Joni:

Hi, this is Dr. Joni Watson. Welcome to The Handoff, the podcast for nurse leaders brought to you by Works. I'm thrilled to introduce our episode guest today, Ann Louise Puopolo is a respected safety professional with a distinguished career spanning various prestigious roles. She's the former vice president of Enterprise Patient Safety and the Patient Safety Organization at CVS Health where she retired in 2020 and has served as vice president of patient safety for CRICO, the risk management foundation of the Harvard Medical Institutions. Her journey in healthcare safety doesn't end there. She's also the chair of the RLDatix Customer Advisory Board, and she presently serves as the president of the Safety Institute, as well as holds several key positions in local healthcare organizations based in Boston. Ann Louise is actively involved in the healthcare community. She sits on the Tufts Medicine Board of Directors Committee on the Quality of Care, serves as the vice chair at Tufts Medical Center Board of Directors Committee on the quality of care, and has been on the board of directors for the Alliance for Quality Improvement and Patient Safety since 2013, her commitment to safety and quality care has had a significant impact across the healthcare landscape.

Ann Louise’s journey began with a Bachelor of Science in nursing from Vanderbilt University, and she worked as a critical care nurse at Boston's Beth Israel Deaconess Hospital. This hands-on experience laid the foundation for her career in patient safety and risk management where she has made substantial contributions. Today we'll explore Ann Louise’s insights into patient safety and the lessons she's learned from her career. Welcome Ann Louise to The Handoff.

Ann Louise: 

Thank you, Joni, and good afternoon. It's a pleasure to be here with you.

Joni:

Oh, it's my pleasure. You have quite the distinguished career, Ann Louise. So I can't wait to learn from you and hear more about what has shaped you and your thoughts on patient safety and quality. So first let's sort of set the foundation. Ann Louise, how do you define quality in healthcare and why do you see it as crucial for optimizing health outcomes?

Ann Louise: 

Well, that's a great question, Joni, and I guess I'd start by saying we have to define our terms. In my world, quality is optimization of healthcare outcomes and safety is the discipline of keeping patients and workforce free from harm. So those two disciplines really do live in harmony. If we optimize the healthcare outcomes of our patients, we are more likely than not to make mistakes and keep them free from harm so that we can put them back into the community where they hopefully started their journey.

Joni:

That's excellent Ann Louise. So risk management is vital in most healthcare settings. It's a large part of healthcare and what we do. I'm curious from your perspective, because you again certainly have years of experience, can you explain your approach to mitigating harm and its importance across healthcare organizations?

Ann Louise: 

Absolutely. I think none of us in healthcare can begin to address harm or potential harm reaching patients unless we truly understand the data and the data comes as a result of a variety of inputs and insights, whether that's voluntary safety event reporting through the various tools that are available in the healthcare community, whether that's through the historical view of claims and suits, where even if the standard of care was met and all things were created equal and done to the best of everyone's ability, well, something went wrong. And oftentimes patients and families are trying to get an answer to what went wrong. So diving deeper into the lessons learned from those case studies in addition to other quality indicators available in our healthcare systems, whether we're talking about CAUTI or CLABSIS or falls or workplace violence, all those data inputs are enormously helpful for setting the agenda for risk mitigation.

And so I like to say, you need to triangulate those insights to put together a prioritization, if you will, of what goes wrong, what could be optimized and improved, and let the data direct you in the right place at the right time. So Joni, I don't know. I mean, it's not about the numbers in terms of the aggregation and that more is worse, the more egregious things that go wrong obviously should be addressed first in some of the lower hanging fruit, although may be easy to tackle from a risk management perspective are the things that we should be doing on a routine basis. But the most high harm like incidents should really provide the roadmap for a risk mitigation strategy.

Joni:

That's great guidance. Ann Louise, it's so interesting because for some reason early in my career, I don't know, I had a negative connotation of risk management colleagues, but the more I worked side-by-side with my risk management colleagues, which often included brilliant nurses and brilliant nurse leaders, man, what great partners in care they are and what great teachers to help support us and not only keep patients safe but keep us safe as well. So I love your approach to mitigating harm, but in healthcare, despite our best intentions, I mean healthcare is complicated, it's complex. We have a lot of things that can go wrong. Nobody wakes up wanting to hurt anybody. At least in my experience, none of my colleagues say, oh, I want to hurt somebody today. But despite our best intentions, things can often go awry in healthcare often with, I mean just devastating results not only for patients, but also for healthcare professionals and clinicians and administrators who are all involved. How can organizations create a culture that encourages reflection and correction rather than one that's kind of based in fear, which often it's easy to let happen? What are your thoughts on that?

