10/21/2013. Hospitals as Highly Reliable Organizations. Examples from Intensive Care Settings. Some Statistics to Ponder - USA

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1 Hospitals as Highly Reliable Organizations Daniel L. Cohen MD, FRCPCH, FAAP International Medical Director/Datix Ltd., UK & Malcolm Daniel MB ChB, FRCP, FRCA, FICM Consultant in Anaesthesia and Intensive Care Glasgow Royal Infirmary Examples from Intensive Care Settings International Comparison of Spending on Health, $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 Average spending on health per capita ($US PPP) $ US SWIZ NETH CAN GER FR AUS UK JPN Total health expenditures as percent of GDP 1. Commonwealth Fund, based on OECD Health Data Notes: PPP = purchasing power parity; GDP = gross domestic product US NETH FR GER CAN SWIZ UK JPN AUS Some Statistics to Ponder - USA Annual toll of medical injuries (multisource): 1.3 million injuries and 180,000 deaths/year $50 Billion total costs $14 Billion uncompensated costs 25-33% of hospitalized patients are injured Each day in US hospitals: Five patients have wrong-site surgery 40,000 patients experience adverse events 10,000 patients have a medication complication patients die EVERY DAY! 3 4 Toward High Reliability: Managing Enterprise Risk at 25,000 feet 5 Highly Reliable Systems Systems that operate in complex environments where accidents might be expected to occur frequently, but which manage to avoid and seek to minimize catastrophes 2 Incorporate/inculcate improvement data driven methodologies such as Lean, Six Sigma, RPI, etc. Incrementalism more than home runs/centuries Cultural commitment- Collective Mindfulness Examples: nuclear energy, aviation, automotive Health care involves patients and is, in some ways, more complex than any of these! 2. WeickK, Sutcliffe K. Managing the unexpected: assuring high performance in an age of complexity. San Francisco: Jossey-Bass;

2 Characteristics of Highly Reliable Organizations 2 Sensitivity to operations-constant awareness by leaders and staff to risks and prevention Reluctance to simplify avoidance of simplistic explanations for risks/failures; delve deeply Preoccupation with failure Every process has risks Near-misses -proof of effective safeguardsand symptomatic of areas needing more attention In healthcare -risks and benefits of interactions and interventions 7 2. WeickK, Sutcliffe K. Managing the unexpected: assuring high performance in an age of complexity. San Francisco: Jossey-Bass; Characteristics of Highly Reliable Organizations Deference to expertise -leaders/supervisors listen to/seek advice from front-line staff who know how processes really work and where risks arise In healthcare who is most expert? Resilience -leaders and staff are trained and prepared to respond when systems fail Collective Mindfulness confronting Complacency 3 3. Chassin M, Loeb J. The Ongoing Quality Improvement Journey: Next Stop, High Reliability. Health Affairs 2011;30: Aircrew interact with each other and with technologies that are redundant/fail-safed 10 Healthcare vice High-Reliability Industries Health care is enormously complicated Health professionals are not pilots, nor engineers Diagnosis includes deductive and intuitive components and often relies on heuristics without appropriate fail-safes Person to person interactions far more common Communication Challenges Abound Patients are not airplanes nor nuclear reactors Behavior, lifestyle, personal choices Genetics predispositions, co-morbid conditions Belief systems, cultural perspectives Social, economic circumstances, education Intellectual and cognitive abilities Language and language context Patients are active participants, not passive recipients Achieving health outcomes involves patients and is more complex than flying an airplane Patients are not passengers on an airplane, not simply passive recipients of healthcare services

3 Personal Vignette When Culture Fails This child s worst nightmare!... and things were about to get a lot worse 13 Elements of Unreliability - System Problems Protocol for intra-operative chemotherapy not evidenced-based, experimental Informed consent lacking for this intervention Obligation for oncologist to cover clinic, ward, operating theaters in three hospitals Cultural barrier forestalled calling for backup Not all anesthesiologists qualified for all procedures Pharmacy multi-tiered double-check for oncology chemotherapy orders not established/utilised High Reliability Organisations anticipate these gaps and mitigate them >>> often checklist-based 14 Elements of Unreliability - Personnel Problems Anesthesiologist does not inform oncologist that shift in responsibility has occurred Anesthesiologist does not brief substitute on requirements for prescription verification Pharmacist errs in preparation - decimal point error Substitute anesthesiologist administers unfamiliar drug without verification of dosage, side-effects I did not call for qualified back-up!!!!!! High Reliability Organisations anticipate these gaps and mitigate them >>> often checklist-based 15 Strategies for Achieving High Reliability Recruit strong intellectual/pragmatic leadership Assure important stakeholders are engaged Establish and sustain a rich Patient Safety Culture Trust and empower Teaming and teamwork Support Robust Process Improvement RPI Develop reliable metrics for quality, safety, financials Anticipate complexities & dive deeply Implement solutions to important causes Assess solutions/modify as necessary Deploy programs to sustain improvement What the Automotive Industry Taught Us High Reliability in the Intensive Care Setting Deference to Expertise Stop the Line! 17 Successes and Remaining Challenges 3

