in that blunt end so we have reliability for our patients when the moment matters for them to receive care.

Michelle Lampton: So what does it mean to live safety and quality in our work as caregivers? How do we really truly demonstrate it?

Leslie Jurecko, MD: To live safety and quality in your work as a caregiver, it's really the essence of being a Cleveland Clinic caregiver. I've seen this time and time again since I've been here. Again, I've only been at Cleveland Clinic six months, and I will tell you, it is an amazing place, the people are amazing. A story that reflects that to me recently, and I hear stories every day and I'm just so blessed to be here, but one of the stories is a story about Claudette.

So Claudette is the winner of our 2020 Speak Up for Safety Award, and Claudette works for Environmental Services for us. She was cleaning a room of a patient, of course, this is during the pandemic, and when she was cleaning the room, the ventilator became detached from a patient, the patient was sleeping. Claudette quickly went to find the nurse. When she found the nurse, the nurse was actually on a phone call. So then she quickly thought of her next avenue to speak up and get help, and she used her Vocera to contact the respiratory therapists, and immediately all to help arrived for her patient and the patient did well. When you think about these behaviors that Claudette showed, and like I said, the essence of a Cleveland Clinic caregiver is not only these behaviors but it's on a so much deeper level. So Claudette spoke up, she used her ability to speak up, she knew it was her responsibility to do something.

I'd say that to every Cleveland Clinic caregiver, it is your responsibility when you work for us to report when things aren't going well, when you see something that could be improved, it is part of your role to report that, and that's exactly what Claudette did. The other thing she does is she brings her whole self to work. So when you talk to her about this event and about the work she does in cleaning patients' rooms, what she loves most about it is that when she gets to talk to patients. She talked about during the pandemic when most patients weren't able to talk because of their respiratory status, that's really where she would connect with patients and found that the patients really enjoyed spending time with her. In fact, she usually was in the patient's room more than a doctor or a nurse was during the day. So she would get to connect with our patients the most. So she brought her whole self to work, and that's also what it means to be a Cleveland Clinic caregiver.

I would just say other behaviors for Cleveland Clinic caregivers is we hired you for your kindness, your empathy, your ability to critically think, your ability to communicate, so important for safety's that communication, the ability to advocate for your patients to any role to speak up, and that recognition that working in teams provides better care, and that's what we do at Cleveland Clinic, it is the essence of what we do. I think other ways to live out safety and quality in your work, we do what's called tiered huddles. Tiered huddles, we have six tiers, we do them every day, really important for messaging and communication for that sharp end of that frontline, but also for leadership to hear how they can help. I asked Cleveland Clinic caregivers to please lean into these huddles to help us achieve our goals as an organization together. We can't do it if we don't hear from you, and we also hope that you're receptive to what we're trying to improve on.

I think a very, very big important for safety and quality behaviors and how you can live it out each day is resilience with change. Change is just a constant in healthcare. Showing that you can be resilient and a team player is really, really important for us to continue to work together to do what's best for our patients. We talk a lot about a questioning attitude or that preoccupation will fail you in everything you do, that preoccupation will fail you. Which seems negative, but what it is is always that mindset of what could fail? When I'm doing this, this medication delivery to this patient, what could go wrong? We ask you just to stop and think and pause for a minute and think about how you can prevent something from happening because we do live in a system of complexity and our caregivers are often our last safety net for our patients.

Then one of the behaviors that I hope and the culture that I hope we breed at the Cleveland Clinic is following best practice not because you have to but because you want to. So when we say you should do the universal protocol so that we do the right procedure on the right patient every time, and when we ask you to do these five things that will prevent central line infection, it's because it's evidence-based and it's not that we just want to tell you what to do, it's because we want you to be using evidence-based care. We know there's five rights of medication administration in nursing, that's so important to make sure it's the right medication for the right patient, the right dose at the right time. All of that is so important, we want you as a caregiver that wants to live out the value of safety and quality to embrace these because you want to and not because you have to.

Michelle Lampton: Thank you for sharing all that. I'm especially struck by the story about Claudette. I feel that if I saw a ventilator fall out, I would have no idea what to do, and I feel like I would panic. Which actually leads to a question, so speaking up can be really frightening, it’s not necessarily because someone's life is literally on the line, but it could be as simple as seeing somebody not follow a process correctly or I notice something wrong, but maybe I'm new to the organization and I don't know what to say or I've been at the organization for a long time, it can just be a very scary place. Do you have any advice for caregivers who find themselves in a situation where they do need to speak up but it's uncomfortable or a scary place?

Leslie Jurecko, MD: Advice for caregivers that want to speak up. I think the advice first starts with the teams that caregivers are on and the leadership that works with our caregivers and how we set the platform or the environment for our caregivers to thrive so they feel psychologically safe to speak up. When I think about what a leader looks in a high reliability organization and how they would promote speaking up, I use a term called first care then learn. So imagine a situation where a caregiver has been part of a case where things didn't go well or that they identified an area for opportunity and maybe the patient did fine, but it's a soft signal that something could go wrong the next time. So that's a perfect spot where we want a caregiver to speak up. Either enter a report or tell their team or tell their leader, "Hey, this can be better the next time." Or, "I wish I would have known this." Or, "We could have learned from this."

