CE Disclosure - Welcome to...

7/2/2014

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Leadership and HROs

Julianne Morath, RN, MS

High Reliability – A Leadership Imperative for Safe Care

Keynote // March 6, 2014 // 1:00-2:15pm

Attaining High Reliability and Safety for Patients –

Collaborating for Change. Patient Safety Collective of the

Southwest (PSCS). March 6-7, 2014; Albuquerque, NM

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CE Disclosure

In compliance with the ACCME/NMMS Standards for

Commercial Support of CME Julie Morath has been asked

to advise the audience that she has no relevant financial

relationships to disclose or does have relevant financial

relationships to disclose which she will disclose here.




7/2/2014

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High Reliability -

A Leadership Imperative

For Safe Care

A Patient Safety Collective of the

Southwest Conference

March 6, 2014

Julianne Morath, RN, MS

Objectives for this session

1. Define Reliability

2. Role of Leaders in building a culture of

reliability and safety

3. Strategies for Risk Surveillance and

Error Management

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Reliability

• Reliability is defined as “failure-free

operation over time”

• Tough tasks performed without

unintended variation under trying

conditions

• Reliability is designed to “error-proof” a

system so that little room is left for human

error

Measuring Reliability

• Reliability is measured this way:

Reliability = number of actions that

achieve the intended result: total

number of actions taken

• Thus, 10-1 means one defect per 10

attempts, 10-2 is one defect per 100

attempts, and so on.

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a complex organization with

consistent performance

at high levels of safety

over long periods of time

across all services and settings

What is a High Reliability

Organization?

High Reliability In Action

Teams produce intended outcomes in complex environments

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Lessons and Applications from other Industries

United Airlines Flight 232

Discipline, Team,

Resilience/Recovery

Captain Al Haynes Co-pilot Bill Records

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Reliability and Resilience are…

• Dynamic, emerging, adaptive.

• They require:

• Dialogue and structured

communications

• Understanding error and learning

from failure

• Rules and breaking rules: heedful

attention

• “Habit of excellence”

Healthcare is, at its heart, people caring for people.

And people are unpredictable, complex, and full of paradox.

Particularly when we interact with each

other and when we are anxious, sick, and confused. Richard Smith

Editor, BMJ

November 2001

Why the Topic of High Reliability in

Healthcare?

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Part of improving the human

condition,

is improving conditions under

which humans work.

From Applications to Explorations

Pervasive Ambiguity

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Think about all that is going on today.

2005 2013

People - relationships - complexity

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Monsters Among Us Adapted from Donald Berwick, MD

Health Forum & AHA Leadership Summit July 25 - 27, 2013

“And the wild things roared their terrible roars and gnashed their

terrible teeth and rolled their terrible eyes and showed their

terrible claws.”

Maurice Sendak

Top 10 Patient Safety Issues for

2014

1. Healthcare-associated infections

2. Surgical complications

3. Handoff communications

4. Diagnosis

5. Medical errors

Source: Becker’s Hospital Review

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Top 10 Patient Safety Issues for

2014 - continued

6. Failure to implement a culture of safety

7. Lack of interoperability

8. Falls (and other geriatric considerations)

9. Better treatment choices

10. Alarm fatigue

Source: Becker’s Hospital Review

Lens: Leadership with “Radical Clarity”

What you give your time, resource, and commitment to and what you do not.

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Practice and Systems

1. Prevent failure

2. Identify and Mitigate failure

3. Design the process

Artifacts – Stories - Heroes

Leaders

Shape

Culture

Results

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The Culture of a High Reliability

Organization is:

• An accountable culture

• A culture of transparency

and learning

• A culture of partnership /

teamwork

• A Just culture

• A culture that supports

situational awareness,

mindfulness, sense making

• A culture of respect

Characteristics of High-Reliability

Organizations

• Process auditing

• Reward systems

• Pursual of quality standards

• Perception of risk

• Command and control Leadership

- Clarity

- Functional hierarchy

- Deference to expertise

- Roles, responsibilities, training

• Sensitivity to operations

• Safety: physical and psychological

Morath J. The Quality Advantage:

