High Reliability Requires Empathy

Podcast Transcript

Steph Bayer: Welcome to another episode of Studies in Empathy, a Cleveland Clinic podcast exploring empathy and patient experience. I'm your host, Steph Bayer, senior director of the Office of Patient Experience here at the Cleveland Clinic in Cleveland, Ohio, and I'm very pleased to have with me today, Dr. Amrit Gill. Welcome to Studies in Empathy. 

Dr. Amrit Gill: Thank you for having me, Steph. I'm so excited to chat with you today. 

Steph Bayer: I am so looking forward to this conversation. Dr. Gill is the Associate Chief Safety Officer at Cleveland Clinic. She's an expert in organizational training of high reliability or consistent excellence in performance, quality and safety over long periods of time. She also specializes in pediatrics and has over 20 years of experience in the field of medicine. I cannot wait to dig into this with you. Are you ready? 

Dr. Amrit Gill: I am. Let's do this. 

Steph Bayer: Let's start though with just learning a little bit more about you. So can you tell us a little bit more about yourself, your background and how you came to become the associate chief of safety here at Cleveland Clinic? 

Dr. Amrit Gill: All right. I'm going to go way back when. So I was born in India and I grew up there and I went to med school there. I'm the very, very proud daughter of a really high ranking bureaucrat in the Indian government. And my dad was also a consultant for the World Bank. So I grew up watching him and he's always been a role model for me with systems thinking, whether it was going to the gemba for farmers during a famine to see how to introduce technology to them on improving systems and processes with a devastating earthquake in Western India or the tsunami in Southeast Asia. I always watched him improving systems, improving process policy, and I was curious and he was a little disappointed that I didn't follow his footsteps and go into his line. 

Steph Bayer: The doctor daughter made him disappointed. I love it.

Dr. Amrit Gill: Yeah, the Indian doctor daughter made him disappointed, but I think he now is very proud of what I do. I'm also the sister to two brothers and my older brother, Monty, he was amazing. So he was born prematurely in the seventies, and so he had retinopathy of prematurity, which kind of can impact your eyesight. So he was legally blind in one eye that turned out okay, didn't stop him. He loved to have fun ever since he was a kid and then grew up to become a high performance race car driver. And we would talk about safety in race car driving because from Laguna Seca in California to the Berg Ring in Germany, he was on every racetrack. And I'd be like, Monty, be careful. Look out. And at the time I was in medicine's training and he'd joke and he'd say, you be careful. 

Dr. Amrit Gill: There is no chance that I'm going to get into an accident because we are so reliable with our checklist. We're safer on the racetrack than we are on the road. However, I'm not so sure I trust hospitals. And then when he was 37, he passed away and I was exposed to some of the holes and the gaps in healthcare. That kind of made me start thinking, patient safety is so important and critical and it can impact so many of us in a way that we don't even realize. I finished residency in 2008 soon after he passed away, which was in 2007. And I was interviewing for jobs and my husband is a physician as well, so it's like, I like this place, but you don't, you like this place. And then we interviewed at Cleveland Clinic and we were so impressed by how much focus there was on quality and safety that we started here in 2009 and we've been here ever since. 

Dr. Amrit Gill: And at the time, Shannon Phillips was a pediatric hospitalist and the first patient safety officer in the children's hospital. And she took me under her wing because she knew I was curious about the subject. And I ended up becoming the physician lead for Epic and Children's because we have our own special guardrails and I had trained at an institution that already had Epic, so it was, this doesn't work, that doesn't work. And she was like, why don't you fix it? And I ended up doing that. We implemented Epic in our regional hospital, so Hillcrest and Fairview and Children's Rehab eventually, and that was a lot of fun. And Shannon went on to take on an enterprise role and I took on the role of the children's safety officer at the same time, solutions for Patient Safety in Ohio was coming together. This was a grassroots movement by eight children's hospitals in Ohio. 