Ann Louise: 

That's a terrific question, Joni, and it's complex in many regards. In advancing the patient safety movement, we have to think about fostering a culture in the healthcare environment where people feel like coming forward is not only the right thing to do, but it will in fact make a difference as a result of their actions and coming forward. So fostering a safety culture in an organization must make people feel as if there's not going to be retribution for bringing forward something, whether it's a broken system or an event or a near event that they personally were involved in. They want to be able to feel as if this is my job, I want to do right by my patients, and I am going to be praised for bringing forward these risk vulnerabilities, and I am going to be acknowledged for being transparent because the leadership in an organization embraces me for being brave and being thoughtful and being part of helping to make healthcare safer.

So that's the first thing that has to happen is really setting the foundation for a healthy safety culture. The other problem that comes to mind, and certainly my experience both in hospitals and in the pharmacy world and across the healthcare continuum, is that we have workflows. And workflows are designed not only for productivity and efficiency, but if well designed and well adhered to. In other words, my big word of the day is compliance. If the workflows are well written and we comply with them and we don't take shortcuts, more likely than not we will get to a positive outcome. Unfortunately, in the healthcare settings where efficiency might become somewhat of a driver for people to feel like they need to do things more quickly, they think that cutting corners in fact will, with all good intentions, get them to the right end result, but in fact, it might not. And I think that that is where the rubber hits the road. 

Did we bring the right people to the table who are intimately knowledgeable about those workflows to help design and then redesign based on what the data tells us about people and their compliance? Because if people are taking shortcuts, that may be an early indication, an early warning that in fact, this workflow would benefit from an overhaul or a tweak. And in fact, we do not do that with a lot of discipline in most healthcare settings. We put something in place, we throw it out there, we hope it hits the sticks and people follow it, and then we think we're done and that we have solved the problem. But in fact, it's more complex than that and it would be helpful to have the right people at the table most of the time and those workflow designs.

Joni: 

Oh my goodness. Ann Louise, I have been emphatically shaking my head, yes, yes, yes. I can't even recall how many workflows we have done just that. We've created workflows, we've kind of just put it loose in the environment and we just let it be and let it go with maybe we do a little bit of audit and follow up, but over time, what does that workflow look like? And you're right, we're the right people, we're the right stakeholders involved in creating that workflow in the first place. It happens all the time with nursing. I can just speak from experience. I think you're, you're spot on then the concept of the integrity of bringing questionable things forward and mistakes forward and what a responsibility we have as leaders to shape that environment so that people do abide by most of the values that our healthcare organizations tout in integrity and honesty and caring for others. Well, that's a big responsibility for leaders. It really is. I'm curious, you've also done a lot with medical malpractice and if any colleagues have actually gone through medical malpractice, wow, it is transformative to go through some of those things. It's pretty painful. It really is. I'm curious, how has your experience shaped your views on its impact on patients and healthcare providers alike when you've worked with medical malpractice?

Ann Louise: 

This is a complex topic, Joni, and it hits home for so many people and it can be such a difficult time, obviously for patients and families, but also for providers. And so let me start by saying that to your earlier point, nobody comes to work to do a bad job. Everybody has good intentions to do the right thing at the right time and take their very best care of the patients that they are serving. And oftentimes when something doesn't go right, patients and families feel the need when there isn't a whole lot of transparency about what were the causes and the contributing factors and why did this happen? Those answers are things that they are seeking intelligence around. And if the medical community is not forthcoming in providing those answers, those tend to be the drivers of why patients and families file claims and suits.

So that first step is usually an early indication that we have not done our best with our patients and families, that they seek a legal avenue in which to get the information that perhaps they didn't get in real time during the episode of care. On the flip side of that, there are providers that are oftentimes very much impacted in a very negative way for having their name and reputation and their credibility and their compassion and their calling for this profession that they've chosen to be put into question. And it is devastating. And so although the rub is patients and families want answers and the provider community is at the other end of this feeling as if their fingers are being pointed at them for something that they may or may not have contributed to, is a very, very upsetting set of circumstances for people to be involved in. And so I like to think about med mal in a couple of ways. That dynamic absolutely encourages the provider community to provide support to their peers and that peer support programs should be first and foremost, and helping our fellow clinicians get through this episode of legal action and it is a very difficult time, even if nothing on their part went awry. It's devastating. 