So that term first care then learn is what I need leaders to embrace in a high reliability organization as the Cleveland Clinic is trying to get to becoming more reliable. So again, as a leader, first care then learn. What that means is if one of your team members or a caregiver on your team comes to you with a concern, the first thing you do is you acknowledge that that caregiver was A, was brave and vulnerable to come to you and you surround them with support. So you identify that must've been tough to go through, you ask them how they are doing, the caregiver, and you support the caregiver. That creates instant psychological safety. You, of course, then as a leader will figure out how the patient and the family are doing. So first care means how is the caregiver, the patient, and family doing, and it's often a team of caregivers. So we support them and if we spend our first 24 hours just caring for our caregivers and the team involved and the patient’s family, the rest we can learn from, the rest can happen later. We can figure out what went wrong, we can learn from that, but that first 24 hours is about caring. Now, how this gets to speaking up, that caregiver will never forget for the rest of their career after they spoke up that one time and were treated like that, fair, they were supported, they were continued to speak up. And not only that, they will tell their colleagues about that because there wasn't a punitive reaction, there wasn't finger pointing, all of that negativity that can be surrounded with speaking up.

As long as leadership and teams around us first care about that and create that safe environment, speaking up will happen, and in fact, it'll be easy for our caregivers to do. So my advice to the caregiver, the leader of course, is first care then learn. But for the caregiver itself is again, we ask you to bring your whole self to work, and part of that is being brave and being vulnerable, and that's what speaking up is all about. We need you to be brave and vulnerable and we have to make a promise to you that we will keep our promise to keeping you in a safe environment.

Michelle Lampton: That’s wonderful, thank you. One of the phrases that comes up a lot, and you've mentioned it a couple of times when we talk about safety and quality, is high reliability. So what does that really mean to you?

 Leslie Jurecko, MD: Yes. We say the term high reliability quite often, and I agree it's kind of like, what does that mean? So a couple of basic definitions of high reliability are it's a durable, repeatable process. I learned that from a team member at Cleveland Clinic since I've been here, I really love that. You create durable and repeatable processes or experiences for patients. Another definition is performed as intended consistently over time. So we said this is how we deliver care at the Cleveland Clinic and we do it each and every time. So that's that reliability piece of it. But there's something important about reliability, it's not just about the process, it's also about everything. All that other stuff around it, the culture that surrounds that. So not only what we say we're going to do, but how we act and those behaviors around that to create that safe, high-quality, person centric experience.

The best vision I have for this and a mindset I'd love to share with you is around the road of trust we create for our patients. We know that they come to us again, in their most vulnerable times and they're on... They trust us with everything, the most intimate details do they trust us with. When they're on this road of trust with us, there's exits off this road. And, of course, if we harm them, that's an exit off that road. I will tell you as a safety and quality leader, very hard to get a patient to trust us again if they received harm with our care.

Another exit is actually if they face a non-engaged caregiver. We don't have very many non-engaged caregivers, but when our patients face that, they know it because it feels different, it feels cold, it doesn't feel like the Cleveland Clinic way to them. Another way is if they don't get the outcomes that they should achieve. They come to us to get those best national or global outcomes, and if they don't get that, that's an exit off that road of trust as well. So it's all of those things, keeping our patients on that road of trust with us, diminishing those exits, that's really high reliability coming to life.

Michelle Lampton: Thank you for that great analysis and summary. I've really liked that road of trust analogy, I think it's really powerful. So as we wrap up our time together today, we always like to ask our guests if they have a piece of advice or a final thing they would like to leave for our listeners, any lesson, anything that you would just like to share with our listeners that they can take away.

Leslie Jurecko, MD:

I would love to share with our listeners, as most of you are probably caregivers or leaders either at the Cleveland Clinic or abroad and probably in healthcare, but we all work in really complex areas. I think it's really important, and it connects to one of our care priorities, is to treat our patients and one another as family. It's very personal to me and I just love that that's one of our care priorities, treat our patients and one another like family. I think of that and I've shared this before, but I'll have my vulnerable moment here and share. I lost both my parents in my 20s, at the age of 10 actually my father was in a traumatic accident and was paralyzed from the chest down. So couldn't use his hands or legs but was just an amazing resilient man that continued to work and get through life until he died 18 years later. Then about the time I was entering college, my mom was diagnosed with lymphoma and had to go through a lot of procedures in the hospital, so STEM cell transplant, so I spent the better part of my teenage years and all my 20s caring for my patients. I spent the better part of my teenage years and 20s caring for my parents. It was my exposure into healthcare, I didn't have a lot of healthcare exposure obviously. But the age of 10, when your father's in a traumatic accident and inpatient for nine months, you start asking questions of like, "Why do things have to be so hard for our patients? Why is there just so many hassles? And why is the communication not good?" You just get inside this burn to make things better. I witnessed that time and time again as my parents went through the healthcare system.

Yes, I will say most of the times they've received amazing care. But I watched the caregivers at the time try to overcome all of these headwinds to try to provide that amazing care for our patients, and they were individually heroes to do it. But I think I ask of all caregivers and leaders to say, what are the things we can do to make things not only easier for caregivers to provide that care that they want to, but easier for our patients? Because if you just experience it and if you really want to treat your patients, you want to know families. We aren't there yet, we're not highly reliable yet. We have to really, really lean in and dig in more to get there. So that's what I implore for all of you, is how do we dig in even more to make the experience even better?

Michelle Lampton: Well, that's really powerful. Thank you so much for spending the time. I really appreciated you giving us more clarity about safety and quality and being open and honest about your own stories and the stories of others. Thank you so much for your time.

Leslie Jurecko, MD: Thank you, Michelle.

Michelle Lampton: And that's our episode. Another huge thank you to Dr. Leslie Jurecko, for sharing her thoughts on what Safety & Quality means and how we can apply it to our work.

That's it for us at GLLI. Stay curious and keep learning!