11

The Quality Colloquium at The Quality Colloquium at Harvard UniversityHarvard University

PrePre--Conference Symposium Conference Symposium

Patient Safety Officer Patient Safety Officer Certificate TrainingCertificate Training

Paul Paul BarachBarach, MD, MPH, MD, MPHJulie K. Johnson, MSPH, PhDJulie K. Johnson, MSPH, PhD

Davis Davis BalestracciBalestracci, MS, MSGwen Sherwood, PhD, RN, FAANGwen Sherwood, PhD, RN, FAAN

Monday, August 16, 2010Monday, August 16, 2010

22

Our AimOur Aim

To start new and meaningful To start new and meaningful conversations about quality and safety conversations about quality and safety ––personally, in our organizations, and with personally, in our organizations, and with our leadersour leaders

33

Learning ObjectivesLearning Objectives

By the end of this Patient Safety Officer By the end of this Patient Safety Officer Training, participants will be able toTraining, participants will be able to––

Reflect on current levels of quality and safety Reflect on current levels of quality and safety in our organizationsin our organizations

––

Change practitionersChange practitioners’’

everyday conversations everyday conversations about safety and the culture of safetyabout safety and the culture of safety

––

Discuss how to engage the leadership in Discuss how to engage the leadership in safety while changing their attitude toward safety while changing their attitude toward safetysafety

44

TodayToday’’s Agendas Agenda9:00 am9:00 am

Welcome and IntroductionWelcome and Introduction

9:30 am9:30 am

Mental Models and Mental Models and Framing of Safety and QualityFraming of Safety and Quality

9:45 am9:45 am

Small Group Discussion about Small Group Discussion about the 5 Prethe 5 Pre--Conference QuestionsConference Questions

10:15 am10:15 am The Patient Safety Core Curriculum and The Patient Safety Core Curriculum and Introduction to Lewis Blackman StoryIntroduction to Lewis Blackman Story

11:00 am11:00 am BreakBreak

11:30 am11:30 am Small group discussion on LewisSmall group discussion on Lewis’’

Story Story

(a Pre(a Pre--Analysis)Analysis)Debriefing from small group discussion: Debriefing from small group discussion: How are we thinking about safety now?How are we thinking about safety now?

12:0012:00

amam Lunch on Your OwnLunch on Your Own

1:00 pm1:00 pm

Data Data ““InsanityInsanity”” The silent improvement killer The silent improvement killer ——

Part 1Part 1

55

1:30 pm1:30 pm

Engaging Leaders Engaging Leaders --

From Turf Wars to From Turf Wars to Appreciative Inquiry, Principles of Leadership Appreciative Inquiry, Principles of Leadership for Quality and Safetyfor Quality and Safety

2:15 pm2:15 pm

Teams, team training and Teams, team training and microsystemsmicrosystems

2:45 pm2:45 pm

Data Data ““InsanityInsanity””

The silent improvement killer The silent improvement killer ––

Part 2 Part 2

3:15 pm 3:15 pm BreakBreak

3:45 pm3:45 pm

Business Case for Safety and QualityBusiness Case for Safety and Quality

4:15 pm 4:15 pm Data Data ““InsanityInsanity””

––Part 3Part 3

4:45 pm4:45 pm

Concluding Comments, Questions and PostConcluding Comments, Questions and Post--

Colloquium Examination LogisticsColloquium Examination Logistics

5:00 pm5:00 pm

Special video presentation: “The Faces of Medical Error...From Tears to Transparency: The Story of Lewis Blackman”

66

IntroductionsIntroductions

Introduce yourself to your neighborsIntroduce yourself to your neighbors––

Who you are? Who you are?

––

Where are you from? Where are you from? ––

What is your dayWhat is your day--job?job?

––

What did you give up to be here today?What did you give up to be here today?––

What are your expectations of this session?What are your expectations of this session?

We will cull expectations from the groupWe will cull expectations from the group

77

Facilitated DiscussionFacilitated Discussion

Real World Dilemmas in Quality and Safety

What are the day-to-day issues that members of the audience face?

88

How Do Mental Models How Do Mental Models Affect Our Work?Affect Our Work?

Exploring Mental Models through Exploring Mental Models through Framing and ReframingFraming and Reframing

99

Before We Begin . . .Before We Begin . . .

Choose an opponent for thumb wrestlingChoose an opponent for thumb wrestlingThe goal is for you to win this competition The goal is for you to win this competition as many times as you can in 15 secondsas many times as you can in 15 secondsWinning means pinning your opponentWinning means pinning your opponent’’s s thumbthumb

1010

What happened?What happened?

How many points did you get?How many points did you get?What were the assumptions you brought What were the assumptions you brought into this game?into this game?How did your assumptions affect your How did your assumptions affect your behavior?behavior?

1111

Mental ModelsMental Models

The images, assumptions, and stories we The images, assumptions, and stories we carry in our minds of ourselves, other carry in our minds of ourselves, other people, institutions, and every aspect of people, institutions, and every aspect of the worldthe worldThey determine what we see, and most They determine what we see, and most importantly, importantly, how we acthow we act

1212

What Might this Mean for What Might this Mean for Our Work?Our Work?

Examples from clinical care, educationExamples from clinical care, education––

Drug seeking behaviorDrug seeking behavior

––

Patient nonPatient non--compliance compliance ––

““DifficultDifficult””

patient/familypatient/family

––

Born surgeonBorn surgeon––

Born internistBorn internist

––

Other ideas??Other ideas??

