Sanford’s journey to zero preventable harm

Podcast: Why every doctor, nurse, and employee receives high-reliability skills training

Sanford’s journey to zero preventable harm

Episode Transcript

Alan Helgeson (moderator):

Hello, and welcome to the “Reimagining Rural Health” podcast series, brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country, from improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high quality, low-cost services in rural and underserved populations.

Each episode examines how Sanford Health and other health systems are advancing care for unique communities they serve.

Today’s topic is a conversation on safety and quality measures – at the core, providing patient care. Our guest is Dr. Jeremy Cauwels, Sanford Health chief physician. Our host is Dr. Luis Garcia, president, Sanford Clinic.

Dr. Luis Garcia (host):

Well, safe and quality as a foundation principle in our everyday activities. Jeremy welcome to this podcast. It’s great to have time to speak to you about such an important topic. How are you doing today?

Dr. Jeremy Cauwels (guest):

I’m wonderful. Thanks for having me.

Dr. Luis Garcia:

Well, thank you, Jeremy. I’m just going to get right into the purpose of this topic. We all talk about quality, and we all talk about being a highly reliable organization, but I got to admit that not everybody gets there and it’s always a work in progress. But tell me a little bit about a physician that just joined the organization, sees everywhere, “safe, safe, safe,” and those that have been here for a long time have seen the transition into this safe thing. What is safe?

Dr. Jeremy Cauwels:

Sure. So SAFE is our acronym. It stands for Sanford’s Accountability For Excellence. If you’re looking for a framework for it outside of Sanford, you would look up words like high reliability organizations. What it really means is that SAFE for us is our individual accountability as people for the things that go on in your work every day that you have direct influence over, and that you can allow or encourage to make better depending on your actions.

And so, as we work on SAFE, the basic principles are as basic as tying your shoes. They’re things like making sure you check your work to make sure you did it right. Making sure you’re engaging people appropriately and making sure that as you’re going through, you’re encouraging the people around you to maintain that same level of culture and ability. The goal really is to say, we’re going to treat other people like we want to be treated.

We’re going to do the things that we promise we’re going to do. And what I mean by that is surgeries and treatments, diseases, and that sort of thing. And we’re not going to do those things which would be unexpected. So our goal is to make sure that every person on the teams are actively engaged in preventing things like negative outcomes or bad experiences. And we can do those things in large part due to the diligence and the intelligence of all of the people that we work with on a day-to-day basis.

And so, using those teams, using a few of those simple skills – one of them we use is called STAR. So we stop, think about what we’re doing, make the action we need to, and then review it. So we actually look back at the things we just did to say, what does it take to check up on this and make sure I did the right thing?

Now the good news is that when we do that, I’m inaccurate probably to the order of 1 out of a thousand times or between 1 out of 1,000, 1 out of a hundred. If you put two of us together and we’re checking each other, we get to 1 out of 10,000 times and our error rate drops down to vanishingly low, which is really our goal every time we work together anyway, is that you and I want to complement each other on a way that makes us better.

Dr. Luis Garcia:

Yeah, and thank you for that last comment, Jeremy. Because I was going to ask you why this work? Because if you think about it, we get into health care and whether you’re a physician or a nurse or a health care provider in any sense, you always want the best outcomes. You always want to be that kind person to the people in need to our patients, to our colleagues. And we always try to work in that environment of collegiality, right?

So what was happening that you felt or Sanford felt that we needed to take a look deeper into it? Because inherently you would assume that everybody’s doing a great job in health care, right? Well, was that not happening?

Dr. Jeremy Cauwels:

I think it’s important to recognize the difference between everybody wanting to do a great job and the systems you can put in place to ensure that everybody is doing a great job.

What I can tell you is that at Sanford, every day we do deliver top-notch medical care. And we do a wonderful job of making sure that the people that we see and that we take care of really appreciate the work that we do.

But that being said, I think we all know the old phrase “two heads are better than one.” And what that means is that if I’m actively engaged in making sure that I deliver for the patient that I’m taking care of, and you’re actively engaged for delivering on the patient that you’re taking care of, we can do the job together and magnify that level of intentionality, that level of thoughtful scrutiny that allows us to do a better job with each patient every day because we’re part of a team.

