This is part of an ongoing series of audio profiles of front-line improvers.
Vice President of Safety Management
I’m Doug Bonacum. I’m the Vice President of Safety Management for Kaiser Permanente. I’ve got responsibilities for environmental health and safety, patient safety, and clinical risk management. I’ve been with Kaiser since 1994. My first seven years were purely environmental health and safety, and after the Institute of Medicine report [To Err Is Human] came out in 1999, I was able to expand my responsibilities to patient safety, and a couple years after that, to clinical risk management.
The environmental health and safety component is largely driven by federal and state regulations, trying to protect the worker and the environment. And largely that involves assessing performance at our hospitals, trying to improve performance around compliance, and also eliminating occupational injuries and illnesses, which we have really tied our thinking to improving the quality of care as well. So that’s a neat connection there. We’re also doing some great work on environmental stewardship and trying to connect that piece to great patient care as well, recognizing that the environment impacts our members’ health outside of the hospital and that we need to take ownership for that.
The patient safety part has largely been modeled after a lot of the programs that the IHI [Institute for Healthcare Improvement] has led. So it’s trying to initially, I would say, eliminate accidents and now really more about eliminating harm. And the risk management part says, “But we’re still going to have accidents and we’re still going to have harm, so how do we recover from that in a way that honors the patient and the practitioner, protects the organization, and learns from that adverse outcome?”
My background’s in chemical engineering. I graduated from the University of New Hampshire in 1983, at which time all of my classmates were going into pulp and paper chemistry and to petro-chemical engineering, neither of which really was floating my boat, so to speak. And I talked to a recruiter in the Navy who got me to sign up for the submarine force. I spent the next eight years on active duty in the submarine force and when I came out of the submarine force, used my chemical engineering skills to get a job in manufacturing doing environmental work. From there, I got a job with Kaiser Permanente largely doing environmental health and safety work and then subsequently patient safety and risk management.
I don’t think I had any understanding of actually what I was getting myself into when I got the job in patient safety, and I think I knew more about risk management when that opportunity came around. But the patient safety connection really was a result of the Institute of Medicine report, and I was one of the few people, I think, at Kaiser at the time that actually read the whole report.
So I knew the piece around benchmarking with other high-reliability organizations and I was able to approach the quality leader at the time, who knew me from some environmental health and safety work actually, and explain to her my Navy background in submarines and in nuclear power and to talk about some of the things that I had learned there that I thought the IOM [Institute of Medicine] report was trying to speak to when it spoke about other high-reliability organizations. And she gave me an opportunity, which was a credit to her. I think it was a big risk to give someone an opportunity like that, but she also surrounded me with some really smart physicians and nurses like Michael Leonard and Suzanne Graham and others who were mentors and coaches along the way. So it was an easy transition.
So I was sitting in a perinatal patient safety training actually at one of our medical centers in 2002, listening to the doctors and nurses sort of talking at each other about how disappointed they were with each other on their communications. And the nurses would say, “You know, when I call the doctor in the middle of the night, I tell the doctor what’s wrong and I really think I’m making a strong recommendation but I don’t get the sort of response that I would hope for.” And our physicians were saying, “You know, when they call me in the middle of the night, they tend to ramble, it’s not very clear what their assessment is, I don’t know what they want most of the time, and most of the calls, quite frankly, are of no use.” And I recognized that the patient was at the middle of all this and it didn’t need to be that way and that a more structured communication might help both the receiver and the transmitter of that information.
So I reflected on how we would make similar conversations in the Navy. Now, of course, we weren’t helping moms give birth to babies, but we were doing important things across some hierarchical structures that existed within my submarine, for example, where someone very low on the totem pole needed to communicate mission critical information to someone higher on the totem pole in a way that got prompt action. And we used a technique that I later labeled as SBAR, which was just to describe the Situation we were seeing succinctly, give a little bit of a Background so the person hearing the information had the context to provide an Assessment ― because no matter where you were in the hierarchy in the Navy, your assessment of the situation was valued ― and most importantly to provide a Recommendation, which was very empowering for someone lower on the food chain, if you will, but gave the person higher up on the hierarchy the ability to say, “No, that’s not right” or “We’re going to make a change.”
And I don’t remember the exact moment that the S, the B, and the A, and the R came out, but it was as a result of those communications. We quickly developed some training around it, allowing people to try to test it out and to give them feedback in a classroom environment. And I didn’t really think it was going to go much further than perinatal patient safety and soon it was sort of everywhere. And now we’re using it to write emails to each other and people are using it during handoffs in transitions in care, so it really has caught on.