A Strategic Guide for Health Care Leaders, American Hospital Association Press,

1999, pp. 62/64

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• Transparency

• Roles of Responsibilities

• Chain of Command

• Reciprocal Accountability

• Respect for People

• Learning System

• Preconditions

Examples: Leadership Actions

• Meaningful work

• Opportunities to Learn and Develop

• Respect and Engagement

Through the Eyes of the Workforce

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Can each person in the workforce

answer yes to these 3 questions

each day?

1. Am I treated with dignity and respect by everyone in each encounter?

2. Do I have what I need so I can make a contribution that gives meaning to my life?

3. Am I recognized and thanked for what I do?

Learning System for Reliability

and Resilience

• Trust and Psychological Safety

• Transparency of errors

• Ask and tell

• Blameless reporting

• Debriefs, simulations and rehearsals

• Stories

• Complex conversations

• Learning from failure

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How Different Organizational

Cultures Handle Safety Information

Pathological

Culture

Bureaucratic

Culture

Generative

Culture

Don’t want to

know

May not find

out

Actively

seek it

Messengers

(Whistle blowers)

are “shot”

Messengers

are listened to

if they arrive

Messengers

are trained

and rewarded

Failure is

punished or

concealed

Failure leads

to local repairs

Failures

lead to far-

reaching reforms

New ideas

are actively

discouraged

New ideas

often present

problems

New ideas

are welcomed

Safety culture is generative, constantly “uneasy”, seeking, learning, changing.

Interprofessional Collaborative Learning

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Experiential Learning

• “Nothing about me

without me”

• “If it looks wrong,

it is wrong”

• Disclosure and

truth-telling

Engage Patients and Families as

Partners in Care

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• Core Measure Bundle Compliance

• Readmissions

• Pressure Ulcer and Falls Protocols

• Adherence to Bundles to Prevent

Infections (CLABSI)

• Monitors, Measures, and Feedback

Examples: Reliable Care Process

34

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Before and After 5-S Lean Methods

Before After

Pathology Office

Readmission

286,755/year 786/day 33/hour

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• Universal Protocol/Time Out (UP-TO)

• Blood Management

• Structured Communications

• Handovers

• Rapid Response Team

Examples: Reliable System Design

Communication at Transitions

and Transfers of Care

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Leaders Role

Assessment and Management

of

Operating Point

Going Solid:

The Nuclear Reactor

• Boiler

• Gas to liquid ratio

• Conditions of all liquid

• Anticipation, control, recovery

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Dynamic Safety Model

We work inside an envelope defined by 3 boundaries

Cook, R and Rasmussen, J. “Going Solid”: A model of system dynamics and

consequences for Patient Safety. Quality & Safety in Health Care, 14, 130-134,

doi : 10.1136 / qshc. 2003. 009530


Low

High

B

enefit

Low Production / Performance High

Operations Boundary

Quality of Work Life

Gradient Towards

Engagement, Joy & Meaning, Respect

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Low

High

B

enefit


Operations Boundary


Management Pressure

Towards Production, Efficiency, and Cost


Low

High

B

enefit


Operations Boundary


Technology Safety Regulations,

Certification,

Standards,

Evidence-based medicine

Psychological Safety*

Morath, J & Leary, M. (2004) Creating safe spaces in organizations to talk about safety, Nursing Economics, 22(2), 344-352

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Questions for Leaders

How do you define your safety

boundary?

- as a work unit?

and

- as an individual?

Balance Seeking Operations


Gradient Towards

Best Effort

Margin of Safety

Production Pressure

Towards Efficiency

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Financial Boundary

(Market Demand)

Operations Boundary


100% Expected Safe

Space

Safety Boundary

Probability of

Accident High B

T

C

U

Amalberti R, Vincent C, Auroy Y, de Saint Maurice G. (2006) Violations and migrations in health

care; a framework for understanding and management, Quality and Safety in Healthcare, 15, i66-

i71, doi: 10. 1136 / qshc. 2005.015982

Considerations for Leaders of

Border-Line Tolerated Conditions

of Use (BTCU)

• Migrate by drift or by design.

