Creating a culture of safety in healthcare requires more than just policies and procedures; it involves a continuous commitment to proactive strategies and learning. Ensuring that both patient and employee safety are prioritized is essential for a high-reliability organization (HRO). By fostering situational awareness and maintaining open lines of communication, hospitals can significantly enhance their ability to prevent and address potential issues.
On today’s episode of In Network's Designing for Health podcast, Nordic Chief Medical Officer Craig Joseph, MD, talks with Steve Muething, MD, senior advisor and former chief quality officer at Cincinnati Children's Hospital. They discuss the importance of patient advocates, situational awareness in healthcare, and the need for a proactive safety culture. Dr. Muething also shares insights on integrating employee and patient safety and reflects on the simple yet effective design of his 85-year-old Ford 8N tractor.
Listen here:
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Want to learn more from Dr. Joseph? Order a copy of his book, Designing for Health.
Show Notes:
[00:00] Intros
[01:24] Dr. Muething’s background
[10:19] Creating a culture of safety
[14:21] The importance of patient advocates
[18:29] Situational awareness in healthcare
[38:34] Something so well designed, it brings Dr. Muething joy
[42:08] Outros
Transcript:
Dr. Craig Joseph: Steve Muething. Thank you for joining the pod today. How are you, sir?
Dr. Steve Muething: Very good. Very good.
Dr. Craig Joseph: Where do we find you today?
Dr. Steve Muething: I am actually sitting in Cincinnati, Ohio, at Cincinnati Children's, at our main location.
Dr. Craig Joseph: Awesome. Why don't you give our listeners a little bit of background about who you are and how you came to be?
Dr. Steve Muething: Wow. That's a long story.
Dr. Craig Joseph: No, no, but in three sentences. I need every, all the details and in three sentences only.
Dr. Steve Muething: All right. Well, thanks for asking. I am a pediatrician. I'm also a dad and a grandpa. I actually started my career as a small town pediatrician out in the middle of Indiana in an area where there was no pediatrician for three counties. Loved it. Wanted to do that for the rest of my career. Some things happen, like they always do, some surprises. And some people at Cincinnati’s Children's approached me and asked me to start doing some leadership roles. And so that was more than 20 years ago. And so since that time I've had various leadership roles. Led safety as the chief safety officer, led as the chief quality officer. Very excitingly, I got to help start solutions for patient safety, which is a network of all the children's hospitals. And now I'm in one of those roles that you are at the end of your career. I'm a senior advisor starting a new part of the Cincinnati Children's.
Dr. Craig Joseph: That's a lot of that's a lot of hats to wear. I think what we're going to focus on today is some of the safety work that you've done, some of the safety and quality work. So, I'm interested, you kind of got tapped to do that. You don't really have, you know, this was not a passion of yours for decades. But patient care was. And so, you know, how did it start? What did you start focusing on?
Dr. Steve Muething: Yeah. Thanks. I, no, I was not a safety expert, I wasn't somebody who was brought in with years of safety expertise to help lead at Cincinnati Children's. I was where Cincinnati Children's as an organization was. We had an awakening. We started realizing how significant safety played in our journey to become an excellent organization. And as an organization we realized we were not good at this. We didn't understand it. This is not where our expertise was, but we needed it. So I was picked as the initial clinical leader for that. Given the support. And most importantly, I was given the mission to go learn. And so I was given the ability to go where we could learn. Other industries tap into experts. I got the time and support. And so I went from somebody who was, I think, a very good pediatrician who understood the impact when harm happened on to patients and families and my colleagues, but didn't really understand the science of safety. And I think over a period of time, years to a decade or so, developed a level of expertise. And then that was accentuated by ongoing relationships with some amazing mentors including Paul O'Neill and Lucian Leap and some others. And, you know, I have to say, Craig, I continue to learn every day. I don't know if it's a sign of how slowly I learn or just how vast the need is to understand safety inside healthcare. But right up to this day, I feel I'm a lifelong learner, could probably do this for another several decades and still be learning.