1313

Mental ModelsMental Models

None are perfectly accurate None are perfectly accurate Differences in mental models explain how Differences in mental models explain how two people can understand the same two people can understand the same event differently event differently Are generally invisible to us Are generally invisible to us –– until we look until we look for themfor them

1414

The Ladder The Ladder of Inferenceof Inference

1515

What Happens on the LadderWhat Happens on the Ladder

We pay attention to some data and ignore other dataWe pay attention to some data and ignore other dataWe impose our own interpretations on these data and We impose our own interpretations on these data and draw conclusions from themdraw conclusions from themWe lose sight of how we do this because we do not think We lose sight of how we do this because we do not think about our own process of thinkingabout our own process of thinkingOur conclusions feel obvious to us Our conclusions feel obvious to us Other peopleOther people’’s conclusions feel obvious to thems conclusions feel obvious to themWhen people reach different conclusions and disagree, When people reach different conclusions and disagree, they often hurl conclusions at each other from the tops they often hurl conclusions at each other from the tops of their respective laddersof their respective laddersThis makes it hard to resolve differences and to learn This makes it hard to resolve differences and to learn from one anotherfrom one another

1616

How Can We Surface Our How Can We Surface Our Mental Models?Mental Models?

Working with mental models requires surfacing, testing, Working with mental models requires surfacing, testing, and improving our internal pictures of how the world and improving our internal pictures of how the world worksworks3 skills can be helpful3 skills can be helpful––

Reflection Reflection ––

understanding your own mental models and the understanding your own mental models and the implicationsimplications

––

Inquiry Inquiry ––

learning the questions you can ask to help you test learning the questions you can ask to help you test othersothers’’

mental modelmental model––

Advocacy Advocacy ––

making your thinking and reasoning more visible to making your thinking and reasoning more visible to others others

1717

Advocacy and Inquiry are Key to Advocacy and Inquiry are Key to CommunicationCommunication

High

Low High

Adv

ocac

y

Inquiry

OneOne--way Communicationway Communication(Explaining, Imposing)(Explaining, Imposing)

TwoTwo--Way Way Communication Communication

(Mutual Learning)(Mutual Learning)

No Communication No Communication (Observing, Withdrawing)(Observing, Withdrawing)

OneOne--way Communication way Communication (Interviewing, Interrogating)(Interviewing, Interrogating)

18

What can we learn What can we learn from the from the futurefuture that will that will help us create a better help us create a better presentpresent for healthcare?for healthcare?

A History of the Future ApproachA History of the Future Approach

19

2020

Who Are We?Who Are We?

We are an overloaded systemWe are an overloaded systemWe cannot keep up with complex We cannot keep up with complex diagnostic and therapeutic technologiesdiagnostic and therapeutic technologiesWe have not changed workflows and roles We have not changed workflows and roles in the past couple of centuriesin the past couple of centuriesWe have placed most emphasis on We have placed most emphasis on sickness control, not on health promotionsickness control, not on health promotionWe face the same challenges everywhere, We face the same challenges everywhere, but are tackling them independentlybut are tackling them independently

2121

Relationship of Relationship of Mental Models to FramingMental Models to Framing

Mental models frame what we see and Mental models frame what we see and how we respondhow we respondOur mental models are internalOur mental models are internalFraming is the interaction of our mental Framing is the interaction of our mental models and the situation at handmodels and the situation at hand

2222

The PreThe Pre--Conference Conference QuestionsQuestions

2323

Small Group DiscussionSmall Group DiscussionThe 5 PreThe 5 Pre--Conference QuestionsConference Questions––

What are the most important patient safety issues What are the most important patient safety issues facing facing yourinstitutionyourinstitution??

––

How does the culture of your institution affect your How does the culture of your institution affect your ability to implement change?ability to implement change?��

––

What are 3 patient safety initiatives that you've read What are 3 patient safety initiatives that you've read about, heard about, or seen that you believe will about, heard about, or seen that you believe will make an impact in your institution?make an impact in your institution?��

––

What are 3 patient safety initiatives you would like to What are 3 patient safety initiatives you would like to implement in the next year?implement in the next year?��

––

Describe the composition of the team that will be Describe the composition of the team that will be necessary to accomplish each of those initiatives in necessary to accomplish each of those initiatives in your institutionyour institution

2424

Debriefing Debriefing

2525

The Patient Core Curriculum The Patient Core Curriculum and Introduction to the and Introduction to the Lewis Blackman StoryLewis Blackman Story

Paul Paul BarachBarach, MD, MPH, MD, MPH

2626

Patient Safety Domains Knowledge, Skills, Attitudes

1. Theoretical Foundations Microsystems, historical trends, chaos, complexity, competency and learning

2. Behavioral Aspects of Medical Professionalism

Ethics, patient quality of life, resolution of conflict

3. Interpersonal Issues Communication, stress and coping4. Human Factors and

ErgonomicsDesign history, error taxonomies, safety tools, decision support systems, fatigue factors, user centered design

5. Systems Analysis Usability criteria , organizations and learning disasters, place for human error

6. QI Learning Pareto/flow charts, and other QI tools, best practices, act cycles7. Injury Epidemiology Workplace hazards, worker safety, phases of injury, medico-legal

aspects8. Medication Safety Adverse and near-miss reporting, ISMP tools and website,

look/sound-alikes9. Crisis Management Tools Team work, shared decision making, situational awareness10. Simulations Micro-, macro-, debriefing, immersion levels, scripting, role playing

THE PATIENT SAFETY CORE CURRICULUM

Gilula, M. and Barach P. Creating a Patient Safety Curriculum: Purposive Sampling of Patient Safety Experts. 79th Clinical and Scientific IARS Congress. S-143. Honolulu, Hawaii. March 12, 2005.; Gilula, Barach, 2009.