4 Incrementalism - Seen from the front line Sensitivity to operations-constant awareness by leaders and staff to risks and prevention Reluctance to simplify avoidance of simplistic explanations for risks/failures; delve deeply Preoccupation with failure Deference to expertise -leaders/supervisors listen to/seek advice from front-line staff who know how processes really work and where risks arise Resilience -leaders and staff are trained and prepared to respond when systems fail Central line related blood stream infection Reduction/Prevention We thought we were good.. 21 Outcome Aims set in 2008 Mortality: 15% reduction Adverse Events: 30% reduction Ventilator Associated Pneumonia: 0 or 300 days between Central Line Bloodstream Infection: 0 or 300 days between Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range MRSA Bloodstream Infection: 30% reduction Crash Calls: 30% reduction We thought we were good.. When we compared ourselves to others the failure of benchmarking In truth, we didn t have a reliable process for the insertion of, or maintenance of, central lines How did we make the central line insertion process more reliable? To be achieved across the nation in

5 Improving Reliability Set aim how much by when Clear specification of process Monthly data A nurse standardised central line trolley contents Developed a checklist Assumed if checklist not completed it was not done Attached checklist to central line packs Checklists often look like the easy answer Safer care is achieved when all three not just one of the following are realised: Summariseand simplify what to do; Measure and provide feedback on outcomes; and Improve culture by building expectations of performance standards into work processes It takes more than a checklist they are a technical solution, there is a wider adaptive challenge 25 Reality check for checklists The Lancet 2009; 374: Improving Reliability A Simple Start Reliability occurs by design not by accident Process is the action point of all improvement methodologies Segmentation allows the perfection of the design Starting Labels of Reliability Chaotic process: Failure in greater than 20% of opportunities. 80 to 90%: 1 or 2 failures out of 10 opportunities. 95% or better: 5 failures or less out of 100 opportunities. Improving Reliability A Simple Start Use the following three step method: Prevent ini al failure using intent and standardization. Iden fy defects (using redundancy) and mi gate. Measure and then communicate learning from defects back into the design process

6 Improving Reliability A Simple Start Select a topic whose outcome you want to improve Determine a high volume segment for initial design testing Build a high level flow chart for that segment Determine where the defects occur in the current system Determine where your design work will begin with by identifying where the commonest defects occur Verbalize the reliability (hint: it is always 95% or better) 31 What is a segment A piece of the whole Selected because allows control of some variables, allows testing of validity of design Should be well defined - have clear cut boundaries Has willing participants Has a reasonable volume to allow testing of validity of design 32 What is a segment A piece of the whole Selected because allows control of some variables, allows testing of validity of design Should be well defined - have clear cut boundaries Has willing participants Has a reasonable volume to allow testing of validity of design A high level flow chart will help Understanding key steps of the process is essential Important that flow map is not too detailed No more than 4 or 5 steps to describe the process from start to finish Identify the step with the highest number of defects Then start testing an improved design for this step A high level flow chart will help A central line needs to be inserted Locate various pieces of equipment Create sterile field Insert central line Document what was done Improving Reliability This will often take the form of standardization Aim initially to get reliability >80% Then learn why standard process not able to be be followed. Develop a second intervention to minimize the effect of this In my experience it sometimes needs a third step too!

7 It s Simple Arithmetic 80% with 1 st change need to address that other 20% Develop a second intervention to minimize the effect of this aim for second intervention to have 80% success rate Over all: = 80% + (20% x0.8) = 80% + 16% = 96% Incrementalism to Collective Mindfulness If we only had to think about central lines. Clinical care in it s native state is mildly chaotic Does emphasize it takes more than one step! A Working Day Handover Ward round prioritisation Keeping multiple people in the loop Interventions + tasks Follow-up Review patients in A&E + hospital Admissions Handover x2 Plus a variety of other tasks Incrementalism to Collective Mindfulness Clinical care in it s native state is mildly chaotic We have designed coping into daily work How about noticing? Start Stop take 5 minutes, gather staff, ask what got in the way today? Then apply some reliable design principles High Reliability in Healthcare Take care of those most vulnerable and the rest is easy! 41 Hospitals as Highly Reliable Organizations Daniel L. Cohen MD, FRCPCH, FAAP International Medical Director/Datix Ltd., UK & Malcolm Daniel MB ChB, FRCP, FRCA, FICM Consultant in Anaesthesia and Intensive Care Glasgow Royal Infirmary Examples from Intensive Care Settings 7