Welcome to the Leadership for Safety Webinar
Reliability: Keeping Our Promises
The webinar will be starting momentarily…
If you are having technical difficulties please contact 202-495-3356 or [email protected]
Chat Box
Please use the Chat Box on the webinar screen to type your question or comment at any time.
NOW: Use the Chat Box to sign in. 1) Enter your organization and names of all people in the room.2) Send to “HOST”3) Click “SEND”
Starting at the Beginning:Two Promises We Make to Our Patients
We will do everything that we know will help.
We will do nothing that will harm.
Copyright, The Reinertsen Group3
How Hazardous Is Health Care?How Hazardous Is Health Care?(Leape)(Leape)
1
10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Number of encounters for each fatality
Tota
l liv
es lo
st p
er y
ear
REGULATEDDANGEROUS(>1/1000)
ULTRA-SAFE(<1/100K)
HealthCare
Mountain Climbing
Bungee Jumping
Driving
Chemical Manufacturing
Chartered Flights
Scheduled Airlines
European Railroads
Nuclear Power
Are we seeing all the harm? Inpatient Surgical Record Review of 854 patients in 11 US hospitals…
• Found 14.6% of patients had a Surgical Adverse Event (SAE)
• 44% of SAEs caused increase LOS or readmit
• 8.7% required life-saving intervention or resulted in permanent harm or death
• “…Most of the events identified by Trigger Tool review had not been detected or reported via any other existing mechanism.”
6
References• McGlynn EA, SM Asch, J Adams, J Keesey, J Hicks, A
DeCristofaro, EA Kerr: The Quality of Health Care Delivered to Adults in the United States. New England Journal of Medicine 2003, 348: 2635-2645
• Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003;290:1868-1874
• Amalberti R, Y Auroy, D Berwick, P Barach. Five System Barriers to Achieving Ultrasafe Health Care Ann. Int. Med. 2005; 142: 756-764
• Griffin, FA and DC Classen. Detection of adverse events in surgical patients using the trigger tool approach. Qual. Saf. Health Care 2008; 17: 252-8
7
How How ReliableReliable is Health Care? (Amalberti, Nolan) is Health Care? (Amalberti, Nolan)
Chaos 10-1 10-2 10-3 , 10-4 10-5
Processes are largely custom-crafted each time
Standard specs, training, trying hard
Standard process; redundancy, habits and patterns…
HRO culture; Obsession with failure, deference to expertise…
Loss of identity
Each doctor writes individual orders, gives to RN
5 people describe 5 processes; feedback on compliance
5 people describe 1 process; multi-disc. rounds
External approval necessary for certain orders
Equivalent
actor
Preventing, treating acute and chronic disease in US
Surgical checklists and harm
Best hospitals Core Measures
ADEs per 1000 doses, blood banking
Safety in anesthesia
Let’s talk about the catastrophic processes—the
right side of this table.Could we do better than this?
10
Unplanned Automatic SCRAMRate – US Nuclear Power Plants
Year
Scr
ams
per
7,0
00
ho
urs
The unplanned automatic scrams per 7,000 hrs critical indicator tracks the median scram (automatic shutdown) ratefor approximately one year (7,000 hrs) of operation. Unplanned automatic scrams result in thermal and hydraulictransients that affect plant systems. The scram rate has been significantly reduced since 1980. In 2000, 59% of operating plants had zero automatic scrams.
Source: Statistics Show US Nuclear Power Plants Always Improving, Nuclear News, May 2001 12
776 aircraftdestroyed in
1954
Fiscal Year
1.64
15 aircraftdestroyed in
2008
0
10
20
30
40
50
60
50 65 80 08
Angled Carrier Decks
Naval Aviation Safety Center
NAMP est. 1959
RAG concept initiated
NATOPS initiated 1961
Squadron Safety program
System Safety Designated Aircraft
ACT
HFC’s
Cla
ss A
Mis
hap
s/10
0,00
0 F
ligh
t H
ou
rsNaval Aviation Mishap Rate
Source: www.safetycenter.navy/mil ORM Flight Mishap Rate
13
US Nuclear Powered Submarines
5,500 cumulative years of nuclear reactor ops
127 million miles submerged (264 round trips to moon)
Operated by 20 year oldsZero reactor accidents
14
Highly Reliable Organizations (HROs) “operate under very trying conditions all
the time and yet manage to have fewer than their fair share of
accidents.”
