A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES
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1 A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES 23 rd Annual HPRCT Conference June 12-15, 2017 Thomas Diller, MD, MMM; Executive Director University of North Texas Health Science Center Institute for Patient Safety (UNTHSCIPS) Rey Gonzalez, President of HOPE Consulting LLC; Associate Fellow, UNTHSCIPS
2 Our Mission: To innovatively impact the lives of every patient, student, and healthcare professional by creating a ubiquitous culture of patient safety throughout our community. Our Goals: To improve patient safety and reduce preventable patient harm through Education, Research, Consulting and Influence.
3 US Nuclear Industry
4 International Nuclear Industry Chernobyl Fukushima
5 Nuclear Industry What Was Done to Become an HRO Focus on running the plant as designed* Emphasis on defense-in-depth mindset A cultural focus shift on our #1 priority; Nuclear Safety = Public Safety (Enhancing Nuclear Safety Culture) Enhanced Training and Qualification (including maintenance of the same) A focus on equipment reliability* A focus on human performance Planning for the unexpected
6 The domestic nuclear generation industry has seen benefits from implementation of HPI.
7
8 Institute of Medicine Reports To Err is Human : November 1999 Estimated 44,000 98,000 annual deaths due to medical error Estimated a cost of $17 to $29 billion Errors are caused primarily by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. Crossing the Quality Chasm : March 2001 Laid out a roadmap to improve the nation s healthcare system Six Aims for Improvement Recommended 4 strategies Healthcare must be evidence-based Substantially increase the use of information technology Align payment policies with quality improvement Must prepare healthcare providers and workforce for change
9 17 Years After To Err is Human Project-Based Process Measures Outcome Measures Risk-Adjusted Hospital Mortality - HealthGrades: American Hospital Quality Outcomes 2013 Infection Rates 50 percent decrease in central line-associated bloodstream infections (CLABSI) between 2008 and percent decrease in hospital-onset Clostridium difficile (C. difficile) infections between 2011 and percent decrease in hospital-onset methicillinresistant Staphylococcus aureus (MRSA) bacteremia (bloodstream infections) between 2011 and 2014 The Joint Commission: America s Hospitals: Improving Quality and Safety 2016 Annual Report CDC s annual National and State Healthcare-Associated Infections Progress Report (HAI Progress Report) (2014 data, published 2016)
10 Medical Error: The Third Leading Cause of Death in the US Makary and Daniel; British Medical Journal 2016
11 Medical Error: The Third Leading Cause of Death in the US Makary and Daniel; British Medical Journal 2016 Location Deaths / Year Deaths / Day Harm / Day United States ~251,000 ~688 ~12,400 - ~20,630 Texas ~21,600 ~59 ~1,065 - ~1,775 11
12 Current Quality Approach Good Quality is Assumed to Equal Safe Patient Care Quality and Safety are Often NOT the Top Priority of Leadership Quality Improvement is Project Based PI Methods are Inadequate Reactive, rather than Proactive We must transform our culture of safety to a high reliability orientation!!!
13 RESEMBLANCE #1 ROOT CAUSE ANALYSIS Challenges: Reactive response to undesirable events Management culture looking for individual blame Ineffective cause evaluations Good News: We are taking some proactive responses Management learned about the impact of system weaknesses and an understanding of a Just Culture Much better at cause evaluations
14 Traditional Healthcare Root Cause Analysis Heavily focused on TJC Sentinel Events Focused primarily on actual harm, rather than the risk of harm. Facilitates a Culture of Blame Find out Who did What, rather than Why an event occurred. Flawed Investigation Process Inconsistent investigation processes and thus findings. Cases are handled one at a time rather than taking a systematic view of error risk. The Root Causes are Usually High Level and Not Actionable We can t improve poor communication. Corrective Actions Do Not Solve the Problems, which then Recur Find who is at fault and punish them. Change a policy or process with variable outcomes. More education and training. Try Harder!!!