Dr. Amrit Gill: We're so lucky to have eight because we don't have that huge a population, but we've serve a population from around the world. And we all decided let's not compete on safety. We all know we can learn from each other, we all know we can teach each other. And so I was lucky enough to work and be mentored by stalwarts like Steven Mu thing and Anne Lyon in that world, in the Ohio Children's Hospitals. And we started seeing great results with implementing high reliability in children's hospitals. And over the next few years, this momentum grew and got notice. And today their a network of 145 children's hospitals around the country and Canada that are making a difference with safety and quality in the land of children. That was really exciting and I led that for a decade in the Cleveland Clinic children's world. And then it was time to make a difference because I said, we can do this insurance, but we have to do this for the larger organization as well. The problems are the same and the solutions are probably similar as well. And I had met Leslie Reco, who's our chief Safety and Quality Experience Officer many years ago when we did a course together at the Institute of Healthcare Improvement with patient safety executive development. And when she joined here, I thought that was the perfect time for me to apply for the position of associate chief safety officer as well. And together I knew we would be a good team that could make a difference. So here I am. 

Steph Bayer: You're not just a good team. You're an exceptionally amazing team. First, there's a lot here to unpack. First, thank you for sharing the story of your brother Monty. I appreciate when someone shares something so personal. I also love that you're kind of born into a family to look for system improvement. I think that's amazing. You talked a little bit though about how you're in the early ground for high reliability and with children's hospitals, the stakes are so high, children especially, but as you said, we can do this for all patients. Before we get too far though, and I know you've been this champion of high reliability for a while, I'm wondering if people that may be listening and unfamiliar with that term, if you can talk a little bit more about what high reliability is and what it actually means. 

Dr. Amrit Gill: So high reliability really means to perform as intended over time, right? It's as simple as that. It's a beautiful concept. It didn't come from healthcare, it came from industries outside. And these are high risk, high consequence industries like commercial aviation, naval aviation, nuclear power, where if something goes wrong, the consequences are really high and devastating. And what they did is they realized there are these behaviors that if they incorporated even with their workforce, which is often in their twenties, they were able to make an impact. And risk is a function of probability and consequence, and they are able to decrease the probability of something going wrong with incorporating high reliability. Therefore, today, if you think of commercial aviation and you take a flight, there's a one in million chance that you're going to go down. So when I have a passenger next to me that's nervous, I tell them there's a really, really, really small chance that we'll go down. 

Dr. Amrit Gill: But as you know, many of us, when we go anywhere for a meeting or a trip, we're very likely to pack our bags and take them with us. And that's because we worry about bags getting lost, and that's not good reliability because there was a much higher chance of that happening. So one in 10 million chance of your plane going down, but probably one in a thousand chance of your bags getting lost. So that's the chance of something going wrong. Well, healthcare is right there too. We are right there with the baggage handlers in terms of how things go wrong when we're taking care of our patients. But what is high reliability when you think of it, it's creating a mindfulness infrastructure and a capability for action so that these organizations can anticipate the unexpected and manage the unexpected. And there's a lot of great books, but w can sutcliffe have one that's called Managing the Unexpected that goes into the details of the five principles. 

Dr. Amrit Gill: So there's five principles. Each of them equally important, and they're preoccupation with failure. So thinking, what are the things that can go wrong and understanding those before you embark on anything reluctance to simplify. So we know we're complex organizations and we have to know that complex problems get complex solutions. It's ity to operations. So knowing that where the work happens and the people that are doing the work probably know what the problems are and probably also know what the best solutions will be, so going there to them for that. And then deference to expertise, knowing who has the answers. It's not always the CEO. It's not the most high ranking person in the room. The experts can be different depending on what you're looking for. And then a commitment to resilience. We know we are not perfect. We know things might go wrong, but are we prepared for this? 