Dr. Craig Joseph: Well, first of all, I suspect that you're not a slow learner. I suspect that there's just a lot to learn.
Dr. Steve Muething: There is.
Dr. Craig Joseph: When we were when we were preparing for this interview, you told me that it's a journey. And you said, like, that was kind of. That was thought number one, that it's a journey and you don't there's no end point. You're just constantly going. So this journey kind of began with you looking for experts. Did you and you mentioned some of those experts. You said there were other industries that you kind of the were exploring. What were some of those and what are some of the things you might have learned from them?
Dr. Steve Muething: So I, you know, when you when you read a lot about safety and, you know, whether it's in the healthcare literature that's growing or in other literature, there's lots of industries that are pointed to. It's typically nuclear power or civil aviation. But I'd say the place where I really had my eyes opened was with Naval Aviation. I met up with some folks who actually helped design and build submarines, believe it or not. But then they connected me with naval aviators. The whole aircraft carrier concept. And I was lucky enough to be taken under their wing to some degree. I got opportunities to really see it and feel it and learn it concepts like the high reliability organization theory, situational awareness, and one of the times that it just really sunk into me is I had the opportunity. Amazing opportunity to go out on one of the US aircraft carriers when it was out in the Atlantic Ocean and actually tailhook on to the deck of the USS enterprise and then get catapulted off a couple days later. And being able to see it come to life, the concepts of high reliability, safety, culture, I mean, to this day, which that's way over ten years ago to this day, I think I tap into those memories and those experiences to say, look, we are not exactly like running naval operate or aircraft operations off of an aircraft carrier. But, man, there's some, parallels that we could really learn from. And can I give you an example?
Dr. Craig Joseph: You can, but first you have to tell me how I get, how I get a ticket.
Dr. Steve Muething: Well, I don't know, but they it was amazing because I think I was with some people from Congress and some defense contractors and things like that. So they treated us pretty well. But, you know, an example and there's so many. But an example is when they are about to catapult one of those amazing jets off of a top of an aircraft carrier. Back in the old days, the person who decided that it was safe to catapult them was the pilot. Eventually, through cause analysis and, after accident reviews, they came to the realization that the worst person on the entire aircraft carrier to decide it's safe to catapult us or me at this time is the pilot or aviator, as they call them. And it came down to is this person's been revved up for hours. Getting ready for the mission. Is thinking about what they're going to accomplish while they are airborne and their adrenaline's pumping. They're ready to go, and they try to pay attention to the checklist. They try to pay attention to every detail, but that's their minds not there. And I have to say to some degree, when I look at us and some of the things we do in healthcare, when we're revving up for a whether it's a complex surgery case or some other very complex thing whereas a team, we want that care team and perhaps the leader of the care team focusing on nothing about accomplishing the mission. But perhaps we need some people like they do on the aircraft carrier who's actually got the final say of whether it's safe or not. So those are the kind of examples that I think we can learn from other industries. I also learn from manufacturing, wild firefighting. I got to go to the National Center, where they share all the data for civil aviation and how they learn across organizations. So again, I think someday, I hope healthcare is one of those industries where everybody says, you got to go learn from healthcare to improve your industry. But I think if we're honest with ourselves, we're still in the, the phase of healthcare safety where we are obligated and should be out learning from other industries, in a very humble, way, which is just where we are.
Dr. Craig Joseph: All right. Well, you know, what I'm hearing is you're not going to get me a ticket to an aircraft carrier, but I'm going to. I'm going to keep on moving. All right. Speaking of honesty, that's an amazing history. And those are some great leaders and some great industries to learn from. One of the things that I've heard you, you mentioned one of the keys to patient safety, to safety in general is transparency. And you kind of mentioned being open and honest. And so I would think that most healthcare systems, most physicians would say, well, of course that's what we do. We're always transparent. I always try to tell my patients what the best thing that they should be doing and what I would do if I were in their shoes. And so, where's the breakdown? And how do you get better?