2727

Institute of Medicine Institute of Medicine November 1999November 1999

Human Error and performance Human Error and performance limitationslimitationsEstablish near miss voluntary reporting Establish near miss voluntary reporting systems and protect from discoverysystems and protect from discoveryCreating Safety systems in health care Creating Safety systems in health care organizationsorganizationsErrors lead as major cause of death, Errors lead as major cause of death, injuryinjuryCreate a safety cultureCreate a safety cultureCreate and inculcate a safety Create and inculcate a safety curriculumcurriculumTeam training and simulationTeam training and simulationEstablish national safety authorityEstablish national safety authorityAnesthesiologyAnesthesiology——only clinical domain to only clinical domain to make patient safety central to its make patient safety central to its missionmissionAltman, et al. 2004Altman, et al. 2004------five years laterfive years later----IOM most important report in 2 IOM most important report in 2 decadesdecadesWachterWachter, 2006, 2006------C+ grade on report C+ grade on report cardcard

PATIENT CENTERED

TIMELY EFFICIENT

EFFECTIVE

SAFE

EQUITABLE

QUALITY

Components of Quality

QUALITY

FURNISHINGS

LIGHT

TEXT

URECOLOR

MATERIALS

SCALE

PRIVACY/CONTROL

WA

YFIN

DIN

G

ACCESS TO

NATURE

AROMA

SOU

ND

ART

SAFETY &

SECUR

ITY

Components of Healthcare Design Quality

3030

3131

Variation in death rates and Variation in death rates and charges in US hospitalscharges in US hospitals

0

20

40

60

80

100120

140

160

180

200

0 5,000 10,000 15,000 20,000 25,000

Standardized $ charges per admission

Stan

dard

ized

Mor

talit

y R

ate

3232

CPR Quality During CPR Quality During Cardiac ArrestCardiac Arrest

Two companion studies of CPR qualityTwo companion studies of CPR quality––

Chest compressions were not delivered half of Chest compressions were not delivered half of the time and compressions were too shallow the time and compressions were too shallow ((““outout--ofof--hospitalhospital””))

––

Quality of multiple CPR parameters was Quality of multiple CPR parameters was inconsistent and often did not meet published inconsistent and often did not meet published guidelines (guidelines (““inin--hospitalhospital””))

Abella BS, Alvarado JP, Hyklebust H, et. al. Quality of Cardiopulmonary Resuscitation During In-Hospital Cardiac Arrest. JAMA, January 19, 2005, 293(3):305-310

3333

U.S. Adults Receive Half of U.S. Adults Receive Half of Recommended CareRecommended Care

Source: McGlynn et al., “The Quality of Health Care Delivered to Adults in the United States,”The New England Journal of Medicine (June 26, 2003): 2635–2645.

55

76

65

54

39

23

45

0

20

40

60

80

Overall BreastCancer

Hypertension Asthma Pneumonia Hip Fracture Diabetesmellitus

Percent of recommended care received

3434

No system

beyond this point

10-2 10-3 10-4 10-5 10-6

Civil Aviation

Nuclear Industry

Railways (France)

Chartered FlightHimalayamountaineering

Road Safety

Chemical Industry (total)

Risk

Medical risk (total)

Blood transfusionAnesthesiology

ASA1Cardiac Surgery Patient ASA 3-5

Fatal Iatrogenic adverse events

Microlight flights helicopters

Very unsafe Ultra safe

Amalberti, R, Auroy, Y, Berwick, D, Barach, P. Five System Barriers To Achieving Ultra-safe Health Care. Annals of Internal Medicine, 2005;142:756-764.

Adverse Adverse Event Rates in HealthcareEvent Rates in Healthcare

3535

3636

The CloakThe CloakPainfully incorporated desire not to appear Painfully incorporated desire not to appear incompetent incompetent Behaviors conferring a sense of protection Behaviors conferring a sense of protection are greater: are greater: ––

The more terrorizing and fatiguing the The more terrorizing and fatiguing the training or the greater the possibility training or the greater the possibility of catastrophic error on a momentof catastrophic error on a moment--toto--

moment basismoment basis

““The problem is we get so used to cloaking The problem is we get so used to cloaking our irrational decisions in the guise of our irrational decisions in the guise of wisdom and experience, we confuse good wisdom and experience, we confuse good luck with good judgment, and thatluck with good judgment, and that’’s where s where diagnostic errors often begin.diagnostic errors often begin.””

Wachter,RM and Shojania,KG: Wachter,RM and Shojania,KG: Internal Bleeding: Internal Bleeding: The Truth Behind AmericaThe Truth Behind America’’s Terrifyings Terrifying Epidemic of Medical MistakesEpidemic of Medical Mistakes. .

20042004..

"It is incident to physicians, I am afraid, beyond all other men, to mistake subsequence for consequence.“

Samuel Johnson, 1756

3737

Meaningful Patient and Family Involvement

3838

3939

Case I: The Role of Human Case I: The Role of Human Factors in an Unexpected MIFactors in an Unexpected MI

A 45A 45--yearyear--old women for parathyroidectomy old women for parathyroidectomy with no past medical history, under general with no past medical history, under general anesthesia anesthesia After uneventful induction of anesthesia, the After uneventful induction of anesthesia, the patient became hypotensivepatient became hypotensiveResident gave 1 cc of phenylephrineResident gave 1 cc of phenylephrineHR went to 150HR went to 150’’s and VTs and VTCPR requiredCPR requiredEpinephrine givenEpinephrine givenST changes; TEEST changes; TEE--severe LV hypokenesissevere LV hypokenesis