Dr. Amrit Gill: Are we ready and resilient to bounce back quickly, to mitigate what might go wrong, the extent of the damage. And then at the same time, really fix things as you're flying, building your plane as you're flying is really what it is. And then there's three means that you get to high reliability. So there's process design, so you have evidence-based bundles that you can use. You have processes that minimize variations, et cetera. And then you go to the next level with culture so that you're making it so that people are consistently doing the right thing, right? Because culture eats strategy for breakfast, lunch and dinner every day. So you could have the best processes, but if your people only do it 20% of the time, we're not going to be highly reliable. So what are we doing when no one is watching? That's what our culture is. 

Dr. Amrit Gill: I love the icebergs culture we have in the Cleveland Clinic in the J hallway because it always to me signifies culture. What is the underbelly of our organization and how do we get it right every time? And then finally, the third step in high reliability is human factors integration. So how do you devise systems so that it's impossible to get it wrong and easy to do it right? So you set your caregivers up for success, and then you talked about why does it matter? Like I said, we are right there with the baggage handlers. The sad thing is Life Magazine was a big thing back in the day, and in 1960 on the cover of Life Magazine was Jackie Kennedy, and the headline there said, our hospitals are killing us. Oh, wow. Yeah, this is what, 63 years ago. And inside it was preventable. Serious safety events and hospital acquired conditions, right, and infections in 1960. Then 1999 comes along and everyone gets really excited with this Institute of Medicine report, which is to her as human. And we all know how impactful that was. And a lot of work and momentum went into the safety movement then. And it's a quarter of a century later, and we haven't made that much of a dent this year. The New England Journal of Medicine published a study on inpatient harm, and those statistics are just mind boggling. So what they've said is 23.6% of all inpatients experience an adverse event. If you extrapolate 

Steph Bayer: 26%, 

Dr. Amrit Gill: 23.6, 

Steph Bayer: But almost one in four, 

Dr. Amrit Gill: Almost one in four, if you think of all of the US and hospitals there, that's 7.8 million adverse events. If you think of preventable events, that is 7.9% of our inpatients. So that's 2.6 million preventable harm events. And if you even look at just the serious safety events, so these are patients that are dying or getting significantly harmed, experiencing harm because of gaps in our care. That's 1% of admissions. If you think of that, that's 340,000 people every 93 seconds. Someone in the US is experiencing significant harm in a hospital according to this study. And we know safety science works. We know if you do this high reliability work, you can decrease those events by 80% with one cycle of that macro culture change. So you would go from every 93 seconds to every eight minutes. Now, not great, but we have to start somewhere. Yeah, 

Steph Bayer: It's interesting listening to your expertise and the history here in that 63 years ago we recognized a problem, and healthcare really hasn't stacked hands and committed on it. And I love what you said earlier about we shouldn't compete on safety. We should all line up and want to be the safest for our patients as far as places to go, one of the things that you've helped lead, and we just finished it over the last several months, every caregiver here, every one of our over 70,000 caregivers had an opportunity to take some high reliability organization or HRO training. It covered those principles you just laid out. It covered how we can build processes and have that ability to think about failure, be preoccupied, how we can do better for our patients and whatever job we have. It was a lot of resources though. It was what does this involve to make that happen and what are you hoping will come from this? What was some of the feedback you're getting? 

Dr. Amrit Gill: So it was exciting. Like I said, I did this for children's years ago. We started in 2011, and I thought I knew what we wanted to do because we'd done it and I was part of the getting started cohort with solutions for patient safety. So we'd done it for a few children's hospitals where I had said, this is how you do it. And I had learned from every one of those implementations. But then we really wanted to incorporate high reliability into how we develop the training as well. And we were like, we're the high reliability experts, but we have resources here. Let's partner with them. Let's defer to expertise on adult learning for how we roll out the training. So we got GLLI involved really early in the course, so that is our learning experts, adult learning experts right here at the Cleveland Clinic. And we're so lucky to partner with them. 