Because every member of the team knows that not only can they intervene, but they should intervene. And that intervention helps all of us deliver care in a way that is less prone to error and more meaningful to the patient because all of us are actively engaged.

Dr. Luis Garcia:

Yeah, thanks Jeremy. And I agree with you. I think that we all should be very proud here in Sanford of the top-notch work that we do. I mean, we’re leading across the nation and it’s all because of all our physicians, nurses, front-line providers. And so our gratitude to them, particularly in the last couple of years that have been very difficult for them.

But you mentioned a team, right? And I want to ask you this question. You have 50,000 employees in Sanford, you know – 8,000 nurses, 3,000 clinicians. How do you go about engaging that amount of people in this kind of work to obtain better outcomes?

Dr. Jeremy Cauwels:

I think first and foremost, it’s about reminding people that they got into health care to make a difference. Whether you’re the one of our folks that cleans our floors, or whether you’re the person that’s actually going to be doing surgery on somebody’s brain. We all got into health care when we could have went and worked somewhere else because we thought that we could truly make a difference in people’s lives.

And I think the most important part about SAFE is that it reminds people of the possibility that when you go to work today, you’re going to intervene in a way that makes somebody’s life either better or longer, or both. And so as we do that, I think it’s extremely important for us to deliver on that promise. And the most important way to deliver on that promise is to make sure that each member of the Sanford family, all 50,000 of them, are empowered to, if they see something, say something. If they need to reach out and say, I have a concern, that we’ve built the culture all around them to address that concern before we move on.

Dr. Luis Garcia:

Thank you for that thought, Jeremy. So you talk about the importance of anybody, regardless of your ranking, regardless of your title, to speak for safety and to speak for preventing potential errors. And I think we all have seen the last five years and the journey that Sanford has undertaken with this SAFE approach, and it’s ingrained in our hearts and it’s part of our culture and we’re so proud of it.

Can you share of some of those results? Because there’s that example of, there was a neurosurgeon in the operating room that perhaps listened to a nurse that raised the concern, and because of that we had a great patient outcome. But can you share some of those results that you have seen, “Wow, this is truly making a difference.”

Dr. Jeremy Cauwels:

So what we call those in our world is SAFE stories. They are the stories that tell us just a little bit about what making a difference or what intervening really matters and how it really matters. One of my favorite stories was one of our brain and spine surgeons who was getting ready to do a case. And while he was going through the timeout, talked to the rest of the team in the room, and one of the team members actually raised their hand and said, you know, I’m not sure if this was the spot that we were supposed to be doing this surgery, and I’d like to review it before we move further.

What we call that in Sanford is having a concern and raising a concern. I am happy to say that that concern turned into a short deviation in the timeout where the surgeon and that person in the operating room reviewed the case, realized that they had indeed marked the wrong spot for where they were going to go and proceeded to correct that and do it in a very real way.

Obviously it prevented an error with the patient, prevented something potentially devastating if you’re involved in it from a health care standpoint, because like all of us, nobody wants to be engaged or involved in a mistake. And so if you can find it on the front end and raise that concern beforehand, you can turn the story in a completely different direction.

One of my other favorite stories is actually involving our AirMed pilots and mechanic teams. One of our mechanics recently was working on one of our helicopters and in that helicopter, he was inspecting the very back of the of the helicopter in the tail and found a really small crack in the paint. Now normally a crack in the paint is something you go get it painted over and you don’t worry about it. But this person wanted to look a little closer.

And so, using the skill we call attention to detail, managed to take apart that back portion of the plane, realized that that wasn’t just a crack in the paint, but that crack extended all the way from the tail all the way forward through that entire long tail piece of a helicopter. And we actually had to take the helicopter out of commission and drive that part to the repair facility in Texas and drive it all the way back just to repair it. But that crack wouldn’t have been found had it not been for the attention to detail of that airplane and helicopter mechanic in our air ambulance crew.

Dr. Luis Garcia:

Talking about preventing errors and saving lives in a different way. Right?

Dr. Jeremy Cauwels:


Dr. Luis Garcia:

I mean, whether you’re in the operating suite or in the front-line or you’re flying helicopters, you are creating a safer place to work and saving lives, right? So that’s a great story.