4040

Similar Vials: Atropine & Similar Vials: Atropine & Phenylephrine Phenylephrine

4141

Elements of Organizational Elements of Organizational FailureFailure

Incompatible GoalsIncompatible GoalsOrganizational Structural DeficiencyOrganizational Structural DeficiencyInadequate CommunicationsInadequate CommunicationsPoor Planning and Scheduling Poor Planning and Scheduling Inadequate Control and MonitoringInadequate Control and MonitoringDesign FailuresDesign FailuresDeficient Training Deficient Training Inadequate Maintenance ManagementInadequate Maintenance Management

JT Reason 1993

Modified from Reason, 1991 ©

1991, James Reason

Triggers

DEFENSES

Accident

Regulatory Narrowness

Incomplete Procedures

Mixed Messages

Production Pressures

Responsibility Shifting

Inadequate Training

Attention Distractions

DeferredMaintenance

Clumsy Technology

LATENTFAILURES

Goal Conflictsand Double Binds

The World

Swiss Cheese Model

43

4444

Elements of Organizational Elements of Organizational AccidentsAccidents

James T. Reason. The Human Factor in Medical Accidents. Medical Accidents.

Vincent C, Ennis M, and Audley R. Oxford University Press 1993

Task and Environmental

Conditions

Individual Unsafe Acts

Organizational Processes

Failed Defenses

4545

Human Error RatesHuman Error Rates

Error of commission (misreading a label)Error of commission (misreading a label) 3/10003/1000

Error of omission (item embedded in Error of omission (item embedded in procedure)procedure)

3/10003/1000

Error of omission (without reminders)Error of omission (without reminders) 1/1001/100

Error in simple arithmetic (with self check)Error in simple arithmetic (with self check) 3/1003/100

Personnel on different shift fail to check Personnel on different shift fail to check conditions unless directed by a checklistconditions unless directed by a checklist

1/101/10

Errors under very high stress when Errors under very high stress when dangerous activities are occurring rapidlydangerous activities are occurring rapidly

25/10025/100

Adapted from: Park, K. Human Error. In Salvendy, G, ed. “Handbook of Human Factors and Ergonomics”, New York. John Wiley & Son, Inc. 1997: 163.

46

4747

Human vs. Design FlawsHuman vs. Design Flaws

Human errors (7%) can be reduced by Human errors (7%) can be reduced by rigorous practices, standardization, rigorous practices, standardization, simulation training, building a safety simulation training, building a safety culture, etc.culture, etc.

4848

Organizational Organizational Design Design 93%93%

The 93% vs. 7% RuleThe 93% vs. 7% Rule

Negligent Conduct

Knowing ViolationsReckless

Conduct

Human Error

(People)

(People)

(People)

(People)

4949

Performance Shaping Factors Performance Shaping Factors Affecting Human Vigilance Affecting Human Vigilance

FatigueFatigueEnvironmental Conditions/BuiltEnvironmental Conditions/BuiltEnvironmentEnvironmentTask DesignTask DesignPsychological ConditionsPsychological ConditionsCompeting DemandsCompeting DemandsHand offs/Sign outsHand offs/Sign outs

5050

Tools and Methods of AnalysisTools and Methods of Analysis

Numerous methods and tools are available Numerous methods and tools are available for analyzing adverse events, near misses, for analyzing adverse events, near misses, and the context of careand the context of careRegardless of the tool used, the goal is to Regardless of the tool used, the goal is to determine at the organizational level how determine at the organizational level how to prevent errors from occurring in the to prevent errors from occurring in the futurefuture

5151

Types of ToolsTypes of ToolsLatent Errors

Latent Errors

Active Errors

Active ErrorsAdverse Events

Adverse EventsDirect Direct ObservationObservation Clinical Clinical

SurveillanceSurveillance

Incident Incident ReportingReporting

Autopsies and Autopsies and M&M ConferencesM&M Conferences

Malpractice Malpractice Claims Files Claims Files AnalysisAnalysis

Administrative Administrative Data AnalysisData Analysis

Information Information TechnologyTechnology

Chart ReviewChart Review

Peterson et al.

5252

Tools and Methods of AnalysisTools and Methods of Analysis

Retroactive AnalysisRetroactive Analysis––

Root Cause Analysis (RCA) is a thorough Root Cause Analysis (RCA) is a thorough retrospective investigation to identify factors retrospective investigation to identify factors that contributed to the occurrence of an errorthat contributed to the occurrence of an error

Proactive AnalysisProactive Analysis––

Failure mode and effects analysis (FMEA) Failure mode and effects analysis (FMEA) identifies potential contributing factors to identifies potential contributing factors to potential adverse eventspotential adverse events

5353

The Haddon MatrixThe Haddon Matrix

HumanHuman VehicleVehicle EnvironmentEnvironment

PrePre--eventevent

EventEvent

PostPost--eventevent

Source: Haddon, W. A Logical Framework for Categorizing Highway Safety Phenomena and Activity. J. Trauma 1972; 12:197.