Dr. Amrit Gill: And then we would talk, and I was used to, let's get it done. Let's put everyone in an auditorium together and we'll teach everyone and then we'll go from there. But what I had also learned from seeing that over and over again is you can't do it as a flash in the pan. We know we want to impact our culture. How do we engage our leaders? How to make it sticky? Exactly. And so then we put our brains together and said, how do we do that best? And came up with a concept of leader guided discussions. So it was not just teaching people the concept. So every caregiver understands what these behaviors are and the tools that go along with the behaviors, but how do we make it personal to every microsystem within our organization? Also recognizing we're a global organization. We could not bring everyone into the Brown Stadium, right? 

Dr. Amrit Gill: There are people in Abu Dhabi and people in Florida, so can we get it to them at their own time in their own microsystems and environments? So we combined some e-learning, which I was really nervous about because I thought people are not going to engage with this. And then we mixed it with after everyone's had a chance every month to get together with their teams and have dialogue around what they learned and how they can incorporate. And every month we introduce new tools, so you're building upon it. But what it was was not just a focus on safety. We wanted it to be about experience. We wanted it to be about quality. We wanted it to be about continuous improvement. So we really use that integrated model that we have at Cleveland Clinic of these are all things that are so interdependent and linked. So 

Steph Bayer: Linked. Yeah, 

Dr. Amrit Gill: They just have to be, you can't do one without the other. What do our patients say when they come to us? They say, keep me safe. Heal me and be nice to me. We can't do one without the other, so keep me safe. That's safety. Heal me, that's your quality and be nice to me. That's your experience. And experience is always safety and quality through the patient's eyes. We had to make that. And so it was, alright, let's roll it out. What we've got in terms of feedback, like I said, I was very concerned about the modules. We learned that if you use data and are transparent with your data so that people don't think it's someone else's problem, it doesn't happen. Here at Cleveland Clinic, we didn't want that. We wanted every one of our caregivers to understand that we are human as well and we make mistakes as well. 

Dr. Amrit Gill: But we wanted to tie that data to real stories and these are our stories from our caregivers and our patients. And I think that was the secret sauce along with the leader guided discussions. So people had the opportunity to really come together and talk about what opportunities do we have, whether it's in the world of finance, environmental services, or neurosurgery. What is it that we can do and how can we incorporate these tools? And the feedback has been tremendous. Every night for high reliability training, my reading was reading the comments from the feedback and it's 77,000 caregivers every month for six months doing it. Lots of comments about how this was the best training in their entire lives and for an e-learning module, I thought that was really important. So I can't thank our colleagues in GLLI for developing that kind of product for us. And I'm just so proud of it. 

Steph Bayer: You should be proud of it. It's amazing. The first time I had my leader guided a discussion with my own team, I thought, well, these are folks that are leaders and directors and patient experience and they helped create some of the content. This to them may not be that interesting because it might feel like we know this already. I have to tell you, that first conversation was so engaging that I gave the 30 minute window to talk it through. I didn't have enough time. People still wanted to talk and I heard it from my own team how important they felt this was even in the nonclinical roles. It's phenomenal and it's transformative. And just before we're having this session, I had talked with Chrissy Daniels from Press Ganey, and she said, it is the next step in healthcare. So even the industry is taking notes. Well done you. 

Dr. Amrit Gill: Thank you. 

Steph Bayer: Can you give us an example or maybe a case study illustrating that high reliability works 

Dr. Amrit Gill: Right here in our backyard? Yeah. Cleveland Clinic Children's. So 2011 is when we started and we'd had a few pretty devastating events at that time, and we were causing harm at a frequency that was at par, maybe better than some other hospitals, but worse than others. And it was concerning. And that's when solutions for Patient Safety came together. And we worked on high reliability then at Children's. And since we rolled out the training in 2011, by about 20 14, 20 15, we were going from about 25 days between some events to over 980 days between serious safety events. And that was tremendous. And to see that sustain over time, it was not just coincidental. You could see the shift in culture in the children's hospital. People were talking the talk and walking the walk and you could see the shift in the outcomes as well. Our collapsing rates were getting better, our hospital acquired infections. Overall, we're getting better. And I think it's all just a testament to high reliability. It works. 

