Dr Maria Kapsali

04/29/2011 POMS

Improving Patient Safety

How to Use Service Modularity in

Healthcare Processes to Manage

Systemic Errors

1. Healthcare error

2. Systems approaches

3. HEPM: a complex adaptive approach

4. Modularity – complementing HCAS

Appendix: The NHS

Contents

1. professional stream: law and litigations

2. human performance stream: psychology and

engineering and includes research in ergonomics and

human factors such as cognition

Problems oversimplification as it does not capture the variability in human behaviour or

the complexity in processes

focused on individuals/groups

overlook the systemic factors linking the environment to people’s actions

Health care error literature

Advantages: enhances

collective effort, addresses

most mistakes happening in

hospital operations

Systems approaches to error

Disadvantages: at this stage

frameworks are still abstract so they

are not widely operationalizable

Focus on holes within the system but

cannot distinguish which may be

critical or not

1. the environment shapes and institutionalizes action

2. discriminate between individual errors which are

inevitable and the majority which are systemic (active vs

latent failures

3. Control the systemic through controlling organizational

processes)

Systems approaches to error

Reason, J., 1995. Understanding adverse events: human factors. Qual. Saf. Health Care, 4;80-89.

Systems approaches to error

Holzmueller, C., P. Pronovost, and R. Branson. 2004. How can we learn from incidents? Critical Connections. 3(1).

HEPM: Healthcare Error Proliferation Model opertionalizes the Swiss Cheese Model to study the

complex adaptive healthcare system in four multiple

layers/discrete locations/interfaces populated with ‘holes’

where the causes of accidents are nested.

1) organizational leadership

2) risky supervision

3) situations for unsafe practices

4) unsafe performance

Complex Adaptive Systems

Palmieri, PP.A., DeLucia, P.R., Peterson, L.T., Ott, T.E., Green, A., 2008. The anatomy and physiology of error in adverse health care events, Patient Safety and Health Care Management Advances in Health Care Management, 7: 33-68.

Methods: Data Collection

Ward Data Collection Industry Data Collection

• Expert Interviews to determine the systemic causes (holes) of medical errors

• Interviews and site visits to industrial settings with similar systems holes

Design and test solutions

• Development of design briefs based on ideas from industries about systems causes

• Testing of final solutions in surgical wards

EPSRC Project: Design Out Medical Error

The five processes are: handwashing, handover, vital signs monitoring, infection control and medication

•FMEAs through focus groups to determine the most frequent medical errors in the ward processes

•Observations in the wards

Methods: Data analysis

1. Find ‘hotspots’ = critical

activities where most

harmful errors happen

2. Find which hotspots

overlap amongst the five

ward processes and are

systemic

3. Find ways to simplify or

standardise these activities

to eliminate erroneous

actions

• Identification of hotspots through:

processes maps; Combined FMEA

results – Pareto

• Use Fishbone and HEPM through

mind maps and causal chains from

content analysis

• Identification of the critical

interfaces in the adaptive complex

ward processes

• Suggestions how to modularize the

processes

Results (29 hotspots within all 5 processes)

Results: identifying the systemic causes

Handover Infection

control

Handwash Vital Signs

Monitoring

Medication

Design of wards-

buildings

Training system

and controls –

infection audits

not effective

Design of reminders

+ lack of control +

standardization (5

Moments)

Problem

standardizing the

measurements

Information accuracy

Systemic controls

through admin

information systems

Lack of

detectability of

infection

lack of systemic

controls

Staff management

Complex workforce

Logistics

Training system and

audit controls

Lack of

equipment

Training system and

controls

Training system and

controls

Technology error

Lack of information

due to admin – (from

training and notes)

Built = location +

Lack of information –

(from training and

notes)

Built = location +

Lack of information –

(from training and

notes)

Staff management

Training system and

controls

Lack of information

(from training and

notes)

Results: HEPM Root Cause Analysis – the systemic causes

Unsafe

performance

Risky Supervision Leadership

Unsafe conditions

Lack of effective

visual directions

information 'holes'

Lack of improvement

culture Avoid personal

responsibility

Ignorance

Emphasis on operational

cost and time metrics

Supervising low level -

little on the job training

Elaborate procedures

Negligence

Time

Human resource is

not invested upon

Lack of training

The Built Environment - lack of

equipment and inhibiting space

Focus on satisfying the

funders not the patients

Process

Reliability

Errors

Leadership-

design

Controls

Capacity

Performance

control

procedures

holes

Lack of facilities

Unsafe

Performance

Lack of training

Fear of blame

Time Pressure

Ignorance

CostNegligence

of important

Information

Lack of Group

SupervisionCapability

Control holes

Information

Lack of

feedback

Lack of Group Supervision

Results:

Feedback

Loop model of

the systemic

causes

Results: the activities amongst the processes overlap Modularize designing for common interfaces amongst overlapping processes 1. Information block

2. Training – routinizing3. Procedures 4. Group leadership 5. Resources 6. Negligence 7. Time

Unsafe conditions

1

7

3

4

6

2

Risky Supervision

Unsafe practices

Leadership

1

1

2

2

2

3

4

5

6

6

73

1

1

1

7

7

Suggestions

Modular designs to enhance the implementation of systemic

models of HC could use the identification of hotspots

The NHS is already modular and needs to redesign its

interfaces and especially the information and control holes

which include the registration and passing on of data

amongst the handover, vital signs monitoring and

medication processes, instead of trying to create a totally

holistic information and communication system.

Thank you

Any Questions

The NHS

• Many structural reforms affecting quality management

• Tried to turn a rigid unitary organization with a clear chain of

command from the Health Secretary to the unit manager into

a looser more flexible one, by separating into purchasers and

providers.

• The result was a quasi autonomous, multidivisional form (M-

form) with operational responsibilities separated from

strategic responsibilities

• The model of the ‘flexible firm’ pursued in these reforms and

as advocated by Atkinson (1984) has an inherent

contradiction, prescribing the combination of Taylorism and

functional flexibility in the same job design

Advantages • Managerial risks improved

• Staff interest and awareness

improved

• Decline in individualism more

teamwork

• Greater involvement in peer

reviews and monitoring

audits

• Efficiency savings

• Establishment of standards

• Quite cheap around 8% of

GDP spent on NHS

Disadvantages 1. Focus on introducing concepts

to managers less focus on how

to implement them

2. Lack of unified quality strategy

which was delegated locally

led to a fragmented system of

various performance

monitoring variations

according to Trust – the

system cannot be assessed

holistically and the guidelines

are usually vague

Effects of reforms on quality management

Morgan and Everett (2007)

Disadvantages

3. Dependence on control through performance measurements

and not on cultural change and brokerage amongst professional

silos

4. Scepticism amongst professionals towards the quality systems

which are perceived as a tool for cost cutting and control over

their individual performance – the system is based on individual

blame

5. The implementation of additional performance criteria led to

fatigue

Morgan and Everett (2007)

Disadvantages

3. Political controversy – demand and access vs efficiency control

4. Care is too often delayed, long queues and rationing

5. Community based care was not fully realized

6. Relations between general practice, public health and hospital

based acute are fragmented

7. The system works in functional compartments that leave

patients unhappy and providers frustrated

Morgan and Everett (2007)