Dr. Steve Muething: How did healthcare culture get established? And why are we the way we are? Which makes it so amazing? But also, look, everything has its strengths and weaknesses, so I, I do agree with you that the vast, vast, vast majority of clinicians, clinical leaders, hospital leaders are trying to do the right thing. And in general, it does no good to say, well, I don't think you're transparent enough. I think, people believe they're being as transparent as they can be and should be. And I think this is, again, one of those examples where you it's hard to see how it could be until you see other ways to do it. And so the same reason we got to get out to factories and learn from manufacturing, or in my case on an aircraft carrier, is it's just hard to see how it can be, if we just stay inside our own bubbles or inside our own system. So how do you do it? I think it's always context dependent, and every organization's on its own journey, but I think it takes senior leadership in the case of if that's how you organized a CEO and their board to say no, we are going to be leaders in safety. We're going to take this on and it's clear we're not. And then once you make that call, then immediately you start saying, well, what did the leaders do and what should we do? And then that causes the thinking to go from, well, we must be okay, because we've been doing great for years and we're filled with amazing people and all that stuff to it. Start saying, no, no, no. What were the leaders doing? And that's when you really have to start. The first transparency is just with yourself to admit that we could do better. We should do better. We must do better, those kind of things. And then eventually as my former boss, Jim Anderson, who was our CEO when we really got serious about this, said, I'm not into transparency for transparency’s sake. I want us to be transparent when it's necessary and appropriate for us to learn and improve. And the other thing he said is that, and he was a lawyer, by training. And he said, as the CEO, I'm the one who has to take on the decision that we're going to expose ourselves to potential risk by being more transparent and being open and honest with families because it's the right thing to do. I can't ask my legal department to make a decision if it's the right thing to do. That's my decision as the chief executive officer to decide that. But then he went to the legal and risk area and said, now tell me how to do it right. So I think my point being is, I think it's, in Paul and I used to preach this is that this is really the most fundamental job of a leader is this is this is leadership is looking at, as we always say, our people are our most important asset, our most important driver of excellence. And outcomes and things. Every organization really goes after that. Well, if that's true, then as a leader, your number one job is to keep that number one asset safe. You know, even if for no other reason than having them come back tomorrow and doing an amazing job at tomorrow. But it’s more importantly these are people. And then we need to make sure they get home to their families and loved ones tonight.
Dr. Craig Joseph: Yeah, well that all makes sense. So being a being, one of the top children's hospitals or if you, if you pay attention to US News and World Report, the top children's hospital in the United States. Congratulations on that, by the way.
Dr. Steve Muething: Thanks.
Dr. Craig Joseph: So you've got patients, of course, but you've also got, their caregivers. Sometimes we call them parents or guardians. How does how does Cincinnati Children's how do you kind of make sure to keep them in the loop when you're being open and honest and transparent? To some extent that's going to be with the with the patient, but it's also going to be with the patient's family, I would presume. Yeah.
