Why It Matters
Amid the COVID-19 pandemic, IHI's Patricia McGaffigan remembers Paul O’Neill’s contributions to the advancement of workforce safety and joy in work.
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What Paul O’Neill Taught Health Care About Workforce Safety

By Patricia McGaffigan | Tuesday, April 28, 2020

Paul O'Neil

Photo by Katie Trevathan

One of the greatest legends in patient safety, Paul O’Neill passed away on April 18 after a long illness. He is largely responsible for recognizing that the physical and psychological safety of the health care workforce is a precondition for patient safety. He called for health care leaders to explicitly commit to workforce safety as a core value and assume full accountability for the safety of their entire workforce. Today, amid the COVID-19 pandemic, I reflect on Mr. O’Neill’s contributions to the advancement of workforce safety and joy and meaning in work.

In 2012, I accepted a dream position to join the National Patient Safety Foundation (NPSF) as Vice President of Safety. Days before my scheduled start date, I sat in on an expert panel discussion on workforce safety hosted by NPSF’s Lucian Leape Institute (now the IHI Lucian Leape Institute).    

Before the event, I reviewed the biosketches of co-chairs and panel members and was impressed by the wealth and diversity of expertise. One bio was particularly intriguing and unique — that of panel co-chair, Paul O’Neill, a member of the Lucian Leape Institute, the 72nd United States Secretary of the Treasury, and former CEO and Chair of Alcoa. I had the chance to meet Mr. O’Neill before the start of the expert panel. He was warm, gentle, and welcoming.  

In Mr. O’Neill’s opening comments during the panel, he decried the current state of workforce illness and injury in health care, characterizing it as unconscionable. He recapped his remarks at his initial meeting with the investment community as the first externally hired CEO in Alcoa’s history.  “I want to talk to you about worker safety. Every year, numerous employees are injured so badly that they miss a day of work… I intend to make Alcoa the safest company in America. I intend to go for zero injuries.”  

In the Power of Habit, author Charles Duhigg relays what happened in the moments after Mr. O’Neill’s opening comments. There was stunned silence. These were not the words that members of the financial community anticipated. Thirsty for financial guidance, they began to pose standard questions to guide their investment decisions. Mr. O’Neill remained unwavering and on point in his subsequent comments.

“I’m not sure you heard me,” he said. “If you want to understand how Alcoa is doing, you need to look at our workplace safety figures. If we bring our injury rates down, it won’t be because of cheerleading or the nonsense you sometimes hear from other CEOs. It will be because the individuals at this company have agreed to become part of something important: They’ve devoted themselves to creating a habit of excellence. Safety will be an indicator that we’re making progress in changing our habits across the entire institution. That’s how we should be judged.” Duhigg describes Mr. O’Neill’s focus on habitual excellence in workforce safety as a classic example of a “keystone habit,” a term coined by Duhigg to reflect habits that automatically lead to multiple positive behaviors and positive effects. 

The resulting report of the NPSF expert panel co-chaired by Mr. O’Neill,Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care, was published in 2013. It summarizes the inextricable link between workforce and patient safety and reminds us that unless caregivers are given the protection, respect, and support they need, they are more likely to make errors, fail to follow safe practices, not work well in teams and be harmed. The report incorporates recommended actions for health care organizations that want to make meaningful improvements in workforce safety and advance joy in work.  

As Mr. O’Neill reminded us at the 2014 Annual Lucian Leape Forum and Keynote, organizations are either habitually excellent or they’re not — there’s no in between.” His own litmus test for determining habitual excellence was deceptively simple. He challenged leaders to ask themselves whether every member of their workforce could respond “yes,” every day, to the following “3 R Questions”: 

  1. Am I treated with dignity and respect by everyone, every day, in each encounter, without regard to race, ethnicity, nationality, gender, religious belief, sexual orientation, title, pay grade, or number of degrees?
  2. Do I have the resources I need — education, training, tools, financial support, encouragement — so I can make a contribution to this organization that gives meaning to my life?
  3. Am I recognized and thanked for what I do?

The much-needed focus on workforce safety, and its broadening to encompass joy and meaning in work, would go on to become further amplified in subsequent reports, recommendations, and initiatives of the National Patient Safety Foundation. The Institute for Healthcare Improvement continues the relentless pursuit of Paul O’Neill’s keystone habit since the 2017 merger of NPSF and IHI. We approach our work through a total systems approach to safety, addressing both patient and workforce safety in a unified and not separate manner, and through our commitment to equity. 

As I think about the current COVID-19 crisis, I wonder: What would Paul O’Neill think? What would he say? What would he shout? I sense he’d say that it’s the responsibility of every federal, regional, local, and organizational leader to wake up and hold our entire society accountable for the physical and psychological protection and wellbeing of the communities that serve and deliver health care. I sense he’d say that what we write on our walls and in our memos about workforce safety is meaningless unless we act on and approach our duty in the manner of habitual excellence. 

I’m confident he’d say that habitual excellence in workforce safety matters more than ever and is a nonnegotiable duty of society. It must be fueled by a sense of urgency and a mindset of innovation, continuous learning, and improvement. I’m certain he’d say that there are no excuses of any kind, whether in “normal times” or amid a pandemic, for lessening our standards for creating a world where patients and those who care for them are free from harm.

I sense he’d say it is time for leaders around the world to put our differences aside and unite in a shared value that enables us to authentically commit to “flipping” health care from one of the most dangerous industries to the safest. I sense he’d say that we are obligated to accept nothing less than zero injuries, zero lives, and if you disagree, he’d ask whether you would choose that your loved ones should be harmed or die as a result of their service.

I am confident he’d demand that leaders must embrace, foster, and meaningfully act on our moral obligation to provide the fullest protection and respect for all who serve in health care. 

The chasm that now exists between the realities and ideals of workforce safety is wide and deep. What we’ll take forward from the COVID-19 experience and all the rightful attention paid to protecting health care staff on the front lines remains to be seen. That’s why lessons learned from Mr. O’Neill, a leader who transformed workforce safety in the aluminum industry, matter more than ever for health care. 

Patricia McGaffigan, RN, MS, CPPS is Vice President, Safety and President, Certification Board for Professionals in Patient Safety at the Institute for Healthcare Improvement.

You may also be interested in:

More COVID-19 Guidance and Resources

Safety and Quality Are Still Paramount During a Time of Crisis

“Every Injury to a Health Care Worker Is Preventable”

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