I think there are probably a number of reasons that SBAR caught on. One is it’s an easy acronym to remember. So people need memory aids, and SBAR is certainly something that’s easy to remember. Two is it does flatten the hierarchy. And health care is hierarchical and needs to be hierarchical, but it also needs to be flattened in the interest of patient safety just like in the interest of shift safety it needed to be in the Navy. And I think it’s a very easy way to flatten the hierarchy quickly. And it’s very empowering, actually, for the person who’s got to make the communication because in the end they recognize, “What I’m doing is a recommendation. It may not be accepted but I do have some background, I’ve got some expertise, and my recommendation’s going to be valued and appreciated and also expected.” And so I think for all of those reasons it’s just caught on. And both the receiver and the transmitter of the information actually benefit from it, so it’s a win-win for everybody and, I would say most importantly, for the patient or the family.
One of the interesting things now, we’re seeing doctors using it with doctors. So we’ve got a couple of little initiatives that have just sprung up where, for example, physicians in our stand-alone ED are using SBAR to communicate to our hospitalists in one of our contract facilities about patients who are on their way. And the hospitalists are enjoying hearing that information that way, and I think the ED practitioners are getting some of the vital information to the hospitals. We’re also seeing it being used in call centers where our nurses have to make very tough decisions and, in certain cases, have to pick up a phone and call the equivalent of an emergency room doctor who’s on duty, so to speak, about certain patients and the nurse then is able to do an SBAR to the doctor about what the right advice would be on a telephone line. So, it again fits a number of different organizational and, I think, personal needs and that’s why it’s caught on.
One of the things I’m still struck by, and I’m part of the problem but I’m also hoping to be part of the solution, is how unstructured and undisciplined most of our communications, including our handoffs and transitions in care, are. So, just as an example, if you were in a nuclear power plant aboard a submarine, you’d be in a room called the control room which is where you had oversight of the entire power plant. If anybody wanted to come into that control room, they basically had to do the equivalent of knocking on the door and using words, “Permission to enter.” Those were the only words that they would ever speak if they were at the door. If you were inside the control room and you could be interrupted, you would just say, “Enter.” And if you couldn’t be interrupted because you were doing something that was critical at the time, you would say, “Wait.”And those were the only words you could say, “Enter” or “Wait.”
Well, when you look at how we interrupt and distract each other in health care, there’s nothing on that level of consciousness about just how vital the operations are that we’re doing. Medication administration is a perfect example where nurses are routinely interrupted from the time they pick up the order to the time that they administer the medication. And these are medications that can wind up saving a life and also destroying one. And yet there’s no acknowledgment of something as simple as an interruption and a distraction and how you would minimize it.
One of the things I’m struggling with lately is not a new idea, although I think I’m thinking about it different than I have in the past. And that is that there’s a series of error-producing conditions and violation-producing conditions that exist in the work place every single day. And those align occasionally sort of in the “Swiss cheese model,” if you will, to create a certain set of behaviors then that, for the most part, get the right outcome and, therefore, get accepted over time.
And the example that everybody always uses is just everybody’s driving habits which, when you start as a 17- or 18-year-old driving a car for the first time, especially with your parents in the car, both hands are on the wheel, you have all the interruptions and distractions down, you’re going the speed limit, you’re slowing down at yellow lights, you’re actually coming to complete stops at stop signs. And if you all examine your behavior today, they’re entirely different and most of it’s because you drifted from those safe behaviors but you haven’t had a recent adverse outcome, telling you that your behaviors are actually acceptable.
And I see the same thing. I would say almost every single medication error that I see has both this combination of error-producing and violation-producing conditions that were present at the time and that caused a certain set of behaviors. And the thing that I think is probably the most frustrating but also gives us the greatest opportunity is that the behaviors are not occurring in a vacuum. It’s not as if these things are occurring and that no one understands or knows about the behaviors that are going on. They’re occurring very much in a visible way, which leads me to the notion that these aren’t really individual errors. They’re more team-based errors.
Hand hygiene is a perfect example. Hand hygiene’s not going on in a vacuum somewhere. It’s going on in a very visible way for the rest of the team. Time-outs and preoperative briefs are the same way. When someone chooses not to do a pre-operative brief the right way or a time-out the right way, the entire team knows about it.
So why is it that health care is allowing us to sort of witness these events as a team and allow one person, if you will, to get away with it? And I don’t quite mean it like that because, again, often it’s not intentional. But allow them to do that as opposed to saying, “In the interest of patient safety, I can’t let you do inadequate hygiene” or “In the interest of patient safety, I can’t let you do a poor time-out” or “In the interest of patient safety, I can’t let you do an incomplete double check.” That’s the greatest challenge, I think, that we have in health care right now which is going to require just a cultural transformation, leadership thinking entirely different about the problem, and also probably provides us our greatest opportunity. But that’s what keeps me up at night.