Dr. Steve Muething: Yeah. I you know, it's a way of thinking, you know, we happened to be talking together, Craig, today because of the, our mutual interest and, and focus on safety in this discussion. But really the reality is as pediatricians, we both know we need the family involved in every discussion on a daily basis. Who knows the situation better than that mom or dad or grandmother or whoever it might be? Nobody. So I would say fundamentally involving parents in discussions is on a daily basis here, like most Children's Hospital, we really push the concept of family centered rounding. You know, having folks involved in the discussion, not having a pre discussion in order to make it right for what the family ought to here. It's, no, respect the family. Ask them how they want to be involved and then make sure we do it. And then it gets down to when harm happens, whether or even just an error happens. The concept of being open and honest about that is not such a oh, now we have to be open and honest because harm happened. It's trying to learn to do it on a daily basis about all kinds of decisions, about all kinds of things that are going on, so that it's more of a, a just a natural leap, to say, oh, this is going to be a little harder because we have to tell them about an error and how this affected their son or whatever. But it's not like this is the first time I've really sat down with them. The other thing I think is critical is we have to acknowledge as an organization, and I think we do a pretty good job of this is, this hurt. It hurt my trust. It may even affect how I think about you and how we interact and things like that. So we need to make sure we take care of families, not just honest with them, but take care of them. And so we actually have an approach when there's any kind of serious harm that's occurred with the child. We assign an individual from our organization to then be the advocate and the representative for that family forever, because for some families, they need help for a day or week or something like that. Other families need help for a lot longer than that, and making sure over time and sequentially, we're checking in with the family, making sure that they're managing it okay. Because just because we hurt or caused a problem for this family. Not only is that not the time to stop caring, it's the time they need actually more caring during that time, not just the clinical care why they came here in the first place, but trying to help us reestablish that trust for them so that they don't have an experience and a change that will affect them for years on end.
Dr. Craig Joseph: That's very interesting. So assigning them an employee and saying, like, hey, this is your contact to our organization forever. Is there a name for that role or is that something...?
Dr. Steve Muething: Well they generally, it’s patient advocates. But it's actually it's not just a random employee. It's a person who's trained in this and things like that, but they make it very clear. My job is here for you. I'm not here to explain away. I'm not even part of the analysis. I'm not part of the action team who's going to try and improve the system. No no no. In fact, sometimes the role they play is they go to the family and say, hey, the, the analysis team is meeting next week and, what kind of input? Or they have some questions. Would you be willing to share some thoughts with them? And then subsequently, when the actions are happening from this event, making sure the family understands it and just whatever else they might need, even if it's just they need some, mental health just to deal with the fact that this this was a terrible event. And those kind of things.
Dr. Craig Joseph: Yeah. So it's not necessarily so it's got to be someone who's got some sort of, but do they have a clinical understanding or is it? No? Okay.
Dr. Steve Muething: No. That part they can we can help them with that. So.
Dr. Craig Joseph: Okay. Awesome. So, you know, it sounds like it's, it's not something that you start thinking about safety as something happens here, you're thinking about or after something has happened. You're thinking about it all the time and, and throughout, you know, all the all the workflows from the first interaction till they, the patient's no longer associated or, you know, getting care with you. One of the things that you've mentioned that's important to kind of make sure to do everything you can to prevent problems from occurring in the first place is, is to have a situational awareness. Now I know what those words mean to some extent, but what does that mean when applied to running a, a major children's hospital?
Dr. Steve Muething: Yeah, that's one of those examples of something that I learned about it through military. This wasn’t in civil aviation. This was actually, infantry. It was the first ones. And then actually the Air Force was very into it. But I came to realize there's a science behind it, which is there's just three levels of situational awareness. Number one is I can see what's going on around me. Number two is I understand what that means of what I can see that's going on around me. And then the third level, which is ultimately where we want to be, which is based on that. I can make predictions about what may happen if we don't intervene or don't do this. So we actually teach that is part of our training programs for nurses, for, physicians. And we want them to understand truly what situational awareness means. And then ultimately, what we really need at a place that's caring for incredibly complex situations with, really at times desperately ill kids is we need teams situational awareness. Because healthcare has gotten so complex, it is impossible for anyone human to really have what we need in terms of situational awareness. It can be the brand new respiratory