High Reliability Healthcare: A Journey to Zero

Transcription

1 High Reliability Healthcare: A Journey to Zero Arizona Organization of Nurse Executives August 19, 2016 Coleen Smith, RN, MBA, CPHQ, CPPS Objectives Discuss the importance of leaders as agents of change on the journey toward high reliability. Describe why leadership commitment, culture of safety, and performance improvement are important elements in the high reliability journey. Articulate how completing the Oro 2.0 High Reliability Assessment, using a recommended strategy, positions organizations for the journey to high reliability and the goal of zero patient harm

2 3 State of Health Care Health care used to be: Simple Cheap Safe Ineffective 4 2

3 State of Health Care Today, health care is extremely complex, exceedingly expensive, often highly effective, and very dangerous 5 Semmelweis Original Data Monthly Death Rates Handwashing Program

4 Florence Nightingale s Data Grey: Death due to preventable diseases Red: Death due to wounds Black: Death due to all other causes 7 How Safe is Healthcare? Dangerous (>1/1,000 Ultra Safe (<1/1M) Total Lives Lost per Year 100,000 10,000 1, Health Care (1 of ~600) Mountaineering Bungee Jumping Driving in US Chartered Flights Chemical Manufacturing Theme Parks Scheduled Commercial Airlines European Railroads Nuclear Power , K 1M 10M Number of Encounters for Each Fatality Amalberti, et al. Ann Intern Med.2005;142:

5 Current State of Quality Routine safety processes fail routinely Hand hygiene Medication administration Patient identification Communication in transitions of care Uncommon, preventable adverse events Wrong surgery, retained foreign objects Fires in ORs Infant abductions, inpatient suicides 9 Current State of Improvement We have made some progress Improvement difficult to sustain/spread Getting to zero, staying there is very rare

6 It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. Florence Nightingale Notes on Hospitals, 1859 Leadership

7 One Vision All people always experience the safest, highest quality, best-value healthcare across all settings 13 Excellence in patient care for every patient, every time

8 How many harm events do you hope to have in your hospital next year? ZERO The essential ingredient for building a high reliability organization. 15 Shared mental models Concepts of reality, often blurred and shifting Roger Bannister CLABSI rates Wrong site surgery Who will change the mental model for health care? Who already has?

9 How Do We Get from Low to High Reliability? Milbank Q 2013;91(3):

10 HIGH RELIABILITY MODEL Leadership Safety Culture Robust Process Improvement Commitment to zero patient harm Empowering staff to speak up Systematic, datadriven approach to complex problem solving Chassin MR, Loeb JM. High-Reliability Health Care: Getting There from Here. Milb Q 2013;91(3): High Reliability Maturity Model Leadership Commitment Board CEO/Management Physicians Quality Strategy Quality Measures Safe Adoption of IT Adoption of Safety Culture Trust Accountability Identifying Unsafe Conditions Strengthening Systems Assessment Robust Process Improvement Methods Training Spread Stages of maturity Beginning Developing Advancing Approaching 10

11 Board s Role High reliability starts with the Board & CEO Fiduciary responsibility includes quality of care delivered Board: Vision, Mission Board/Management: Strategy Management: Operational Tactics 21 Leadership Commitment Board Quality & Safety on full Board agenda: First, Every time Actual counts Stories Specific aims % of meeting time devoted to: finance, operations, quality, strategy Education of the Board

12 Leadership Commitment: CEO Commitment to high reliability Commitment to quality & safety Personal involvement by CEO in QI efforts Is the aim explicit at your organization? VanDeusen Lukas C et al. Transformational Change in health care systems. An organizational model. Health Care Manage Rev 2007; 32(4): Leadership Commitment: CEO and Management Are we engaged in these activities? Daily Safety Huddles: Macro, meso, & microsystem levels Leadership rounds Identifying key safety protocols Ensuring education, training, and accountability mechanisms for key safety protocols If so, how well are these strategies working? Are we measuring the effectiveness?

13 Physicians & Quality/Safety Essential to success of any quality initiative: leadership and participation Visible and active enthusiasts: Formal leaders (CMO, VPMA) Informal leaders (medical staff president, voluntary medical staff leaders) 25 Quality Strategy What priority is given to improving quality and safety? Quality is one of the top three or four strategic priorities OR the highest-priority strategic goal Improvement efforts directed at the most important causes of harm in the organization s patient population Stated goal Zero harm

14 Ensuring patient safety is our core value, and it s our only core value. Dan Wolterman, CEO, Memorial Hermann Health System 27 Quality Measurement What is the organization s approach to measuring quality and safety? Measurement goes beyond the regulatory requirements Transparency of Information Who can access & How often? Align incentive systems based on results

