Nowhere is this attitude more apparent than at the Dana-Farber Cancer Institute (DFCI) in Boston, where a high-profile patient death in 1994 touched off a profound and intense campaign to re-engineer how the organization views, understands and manages patient safety. According to Jim Conway, DFCI’s Chief Operations Officer, "Leaders play an extraordinary role in patient safety." Having spent the last six years driving DFCI’s innovations in patient safety, Conway now spends time sharing his lessons with peers in numerous health care communities. His description of the leader’s role is part strategic, part organizational, and part cultural. First and foremost, he explains, leaders must: "Provide focus, make patient safety not just another ‘program de jour’ but a priority corporate objective. You must make everyone in the institution understand that safety is part of his or her job description."

To make this more than a general pronouncement, Conway clarifies that it is up to executive leaders to provide the human and financial resources to safety teams necessary for them to design and implement an integrated program for identifying risks and reducing errors.

Along with the required technology and systems investment, an effective safety program entails a leadership-driven cultural shift, according to Conway. "You have to set the tone," he explains, "provide a supportive, non-punitive environment for your staff. The goal is transparency – an atmosphere of open communication about safety concerns and incidents."

In more specific terms, this means leaders have to learn how to listen and start talking about safety concerns continually – with front-line staff and at the highest levels of the organization. Conway says, "If you’re not hearing about errors, don’t assume they’re not happening." He urges leaders to "Go looking for trouble, probe your staff, ask people ‘What feels unsafe?’ Your staff is incredibly worried about safety," he says, "a situation made worse by financial and staffing pressures. You must provide opportunities for conversations."

Organizationally, leaders must put in place an interdisciplinary review process "so that when an error occurs everyone involved – nurses, physicians, staff, students, all those ‘on the sharp end’ – sit around the table," says Conway, to talk about the painful experience. Further, he adds, "You have to be there with them at that meeting to support your staff, often devastated by the incident."

At the other end of the spectrum, leaders must involve the board, trustees and executive committee in safety discussions. This can take a variety of forms: sharing adverse event reports, being included in root-cause analysis meetings, hearing patient stories. Conway says "I’m a big believer in run charts, Pareto charts and statistics, but there is nothing that engages a board in safety issues as effectively as a patient’s story."

Patients are very much at the center of DFCI’s safety mission. Conway speaks passionately about the rewards of forming partnerships with patients in the safety drive. "Patients and their families can make unbelievable contributions," he says. "That errors happen and patients are at some risk when they come to your institution for treatment is no secret to them," he adds, and the atmosphere of silence is outdated and counterproductive. Conway paints his interactions with patients in language of humility and respect; hearing their experiences is "sobering but incredibly useful. Again and again I hear from patients and families that they want to find leaders in the hospital who will talk to them about safety. They want opportunities for conversations."

To build such partnerships, DFCI has put into place several vehicles of communication. They sponsor both adult and pediatric patient-family advisory councils that are actively involved in the design, implementation and assessment of safety initiatives and care overall. The adult advisory committee, for example, includes some 15 members who meet monthly, led by the chief nurse and chief of adult oncology. The co-chairs of this adult advisory committee actually attend meetings of DFCI’s Adult Oncology Clinical Services Committee (AOCSC), the Institute’s interdisciplinary forum for adult care, run jointly with counterpart, the Brigham and Women’s Hospital (BWH). These are the meetings, says Conway, "where we discuss the good, bad, and ugly of our care and care processes. So our patient advisors hear about our med errors, our slips and falls, our infection control rates." And yet, despite understandable fears about legal consequences of this access, Conway says, "Nothing terrible happens in those discussions, only positive interactions."

DFCI management aims to be open to impromptu lessons from patients as well. Conway describes invaluable risk management feedback he received from a patient who once phoned him from the chemotherapy infusion room. The patient urged Conway to come down and see the treatment room at that moment, for he and other patients felt it was unsafe. Conway did so, and he agreed: "It was crowded, cramped, and unbelievably busy." The visit led DFCI to halt an expansion underway that would have added chairs. With further consideration, they ultimately revised the plan completely, opening up a safer, more comfortable space with fewer units.

Conway’s enthusiasm about opportunities to advance patient safety is heartening, especially given his location in Boston’s bastion of medical establishment. The open, flexible, respectful environment DFCI has shaped should be a model for all of us. Moreover, his assertion that executive-level leadership is critical to such success is a wise tip for boardrooms everywhere.