Copyright 2006 Healthcare Performance Improvement, LLC.ALL RIGHTS RESERVED.
15
Processes: workflow scheduling,
complexity…
Culture and Structure: hierarchy, transparency,
safety rules, accountability…
The Swiss Cheese ModelAdapted from James Reason Managing the Risk of
Organizational Accidents 1997
Harm
Human error(slip, lapse, reliance on
memory, confirmation
bias…)
Technology and Environment: error
proofing, distractions…
17
1200 mg Tobramycin IV
Nurse doesn’t check dose closely in rush to get all QD doses in at 8
am
Culture: error has happened before; no
one questions 1200 mg in IV bag rather than
irrigation
Renal failure,death
Pharmacist clicks 1200 rather than 120 mg on computer
picklist
Rx Computer system accepts “1200 mg IV”
18
Errors, Harm, Negligence, and Intent
ErrorsSkill basedRule based
Knowledge based
Harm
Negligence, Reckless Disregard Intent
19
Two Key Approaches to Higher Levels of Reliability for “Immediately
Catastrophic” Processes
Harm
2. Work as leaders to detect and plug
the holes in processes, structures,
cultures, and technologies
1. Accept that human error will
occur. Use human factors engineering to
reduce the likelihood of it, and develop a
culture of accountability 20
Working both the Sharp End and the Blunt End
# 1Reduce likelihood of individual behavior failures•Competency•Consciousness•Communication•Compliance•Critical thinking
#2 Find and Fix system “latent errors”•Structure•Culture•Policy/protocol•Process•Technology & environment
Adapted from Kerry Johnson, HPIpyance.21
Reducing the likelihood of skill-based (automatic) errors
─Fatigue: work schedules
─Distractions: “do not disturb”
─Error-proofing, design: Separating IV and topical dose forms in computer
─Visual signals
Stop, Think, Act and Review
22
Reducing the likelihood of rules-based errors
• Make it easy to comply with the rule
• Increase the perception of “likelihood of being observed” while carrying out the rule
• Increase the perception of the risk of non-compliance
23
Accountabilityfrom Leaders
Accountabilityfrom Self
Accountabilityfrom Peers
Establish Accountability
OptimalAccountability
Healthcare Performance Improvement
24
How How ReliableReliable is Health Care? (Amalberti, Nolan) is Health Care? (Amalberti, Nolan)
Chaos 10-1 10-2 10-3 , 10-4 10-5
Processes are largely custom-crafted each time
Standard specs, training, trying hard
Standard process; redundancy, habits and patterns…
HRO culture; Obsession with failure, deference to expertise…
Loss of identity
Each doctor writes individual orders, gives to RN
5 people describe 5 processes; feedback on compliance
5 people describe 1 process; multi-disc. rounds
External approval necessary for certain orders
Equivalent
actor
Preventing, treating acute and chronic disease in US
Surgical checklists and harm
Best hospitals Core Measures
ADEs per 1000 doses, blood banking
Safety in anesthesia
Let’s look at the left side of this table
25
Discussion for NAPH Leaders
• Describe the reliability of a safety process your teams are currently working to improve. Where does that process fall on the reliability grid?
• What are your current ideas for making the process more reliable?
• What is your aim: how reliable are you trying to become?
26
Why do we get “stuck” at low levels of reliability?
• We tend to rely on vigilance and hard work
• We focus on outcomes rather than process
• We fail to design and implement standard work
• We don’t understand and use sophisticated designs for reliability
27
Improvement Concepts Associated with 10-1 Performance
• Common equipment• Standard order sets• Care protocols and pathways• Written policies/procedures • Personal check lists• Feedback of information on compliance• Suggestions to work harder, pay closer attention…
next time• Awareness and training
28
Improvement Concepts Associated with 10-2 Performance
• Build decision aids and reminders into the system
• Make the desired action the default• Redundancy• Scheduling• Take advantage of existing habits and
patterns of work• Standardize who, where, when…not just
what (Standard work, not standard specs)
29
Examples of Level 2 Concepts for CHF or CAP
• Decision aids or reminders in real time: – Standing order set is placed on front of chart
when decision to admit is made
• Desired action the default:– All patients with diagnosis of pneumonia will
get pneumovax by nurse, with or without specific order
• Redundancy: – Multidisciplinary rounds on every patient daily– Home visit to check on meds after 48 hours
30
Examples of Level 2 Concepts for CHF or CAP (2)
• Scheduling:– Make a discharge appointment for all patients at
least 24 hours prior to discharge• Smooths nursing workflow• Starts process of discharge instructions well in advance• Engages family members in planning
• Take advantage of existing habits and patterns– Visual cue to “start pre-op antibiotics” based on
measured flow of pre-op work31
Example of Level 2 Concepts
• Bundles–clusters of evidence based services
in space and time, treated as “all or none” e.g. “sterile technique in the OR”, ventilator bundle…
32
Key Learning Points for Leaders
• Hard work and vigilance alone will condemn the team to 10-1 performance at best
• If 10-2 change concepts do not make up at least 25% of the improvement effort on a given project require the team to rethink the design
33
Why is health care so unreliable?