15 ansparency/outcomes/ventila tor-associatedpneumonia.html 29 Safe Adoption of IT Safety deployed IT solutions Coordination of health IT Principles of Safe Adoption *Health IT Implementation: SAFER Guidelines. (Accessed June 7, 2016)

16 Paradox: Part I Trained perfectibility belief Medical errors = incompetence Paradox: Part II Activities that are highly errorproducing: Aircraft maintenance Delivering health care Health care is highly error-provoking yet reporting errors is stigmatized and care givers are not trained in error management or detection. Reason J. (2013) A Life in Error: From Little Slips to Big Disasters. Burlington, VT: Ashgate Publishing. Drive out fear and create trust - W. Edward Deming 16

17 Role of Hospital Leaders in Building a Culture of Safety Motivate care teams to uphold a fair and just safety culture. Provide a transparent environment in which patient safety events are honestly reported. Model professional behavior. Remove intimidating behavior that might inhibit a culture of safety. Provide the resources and training necessary to take on improvement initiatives. 33 Culture and Accountability Health care struggles to apply disciplinary procedures equitably and uniformly Lack of uniform accountability also erodes trust; stifles reporting of unsafe conditions HROs strike a balance: Learning from blameless errors Accountability for adhering to safe practices 17

18 Accountability Health care also fails to apply disciplinary procedures equitably and uniformly Lack of uniform accountability also erodes trust, stifles reporting of unsafe conditions Belief in a completely blame-free culture further impairs progress toward accountability Striking the balance is critical: Learning from blameless errors Accountability for adhering to safe practices Culture and Accountability How do we decide whether discipline should be considered in evaluating behavior? Critical to establishing trust is having the same process for all caregiver groups Address these 4 questions every time 1. Was harm intended? 2. Evidence of illness or substance abuse? 3. Foresight test 4. Substitution test 18

19 Start here Assessing Errors Systematically MD Deliberate harm test Incapacity test Foresight test Substitution test Were the actions intended? No Does there appear to be evidence of ill health or substance abuse? No Did the individual depart from agreed protocols or safe procedures? No Would another individual coming from the same professional group, possessing comparable qualifications & experience, behave in the same way in similar circumstances? Yes Yes No Yes No No Were adverse consequences intended? Were the protocols and safe procedures available, workable, intelligible, correct and in routine use? Were there any deficiencies in training, experience or supervision? Yes Yes Yes Yes Is there evidence that the individual took an unacceptable risk? No Yes No Were there significant mitigating circumstances? No Yes Summarily suspend/ terminate CONSIDER Police Report to state quality investigation office Report to National Practitioner Databank (NPDB) IDENTIFY SYSTEM FAILURES Summarily suspend/terminate CONSIDER Report to NPDB Referral to internal physician impairment program Referral to state physician impairment program Report to state quality ] investigation office Corrective training/education IDENTIFY SYSTEM FAILURES CONSIDER Discipline Potential adjustment to clinical duties Corrective training/ education Improved supervision Refer to Employee Assistance Program IDENTIFY SYSTEM FAILURES CONSIDER Discipline Report to NPDB Potential adjustment to duties Report to state quality investigation office Refer to Employee Assistance Program IDENTIFY SYSTEM FAILURES SYSTEM FAILURE Free Lessons Reporting of errors and mistakes (whether or not they reach the patient) as well as adverse events is crucial to improving systems. Obstacles: Fear (Punitive Response domain; AHRQ survey) Difficult to use reporting system Time pressures No feedback on what was done with reports 19

20 Increase near miss/error reporting Be clear on purpose of reporting Thank those that report (if known) Communicate actions taken Visual Display Board 20

21 Aggregate analysis of near misses Near miss data can be analyzed to determine: Type of mistake: Slip (mistake made in execution of valid plan) Lapse (mistake made by forgetting to do something that should have been done) Most common near miss event type (e.g. medication error, communication, etc. Day of week/day of stay Reasons RCAs lack effectiveness No standardized and explicit processes to: Ensure timely execution of an RCA and resulting actions Leadership accountability to ensure followthrough to implement recommendations Measure whether actions were successful National Patient Safety Foundation. (2016) RCA² Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: NPSF. 21

22 Tactics around Measuring/Acting If you already measure safety culture: develop a plan with built in accountability to review the results and work to improve All units/departments routinely report on progress (which won t be immediate or fast in many cases) Discuss these results with the Board Role of Hospital Leaders in Building a Culture of Safety Motivate care teams to uphold a fair and just safety culture. Provide a transparent environment in which patient safety events are honestly reported. Model professional behavior. Remove intimidating behavior that might inhibit a culture of safety. 22

23 Safety Culture Summary Fully functional safety culture is essential to achieving high reliability in healthcare Will take time and consistent effort on the part of all leaders and the Board No guaranteed or foolproof methods Expect setbacks, non-linear progress Measure trust, intimidating behavior, culture No challenge is more important The most detrimental error is failure to learn from an error. ~James Reason 23