Alcohol intoxication

Braking capacity

Visibility of hazards

Resistance to injury insults

Sharp, pointed edges and surfaces

Flammable materials

Hemorrhage Rapidity of energy dissipation

Emergency medical response

5454

Haddon Matrix adapted to Patient Haddon Matrix adapted to Patient Safety in the MicrosystemSafety in the Microsystem

Patient/Patient/

FamilyFamilyHealth Care Health Care ProfessionalProfessional

Systems/Systems/EnvironmentEnvironment

PrePre--eventevent

EventEvent

PostPost--eventevent

5555

DebriefingDebriefing

Patient/Patient/

FamilyFamilyHealth Care Health Care ProfessionalProfessional

Systems/Systems/EnvironmentEnvironment

PrePre--eventevent

Orientation to the Orientation to the processprocess

Probablistic Risk Probablistic Risk Assessment (PRA)Assessment (PRA)Scenario BuildingScenario BuildingHazard AnalysisHazard AnalysisChecklistsChecklists

Failure Modes Failure Modes Effects Analysis Effects Analysis (FMEA)(FMEA)Human Factors Human Factors EngineeringEngineering

EventEventInterviewInterview Crew Resource Crew Resource

Management (CRM)Management (CRM)ChecklistsChecklists

Root Cause Root Cause Analysis (RCA)Analysis (RCA)

PostPost--

eventevent

Interview, Interview, Focus Group Focus Group InterviewsInterviews

Microsystem Analysis Microsystem Analysis Morbidity and Mortality Morbidity and Mortality Conference (M&M)Conference (M&M)

Root Cause Root Cause Analysis (RCA)Analysis (RCA)

5656

ManagementDecisions

& Organisational

process

Accidents

DefensesPerson/teamWorkplaceOrganization

Latent conditions pathway

Organizational Accident Causation Organizational Accident Causation ModelModel

5757

ManagementDecisions

& Organisational

process

Accidents

DefensesPerson/teamWorkplaceOrganization

Latent conditions pathway

Error &Violation

Producingconditions

Organization Accident Causation Organization Accident Causation ModelModel

5858

Workplace Conditions Workplace Conditions Promoting Unsafe ActsPromoting Unsafe Acts

High WorkloadHigh WorkloadInadequate Knowledge, Ability or ExperienceInadequate Knowledge, Ability or ExperienceInadequate Supervision or InstructionInadequate Supervision or InstructionStressful EnvironmentStressful EnvironmentMental StateMental StateChangeChange

5959

WorkplaceWorkplace Error Producing ConditionsError Producing Conditions

Unfamiliarity(x17)Unfamiliarity(x17)Time Shortage(x11)Time Shortage(x11)Poor HumanPoor Human--System System Interface (x8)Interface (x8)Information Overload (x6)Information Overload (x6)Negative Transfer(x5)Negative Transfer(x5)Misperception of Risk (x4)Misperception of Risk (x4)

Inexperience Not Lack of Inexperience Not Lack of Training (x3)Training (x3)Inadequate Checking (x3)Inadequate Checking (x3)Poor Instructions(x3)Poor Instructions(x3)Educational Mismatch (x2)Educational Mismatch (x2)Disturbed Sleep (x1.6)Disturbed Sleep (x1.6)

6060

Work EnvironmentWork Environment Violation Producing ConditionsViolation Producing Conditions

Lack of Safety CultureLack of Safety CultureManagement/Staff Management/Staff ConflictConflictPoor MoralePoor MoralePoor SupervisionPoor SupervisionCondones ViolationsCondones ViolationsMisperception of HazardMisperception of HazardLack of Management Lack of Management ConcernConcern

Little Pride in WorkLittle Pride in WorkMacho CultureMacho Culture““Bad outcomes Bad outcomes WonWon’’t Happent Happen””Low SelfLow Self--EsteemEsteemLicense to Bend License to Bend RulesRulesAmbiguous or Ambiguous or Meaningless RulesMeaningless Rules

6161

Organizational Accident Causation Organizational Accident Causation ModelModel

ManagementDecisions

& Organisational

process

Accidents

DefensesPerson/teamWorkplaceOrganization

Latent conditions pathway

Error &Violation

Producingconditions

Errors &violations

6262

Person /TeamPerson /Team Individual Unsafe ActsIndividual Unsafe Acts

ErrorsErrors––

Attentional Slips and memory lapses (Intrusions, omissions)Attentional Slips and memory lapses (Intrusions, omissions)––

MistakesMistakesRule Rule ––basedbasedKnowledgeKnowledge--basedbased

Violations( deliberate deviation from regulation)Violations( deliberate deviation from regulation)––

Routine ( shortcuts)Routine ( shortcuts)––

Optimizing Violations Optimizing Violations ––

ExceptionalExceptional––

DeliberateDeliberate

6363

ManagementDecisions

& Organisational

process

Accidents

DefensesPerson/teamWorkplaceOrganization

Latent conditions pathway

Error &Violation

Producingconditions

Errors &violations

Organizational Accident Causation Organizational Accident Causation ModelModel

6464

Barriers to Significant Quality Barriers to Significant Quality ImprovementImprovement

Biases/mental model clinicians bring to Biases/mental model clinicians bring to the tablethe table

Variation in Clinical PracticeVariation in Clinical Practice

High Powered TeamsHigh Powered Teams

Learning From Our MistakesLearning From Our Mistakes

Service and TechnologyService and Technology

Linking Incentives with Report CardsLinking Incentives with Report Cards

6565

Small Group ExerciseSmall Group ExerciseReflect on the time you have been in your current organization. Reflect on the time you have been in your current organization. What gives life to this organization? Why do you want to belong?What gives life to this organization? Why do you want to belong?Think for a moment about what you value deeplyThink for a moment about what you value deeplyWithout being humble, describe what you value most about your Without being humble, describe what you value most about your self, your work and your contribution to the organizationself, your work and your contribution to the organizationLocate a high point when you felt most effective and engaged in Locate a high point when you felt most effective and engaged in contributing to the life of the organizationcontributing to the life of the organizationDescribe how you felt and what makes this possibleDescribe how you felt and what makes this possibleHow does this contribute to a culture of safety?How does this contribute to a culture of safety?How do you individually add value to the safety culture of your How do you individually add value to the safety culture of your organization?organization?What are your three concrete wishes for insuring a culture of saWhat are your three concrete wishes for insuring a culture of safety fety in your organization?in your organization?What are the forces and factors that can make these best practicWhat are the forces and factors that can make these best practices es happen?happen?