Steph Bayer: And it's been sustained, so we know it works. It's great stuff. I know you as a friend, I know the answer to this question, but I'm going to ask it anyways. Our podcast today, we like to call it Studies in Empathy, and we like to focus on empathy. So I'm going to ask you, is there a relationship between high reliability and empathy? And does building a culture of high reliability help caregivers show empathy to patients and to each other? 

Dr. Amrit Gill: I cannot think how they would not be tied naturally, right? Yeah. What do our patients want when they come? Patients don't care how much we know until they know how much we care. They absolutely want to know, do you really care? And that was important to understand as we rolled out training for our leaders as well as the core, which is our training for all caregivers. So with respect to the leaders, we wanted to create psychological safety. To do that, you have to lead with empathy. You cannot. That's such a great point. You cannot just create psychological safety without empathy, understanding and knowing your teams better. 

Steph Bayer: Absolutely. 

Dr. Amrit Gill: And you cannot have a just culture unless you have empathy. So that was essential. We embraced the ethos of first caring, then learning. We want to be a learning organization. We know things will go wrong, but we have to care first before we ask the tough questions. We want to make sure our patients are safe, our caregivers are safe because guess what? Everyone is here to do the right thing. So empathy for leaders is essential. And then for our teams, I really believe a team is not just a group of people that comes together and works. A team of people that is effective is really a group of people that implicitly trusts each other. And trust comes from empathy, start with heart. That was the core of core is how I think of it, right? So core is our behaviors for all caregivers. And it's an acronym as we all love acronym. 

Dr. Amrit Gill: We love healthcare. Healthcare, yeah. So C is communicate clearly. O is openly and courageously speak up. R is retain a questioning attitude. And E is embrace accountability. And in that C, communicate clearly we start with heart. And it's all about smiling, telling people your name and your role. And it's really relationship building, thanking them for the conversation. And that we really want to say is not just a patient experience thing, it's a team building thing, right? When I come together with a team for a code, sometimes it may be people from different areas, we don't know each other, but if we are quickly able to level set to just smile at each other and tell each other our names and roles, we are going to function much more effectively. And there is literature that says that will improve outcomes. It's the same everywhere. It's our ORs, right? 

Dr. Amrit Gill: If that team feels safe, they're going to speak up when they think something's not okay, are we sure we have that consent on that right patient? Are we sure we look for that retained foreign body? Can we stop to make sure we did this? That is only when we remove that hierarchy. And that comes from empathy. And we have such great tools with empathy and with experience that we have to incorporate into high reliability. So we were not going to reinvent the wheel, but use what is already beautiful and developed and take it into, incorporate it into the high reliability work. So that I think they're absolutely tied together. 

Steph Bayer: I thought you would say that, but I didn't know you would say it so well, can you talk about the importance of safety event reporting? We need to report, we need to speak up. What's the relationship between safety reports and the occurrence of safety events? 

Dr. Amrit Gill: This is one of my favorite things, and what's tremendous has been like as we've rolled out, high reliability or safety event reporting continues to go up. And if you're not in the world of safety, you think, whoa, that's not a good thing. Why are you having more safety events? But what we think of it as, these are not significant harm events. They're often near what we call near misses. They've never reached a patient. But there are opportunities where something may have gone wrong. And what we want to see is those reports keep going up because that preoccupation with failure that we talked about with high reliability. It's really knowing where your opportunities are, where do you need to focus? Where do you need to improve your work? And so the more reporting you have, the more you can mitigate things before they become a disaster. And so typically the relationship is the more robust your reporting is, the fewer your significant harm events are because you know what could go wrong and you're being proactive as opposed to reactive with 

Steph Bayer: That makes sense. 

