Resilience in Healthcare
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- Cathleen Horton
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1 Resilience in Healthcare The Other Side of Human Error Dr Carl Horsley, Critical Care Complex, Middlemore Hospital
2 Patient Safety
3 Staff Safety
4
5 Outline The current model of safety The problems with the current model A new view of safety How it changes the way we work
6 The Aim of Safety That as few things as possible go wrong
7 The Current View of Safety Safety I Normal functioning (compliance) Acceptable outcomes (successes) Unwanted transition (sudden or gradual) Malfunctioning (non-compliance) Unacceptable outcomes (failures) Hollnagel E. Safety-I and Safety-II; the past and future of safety management 2014
8 The Swiss Cheese Model
9 Find and Fix
10 Compliance
11 More Defenses
12 Safety: A non expert viewpoint People are a liability
13 Your Hospital to follow the rules
14 Work-As-Imagined
15 Definition of safety Safety - I That as few things as possible go wrong Safety management principle Reactive; responds when something happens or something is deemed an unacceptable risk View of the human factor in safety Humans are predominantly seen as a liability or hazard Accident investigations Accidents are caused by failures and malfunctions. The purpose of investigations is to identify the causes. Risk Assessment Accidents are caused by failures and malfunctions. The purpose of investigations is to identify the causes and contributory factors
16 Reactive Retrospective Biased
17 Limits Learning About Our Systems
18
19 What We Focus On Matters
20 Things that never happened before happen all the time Scott D. Sagan The Limits of Safety
21 Creates Brittleness Hides the sources of Adaptability and Innovation
22 Safety vs Productivity
23 Healthcare Worker Patient and family
24
25 Starlings by Elbow 2008
26 Work-As-Done
27 Hollnagel The ETTO Priciple: Efficiency Thoroughness Tradeoff 2009
28 The New View Safety II Acceptable outcomes (successes) Performance adjustments Unacceptable outcomes (failures) Hollnagel E. Safety-I and Safety-II; the past and future of safety management 2014
29 The system only succeeds because people/teams are able to adjust to meet the conditions of work
30 Ghaferi 2009
31 Complexity is the problem People are the solution
32 The New Aim of Safety That as many things as possible go right
33 Definition of safety Safety - II That as many things as possible go right Safety management principle View of the human factor in safety Accident investigations Risk Assessment Proactive, continuously trying to anticipate developments and events Humans are seen as a resource necessary for system flexibility and resilience The purpose of an investigation is to understand how things usually go right as a basis for explaining how things occasionally go wrong To understand the conditions where performance variability can become difficult or impossible to monitor and control
34 What Does This Mean For How We Work?
35 1. Understand Success and Failure Come From the Same Source Are you making failure less likely? Or usual success more likely?
36 Work as Done Work as Imagined
37 2. Learn from all events
38 Build in time for reflection
39 3. Build Resilient Teams and Systems
40 Not this
41 Resilience is the ability of the team/system to monitor and adjust performance to achieve its goals, under expected and unexpected conditions.
42 The system must be both prepared and prepared to be unprepared J. Paries Resilience Engineering in Practice 2011
43 Anticipate How Things Might Fail
44
45 The Law of Requisite Variety The greater the variety of responses, the greater the variety of conditions the system can cope with First Law of Cybernetics: Ashby, 1956
46 Requisite Variety Requisite Variety
47 Middlemore Hospital, Counties Manukau District Health Board
48 A Common Framework
49 Build a Shared Understanding
50 Leadership and Active Followership
51 Speaking Up
52 Resilience
53 Focus on Learning Why did that seem the right thing to do at the time? Dekker A Field Guide to Understanding Human Error 2014
54 Demonstrate
55 Reinforce and Model Interwoven into the daily
56 What Changes Have You Seen?
57 Improved Team Organising We are less dependent on individual experience now that people work together better, and have a bit more of an expectation about how things will go, that we will talk about what we are expecting. (Nurse, CCC)
58 Structured Variability Knowing the normal, so you can tell when it s not
59 Some Surprises Followers help leaders lead
60 Enrt
61 Proactive Safety Behaviours So, for me the difference is sharing that worst case scenario saying I don t think that is going to happen, this would be the worst thing, what I think is going to happen here is, it would be terrific if this happened. I think that has allowed people to relax a little bit and focus on good care rather than everything being a surprise. (Doctor CCC)
62 Psychological Safety The whole culture has changed and I think it has become a really focused group effort department with everyone looking out for each other and working for each other and with each other. (Nurse, CCC)
63 Psychological safety A shared belief held by the team that the team is safe for interpersonal risk taking Google Project Aristotle
64 Improved Psychological Safety More effective More engaged Safer (Edmondson 1999, Nembhard and Edmondson 2006)
65 What Else Have We Seen?
66
67 Contributing Factors Lack of valve/cap on the access device Student nurse supervision Patient's condition Patient position
68 What helped get a fast response? Personal: Reading and talking to people helped to gain insight into identifying the signs/symptoms; always think and prepare for the worst possible outcome/scenario Environment: Bedspace was tidy; emergency bell and equipment were within reach (only one pendant has emergency buttons - extra time to reach for the bell on the other side of the patient's bed would have cost valuable time).
69 What helped during and after the event? Team came promptly Self-introduction during rounds helped to identify team leader Plan of care was clearly stated Patient progress and staff followed up by team Reassurance and support offered by team "no blame" culture helped to debrief and hold open discussions to allow others to learn from this Debriefing with different members of staff Family meeting with team leader and staff
70 Other Ideas? Multiple voices and questions asked by different team members while primary nurse was attempting to bag patient. Suggest for other team members to take over ventilation to free primary nurse for a clear, concise SBAR to the team leader Potential scenario for focus day/students on orientation/graduate RNs
71 Family response?
72 A Change of Perspective
73 How Does This Fit With CCDM?
74 Right staff, right place, right care
75 The mind, once stretched by a new idea, never regains its original dimensions Oliver Wendell Holmes
76 Team Resilience Helmer Zijdel Pam Culverwell Sunetra Chan Susan Archibald Steve Kirby Andrew Gilhooly Sheeja Joseph Eve Christophers Reena Patel Catherine Hocking Kylie Julian Carl Horsley Sue Takarei
77 Resilient Healthcare Network From Safety-I to Safety-II: A White Paper Hollnagel, Wears, Braithwaite 2015 Website
78 Discussions, Arguments,
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