And you know many other stories, Jeremy. I remember that one story where somebody called in to get an appointment to see their physician and the registrar asked some questions and noted something different with the patient, gave him the appointment. The appointment was for the following week. And further inquiring from the registrar she continued to notice something different. This turns out to be a patient that was actually thinking about committing suicide and needed immediate help. Had it not been for her attention to detail and listening with the intent to help, that patient would not be with us today.

So, once again, it just speaks to the fact that no matter what your ranking is in this organization, no matter what your title is, we all are important, right?

From the environmental services people that help us to all the way to whichever direction you want to take it. We are all important. So thank you for that.

So Jeremy, these are safety stories and I’m sure there’s a plethora of them that you can talk and we could spend here hours. But how do these individual safety stories start translating into trends, cultural trends and outcome trends? And once again, we’ve been five, six years in this journey. Can you speak about some of those trends, those bigger picture findings that you can share with us?

Dr. Jeremy Cauwels:

Certainly. I think one of the things that we talk about on a regular basis is what we call power distance. And power distance really is that space that exists in your head between me as a worker and the person that I have to report something or raise that concern to. And one of the things that’s important about telling these stories and about being receptive when people have a concern, is that that distance can get lowered. And whether that’s because, you know, you’re brand new in the operating room and you’re talking to an orthopedic surgeon who’s been around for 40 years, or whether it’s because you are a new nurse and you’re talking to a nurse that’s been around the floors for 30 years, that power distance isn’t necessarily a physical distance. It doesn’t even have to be a difference in career or degree.

It’s just that ability to make sure that everybody is engaged and everybody is encouraged to speak up when they find something that’s concerning. And so for us, as we talk about that, what we get into is we can actually monitor those safety events. We can monitor and put numbers to how many times out of 10,000 patient days we actually have a serious safety event. And I am very happy to say, as we’ve went down through this journey, we have reduced our number of serious safety events so far by over 50%. And that turns out to be a number that ranks up there in the hundreds of people. And our goal, of course, is to reduce it more than 80%.

Dr. Luis Garcia:

And also that’s in the middle of a pandemic where we were dealing with workforce shortages, where we were dealing with supply chain issues, where there was a lot of instability in the clinical field. And yet our teams, despite all those challenges, happened to reduce that number by a significant amount. Isn’t that impressive?

Dr. Jeremy Cauwels:

It is remarkable. If you look around the country in the same set of circumstances that we were in, what you would find is that many, many hospitals unfortunately didn’t have that same encouragement, didn’t have that same timing to be rolling out high reliability during the pandemic. And they did actually see an increase in hospital acquired conditions and infections while we saw a 60% decrease. So for us, it very much was changing the culture at a time when culture would be the most difficult thing to maintain and the most difficult thing to keep going in a good direction.

Because as you all know, the difficulty with keeping our patients safe while the pandemic was going on, while we were having nursing shortages, while we were all trying to figure out how to wear masks and when to wear masks and when to get our vaccine and all of those things, were the exact things that we leaned into and said, this is how we keep our patients safe and this is how we keep our coworkers safe and we want to make sure we continue to do that.

Dr. Luis Garcia:

And of course, Jeremy, you’re too humble. You always are, and you’re not going to be bragging about the tremendous work that you lead. But I really want you to brag in this conversation about the tremendous work that you do. And I hear that one of our markets right now has gone six months without a surgical site infection and another of our markets had over two years without a CLABSI (central line-associated bloodstream infection). And then you see our hospital start rating continuously go up. I want you to talk about that and what it means for the teams in each one of the markets and your team that is leading all these efforts. These are times where just watching these outcomes is just something to celebrate.

Dr. Jeremy Cauwels:

When we started SAFE, we estimated that our error rate would put us at somewhere around an adverse event more often than every single day in Sanford Health. If you looked at us for a system, I am happy to say that so far we’re pushing to towards two days between an event anywhere in the system. And our goal is obviously to push towards zero. I’ve often said somewhat with a smile that I believe that the best day in Sanford Health is when we can deliver on a day where nobody had a medical error occur at any point during their care.