• We tend to rely on vigilance and hard work
• Greater focus on outcomes than process• We fail to design and implement standard
work• We don’t understand and use
sophisticated designs for reliability
34
Outcomes versus Process
• Biology protects us: each process defect doesn’t necessarily lead to a bad outcome e.g. hand-washing
• Systems protect us…except when they don’t e.g. 1200 mg tobramycin i.v.
• Benchmarks reassure us…e.g. “2.0 BSI’s per 1000 line hours is better than the benchmark so our processes must be OK”
35
Why is health care so unreliable?
• We tend to rely on vigilance and hard work
• We focus on outcomes rather than process
• We fail to design and implement standard work
• We don’t understand and use sophisticated designs for reliability
36
Level 2 Concept: Standard WorkIs this what you mean by standardization?
• Months of meetings designing a care pathway, standing order set, protocol…
• Focus is on WHAT should be done (not HOW).• 10,000 copies of the final version are printed up.• Changes to the final version are discouraged.• Physicians are encouraged to “opt in”.• Even though the protocol or order set has never
been tested in the field
37
A Better Way to Standardize
• Spend no more than one meeting on “what”.• Start testing one way to do the “what” in the
field, on a small scale.• Encourage many rapid tests of change in
how, when, where, who…and in the what, if necessary…to make the standard way work well for 90% of doctors and nurses.
• Once you’ve got it right, expect all the doctors and nurses to use it (opt out if you have to, not “please opt in”).
39
Design
Test and Modify
Test and Modify
Test and Modify
Approve(if necessary)
Conference Rooms
Real World
Implement
40
OK…But what do Leaders do?• Choose the outcomes that you want to achieve• Hypothesize: process and outcome• Set reasonable timelines• Expect teams to
– Achieve process reliability at 95%– Use good design principles, not just vigilance and hard work– Test designs frequently, on small scale, not in one big spasm
• If the process gets to 95% and the outcome doesn’t improve…– Check the data on the process– Revise your theory
42
A Key Question Leaders Should Ask
Is there a logical, evidence-based connection between the process the team is trying to improve, and the outcome you wish to achieve?
43
Is this a good plan to reduce injuries from falls?
Outcome Goal
Key Drivers Processes
Decrease Falls
Reliable risk assessment of patients for falls
Red booties for at risk patients
44
Evidence-Based Thinking!
Outcome Goals
Key Drivers Processes
Decrease Falls
Toileting in at risk patients
Every 2 hour toileting rounds on at risk patients
46
Summary: To become more reliable for non-catastrophic processes…
• Choose a process that has a high likelihood of affecting the outcome of interest
• Set an aim for 10-2 reliability of the process• Move toward that aim in three steps:
1. Segment and standardize to get the basic process to solid 10-1 using Level I and Level II concepts
2. Identify remaining defects and mitigate them in real time to get to 10-2
3. Redesign the process to reduce likelihood of defects
47
Where to read more….
• http://www.ihi.org/IHI/Topics/Reliability/
48
Next Month:Thursday, May 23 9am PT/10am MT/11am CT/ 12am ET
When Things Go Really Wrong: Responding to Organizational CrisesWith special guest speaker Jim Conway!
Assignment:
• Find out if your organization has a crisis management plan for safety disasters.
Then ask:
• What is the plan for notifying the board? Which board members? When? By whom?
• Who will speak for the organization? Who is to speak to family members?
• What training is in place?
Be prepared to discuss your plans on the webinar.49
Leadership for Safety: Yes, It’s PersonalA Workshop for Boards, C-Suite, and Senior Leaders
June 19, 20138:00am – 5:00pm
Westin Diplomat Resort in Hollywood, FL
SAVE THE DATE!
50
Top Related