June 22nd 2021 Lecture

In 1999 the Institute of Medicine’s To Err is Human report pushed patient safety onto the public stage although
the problem of medical harm had been recorded since ancient times. Central to the report were illustrations of
safety principles from high-risk industries and various insights from the high reliability organization paradigm.
In effect, the authors of the report conceded that health care is not unique among high-risk, high-reliability
industries because it too is concerned with learning how to prevent, detect, recover, and learn from mishaps and
accidents. Twenty years later, we have to ask two questions: Has the fight for keeping patients safe gained
traction from these domains of insight? Are these ideas still worthy of health care’s attention? This presentation
addresses these questions and weighs in on the continuing relevance of insights from outside of health care.

Kathleen M. Sutcliffe

Kathleen M. Sutcliffe (Ph.D. University of Texas – Austin) is a Bloomberg Distinguished Professor at Johns Hopkins University with appointments in the Carey Business School, the School of Medicine (Anesthesia and Critical Care Medicine), the School of Nursing, the Bloomberg School of Public Health, and the Armstrong Institute for Patient Safety and Quality.
She is also Professor Emeritus of Management and Organization at the University of Michigan’s Ross School of Business. Her research program has been devoted to investigating how organizations and their members cope with uncertainty and how organizations can be designed to be more reliable and resilient. She has investigated organizational safety, high
reliability and resilience practices in oil exploration and production, wildland firefighting, and in healthcare. Her research has appeared widely in management and healthcare journals. Her most recent book Still Not Safe: Patient Safety and the Middle Managing of American Medicine, co-authored with the late Dr. Robert Wears, was published last year by Oxford University Press.

The Stanford Medicine Center for Improvement benefits from the diversity of its members and the richness of the experiences that they bring. Although the program continues to evolve from when it first launched in October 2019, we continue to reach out to improvers across Stanford Medicine in the School of Medicine, Stanford Health Care, Stanford Children’s Health, Stanford ValleyCare, UHA and PCHA. We welcome everyone from every discipline and recognize that we are stronger together as we value the contributions of every member of our teams.

Dr. Paul Maggio is Vice Chair of Surgery for Clinical Affairs, Associate Chief Medical Officer of Operational Effectiveness, and Associate Director of the Adult Intensive Care Unit. He trained in General Surgery at Brown University and obtained advanced training in Adult Surgical Critical Care and Trauma at the University of Michigan. He holds a Masters of Business Administration from the University of Michigan and is triple board certified in General Surgery, Critical Care, and Medical Informatics. In addition to being a clinician and surgeon, Dr. Maggio participates in the National Committee on Healthcare Engineering for the American College of Surgeons, and his research interests are focused on the delivery of high-value care.

Dr. Maggio received the SHC Board of Hospital Director’s Denise O’Leary Award for Clinical Excellence in 2013

Micah Duchesne joined Stanford Medicine in 2020 as a Principal Consultant project managing the deployment and operations of the Hospital Incident Command System (HICS) for COVID-19. He is now the Administrative Director of Performance Improvement at Stanford Health Care where he leads annual operations planning, improvement consulting, and capability development. Micah is also a Fellow at the Stanford Medicine Center for Improvement.

Before joining Stanford, Micah was an independent consultant for his company Silicon Valley Strategy Group, which partnered with Novartis and the Perelman School of Medicine at the University of Pennsylvania to commercialize cellular therapies. He led a team of clinicians from Europe, Japan, and Australia in designing a global logistics model and quality management system for Kymriah, the world's first approved CAR-T therapy, and helped create an international advisory board aimed at improving global capacity.

Prior to independent consulting, Micah was the Director of Performance Improvement at Kaiser's Santa Clara Medical Center, and he previously held improvement roles of increasing complexity within other health systems. Micah has both a Bachelor of Science in Accounting and Master of Health Services Administration from Mississippi College. He also holds certifications as a Lean Six Sigma Master Black Belt and Project Management Professional.

As a professional, Micah enjoys organizing complex stakeholder ecosystems, clarifying ambiguous goals, aligning visions, and driving high-stakes change. As a human, Micah just enjoys breaking a sweat. While he's not at work, he's at his very own gym in San Jose, CrossFit Moxie. You can find him there coaching olympic weightlifting or working out with his wife. He has a daughter in elementary school and two gym dogs.