On the patient and family side. Again, answers are being sought, even if the standard of care and no negligence was the end outcome of the malpractice action, there are insights that something didn't go right. And so from an improvement perspective, I think it's enormously important to use those insights. Even with well resolved in terms favorably resolved med mal cases, there are still opportunities for learning. And so this is where risk management and patient safety at the hospital, health system ambulatory, whatever the care setting is needs to dig deep and look at those insights. So it's sort of parallel tracks. We've got people and then we have intelligence as a result of these episodes that may have resulted in malpractice action.

Joni: 

Oh, wow. That's great. Ann Louise, you mentioned peer support being vital for those dealing with safety and quality issues. How do healthcare systems implement effective support mechanisms for those individuals?

Ann Louise: 

This is really a great movement that is really taking hold across the country, and that is this notion of identifying appropriate people within any healthcare setting who not only are interested in being a peer supporter but who have experienced something like this themselves. There is nothing better than like-minded people having an opportunity to learn and be supported through this kind of a relationship. So we see this across the healthcare continuum that there are people raising their hands that have said, this has happened to me. I'd like to give back and be able to support and help another individual get to the other side of a very difficult situation. And it's a hard thing to implement. But once it has a programmatic approach within a healthcare organization and there are tools out there that help organizations keep those programs running smoothly and robustly, these programs can be enormously effective and it eases the burden of something that's really difficult for all people involved.

Joni: 

Yes, absolutely. When I have seen peer support programs work well, I mean they've actually saved clinicians from walking away from their entire career and their specialty and their passion and their love. I mean, there's so much intertwined in medical malpractice, or even if it doesn't go into a malpractice situation, just knowing that you were involved in a scenario that caused harm to a patient. Wow, it is so impactful in so many ways to clinicians. So our peers who have gone through those difficult scenarios, I've also seen it kind of be healing to those peers as well, which is pretty powerful. So as we lean back into some workflow discussions, because we've all, throughout this season, we've had quite a few guests talk about workflows and workflow redesigns and bringing nurses to the table. And as end users, nurses are often left out of quality and safety workflow redesign, which is a little bananas because it's like the key thing that we do to take care and safeguard patients in lots of ways. What changes would you advocate for to involve more frontline team members in these crucial conversations?

Ann Louise: 

I think healthcare organizations are very knowledgeable that that's the right thing to do, to bring in the parties that are closest to the frontline execution of the work. But we need nursing leaders to be champions to make sure that they have oversight of these working groups, if you will. And if they're lacking in terms of nurse participation, stop the line and make sure that the right professionals are assembled at the table to be part of the solution. Again, it's oversight. Obviously it's good listening skills. I think that sometimes the most obvious human resource is the one that's the one left behind, which is our colleagues in nursing. And so just being mindful is a good first step.

Joni: 

Yes, that's great guidance. I mean, as executive nurse leaders, sometimes we may be the only nurse at the table, honestly. And so you're right, executive nurse leaders have a responsibility just like everyone else to stop the line when they see that quality and safety are impacted. And this is a great example of stopping the line at the boardroom or in the workflow redesign session. Absolutely. I love that. How can healthcare executives use the lessons from both medical malpractice cases and adverse events to make a case for investing in safety and quality improvements? Because often I've come to the table, and let's be real, finances are tight everywhere in every healthcare organization. Margins are razor thin these days. We have to make a business case for everything, including quality and safety, which I think a lot of nurses think, oh, well, it's just there naturally. Right. What are your thoughts on how we can use what we have to make the case for investing in these things?

‍Ann Louise: 

This is a good one, Joni. I think it has a variety of different facets, what you're asking about. First and foremost, everybody thinks safety is in the top five. I don't think you'd find a healthcare executive that wouldn't tell you it's not number one, two, or three, let alone in the top five. But to your earlier point, the financial constraints have oftentimes made safety and quality fall below the five. And that oftentimes creates a fair amount of discontent, particularly amongst our nursing colleagues who feel as if they are being made more vulnerable because they do not have what they need to keep their patients free from harm and deliver high quality care to optimize patient outcomes. So it's a rub, right? Yes. Everyone says that it means a lot. We can't run a healthcare organization without it. But when something needs to get cut under enormous economic pressures, it's funny what happens to quality and safety.

