Leading Quality Improvement -...
19
5/21/2015 1 Leading Quality Improvement Essentials for Managers Session 8: Create a Culture of Safety May 26, 2015 These presenters have nothing to disclose Frank Federico, RPh Kathy Duncan, RN Today’s Host 2 Akiera Gilbert is a Project Assistant at the Institute for Healthcare Improvement. She is primarily responsible for the Passport membership, and is involved in the facilitation of Expeditions. Her work also delves into the Conversation Ready Project within Patient and Family- Centered Care, as well as the Primary Care Collaborative. Akiera is a second-year student at Northeastern University, and is on her first co-op at IHI. She is pursuing a Bachelor of Science in Human Services (concentrating in Public Health) and a minor in Social Entrepreneurship.
Transcript of Leading Quality Improvement -...
5/21/2015
1
Leading Quality Improvement
Essentials for ManagersSession 8: Create a Culture of Safety
May 26, 2015
These presenters have
nothing to disclose
Frank Federico, RPhKathy Duncan, RN
Today’s Host2
Akiera Gilbert is a Project Assistant at the Institute for
Healthcare Improvement. She is primarily responsible
for the Passport membership, and is involved in the
facilitation of Expeditions. Her work also delves into the
Conversation Ready Project within Patient and Family-
Centered Care, as well as the Primary Care
Collaborative. Akiera is a second-year student at
Northeastern University, and is on her first co-op at IHI.
She is pursuing a Bachelor of Science in Human
Services (concentrating in Public Health) and a minor in
Social Entrepreneurship.
5/21/2015
2
Phone Connection (Preferred)3
To join by phone:
1) Click on the
“Participants” and “Chat”
icons in the top right
hand side of your
screen.
2) Click the button
on the right hand side of
the screen.
3) A pop-up box will
appear with the option “I
will call in.” Click that
option.
4) Please dial the phone
number, the event
number and your
attendee ID to connect
correctly .
WebEx Quick Reference
• Please use chat to
“All Participants”
for questions
• For technology
issues only, please
chat to “Host”
4
Enter Text
Select Chat recipient
Raise your hand
5/21/2015
3
Kathy Duncan, RN5
Kathy Duncan, RN, Faculty, IHI, co-leads IHI's National
Learning Network. Ms. Duncan also directs IHI Expeditions,
manages IHI's work in rural settings, and provides spread
expertise to Project JOINTS. Previously, she co-led the 5
Million Lives Campaign National Field Team and was
faculty for the Improving Outcomes for High Risk and
Critically Ill Patients Innovation Community. She also
served as the content lead for the Campaign's Prevention
of Pressure Ulcers and Deployment of Rapid Response
Teams areas. She is a member of the Scientific Advisory
Board for the AHA NRCPR, NQF's Coordination of Care
Advisory Panel, and NDNQI's Pressure Ulcer Advisory
Committee. Prior to joining IHI, Ms. Duncan led initiatives to
decrease ICU mortality and morbidity as the director of
critical care for a large community hospital.
Schedule of Sessions
Session 1 – Coach Versus CommandDate: Tuesday, February 17, 12:00 – 1:00 PM ET
Session 2 – Understand and Manage Systems
Date: Tuesday, March 3, 12:00 – 3:00 PM ET*
Session 3 – Practice Improvement Essentials
Date: Tuesday, March 17, 12:00 – 1:00 PM ET
Session 4 – Build Sustainable Systems
Date: Tuesday, March 31, 12:00 – 2:00 PM ET*
Session 5 – Manage Connections Across Systems
Date: Tuesday, April 14, 12:00 – 1:00 PM ET
* Breakout session: Clinical & Allied Health Professions Managers 12:00-1:00 PM ET, Quality
Improvement Managers 1:00-2:00 PM ET
6
5/21/2015
4
Schedule of Sessions
Session 6 – Identify and Spread Successful ImprovementsDate: Tuesday, April 28, 12:00 – 2:00 PM ET*
Session 7 – Partner with Patients and Families
Date: Tuesday, May 12, 12:00 – 1:00 PM ET
Session 8 – Create a Culture of Safety
Date: Tuesday, May 26, 12:00 – 2:00 PM ET*
Session 9 – Empower Teams to Engage in Improvement
Date: Tuesday, June 9, 12:00 – 1:00 PM ET
7
* Breakout session: Clinical & Allied Health Professions Managers 12:00-1:00 PM ET, Quality
Improvement Managers 1:00-2:00 PM ET
Today’s Agenda
Welcome & Introductions
Action Period Assignment Review
Create a Culture of Safety
The Chandra Banerjee Case Study
Action Period Assignment
Closing & Next Steps
8
5/21/2015
5
Session 7 Action Period Debrief –
Thanks Laura Morgan – New Mexico
One mechanism for involving patients and family members
is the creation of a Patient and Family Advisory Council.