therapist. It can be an intern, it can be the chief surgeon, it can be the nurse who was there all night. It can be the mom. And so we have built systems slowly but surely over time that have moved away from the way it was when I trained, which was my superior, my chief resident, or my faculty member would say, call me if you need me. And the reality was, nobody ever called him, for whatever reason, whether it was fear or just didn't want to look dumb or whatever it was, we've evolved that the system is oh, no, no, no, no, the supervised. You're in the front line check in on a pre-scheduled sequence every so many hours based on the severity of the situation, whether it's in intensive care unit or a unit or an emergency room or whatever it might be, they don't check and say, do you need anything? They check and tell us who you are most worried about and how you will know things are changing and deteriorating and what we are going to do about it, and have the whole team on that same page. And so and there's ways of getting that organized and things. So it's most fundamentally and with situational awareness, and it gets the whole concept of high reliability with predictive approaches or predictive management or predictive leadership is rather than just being reactive and trying to be a great code team or a great trauma team when something comes in being predictive of what's going to go wrong, or what's most likely going to go wrong in the next hour or four hours, eight hours and prepare for it both picking up early signs of progression so we can prevent anything from going on, or even if it does go all the way to where there's a significant trouble, have already talked it through, maybe even practiced it ahead of time. So it's that this is critical for healthcare is especially in the hospital as things have moved from, are increasingly getting more complex and, with more and more serious illness, being predictive in our day to day approach is going to be as critical as it was where we learned it from the military or naval aviation, where think about not the fact that we just have to do this air operations, but what might go wrong? How will we know? Who's going to respond? All those kind of things. And they are actually a lot of those people, naval aviation says, man, you're more complex than we are. And perhaps that's true.
Dr. Craig Joseph: Yeah. I, I believe that you're, you're, you know, I think a key message or lesson that I'm taking from, from this conversation is, is the intentionality, right. Like you that you have to kind of you have to think about this and not just wait and, and say, well, if this happens, then, you know, we'll figure it out at that. We'll cross that bridge when we come to it, that there's very little of that. Right.
Dr. Steve Muething: Well, there's, no, I think there is still some of that, Craig. You know, that's you know, I'm a little older than you, but I think our training experience was generally the same and that there was a lot of we'll figure it out. And the reality is we're pretty amazing at doing that. Because healthcare. Yeah. Because we're filled with passionate, smart people. It is amazing how often we get it right without even that intentionality. So this is not in my mind, a matter of going from terrible to great. It's, in healthcare, going from we're pretty amazing is it is to. Nope. We want to take it even to a higher level. And I think that's, you know, once that comes across and this is not a, indictment or saying hospitals that don't do this are terrible. They're not. There's some terrible hospitals. But, you know, the vast majority hospitals are amazing. And so this is just trying to take it one more level up, which is what every patient family deserves. That's what we'd want if our loved one was in that hospital.
Dr. Craig Joseph: Yeah. You know, just reminds me of my first weekend on call as an intern. And it was it was a long time ago. I think things were quite different, but I was rounding by myself as an intern, meaning that I graduated from medical school weeks before. I was running by myself with, the chief of staff, of this children's hospital. And he was dressed to go to golf, literally. He was dressed to go to golf on the Sunday morning. And, we had one patient who had, kidney transplant. And, as we're as I'm walking him to the elevator, he said, you know, did you need anything? Are you worried about anything? I said, well, yeah, I'm really worried about that That child in the first bed with the kidney transplant and, and the doors open to the elevator, and he got inside and he turned around and he said, Craig, you should be worried. He's very sick. And as he said that the doors were closing. Yeah. And I was just and I, of course, was just standing there staring at the, at the elevator for, a minute or two after he left thinking, what, what am I going to do? So I, you know, I didn't really understand how hospitals work then, or at least this hospital was working. And so I did what I, you know, I, I prepared as much as I could. Couple hours later, I, I told the nurses that I was, I had my beeper, but I was going to go get lunch. I came back up to the floor, and there's a dozen people in this patient's room, and I. I was like, oh, my God, this, was there a code? Did they code? I didn't hear any. Like, no. Nope. But the nurse didn't like the looks of the patient and she just jumped right over me, as well she should have, because I was not going to be very helpful. Right. And, I had the, I had the senior ICU fellow in there, who was barking out orders. And about a minute later, the I could hear the bed wheels, open up so that the patient was being, you know, rolled into the ICU, which was, just down the hallway. And it, I did not know at that time as an intern about the 3 or 4 levels of supervision that were above me that were.