• Result in “stabilized usual level of performance” that

lies outside the expected safe field of use defined in

design.

• To do so safely all aspects of system

production/recovery must be known.

• First seen as benefits, rather than problems. Benefits

are immediate payback, additional risks are felt to be

known, control is supposed, and de facto scarcely

penalized. (“Power through”)

• Driven by performance demands, system

improvements (technology), and individual benefits.

• Implicitly tolerated by proximal hierarchy.

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Flirting With The Margin

Original Boundary

Acceptable

Operating Point

Repeated shifts,

no error, Margin

redefined

New Acceptable

Operating Point

Normal Conditions

take Operating Point

beyond Margin

Corrective Action

Taken

2

3

4

5

1

New Marginal Boundary

Borderline Tolerated

Conditions of Use (BTCU)

BTCU Management by Design

• Transparent system of production and

recovery

• Anticipation

• Teamwork

• Pullbacks and recovery

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Financial Boundary

(Market Demand)

Operations Boundary


Hospitals

BTCU

Safety Boundary

Probability

of Accident

High

HRO

100% Expected Safe

Space

Question for Leaders

What are conditions under which

your operating unit / function

migrates to BTCU or beyond?

What are your early warning

indicators?

How do you mitigate risk?

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Going Solid

Here is what the research says:

• Production demands

• Management efficiencies

• Tightly coupled processes

• Technology

• Loss of buffers

• Escalating risk (volume, severity,

complexity)

• Lack of established teamwork

• Perverse reward systems

Question for Leaders

How do you know when you are

approaching boundaries of

exceedency (BTCU)?

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Early Warning Signals of

Drift Into BTCU

• Denigration in teamwork and

communication

• Interprofessional / Interpersonal jousting

and conflict

• Assumptions verses Clarifications

• Denigration in trust and psychological

safety to speak up

• Clinical “surprises”

• Increase in error-making

Early Warning Signals of

Drift Into BTCU - continued

• Missed “pink flags” and escalation to

emergency responses

• Increased absenteeism / Increased extra

hours or shifts

• Rigidity in work flows and roles

• Increase in work arounds

• Increase in complaints / concerns

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Common Factors in Safety

Leadership of

High-Reliability Organizations

• Mindful organizing

• Situational Awareness

• Perception of risk

• Process auditing and

feedback

• Aligned reward systems

• Perusal of quality standards

• Command and control

‒ Clarity

‒ Functional hierarchy

‒ Deference to expertise

‒ Roles, responsibilities, training

• Sensitivity to operations

Red Rules

• Actions that pose the highest level of

risk and consequence to safety

• Few in number

• Consequence for non-compliance

• GOAL – Create solid habits in these

actions and reduce the incidence of

human error.

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Red Rule Examples

• Hospital Wide: Patient Identification

• OR / Procedural: Universal Protocol /

Time Out / Debrief

• Alarm monitoring system

• EVS: Never mix chemicals

• Other candidates?

Executive WalkRounds

• Demonstrate commitment to safety.

• Fuel culture for change.

• Find out what is going on: learn.

• Identify opportunities to improve safety.

• Establish lines of communication about patient safety.

• Allows for the rapid testing of safety improvements.

• Do the obvious things one by one. When processes

need correction, take action.

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Sharp and Blunt Ends

Errors and

Expertise

Monitored Process

Organizations, Institutions,

Policies, Procedures, Regulations

Practitioner

Knowledge

Focus of

Attention

Goals

Modified from Woods, et al., 1994

Resources and

Constraints

Engage, Align, Model the Way

A string is needed to pull together scattered beads…. Somali proverb

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Julianne Morath




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