6666

DebriefingDebriefing

6767

See Handout with LewisSee Handout with Lewis’’

StoryStory

6868

BreakBreak

6969

Small Group DiscussionSmall Group Discussion

A Pre-Analysis of the Lewis Blackman Story–

In small groups discuss the case

–

Discuss how you would approach the analysis (e.g., the types of tools you are familiar with in analyzing adverse events)

–

Prepare to report back

7070

DebriefingDebriefing

How are we thinking about safety now?

7171

LunchLunchReconvene at 1 pmReconvene at 1 pm

7272

Data Data ““InsanityInsanity””

--

The Silent The Silent Improvement KillerImprovement Killer

Part IPart I

Davis Balestracci, MSDavis Balestracci, MS

7373

Group DiscussionGroup Discussion

1.1.

How does your organization react to, report, and How does your organization react to, report, and analyze analyze ““incidents?incidents?””

2.2.

Have you ever considered Have you ever considered ““safetysafety””

in a processin a process-- oriented context?oriented context?

3.3.

Have you, with the best of intentions, been using Have you, with the best of intentions, been using ““special causespecial cause””

strategies? Could you strategies? Could you ““plot the dotsplot the dots””

to see whether you have been successful? to see whether you have been successful? 4.4.

Does this material suggest situations in your Does this material suggest situations in your organizations that might respond better to organizations that might respond better to ““common common causecause””

strategies?strategies?

7474

Engaging Leaders Engaging Leaders --

From Turf Wars to From Turf Wars to Appreciative Inquiry, Principles of Leadership Appreciative Inquiry, Principles of Leadership

for Quality and Safetyfor Quality and Safety����Gwen Sherwood PhD, RNGwen Sherwood PhD, RN

7575

Teams, Team Training Teams, Team Training and microsystemsand microsystems

Paul BarachPaul Barach

7676

Team videoTeam video

7777

Consider the MicrosystemConsider the Microsystem

Small group of clinicians and staff working Small group of clinicians and staff working together with a shared clinical purpose to together with a shared clinical purpose to provide care for a defined set of patientsprovide care for a defined set of patientsThe clinical purpose defines the essential parts The clinical purpose defines the essential parts of the microsystemof the microsystem––

Clinicians and support staffClinicians and support staff

––

Information and technologyInformation and technology––

Care processesCare processes

Source of excellence in health care organizationsSource of excellence in health care organizations

Mohr(Johnson) J, Batalden P, Barach P. Qual Saf Health Care 2004;13 Suppl 2:34-8.

7878

What Are the Essential Elements What Are the Essential Elements of a Microsystem?of a Microsystem?

Core team of health professionalsCore team of health professionalsDefined population of patients they care Defined population of patients they care forforInformation & information technologyInformation & information technologySupport staff, equipment, environmentSupport staff, equipment, environmentProcesses, activities specific to Processes, activities specific to accomplishing the aimaccomplishing the aim

7979

A Microsystem Framework for A Microsystem Framework for Analyzing EventsAnalyzing Events

One method that we have found to be One method that we have found to be useful for systematically looking at patient useful for systematically looking at patient safety events builds on Haddonsafety events builds on Haddon’’s s overarching framework on injury overarching framework on injury epidemiologyepidemiology

8080

Medical Team TrainingMedical Team Training Team CompetenciesTeam Competencies

Knowledge Competencies Knowledge Competencies ––

The principles and concepts that underlie a teamThe principles and concepts that underlie a team’’s s effective performanceeffective performance

Skill CompetenciesSkill Competencies––

The learned capacity (psychomotor and cognitive) to The learned capacity (psychomotor and cognitive) to interact with other team membersinteract with other team members

Attitude CompetenciesAttitude Competencies––

Internal states that influence team members to act in Internal states that influence team members to act in a particular waya particular way

8181

The TeamSTEPPS FrameworkThe TeamSTEPPS Framework

KnowledgeKnowledge––

Shared Mental ModelShared Mental Model

AttitudesAttitudes––

Mutual TrustMutual Trust––

Team OrientationTeam Orientation

PerformancePerformance––

AdaptabilityAdaptability––

AccuracyAccuracy––

ProductivityProductivity––

EfficiencyEfficiency––

SafetySafety

Baker D, Salas E, Battles J, King H, Barach P, 2005, 2007

8282

MillerMiller’’s Pyramids Pyramid

Does

Shows How

Knows How

Knows

8383

8484

ResourcesResources

Advanced Training Program, Intermountain Advanced Training Program, Intermountain Healthcare, Salt Lake City. Healthcare, Salt Lake City. http://intermountainhealthcare.org/xp/public/institute/courses/ahttp://intermountainhealthcare.org/xp/public/institute/courses/atp/tp/#objectives#objectives

Leadership Guide to Patient Safety from the Leadership Guide to Patient Safety from the Institute for Healthcare Improvement at Institute for Healthcare Improvement at http://www.ihi.orghttp://www.ihi.org

The University of Michigan Healthsystem Patient The University of Michigan Healthsystem Patient Safety Toolkit at Safety Toolkit at http://www.med.umich.edu/patientsafetytoolkit/http://www.med.umich.edu/patientsafetytoolkit/

8585

Data Data ““InsanityInsanity””

--

The Silent The Silent Improvement KillerImprovement Killer

Part IIPart II

Davis Balestracci, MSDavis Balestracci, MS

BREAKBREAK

8686

8787

Business Case for Safety Business Case for Safety and Quality and Quality

Paul Barach, MD, MPHPaul Barach, MD, MPH

88

Transformed Hospitals Have Clear Definitions

ν

What do you mean by great performance?