Dr. Steve Muething: Yeah, exactly.
Dr. Craig Joseph: Absolutely. I was unaware that there were people much smarter, much more experience than I was at the time, who were asking those very questions that you would just mentioned, you know, who's, who are the who are the sick children? What do we need to do? What are we going to do when something happens and, and that was, you know, reassuring. And then when I kind of progressed through, I, I remember being a senior, a senior resident, and I think I, I did that to some intern. The roles were reversed, a short three years later when I kind of walked in and I knew everything, and this intern was just looking at me with the mouth agape, like how do you know about all these things? And, well, the answer was, well, I got sign out from other senior residents, who got signed out from the junior residents, who got signed out from the interns and the important, the important, really sick kids kind of rose to the top. And so, yeah, but to take it even one level further, it sounds like you all have, formal classes for your clinical staff, for your nurses and doctors. How does that how does that work? When do you when do you kind of educate them about some of these, some of these principles?
Dr. Steve Muething: No, two things I would share is, it's become, you know, how we just we have, pediatric residency, we have nurse residency. We have all those kind of things. Now that we've been doing it for over ten years, it's just built in. This is the way you do it. This is how this is the concepts and things. These days I would say much more important is the continuous learning from where it either did go wrong or almost went wrong and things like that. So the example being, first of all, back in the day when a code happened at Cincinnati Children's, there was no learning from it. It was just a oh, a code happened, or maybe you didn't even know it could happen. Eventually we started saying no, we should learn from every code and start studying it and have a huddle right afterwards and start figuring it out. Eventually we realized, well, that was too late. You had to start studying where codes almost happened. And so we've created a definition of what's called an emergent transfer to the ICU, where when a child gets the ICU, everything's okay. But in the first hour they needed to be, really, their care needed to be escalated, which just back in the old day, we just said, well, that's fine. Eventually we said that was too close. You know, if it. What if that had happened and they didn't get moved, and that could have been the code? So now we learn from we study every, emergent transfer with the goal of no, no, no, no, we're trying to create a system where there never is a code. So, studying codes is too late. So that's as we've seen in other industries. You got to create that learning culture. You got to create that transparency that we talked about earlier. But eventually, you're either moving down the pyramid of harm or you're moving upstream. And so, you know, in manufacturing industries, they're not studying when an employee's injured, they're studying when something almost went wrong or just a, a near miss and things. And that's in healthcare where we're just going to have to get slowly but surely this learning about safety, learning from events is just natural as getting lunch every day. Of course, we learn from events. I remember I was at one manufacturing plant where they showed me how a supervisor shift supervisor job is every day they come in 15 minutes before their team shows up and they log into the safety system for the entire industry, which has plants all over the globe. And they have to find one new learning from the safety reporting system for the industry every day and share it with the team in their huddle. And then before they go home, they have to add one something to this safety system. So it's not like please report, like we say in healthcare, if something went wrong. In that industry, no, no, no. It's part of my expectation. This is just it's what I do. Just like I punch the time clock or I swipe in or out. They just know, no, no. You add something to the safety reporting system and tomorrow you tap in and learn something from the safety reporting system. That's where I think we'll get there. But we got to keep pushing ourselves.
Dr. Craig Joseph: Well, so one thing you just mentioned was the employees safety. Yeah. And so we've been focusing on, patient safety as well. We should. But I think there are two sides of the same coin. How does patient safety rely on and on workforce safety in your experience?
