Loss, Tragedy Led Two Anesthesiologists to Reimagine Hospital Care, Safety
In 1992, a 15-year-old girl went in for elective surgery to fix an issue with her jaw. But her airway was compromised while in recovery and she never woke up.
Seven months later, an eight-year-old boy went into the operating room to patch a hole in his eardrum. It was routine. A straight-forward, two-hour surgery. He died on the table with a temperature of 108 degrees.
And in 1997, two mothers died within the same 24 hours of giving birth. The first died of fulminant sepsis, and the second gave birth via C-section and never woke up.
For Michael Leonard and Allan Frankel, two former anesthesiologists, longtime friends and current Vizient executive principals, these tragic circumstances changed their careers and lives in ways they hadn't anticipated.
Leonard, a colleague of the anesthesiologist who cared for the boy during the surgery, reported the circumstances of the death to the Colorado attorney general's office, launching a five-year court case that would eventually rule in favor of the family. Frankel launched an investigation into the two mothers' deaths, analyzing the underlying reasons behind their deaths and how they could be avoided.
Ultimately, each realized that the underlying causes of these tragedies could be attributed to cultural dynamics. Leonard's court case revealed personnel issues with the attending anesthesiologist exacerbated by hierarchical power dynamics. Frankel's investigation pointed out system process failures, like a lack of standardization in post-operative C-section pain management, exacerbated by other clinical, operational and team-based issues at the health system.
"In healthcare, there's a lot of given assumption of excellence in care – that they've got all these smart people, so therefore, they're excellent, but the complexity of care and the ability to do it consistently the same way every day can't be assumed," said Leonard. "The most common condition that you're most likely to see in an American hospital and not survive is sepsis, which has a 20% mortality rate, and you can find dramatically different outcomes in sepsis across hospitals depending on whether teams are organized and hardwired through consistent organizational processes focused on patient care. You never want to assume safety; you want to assure it."
Coupling these discoveries with their experiences, Frankel and Leonard quit anesthesiology and launched Safe & Reliable Healthcare. This new company focused on improving patient care through high reliability, a cultural mindset that prioritizes continuous learning and systems improvement with a goal of failure-free performance over time. They hired a team, and through their decades-long expertise, provided guidance to healthcare providers on how to effectively assess and manage risk to minimize adverse events, like those that occurred in 1992, 1993 and 1997.
Leonard and Frankel went on to create SCORE, a validated survey that measures the culture and engagement of a healthcare organization's workforce, gathering data on culture, engagement, burnout and physician satisfaction within a healthcare work setting. It's now used by more than 500 facilities with more than 300,000 rolling benchmark respondents. They also created the Learning and ENgagement System (LENS), a digital board that enables hospital leaders, managers and frontline staff to communicate efficiently and effectively by fostering transparency, enabling collaboration and eliminating communication barriers. More recently, they created an academy where high reliability experts teach leaders and teams the skills, activities and behaviors necessary to become highly reliable based on best practices and lessons learned.
"In healthcare, we have certainly embraced the idea of process improvement through methodologies like Lean Six Sigma, but simply relying on these sorts of process improvement methodologies won't improve culture on their own, because improving culture has a great deal to do with relationships and psychology," Frankel said.
That's where SCORE and LENS helped: SCORE took the survey data they collected and informed the research and guidance provided to hospitals, and LENS put it into practice. Healthcare leaders, managers and frontline staff could now access huddle notes and scheduling assignments and report issues or concerns to the LENS board 24/7/365, all at the touch of a finger. And, what's more, Frankel's and Leonard's teachings detailed a step-by-step process for resolving and tracking reported issues through the LENS board, ensuring the issue was not only resolved but that frontline staff could be confident in its completion. They coupled this process with other best practices, like executive walk-arounds and posting completed huddle notes for all work setting staff to review at any given time.
Frankel's and Leonard's organization was acquired by Vizient in 2022 and their work continues through Vizient Safe and Reliable Healthcare. It's a move that Frankel and Leonard believe will help the organization broaden its scope and reach while also continuing the research the two anesthesiologists started.
"Vizient is a data-rich organization with assets such as the Clinical Data Base and Operational Data Base. How they're used to improve healthcare organizations and overcome workforce challenges is both prodigious and powerful, and having that ability to mesh our SCORE cultural data with the Vizient Clinical Data Base and Operational Data Base to inform healthcare culture—to me, that's the Holy Grail," Frankel said.
The Vizient Clinical Data Base is a benchmarking and analytics tool that helps healthcare organizations better understand their outcomes data and improve their performance in finance, quality, safety, operations and satisfaction. It enables hospitals to benchmark against their peers and identify performance improvement areas. The Operational Data Base allows hospitals to evaluate performance, reduce costs and improve budgeting at the hospital and unit levels. More than 1,000 facilities use the Clinical Data Base and 650-plus hospitals use the Operational Data Base.
"The dream here is to evolve the work we do in high reliability, inclusive of our consulting and the academies we teach, our SCORE survey and LENS boards, and evolve them so they become the standard in American healthcare," Leonard said.
Leonard and Frankel hope this new acquisition and ability to merge data will help scale the work the two anesthesiologists started, reaching more healthcare organizations and enabling them to adopt high reliability into their practices. And, with more healthcare organizations doing so, lower the likelihood of future tragic and adverse events like those Frankel and Leonard experienced in 1992, 1993 and 1997.