15 RCA 2 Root Cause Analysis and Action Root Cause Analysis An investigation of an adverse event or near miss with the intent of identifying its causes. The goal is to reduce or eliminate the likelihood of a future similar event. Health Care RCA s have not been as effective at preventing future harm as needed. Lack of standardized approach to the RCA. Failure to identify true root causes and prioritize them. Failure to identify systems-based corrective actions. Failure to timely execute the RCA and corrective actions. Failure to ensure follow-through on corrective actions implementation. Failure to measure and reassess the effects of the corrective actions. Failure to engage leadership at all levels of the organization in preventing harm.
16
17 Organizational Influences (96) Inadequate Staffing (21) Inadequate Policies (13) Inadequate Strategic Risk Assessment (13) Inadequate Corporate Procedures (9) HFACS Findings Supervision (69) Failure to Enforce Policies / Procedures (15) Inadequate Mentoring, Coaching (7) Inadequate Oversight (7) Inadequate Training (6) Preconditions for Unsafe Acts (694) Inadequate Comm. Between Providers (82) Failure to Warn/ Disclose Critical Information (58) Inadequate Comm. During Handoff (46) Failure to Use All Available Resources (41) Inadequate Comm. Between Workgroups (41) Lack of Teamwork (32) No or Ineffective Communication Methods (30) Task Overload (26) Confusing / Conflicting Directions (21) Inadequate Comm. - Staff to Patient (21) Perceived Haste (18) No One in Charge (18) Unsafe Acts (852) Routine Violation of Policy / Procedure (76) Inadequate Risk Assessment (75) Critical Thinking Failure (66) Caution / Warning Ignored or Misinterpreted (65) Wrong Response to Urgent Situation (50) Failure to Assess Patient (47) Inadequate Report Provided (44) Misinterpretation of Information (39) Failure to Monitor Patient (34) Inadequate / Untimely Communication (33) Distracting Behavior (26) Selected Incorrect Procedure (23)
18 RESEMBLANCE #2 CHECKLISTS Challenges: Some of the original culture didn t value and therefore didn t start with many checklists, job aids, or procedures Didn t start with any reinforced expectations for use Good News: Checklists, job aids, procedures and standard work documents exist in plenty Reinforced expectations for use by top performers
19 I Have a New Surgical Instrument!!! I will give it to you FREE. Surgical staff find it easy to use and learn. It will take about 3 minutes per case. It s proven to: Cut operative mortality by 50% Cut surgical site infections by 50% Cut any surgical complication by 33% Cut all unplanned returns to the OR by 25% Will you use it???
20 Surgical Safety Checklist NEJM January 29, 2009
21 RESEMBLANCE #3 COMMUNICATION Challenges: Established verbal communication did not close the loop Verbalized organizational communication left un-validated No structure provided on what to communicate Good News: 3-way communication is an effective technique Top performers validate communication flow throughout the organization Several tools; PJBs/Turnovers/SAFER conversations
22 Health Care Communication Improvement Daily Safety Huddles Structured Hand-Offs Face-to-Face with the Patient Use of Checklists Medication Reconciliation SBAR Situation Background Assessment Recommendation Team STEPPS (Crew Resource Management) Read Back Protocols
23 THE HOLY GRAIL SAFETY CULTURE
24 A Call for High Reliability
25 Leadership High Reliability RPI Trust Improve Report Health Care Safety Culture Mark Chassin, MD th International HRO Conference May 21, 2012
26 Health Care Reliability Cannot show reliable and valid safety statistics! Error is too often viewed as a challenge to professionalism and self worth, rather than an opportunity to learn. Ongoing training, simulation and team development is often lacking. Zero harm is often not the primary focus of leadership.
27 Medical Areas for Improvement Transposition errors in patient information (administrative) Non-approved pens for marking ( it washes off ) Not being attentive during the Time-out or Safety Huddle (most prominent) Rushing to keep the OR schedule on track Pre-Op Nurse needs to be able to STOP the line, if necessary (part of the layers of defense)
28 Common Cultural Whole team solutions It takes total dedication to your #1 priority (public safety/ patient health & safety) It takes a release of egos (it s not about competency) It takes courage to speak up (e.g. for patient/nuclear safety) It takes effective communications (are you sure you were understood?)
29 Common Cultural Whole team solutions It takes a relentless pursuit and correction of system weaknesses It takes practice; using effective tools & techniques It takes a dedication to safety over production (managing schedule/time pressure) It takes an entire team commitment
30 QUESTIONS???
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