It's just sort of in your face. So one of the business cases I like to make, I think it has a lot of credibility with our friends, our CFO friends across the healthcare environment, which is the return on investment. And one of the areas of patient safety and quality that is very well articulated as being a good return on investment is back to our conversation about medical malpractice. If you think about the legal expenses just to defend a healthcare provider or two, a hospital, a health system, enormous resources get invested to uphold the reputation of these individuals as well as these healthcare organizations. And if it's a favorable outcome, everyone sees that as money well spent. And if it's an unfavorable outcome, everyone sees it as well, the legal expenses were enormous as well as the settlement. Wouldn't it be nice to take those economics and put those in front of our boards of directors and our hospitals and have our CFOs be the champions of saving the costs related to even one malpractice action, just the legal expenses, let alone the settlement could pay for a multitude of interventions to make patient care delivery safer. And if that isn't a good ROI conversation, I'm not sure what is.

‍Joni: 

Yes, I wholeheartedly agree. Ann Louise, absolutely. Well, you have given us a lot to think about today, Ann Louise, and you clearly have a distinguished career in this field. I am always curious, I ask this of all of our guests, I'm always curious what makes a leader, what do leaders do to sharpen themselves, especially once they're already leaders in the field? How does a leader become even more of an expert and push the limits of their field? So I'm curious, what are you reading or learning about these days? What are you doing to spur your thinking or nourishing your soul so that you can continue this work? What are you doing?

Ann Louise: 

Well, thanks for asking that, Joni. I would say it's probably more challenging for me than the average person since I'm in a semi-retired state, and I still am so curious and so eager to continue to make an impact, mostly with my work with my boards, but as well as my role at RLDatix and in all those arenas, I feel like the one topical area that I continue to pursue more intelligence around is this unfortunate thing that we have all been struggling with that really kind of made it to prime time is this workplace violence concept. 

Joni: 

Oh, man. 

Ann Louise: 

And I seek out any conference, webinar opportunity even to listen to people on the front lines about what this looks like and what we're doing to mitigate these risks. Because at the end of the day, this topic is not going to go away. And the more we can learn, even though I personally haven't experienced, hopefully you have never experienced, it's real and it is not getting better fast enough. And so I seek out any opportunity to learn more in that arena. I don't have one single source of truth, but it is a topical area that I am trying desperately to become much more fluent in and more knowledgeable about what best practices look like to impart that wisdom as I have opportunities to talk to healthcare organizations around the country. So that's an area that I'm particularly curious about and try to learn more about as I go about my day.

Joni:

I love that. It just goes to show you how rapidly healthcare continues to evolve. I mean, workplace violence was kind of on our radars maybe even 10 years ago, but oh my goodness, it has just kind of exploded. And so yeah, there's always something to keep us busy and to learn more about. I love that you're leaning into this from a clinician perspective because again, I do feel like our risk management, medical malpractice leaders, they have always had us in mind. I mean, even though a lot of people think that they're solely patient focused, they are not. They really aren't. They have us in mind. And so that's interesting. I never really thought about how much my risk management colleagues are probably leaning into this right now. So thank you for spurring me with that ultimately, Ann Louise, you've mentioned some great topics and you've given us some food for thought. What would you like to handoff to nurse leaders at all levels and in every setting today?

Ann Louise: 

Thanks, Joni. I would say that nurse leaders need to keep their door open and listen, and they need to listen to their workforce and what keeps them up at night. And I think the labor shortage that we're all experiencing across all healthcare disciplines is worrisome, but particularly in nursing, what we're hearing and what the literature is telling us is that throwing money at this is not the solution. Listening to the needs, respect of the people that are providing the nursing professionals that are providing services, giving them as much autonomy over their work life balance are some of the important ingredients to a healthy workforce. And I think nurse leaders are at the top of that pyramid to provide those sorts of insights, if you will, into their management styles and the listening and respect they want. Those two talents really need to be well tuned in this particular healthcare environment.

Joni: 

Beautiful. Beautiful. Ann Louise, where can people follow you or connect with you after this Handoff podcast to find more of your work?

Ann Louise: 

Well, Joni, like everybody else, I'm on LinkedIn, so please feel free to find me there. But people are welcome to email me directly at ann.puopolo@daytex.com. 

Joni: 

Perfect. Excellent. Everyone, be sure to find Ann Louise on LinkedIn or send her an email. She's clearly an expert in this area and passionate about patient care, but also care of our clinicians and our healthcare team as well. Ann Louise, thank you for joining us on the Handoff. I love your passion for safety and quality. Thanks for sharing your expertise with us today. It's been a real joy.

Ann Louise: 

Joni, Thank you for having me. It's been fun.