24 RPI in Health Care Today Only a small percentage of hospitals or systems use RPI in any form or fashion RPI is used differently by different hospitals Most use only some of the parts; change management is most often left out Most do not use it to transform Most do not have a plan for spread or for linking RPI training to staff development Compelling business case for RPI ROBUST PROCESS IMPROVEMENT Facilitating Change Lean Six Sigma FOCUS IS ON THE PATIENT

25 Robust Process Improvement Systematic approach to problem solving Not just a Black Belt in the quality department Not just tools More than tools Strategic project selection Common language Competency-based deployment Project management Data driven analysis is critical for complex problems 25

26 Usual Approach to Improvement Usual approach: best practices, toolkits, protocols, checklists, bundles Typical best practice is one-size-fits-all Can produce modest improvement Difficult to sustain Cannot get to zero this way The one-size-fits-all approach works well only for simple problems that do not vary Toughest problems are not simple Causes Differ by Hospital Each letter = one hospital 26

27 The Technical Solution Is Not Enough Lean, Six Sigma provide technical solutions Why does improvement fail so often? Not for lack of a good technical solution Failures occur when organization fails to accept and implement a good solution it had RPI addresses this challenge directly Change management = a systematic way to implement and sustain good solutions Facilitating Change Plan Inspire People Launch Support the Change Facilitating Change

28 Why RPI? The Business Case Administrative processes in health care are just as broken as clinical processes Billing, supply chain, throughput RPI can directly improve margins Learning RPI allows organizations to solve their own problems Generate positive ROI now while learning how to redesign care processes for future Mayo program ROI = 5:1 J Patient Safety 2013;9(1):44-52 The Commitment Quality is an investment, like a new building Resources and funding approved by Board Measure the progress towards building a PI infrastructure Have finance track the ROI Quality is of the highest importance At the beginning of every Board meeting Excellent care is the organization s product

29 Sustainability Don t confine training to group of experts Aim to spread improvement approach throughout system Establish different levels of training Transformation occurs when: It becomes the way we work every day Front-line employees see opportunities and have the tools to initiate improvement Enables a learning culture Characteristics of High Reliability Robust Process Improvement Adoption of RPI tools accepted fully throughout organization Training in RPI is required for all staff, as appropriate for their jobs Used throughout organization for all improvement work Key stakeholders including front line staff are engaged in improving processes 29

30 Why RPI? Major Improvements Center Projects Results(%) Hand hygiene 71 Hand-off communication failures 56 Wrong site surgery risks Scheduling 46 Pre-op 63 Operating Room 51 Colorectal SSIs 32 Falls with injury HAI Hospital Scorecard Number of HAIs in one month

31 TOOLS FOR HIGH RELIABILITY Patient Safety Systems Chapter ation/hospitals.aspx

32 Guided Robust Process Improvement Confidential Separate from Accreditation

33 Quick Access via the Website Existing User Log in New User Request Access 65 and Transformation Provides crucial, leading indicator information about strengths, opportunities, and potential investment strategies for achieving performance Incorporates and reflects performance across multiple domains A guiding force for enterprise transformation A look in the mirror Not a benchmarking tool Assess progress on the high reliability journey over time Leading from Within

34 Organizational Assessment 49 questions with branching logic for hospital senior leadership Evaluates level of maturity in 14 components Resource Library Oro 2.0 is separate from Joint Commission accreditation. 67 DECIDE ON AN ASSESSMENT METHOD Method 1 Individual and Consensus - Recommended Senior leaders first complete the Assessment individually Senior leaders meet as a team and complete one Assessment, by consensus, for the hospital. Method 2 Consensus Only Senior leaders meet and complete one Assessment, by consensus, for the hospital

35 Ideal group to take the Assessment CEO participation is essential Clinical leaders (e.g. CMO, CNO, VP Medical Affairs) Administrative leaders (COO, CFO) Board chair/board Quality Committee Chair Quality and Patient Safety leaders (e.g. VP PI, Patient Safety Office, Risk Management) Ideal participant group size is no more than 15 to allow in-depth conversation and high level perspective 69 Consensus Meeting Dynamic conversation & sharing of viewpoints by the Senior leadership team Schedule hour meeting Experienced Facilitator Scribe Post-Assessment Meeting Review results and Resource Library materials Prioritize next steps

36 Assessment Results: Executive Summary 71 Resource Library Materials

37 Transformation to High Reliability Striving for high reliability is not a project We must have much more ambitious goals for healthcare improvement: ZERO harm Current methods will not get us there Lean, six sigma, and change management (RPI ) have far greater promise Culture change is difficult, takes time Some hospitals and systems making real progress; showing that zero is achievable 73 Thank you! For more information: Coleen Smith Director, High Reliability Initiatives Phone: csmith@jointcommission.org