ν

Have you established a baseline?ν

Are you improving?ν

If not, why not?ν

How can you improve even faster?ν

Settling upon a consistent and intelligent method of assessing your output results

8989

Patient Safety PlanPatient Safety Plan

Reliable Design

Teamwork / Human Factors

High Reliability Organization Culture/Leadership

2

PatientCenteredness

Knowledge Sharing

Identify Failures

Manage Failures

Adapted from Kaiser Permanente

9090

Getting StartedGetting Started

SelfSelf--assessmentassessment––

Alignment with organizational strategyAlignment with organizational strategy

––

Program InfrastructureProgram Infrastructure––

Inventory of current patient safety activitiesInventory of current patient safety activities

Resource allocationResource allocationCapacityCapacity

––

ResultsResults

9191

Safety ProgramSafety Program

Linkage with Leadership/Organizational Linkage with Leadership/Organizational CultureCultureOversight responsibility/infrastructureOversight responsibility/infrastructureStakeholder EngagementStakeholder EngagementWork Plan DevelopmentWork Plan DevelopmentExecution Model(s)Execution Model(s)Monitoring/MeasurementMonitoring/MeasurementParticipation/accountabilityParticipation/accountabilitySpread/SustainabilitySpread/Sustainability

92

•

Do staff feel safe about reporting health care errors or care related injuries and deaths? If not, what are we doing to create a “culture of safety”

–

a “just culture”?

•

What happens when a heath care error occurs at our facility?

•

What serious care related adverse events have occurred during the past year?

•

What systems related quality and patient safety improvements have occurred during the past year?

•

How are our financial, professional, personal incentives aligned

to get the best performance from our staff?

What Boards Should Ask About Quality and Patient Safety

•

How would you change your current hospital construction and operating payment systems to provide incentives and rewards to build optimal hospitals?

•

Who should receive the long term financial benefit from building hospitals that are optimal for patients, families and staff?

•

Who should receive the long term financial benefit from operating hospitals that are optimal for patients, families and staff?

Policy Question: If You Were CEO For a Day

How to move from “light green dollars”(theoretical savings)

To“dark green dollars”

(actual savings that show up in someone’s budget that the CFO will

support)

The Challenge:

1.

Urgency/Need?2.

Appropriateness of solution?

3.

Relative cost per square foot?4.

Overall financial impact?

5.

Sources of funds?6.

Incorporate evidence-based design?

From Ideas to Action:

1.

Identify the number of patients & costs associated with hospital acquired infections

2.

Identify your improvement target goal (aim) and dollars that could be saved

3.

Outline specific clinical & administrative strategies as well as evidence-based

design strategies to reach your target goal & identify associated costs

4.

Calculate your ROI by subtracting improvement costs from savings achieved

A Proposed ROI Framework (using hospital-acquired Infections as an example)

OutcomeOutcome Number ofNumber ofCasesCases

Average Cost per Average Cost per CaseCase

Total CostTotal Cost

Hospital Acquired Hospital Acquired InfectionsInfections

No Hospital No Hospital Acquired InfectionsAcquired Infections

DifferenceDifference

Step # 1: Quantify the Problem

Outcome Target Calculations Cost Avoidance

Decrease HAIs by __% or __ cases

Identify the total number of cases to be eliminated and multiply by the average increased cost for patients with an HAI

Expressed in dollars

Total Cost Avoidance Expressed in dollars

Step # 2: Identify the Improvement Target and Costs Saved

InterventionIntervention Initial Initial costcost

Life cycle cost Life cycle cost Calculations/CommentsCalculations/Comments

Provide 100% single patient rooms

Increased SF with associated housekeeping, energy, replacement furnishings costs

Single patient rooms are now the standard. However, these rooms are estimated to be __SF larger which could increase life cycle operational costs.

Separate sink for staff in patient room

Increased operational plumbing maintenance costs

Separate staff sinks now standard for hospital construction. There may be minimal increased operational costs.

Alcohol-based gel devices

Replacement, maintenance and gel refill costs

Initial cost = total number of devices per room X number of rooms

Administrative & training 

interventions

Training costs Include all incremental operating costs

Total Intervention Total Intervention CostsCosts

Step # 3: Estimate Intervention Costs

Variables Initial, First Year

Two Year Life Cycle Point

Five Year Life Point

Total cost avoidance

Total intervention costs

Savings

Step # 4: Calculate Your ROI

101

Data “Insanity”

-

The Silent Improvement Killer

Part IIIDavis Balestracci, MS

102102

Concluding comments, Concluding comments, questions, and Post Test questions, and Post Test

logisticslogistics

103

““There are known knowns. These are There are known knowns. These are things we know that we know. There things we know that we know. There are known unknowns. That is to say, are known unknowns. That is to say, these are things we know we donthese are things we know we don’’t know. t know. But there are also unknown unknowns. But there are also unknown unknowns. These are things we donThese are things we don’’t know we dont know we don’’t t know know ””

-- Donald Rumsfeld Oct 3, 2006

Getting Serious About Hospital Quality

104104

The Lewis Blackman The Lewis Blackman Story revisitedStory revisited

What have we learned today that would What have we learned today that would help us approach this event differently?help us approach this event differently?

105105

Disclosure of Adverse Disclosure of Adverse Events: What Do You Do Events: What Do You Do

When Bad Things Happen?When Bad Things Happen?