What are some other means that you can utilize to include
them and to hear their voice?
– We are working on the implementation of Bedside Shift Report in our
hospital. This gets the patient and whomever s/he chooses to be
involved in the care plan and to become more knowledgeable about
the aftercare plan. Of course, HCAHPS is a great tool for
patients/families to voice both their concerns and praises for a
hospital, and guides the facility in ways they can improve (e.g.,
nurse/physician communication).
9
Session 7 Action Period Debrief –
Thanks Laura Morgan – New Mexico
One mechanism for involving patients and family members
is the creation of a Patient and Family Advisory Council.
What is one thing that you can do in the next two weeks to
seek out the patients and listen to them?
– Based on our recent HCAHPS scores, our nurses have been
instructed to speak to patients more about their medications, such as
the indications and potential side effects. I will also be working on
getting the training sessions set up for our Bedside Shift Report in the
next two weeks.
10
5/21/2015
6
Today’s Faculty11
Frank A. Federico, RPh, Executive Director of the Institute for
Healthcare Improvement (IHI), works in the areas of patient safety,
applying reliability principles in health care, preventing surgical
complications, and improving perinatal care. He is faculty for the
IHI Patient Safety Executive Training Program and co-chaired a
number of Patient Safety Collaboratives. Prior to joining IHI, Mr.
Federico was Program Director of the Office Practice Evaluation
Program and a loss prevention and patient safety specialist at the
Risk Management Foundation of the Harvard-Affiliated Institutions;
he also served as Director of Pharmacy at Children's Hospital,
Boston. He has authored numerous patient safety articles, co-
authored a chapter in Achieving Safe and Reliable Healthcare:
Strategies and Solutions, and was an executive producer of the
film First, Do No Harm, Part 2: Taking the Lead. Mr. Federico
serves as Vice Chair of the National Coordinating Council for
Medication Error Reporting and Prevention. He also coaches
teams and lectures extensively, nationally and internationally, on
patient safety.
A Culture of Safety
Frank Federico
Executive Director
Institute for Healthcare Improvement
5/21/2015
7
What does a culture of safety mean to you?
Culture of Safety
“ . . . the product of the individual and group values,
attitudes, competencies and patterns of behavior
that determine the commitment to, and the style and
proficiency of, an organization's health and safety
programs.”
-Or-
“Safety culture is how the organization behaves when no
one is watching.”
5/21/2015
8
15*Adapted from Safeskies 2001, “Aviation Safety Culture,” Patrick Hudson, Centre for Safety Science, Leiden University
PATHOLOGICALWho cares as long as we’re not caught
Chronically Complacent
REACTIVESafety is important. We do a lot every
time we have an accident
CALCULATIVEWe have systems in place to manage all
hazards
PROACTIVEAnticipating and preventing problems
before they occur
GENERATIVESafety is how we do business around here
Constantly Vigilant
Evolution of A Culture of Safety and Reliability
15
Elements of a Culture of Safety
Make safety as a core value- the role of all leaders
Provide strong leadership at all levels
Model and demand desired behaviors- vital behaviors
Be reluctant to simplify
Empower individuals to successfully fulfill their safety
responsibilities
5/21/2015
9
Effective Leadership
With regard to quality and safety work, the most important factor
in predicting success was the quality of leadership and the
organizational culture (Krause)
Organizations highly successful in safety were also generally
successful in operational performance (Krause)
Clear commitment of senior and clinical leaders to quality and
safety efforts is essential
Effective leaders define very clear behaviors that create value for
the patient, clinicians and the organization. They model these
behaviors, and have “one set of rules”, i.e. they apply to
everyone.
There is engagement at all levels of the organization
Vital Behaviors
Do we understand the vital behaviors required to make
the improvement work?
How do we handle disruptive behavior?
– Behavior that Interferes with work or creates a hostile
environment
– Whose task is it to deal with disruptive behavior?
