The Journey to High- Reliability
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1 The Journey to High- Reliability Georgia Osteopathic Medical Association (GOMA) 2017 Fall CME Conference 5 November 2017 Barbara Chase McKinney, MD, MPH
2 Disclosure The presentation is my own
3 Remember the Vasa
4 The Warship Vasa, Stockholm Sweden Build
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11 10 August 1628
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13 Video
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15 By Govert Dircksz Camphuysen Inquest: Swedish Privy Council Royal Palace 5 September 1628 Captain Officers/Sailors Boat builders
16 Captain Captain Söfring Hansson Testified that the guns were secure the crew was sober
17 Officers/Sailors Was it rigged properly for the wind? Was the crew sober? Was the ballast properly stowed? Were the guns properly secured?
18 Ship Builders Henrik Hybertsson Henrik Jacobsson Arendt de Groote 'Why did you build the ship so narrow, so badly and without enough bottom that it capsized?'
19 King Gustavus Adolphus 'Imprudence and negligence = The cause Attributed to Jacob Hoefnagel ( )
20 What actually happened?
21 Objectives for today Determine Best Practices to Build a Culture of Safety Define Quality Improvement (QI) and the goal of QI efforts State the three elements that together lead to High Reliability Be Inspired to create High Reliability in your practice Implement one practice of high reliability by Next Tuesday
22 The great aim of education is not knowledge, but action! Herbert Spencer
23 GOMA Fall CME Conference NOVEMBER 2011
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25 High Reliability Why? What/How? When?
26 WHY?
27 The Quality & Safety Movement The US Timeline Benign Ignorance IOM Report: Crossing the Quality Chasm Affordable Care Act Pay for Performance IOM Report: To Err is Human IHI 100,000 Lives Campaign
28 The Institute of Medicine Report: To Err is Human September ,ooo 98,ooo lives lost / year due to medical errors $17-$29 billion financial cost Loss of Trust Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
29 The Quality & Safety Movement The US Timeline Benign Ignorance IOM Report: Crossing the Quality Chasm Affordable Care Act Pay for Performance IOM Report: To Err is Human IHI 100,000 Lives Campaign
30 High Profile Cases 2001 Josie King s Story & others Prompted Patient Safety Efforts
31 Where are we now? Consumer Reports - May 2013
32 Study Suggests Medical Errors Now Third Leading Cause of Death in the U.S. BMJ 2016;353:i2139 doi: /bmj.i2139 (Published 3 May 2016)
33 Killer Care: How Medical Error Became America s Third Largest Cause of Death and What Can Be Done About It, By James B Lieber, OR Books 2015
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35 WHAT? HOW? What can be done? How to start?
36 Five Suggested Reforms 1. Adopt Structured Handoffs 2. Bring in the Pharmacists 3. Get Serious about Infection 4. Fight Diagnostic Error 5. Make Electronic Health Records Interoperable Killer Care: How Medical Error Became America s Third Largest Cause of Death and What Can Be Done About It, By James B Lieber, OR Books 2015
37 IOM s Six Aims for Healthcare Improvement Healthcare must be: SAFE EFFECTIVE PATIENT-CENTERED TIMELY EFFICIENT EQUITABLE The Joint Commission s (TJC) Performance Metrics are built around these six aims
38 Quality VALUE The Value Equation Value = Quality (Outcomes + Safety + Service) Cost
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40 GOMA Fall CME Conference NOVEMBER 2011
41 Quality Improvement is Combined and unceasing efforts of everyone healthcare professionals, patients and their families, researchers, payers, planners and educators to make changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning) The Goal = Transformation of Healthcare Batalden, P and Davidoff, F; What is quality improvement and how can it transform healthcare? Qual Saf Health Care 2007;16:1 2-3 doi: /qshc Downloaded from on September 1, 2015
42 Learning Board Examples
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44 The Role of a Fair and Just Culture
45 What will you do by next Tuesday? Communicate - Behavior Huddle Brief Debrief Handoff Team Move a Metric Learning System Surface Issues Create an Aim Statement Select a Metric PDSA
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47 Process Improvement + Culture of Safety + Leadership = High Reliability
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49 Process Improvement Culture of Safety Leadership How to Build High Reliability Quality /Process Improvement Evidence Based Medicine Standardize Work as a Team Safety Huddles Speak Up Time Outs Read Back Listen Actively engage front-line staff, patients & family Joy in your work
50 WHEN? What can you do by next Tuesday?
51 Remember the Vasa
52 Questions? Comments? Feedback? Thank You
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