My honest goal is that we can go a month, that we can go a year, that at some point we get good enough at this, reliable enough at this and that we trust each other enough while we do this, that we can prevent all the errors in health care.

Now you may tell me that’s a pipe dream and I’m OK with that, but it has to be the aspiration of every member of Sanford that only in the paint pool that they took care of that day, they did everything they could to be as close to perfect as a human can and that the person that worked on their left and their right was helping them achieve that level of perfection that allows us to walk home and say, you know what? We did the best we could for every patient we had all day today. And that is truly the goal each time we step in.

Dr. Luis Garcia:

Hey, I’ll buy into that aspiration any day, Jeremy, and kudos once again to you and your team for what you’ve been able to achieve in these last five, six years since SAFE started. So, so let me just ask you something. Why does this continue to be important for us? We onboard 150 clinicians every year and we employ many hundreds more nurses every year. Why does this continue to be important? What would you tell a new clinician that is just joining our forces?

Dr. Jeremy Cauwels:

What I would tell a new clinician is something they already know, even on their best day, they’re not quite perfect. And if they’re not quite perfect, what a better way to come to work than to know the person on your left and the person on your right are there to help you be as close to perfect as you can and that you all have the same goal. And when everybody aligns on that goal that we’re going to deliver absolutely exemplary care, then we can honestly say that if somebody stops me from doing something, they were stopping me from doing something because they had a concern. And that concern was not only for the patient in the bed, but it was for me as a doctor as well. Because I think we all know that we beat ourselves up when we find out something didn’t go as well as it could have.

And it helps prevent those days as well. It helps prevent burnout in our health care teams because we have friends around us that are helping us out. It obviously prevents adverse actions and reactions in our patients, which help us feel better about all the people that are able to leave the hospital under their own power and own care. And it helps our patients directly with the fact that they know they are walking into a transparent organization that’s there to treat them as well as they possibly can and to do it as honestly as we possibly can every single day.

Dr. Luis Garcia:

So, so you mentioned the word burnout in your statements and that is something that directly or indirectly we’ve been feeling in the last couple of years more pronounced than before. Do you feel that this work in any way impacts the level of burnout for our employees?

Dr Jeremy Cauwels:

I think this work impacts the level of burnout directly. I think one of the leading causes of burnout is the feeling that you don’t make a difference. That I don’t need to go to work today or I don’t want to go to work today because my opinion doesn’t matter. And I think the more you can engage people in saying, you know what? Your opinion does matter and every action that you have while you’re inside of our walls is going to help us deliver that perfect patient care. Those people keep coming back to work because they have a mission, they have a longing to keep doing that work well. And I think it gives us the opportunity to do a perfect or nearly perfect job of caring for each patient as we go through. But in order to do that, you have to have people that are engaged and you have to have people that are in it for the right reasons. And the good news is that automatically breeds engaged people who aren’t going to burn out because they knew when they went into work that day, they could make a difference.

Dr. Luis Garcia:

Well, Jeremy, you talk about mission. Our mission is to improve the human condition, right? And we have made it your vision to once again elevate quality and safety as a foundation of our culture. And I think that you have been extremely successful at that. And kudos to you and your team. Aristotle said that quality is not an act; it’s a habit. And I think that you have described throughout this podcast how the excellent outcomes that you have achieved with your leadership have been a matter of habit and a matter of creating a new culture for our organization that would allow us to deliver on that promise, which is excellent self-care. So Jeremy, thank you very much for being here today. Thank you very much for what you do every day and the impact that you have not only in our culture, but in our employees and in turn in our patients. Any closing thoughts Jeremy?

Dr. Jeremy Cauwels:

I would just like to thank you for the time today. Thank you for the ability to get in front of this microphone and talk just a little bit about the care that we deliver every day. And I would like to encourage anybody who’s listening to make sure they understand that this is the way we do things here at Sanford. That our goal is to make sure that every single person has the ability to make an impact on our patients, our residents, and our teams every time they walk in the door.

Dr. Luis Garcia:

Thank you Jeremy. My gratitude. Thank you for being here.

Alan Helgeson:

You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health series on Apple, Spotify, and For Sanford Health News, I’m Alan Helgeson, and thank you for listening.

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