This document discusses creating a culture of safety in healthcare. It notes that medical errors are a leading cause of death, exceeding deaths from airline accidents. A culture of safety requires shared values around safety, anticipating risks, reporting errors to learn from them, and a just culture that recognizes human fallibility. It outlines key factors like transparency and leadership from management, medical staff, and boards. It also lists Deming's 14 points for quality improvement in healthcare, focusing on constancy of purpose, new philosophies, education, eliminating fear and barriers, and driving continuous improvement.

1. Quality Leadership in Health Care: Creating a Culture for SuccessDecember 2009 John G. Reiling President/CEO

3. Death on domestic flights: 1 in 8,000,000 flights. 2

7. AMA - NPSF

8. AphA - PSI

9. ASQ - WHA

10. Center for Patient - UW-Milwaukee

11. Safety at VA - University of MN

12. IHI - VHA

13. ISMP

14. JCAHO 5

16. Always Anticipating Precarious Events

17. Informed Employees and Medical Staff

18. Culture of Reporting

19. Learning Culture

20. “Just” Culture

21. Blame-Free Environment Recognizing Human Fallibility

22. Physician Team Work

23. Culture of Continuous Improvement

24. Empowering Families to Participate in Care of Patients

25. Informed & Activated Patient6

26. National Advisory Committee(Invitees) Jim Adams, Exec. Director & Fellow, IBM Center of Healthcare Management Frank T. Brogan, President, Florida Atlantic University Carolyn Clancy, MD, MPH, Director of Agency for Healthcare Research & Quality William F. Coyne, PhD., Former Senior VP for R&D for 3M, Healthcare for 3M, and 3M Canada Tim Flaherty, M.D., Past Chairman, NPSF & Past Chair of American Medical Association Lillee Smith Gelinas, RN, BSN, MSN, FAAN, Vice President & Chief Nursing Officer of VHA, Inc. Pascal Goldschmidt, MD, Senior Vice President & Dean, University of Miami Miller School of Medicine Donald Holmquest, M.D., Ph.D., J.D., President & CEO of California Regional Health Information Org Beverly Johnson, President & CEO, Institute for Family Centered Healthcare Lucian L. Leape, MD, Adjunct Professor, Harvard Univ. School of Public Health Kathy Malloch, PhD., MBA, RN, FAAN, Pres of Malloch & Assoc & Director of the MHI Program at ASU David Marx, J.D., President of Outcome Engineering, LLC David Nash, M.D., M.B.A., FACP, Chairman, Jefferson Medical College, Thomas Jefferson University Richard Norling, Chief Executive Officer and Director of Premier, Inc. Dennis O’Leary, President Emeritus of Joint Commission Paul O’Neill, Former Secretary of the U.S. Treasury Mary A. Pittman, Ph.D., American Hospital Association & Current President of the Public Health Institute & Past President of the Health Research and Educational Trust William Rupp, MD, Past President of Luther Midelfort & Immanuel St. Joseph’s-Mayo Health Systems & Institute for Healthcare Improvement Donna E. Shalala, Ph.D, President, University of Miami Gail Warden, President Emeritus, Henry Ford Health Systems Bennet Waters, D.H.A., Chief of Staff for the US Dept. of Homeland Security, Office of Chief Medi Officer 7

27. Results of NAC Leadership Keys: Transparency Leadership

28. Leadership Management, CEO Medical Staff Board

29. Deming’s 14 Points 1). Create Constancy of Purpose for the Improvement of Product and Service 2). Adopt the New Philosophy 3). Cease Dependence on Mass Inspection 4). End the Practice of Awarding Business on Price Tag Alone 5). Improve Constantly and Forever the System of Production and Service

30. Deming’s 14 Points 6). Institute Training and Retraining 7). Institute of Leadership 8). Drive Out Fear 9). Break Down Barriers Between Staff Areas 10). Eliminate Slogans, Exhortations, and Targets for the Workforce

31. Deming’s 14 Points 11). Eliminate Numerical Quotas 12). Remove Barriers to Pride of Workmanship 13). Institute a Vigorous Program of Education and Retraining 14). Take Action to Accomplish the Transformation