Dr. Amrit Gill: And so too often we are in the world of let's do an RCA because something happened. But that's really looking in a rear view mirror reporting is looking through the front windshield of your car. You have the whole view everything that is potentially in your way that could cause harm. Is it raining? Is it dark? Is there a deer running by? Is the pothole there? Those are all near misses because you know that something could go wrong because of those, and you want to be aware of that. So that's your reporting culture. 

Steph Bayer: That's perfect. As we start to wrap up this conversation though, I think we could talk for a lot longer and we will, you and I afterwards. Stories are so important in our empathy podcast and patient experience. And as you said, we take the data and the stories in our training. So stories help drive home conceptual work. Patient safety is an issue that touches so many personally. I'm wondering if there's any stories that you can share about patient safety that might show why it's important. 

Dr. Amrit Gill: Sure. I'll share a couple. So I started with Monty's story and I told you I knew I wanted to do something about safety, but I didn't know what exactly. And so soon after I joined Cleveland Clinic, I learned about a little girl, Stephanie, who is adorable, who had passed away because of gaps in our care. And then I met her mother, Katie, and she was the most amazing, inspiring person ever. And what blew my mind is her altruism. Because what they wanted her family was, what are you going to do so that this doesn't happen again? What are you going to learn? How are you going to prevent this? And for me, that kind of gave me direction. And I feel like Stephanie has become my north star and her mom, we invited her back after 10 years of Stephanie's passing to talk to the children's hospital. 

Dr. Amrit Gill: And what she often says, and she said there is turn the lights on. Because during Stephanie's care, people hadn't turned the lights on often in the room, but it wasn't a failure of one person or one little thing. It was our system that had failed. And when she said, turn the lights on, it's not just that literally turned the lights on, but metaphorically what critical thinking that situational awareness, that mindfulness. And so I carry that with me, and we used that story and we used, Katie was gracious enough to let us use that recording for the high reliability training. And when we rolled the training out, I got an email from another mom. And this time, this is Kristen, one of our caregivers, she's a dietician and she is the mom of two sets of twins and she has five kids in all. And so she was postpartum from her second set of twins, and you can imagine exhausted two weeks postpartum. 

Dr. Amrit Gill: And she noticed that Eleanor, one of her twins wasn't feeding so well. And so she went to the pediatrician and very quickly things moved and she went to the emergency room. She was critical care transport. And within 36 hours of her concern, she was diagnosed with SHO's complex, which is a very complex congenital heart defect that can be devastating if not identified quickly and treated. And Dr. Najm, our awesome CT surgeon and his team were able to repair it, and a week later she was home and she's now growing and thriving. This was in May of 2022 that this happened. And Kristen felt like she needed to tell us about this because she said, you know what happened? Every caregiver that Eleanor encountered along the way, whether it was a tech, a nurse, a nurse practitioner, an md, everyone turned the lights on, everyone listened. And this is what's rewarding about high reliability, and this is what we can learn from excellence. So we don't just want to learn from our failures as we did, and I'm so grateful for learning from Stephanie, but we want to learn from what goes right and from the excellence that happens. And so that's this next story that we want to keep telling is there is lots to learn from success as much if not more from success than as from your failures. 

Steph Bayer: That's a terrific way to wrap up and the work you do every day and the work you've led with high reliability, it honors Eleanor and Katie and Stephanie and Monty. So thank you for leading this work. It's so important. We're lucky to have you. 

Dr. Amrit Gill: Thank you. I'm so lucky to work with you. 

Steph Bayer: This concludes the Studies in Empathy podcast. You can find additional podcast episodes on our website, my.clevelandclinic.org/podcast. Subscribe to the Studies in Empathy Podcast on iTunes, Google Play, SoundCloud, Stitcher, or wherever you get your podcast. Thank you for listening. Join us again soon.