18
5/21/2015
10
PERFORMANCE
ACCIDENT
System Migration to Unsafe Practices to
VE
RY
UN
SA
FE
SP
AC
E
The
guidelines
and policy-
take meds
out for one
pt. at a time
Belief
Systems
Life Pressures
INDIVIDUAL BENEFITS
More than one
patients meds
placed in
pockets=
Legal/normal
‘
All patients
meds placed
in pockets
= ‘Illegal-
Illegal’ space Perceived
Vulnerability
Amalberti
Reluctance to Simplify
The answer to a defect is not always the first solution
you find
Do not accept overly simple explanations of failure
(unqualified staff, inadequate training, communication
failure, etc.)
Do not accept simplistic solutions for challenges
confronting complex and adaptive systems
5/21/2015
11
21Error Reduction Overview: Hierarchy of Controls
Standardization & Simplification
Policies,
Training,
Inspection
Minimize consequences
of errors
Make it easy to do
the right thing
Make it hard to do the wrong thing
Eliminate the opportunity for error
Human
Factors
Mitigate
Facilitate
Eliminate
Make errors visible
Least Powerful
Most Powerful
Infrastructure
Do staff have what they need to do the job correctly?
Do staff have the knowledge and skill to do the job
correctly?
Do staff have the time to do the job correctly?
Works in one area but when we scale up, the resource
that made it works in first sites is not available
22
5/21/2015
12
Deference to Expertise
Frontline staff know the work best: leaders must be
willing to listen to those who know the work and risks to
patients
Frontline/lower-level staff should make decisions that
must be made quickly
Psychological Safety and Trust
Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes.
A shared sense of psychological safety is a critical input to an effective learning system.
Trust flourishes when people exhibit their vulnerability to others without knowing what may result
Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, Vol. 44, No. 2 (Jun., 1999), pp. 350-383 Amy Edmondson
5/21/2015
13
Michigan Intensive Care Units
Prospectively divided into 3 groups
25
Low
Teamwork
Score
Medium
Teamwork
Score
High
Teamwork
Score
Frankel
Goal: NO blood stream infections for 5 consecutive months
in the next 12 months by implementing a checklist for
central lines insertions?
26
21%
31%
44%
Frankel
5/21/2015
14
28
5/21/2015
15
Transparency
Deeply held beliefs:
– Sharing data is a disruption: keep things as they are
– Middle managers will ask: Why are you sharing? Is this a way to
judge my performance?
– Patients will ask many questions
Transparency should be a vehicle for learning and
accountability
29
Fair and Just Culture
“Just Culture” is a defined set of values, beliefs, and norms
about what is important, how to behave, and what
behavioral choices and decisions are appropriate related to
occurrences of human error or near misses.
A “Just Culture” balances the need to learn from mistakes
with the need to take corrective action against an individual
if the individual’s conduct warrants such action.
5/21/2015
16
Drawing the Bright Line
Malicious
Substance Use
Conscious unsafe act
Substitution Test could 2-3 others make the same mistake in similar circumstances?
Repeat Events
Remediate / replace
Safe Harbor – Systems ApproachReason, James
Adapted by M.Leonard
In Summary
In order to develop a culture of safety:
“Act your way into believing”
5/21/2015
17
Questions/Discussion33
Raise your hand
Use the chat
The Chandra Banerjee Case Study
What is your opinion of the culture of safety in this
facility?
What is the role of a manager in developing a culture of
safety?
What communication strategies could the clinical team
use in the future if such an issue occurs?
Did the surgeon respond inappropriately when he found
the surgical team re-orienting the OR suite? What
message did he send to them and how might this have
led to further complications in the surgery itself?
34
5/21/2015
18
The Chandra Banerjee Case Study
As a QI manager, what is your assessment of the culture of safety in this facility?
What is the role of a QI manager in developing a culture of safety?
What types of processes might quality improvement managers implement in a center like this one to prevent such errors from occurring and better protect patient safety?
What type of outcome measurements and monitoring processes might be helpful to track progress of these efforts?
35
Communications
All sessions are recorded
Materials are sent one week in advance
Listserv address for session communications:
If you’d like to be re-added, add colleagues or change
your subscription to a daily digest, email us at
36
5/21/2015
19
Next Session
Session 9
Empower Teams to Engage in Improvement
Janet Porter
Tuesday, June 9th, 12:00 – 1:00 PM EST
37
Thank You!38
Kathy Duncan
Dorian Burks
Please let us know if you have any questions or
feedback following today’s session.