106106

Adverse Event Management PlanAdverse Event Management Plan

ActivationEvent Crisis Mgt Team

Containment Plan• Render care to pt• Staff Support• Contain risk of

harm/recurrence• Notification• Securing scene

Investigation & RCA

Communication Plan•Patient•External Audience•Internal Audience•Notify Billing to hold bills

Corrective Action & Prevention

RecoveryMonitoringRestitution

Disclosure/OrganizationalRecovery

Immediate Response Follow‐up Response

107107

Disclosure ProcessDisclosure Process

Identify incidence of patient harm or Identify incidence of patient harm or a potentially compensable event a potentially compensable event Initial disclosure and apologyInitial disclosure and apologyCase ReviewCase ReviewFollowFollow--up disclosureup disclosureDiscuss restitutionDiscuss restitution

108108

What do patients want?

1.

To know what happened

2.

To receive an apology

3.

To know what is being done to prevent it from happening again

109109

Disclosing Adverse EventsDisclosing Adverse Events

Disclosure is required whenDisclosure is required when––

Has a perceptible effect on the patient not Has a perceptible effect on the patient not discussed in advanced with patientdiscussed in advanced with patient

––

Necessitates a change in patient careNecessitates a change in patient care––

Poses risk to patientPoses risk to patient’’s future healths future health

––

Involves nonInvolves non--consented treatment or procedureconsented treatment or procedureReduces chances of being suedReduces chances of being suedTransparency in process helps the team address guiltTransparency in process helps the team address guiltNew laws in 22 states requiring disclosureNew laws in 22 states requiring disclosure

Cantor M, Barach P, et al. Jt Comm Qual Patient Saf 2005;31:5-12. Barach, P, Cantor M, 2007

110110

Disclosure Conversation PlanningDisclosure Conversation Planning

Review disclosure principlesReview disclosure principlesDecide who, when, whereDecide who, when, where––

Decide who will be point contact person for patient/familyDecide who will be point contact person for patient/family

What to say and how to say itWhat to say and how to say itAnticipate questionsAnticipate questionsPlanning next stepsPlanning next stepsDebriefing/emotional support for the Debriefing/emotional support for the individual(sindividual(s) doing ) doing the disclosingthe disclosing

111111

Disclosure ConversationDisclosure Conversation

Learn to effectively communicate and Learn to effectively communicate and explain the factsexplain the facts

Expression of concern/responsibilityExpression of concern/responsibility

Discuss present/future needsDiscuss present/future needs

Describe actions taken and explain specific Describe actions taken and explain specific process for finding the answersprocess for finding the answers

112112

Risk Management SupportRisk Management Support

Manage contact with patient and/or family Manage contact with patient and/or family

Coordinate regulatory/accreditation Coordinate regulatory/accreditation requirementsrequirements

Managing reputation risksManaging reputation risks––

Media/Crisis communication Media/Crisis communication

––

Internal and externalInternal and external

Managing complaints and claims Managing complaints and claims ––

Early non litiginous settlementEarly non litiginous settlement

113113

ResourcesResources

Cantor M, Barach P, Derse A, et al. JCAHO 2005;31:5Cantor M, Barach P, Derse A, et al. JCAHO 2005;31:5--13.13.Kramam SS, Hamm G. Ann Intern Med 1999;131:963Kramam SS, Hamm G. Ann Intern Med 1999;131:963--967.967.Clinton H, Obama B. NEJM 2006.Clinton H, Obama B. NEJM 2006.Gallagher T, et al. NEJM 2007.Gallagher T, et al. NEJM 2007.http://http://www.sorryworks.netwww.sorryworks.netRisk Management Pearls on Disclosure of Adverse Risk Management Pearls on Disclosure of Adverse Events. American Society for Healthcare Risk Events. American Society for Healthcare Risk Management at Management at http://http://www.ashrm.orgwww.ashrm.org

114114

WhatWhat’’s on the Horizon for Patient s on the Horizon for Patient Safety?Safety?

The role of the built environmentThe role of the built environmentPatient centered processesPatient centered processesSmart automationSmart automationAdaptive informaticsAdaptive informaticsFocus on the team and simulationFocus on the team and simulationFull disclosureFull disclosureTelemedicine/remote careTelemedicine/remote care

115115

Rules for Health Care Design in Rules for Health Care Design in the 21st Centurythe 21st Century

Current ApproachCurrent Approach––

Do no harm is an individual Do no harm is an individual responsibilityresponsibility

––

Information is a recordInformation is a record––

Secrecy is necessarySecrecy is necessary––

The system reacts to needsThe system reacts to needs––

Professional autonomy Professional autonomy drives variabilitydrives variability

New ApproachNew Approach––

Safety is a system Safety is a system propertyproperty

––

Knowledge is shared Knowledge is shared and information flows and information flows freelyfreely

––

Transparency is Transparency is necessarynecessary

––

Needs are anticipatedNeeds are anticipated––

Decision making is Decision making is evidenceevidence--basedbased

IOM. Crossing the Quality Chasm. National Academy Press,

2001.

116116

Barriers To Achieving UltraBarriers To Achieving Ultra--safe safe HealthcareHealthcare

Acceptance of limitations on maximum Acceptance of limitations on maximum performanceperformanceAbandonment of professional autonomyAbandonment of professional autonomyTransition from mindset of craftsman to Transition from mindset of craftsman to that of an equivalent actorthat of an equivalent actorDevelop a culture of safetyDevelop a culture of safetySimplify professional rules and regulationsSimplify professional rules and regulations

Amalberti R, Berwick D, Barach P. Annals of Internal Medicine 2005;142:756-764.

117117

AdjournAdjourn