Dr. Steve Muething: You can't get one without the other. We're totally on two sides of the same coin or just one safety system. Yeah, we our organization came to that realization almost ten years ago, and we stopped having patient safety and employee safety. And we just have safety because the systems necessary to keep the kids safe are often the same ones as for employees and vice versa. So, for instance, situational awareness, you know, we're all totally concerned about the increasing rate and severity at times of violence in the workplace. Well, starting to predict what might go wrong, which family might get escalated, which patient might get escalated, what causes that? How are we going to see early signs of it? How are we going to respond in that effective, respectful manner to prevent this escalation from causing injuries? It's the same concept is looking for clinical deterioration in a kid. So, you know, we worry a ton about you know, and appropriately, washing hands and, you know, wearing gloves for the kids and things like that. But the idea of, wait a minute, are we taking care of ourselves? And why is it that the firm that's building the addition to our hospital is so diligent about their protective equipment? But inside the hospital, we're not as diligent as they are, even though healthcare is more dangerous now than construction. So, that culture change, that behavior change that we talk about for patient safety very appropriately, it's the same things we got to be doing for ourselves. And then and I think most fundamentally, Craig, I think we as healthcare organizations need to be caring organizations in the most fundamental way to care for each other, care for our staff, care for our workers to make sure that they are safe. And so we have to be creating systems that tolerate no harm for our staff, just like we're trying to create systems that will tolerate no harm for the kids we take care of.
Dr. Craig Joseph: Lastly, I think, I would love to hear more about the safety culture. And, and, you know, you said it's very important, obviously, to maintain a safety culture. It's, it starts from the top down. So you'd mentioned kind of early on that the chief executive officer and the board need to be kind of brought in. Are there other things you can do? I'm, I'm assuming that sending out an email, once a month to all of your employees telling them that safety is important is not very effective. And in establishing the safety culture, are there maybe I'm wrong, but I'm pretty confident I'm right on that one. What does one do to model that, to kind of make sure that that just how we do things. You're, you're getting you're an academic medical center. You're getting, residents and fellows that are coming through, but you're also getting new, new attendings and, and some of them have been, you know, around the block a couple times and, and they've got their own idea of how it's supposed to work and, how do you kind of get that message through to, to them that Oh, well, that might have been okay there, but that's not okay here, is it a is it a formal class? Is it a is it just kind of peer pressure that now that you're you've been doing it for over a decade, are there things that, that organizations that might have not be as advanced as yours, can do to, to kind of catch up?
Dr. Steve Muething: Yeah, thanks for asking. I, this is a place where I think the word journey so appropriate, Craig, because it does depend on where you are in the journey. What you see at Cincinnati Children’s and the way we reinforce it on a daily basis today in 2024 is very different than the way it was in 2014 and definitely from 2004. So I would say in the early phase, the first 5 or 7 years, we did a number of training programs, number of classes taught, the leaders, taught the front lines, did interdisciplinary classes, reinforce behaviors, relentless communication, and multiple streams and multiple modes. And it was critical even getting the language clear. Starting to build peer to peer. Not as much pressure, but peer to peer changing of opinions, getting those opinion leaders out there. I can remember one time when we were having a surgical safety stand down and a leader in neurosurgery stood up and talked about an event, they had had several months ago and how the youngest nurse in the O.R. at that day saved the day, and how they spoke up and how his natural inclination was just to keep going. And he said something about how that day made me stop and listen, and it made all the difference and those kind of things. When the head of neurosurgery is talking like that, you go, okay, now with that. So nowadays it's more it actually is just the way it is here, not that we're there. And I'll explain that in just a second, but people know that before they even come and apply for jobs here. And then on day one, our CEO meets with every group every week who are starting work that week, every Monday. And it's one of the first things, in fact, it is the first thing he talks about is not speak up, get comfortable speaking up. He says it in a more abrupt way. He says, this is what we do here. I expect you to speak up. We're trying to make the system so it's easier and easier for you to speak up, but I expect that, I don't expect you to wait till things are perfect. It's the way we do it here. And then to that end, the thing I really want to emphasize is we're not there. I worry a lot continually. And even I actually worry more about it to some degree post-pandemic, as we have a lot of new people in our organization. Psychological safety. I think you know, we're generally a nice place. We're generally a place where people, are, are respectful to each other. But I still worry about it, in that to some degree, even should I speak up? Because I don't want to look stupid, I think is more of an issue than some of you will get mad at me. Or should I speak up because these people are so nice to me. I don't want to, you know, I, I don't want to say anything that might offend them and those kind of things. I think learning that speak up isn't like, ultimately, psychological safety is less about making it safe to speak up, and it's making it. It's just that's the way it is. It's second nature. That of course, we speak up. And I think that mostly falls on leaders, leaders learning how to lead teams. The simple stuff we even hear, like use first names, introduce yourselves, you know, before a case or before rounds or whatever. Tell people exactly how it what you expect of them and why you need to speak up. But the what and the why. So I don't in any way, shape or form want to imply Cincinnati Children's has perfect culture. We don't. And I think the reality is culture is never something where you're there. I think as leaders we have to constantly be assuming our culture, needs work continuously, and we just have to figure out where does the culture need work at this time.
