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Building a Culture of Safety and Improvement in Brazil

By Kimberly Mitchell | Tuesday, September 22, 2015

Antonio Capone Neto, MD, PhD, FCCM, a 2014-2015 Hospital Israelita Albert Einstein Fellow at IHI, was the first person from Latin America selected for IHI’s year-long fellowship program for mid-career health professionals. In this blog post by IHI project assistant Santiago Narino, Dr. Capone Neto describes his improvement journey.

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Antonio Capone Neto

Before starting his fellowship year at IHI, Dr. Capone Neto was Medical Coordinator (Director) of Critical Care Medicine at Hospital Israelita Albert Einstein in São Paulo, Brazil. It was when he started his role in the ICU five years ago that he became keenly aware of quality and patient safety problems. As he took on a leadership role in the ICU, he noted that “a feeling of fear infiltrated much of the culture surrounding medical errors.” Dr. Capone Neto was determined to create an environment in which doctors and care teams could have honest conversations about safety despite the cultural challenges. To this end, he helped frame discussions about safety issues as learning and improvement opportunities for the whole hospital, and not as a means for assigning blame and enacting punishment.

At the first few patient safety meetings, a number of physicians found the purpose of such meetings difficult to understand. “You are trying to make us feel uncomfortable,” they complained. “We are not incompetent.” It took time for them to view patient safety as a systemic issue and not one focused on individual blame, but eventually Dr. Capone Neto started to see a gradual culture shift. “They moved from feeling incompetent, to blaming the moderator for exposing them,” he notes, “and now to something more positive.” Eventually, the voluntary safety meetings Einstein held grew in size from 20 doctors to 300 individuals filling Einstein’s auditorium. He credits the reward of “seeing results...  and seeing how improvement projects advance [safety]” for the steady, positive shift in attitudes among hospital staff.

Dr. Capone Neto took the experience of making progress at Einstein with him to IHI. “The fellowship was a transformative experience,” he says. “The dynamic environment throughout the year really allowed me to re-energize and come to understand how improvement projects are done.” He describes his participation in IHI’s Improvement Advisor Professional Development Program, in particular, as helping him understand why projects fail. He also described how the experience of talking with pioneers and experts in patient safety all over the world while reflecting on the Brazilian context changed his vision for his work. He has decided, for example, that “the attitude, training, and management of hospitals are what really matter” to make culture change.

Now that he is back in Brazil, Dr. Capone Neto is optimistic about applying what he learned during his IHI fellowship to his home organization. Although the magazine America Economia Intelligence named Einstein the number one hospital in Latin America, the hospital continues to work toward world-class results. He looks forward to building on IHI’s Strategic Partnership with Einstein. The commitment of Einstein’s leadership to quality and safety, he says, has been the driving force behind the cultural changes that continue at his organization.

In the ICU, for example, staff now understand the importance of addressing difficult issues and have focused on making their care more patient- and family-centered. Einstein now responds to adverse events by engaging the families through every stage of the process. “There is transparency and respect in the event of an error,” says Capone Neto, and self-reflection from the doctors when errors occur is a big change from only a few years ago.

In addition to his QI work at Einstein, Dr. Capone Neto helps future health care providers through the IHI Open School. Latin America is now the region with the second highest number of Open School participants, and he wants that representation to grow. He is starting to engage universities in Brazil to show them the Open School’s energy and value.

Asked to sum up some of what he’s learned in the last few years about the challenge of transforming health care, Dr. Capone Neto remarks, “Everybody is afraid of things they don’t know. Until you show them and walk them every step of the way, you won’t achieve culture change.” He believes that most people want to improve care. “Resistance always comes from only a minority of people,” he notes, “and you overcome the critics by showing them results.”
 

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