Dr. Craig Joseph: Excellent. Well, it's a journey. We started off with it's a journey, and we're going to end with it's a journey. But you have to you have to stay on it. Right. And I think that's one of the messages. Well, we've been talking about essentially designing a safety culture, safety mechanisms. We like to talk about design on this podcast. One of the questions or the very last question I'm going to ask you, that we ask all of our interviewees is: are there products or workflows or things that are so well designed, that they bring you joy and happiness when you engage with them? And so are there are there 1 or 2 things that, you want to tell us about?
Dr. Steve Muething: Well, after hearing I'm a physician leader at a major children's hospital, the one thing I want to share will surprise people. I have 30 acres of land and an old barn. And inside that barn is an 85 year old Ford 8N tractor. That tractor starts every time, no matter what the weather, no matter what the conditions are. Sometimes it needs some work. But that design of what Henry Ford and his team thought up 85 years ago, the simplicity of design, knowing that what the farmers could figure out how to work on this thing, but what they really needed is a simple design so that anybody could figure out how to work on this because they can't have any downtime on a farm. That tractor is too mission critical for them. And so thinking back that 85 years ago, they figured out that simplicity of design, knowing that my high end computerized vehicle sitting in the other garage, needs service every six months. And then thinking about that design of that Ford 8N just always boggles my mind.
Dr. Craig Joseph: That's amazing. I can't believe that you're saying that electric cars, today that we have are, are not as easily serviced. Actually, I, I can believe that. So. Yeah, it's, they don't design them like they used to. And part of the reason is that they didn't. They don't have to anymore. Right? Right. Those things now are so complicated. That's impossible to, to get the computers and the and the sensors out. And so, Awesome. Well, that's a that's a great. That's a that's a great design choice. Congratulations to you. Now, what do you use that tractor for? That's the that's the major question everyone wants to know.
Dr. Steve Muething: Well, it actually, it's, it's my hobby. And my vocation is I've turned these 30 acres basically into a nature preserve, so I use it to cut. I have two miles of trails I've created across this land and these hills and things. And so the tractor keeps me from doing it all by hand.
Dr. Craig Joseph: Awesome. That's very, that's great.
Dr. Steve Muething: And I really try to be safe when I do it, Craig.
Dr. Craig Joseph: No. That's good. I want you to be safe. And, you know, normally I'd ask you for tickets to the nature preserve, but already you've told me no for tickets to getting onto the aircraft carrier. So I'm already. I'm already.
Dr. Steve Muething: I owe you something, Craig.
Dr. Craig Joseph: Yeah. Well, thank you, Steve, this has been great. It's a great conversation. And we look forward to kind of finding out what you do and what Cincinnati Children's does in the future with regard to kind of safety, both your, your employees, your clinical staff and your operational staff and, and of course, your patients. So thank you for your work, that you've done and the work that you will do in the future. Really appreciate it.
Dr. Steve Muething: Thanks for having me, Craig.