Creating a Safe Day the science of safety and operational excellence

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Creating a Safe Day the science of safety and operational excellence August 21, 2015 2015 Healthcare

This material is a proprietary document of Healthcare Performance Improvement LLC.

1 Creating a Safe Day the science of safety and operational excellence August 21, Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. This material is a proprietary document of Healthcare Performance Improvement LLC. Reproducing, copying, publishing, distributing, presenting, or creating derivative work products based on this material without written permission from Healthcare Performance Improvement is prohibited.

2 Topics 1. High Reliability Organizations (HROs) 2. Measuring Safety and Emerging Causal Themes in Healthcare 3. Creating a Safe Day Everyone Has a Role 4. Unique Role of Medical Staff in an HRO 5. Closing Remarks Slide 2

3 High Reliability Organizations (HROs) Slide 3

4 Key Points 1. Safety is a science. Ultra-high levels of safety can be achieved by employing High Reliability principles. 2. Attention is the currency of leadership. The role of senior leaders is absolutely critical to HRO success. 3. Safety is a dynamic, non-event. Everyone has a role in creating and maintaining a high reliability, safe culture. 4. The medical staff is critical to sustain safety as a core value. 5. Everyone makes errors serious patient harm events are almost always a result of the system failing not an individual human error. 6. Staff, physicians and leaders must make proven error prevention strategies practice habits. Slide 4

5 Reliability Defined Reliability: The probability that a system, structure, component, process or person will successfully perform the intended function(s). Slide 5

6 High reliability organizations (HROs) operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents. Managing the Unexpected (Weick & Sutcliffe) Risk = Probability x Consequence Slide 6

7 Reliability from the patient s perspective 1. Don t Harm Me 2. Heal me 3. Be nice to me...in this order SM Slide 7

8 Complementary Strategies Codes Outside the ICU Surgical Site Infections Central Line Infections Hand Hygiene Culture and on, and on, and on 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Slide 8

9 Journey to improving reliability the next zero 10-8 Optimized Outcomes Reliability Process Design Reliability Culture Human Factors Integration Intuitive design Impossible to do the wrong thing Obvious to do the right thing Core Values & Vertical Integration Hire for Fit Behavior Expectations for all Fair, Just and 200% Accountability Evidence-Based Best Practice Focus & Simplify Tactical Improvements (e.g. Bundles) 2010 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Slide 9

Five Principles of HROs Three Principles of Anticipation Preoccupation with Failure Regarding small, inconsequential errors as a symptom that something s wrong Sensitivity to Operations Paying

10 Five Principles of HROs Three Principles of Anticipation Preoccupation with Failure Regarding small, inconsequential errors as a symptom that something s wrong Sensitivity to Operations Paying attention to what s happening on the front-line Reluctance to Simplify Interpretations Encouraging diversity in experience, perspective, and opinion Two Principles of Containment Commitment to Resilience Developing capabilities to detect, contain, and bounce-back from events that do occur Deference to Expertise Pushing decision making down and around to the person with the most related knowledge and expertise Slide 10

11 HRO Experience Slide 11

12 Total lives lost per year 100,000 10,000 1, Dangerous (>1/1,000) How Safe Is Healthcare? Mountaineering Health Care (1 of ~600) Driving In US Bungee Jumping Chartered Flights Chemical Manufacturing ,000 10, K 1M 10M Number of encounters for each fatality Ultra Safe (<1/100K) Scheduled Commercial Airlines European Railroads Nuclear Power Slide 12

13 But Healthcare is Different Right? Slide 13

14 One Global Measure of Patient Safety Serious Safety Event Rate (SSER) Slide 14

Unreliability and Patient Safety Deviations from bestpractice care causing Significant Patient Harm = Serious Safety Event Serious Safety Events include errors that result in death, permanent loss of

15 Unreliability and Patient Safety Deviations from bestpractice care causing Significant Patient Harm = Serious Safety Event Serious Safety Events include errors that result in death, permanent loss of function, or injury, such as: transfusion reaction medication event hospital-acquired Infection treatment error delay in treatment wrong site/side surgery or procedure fall with serious injury etc. Slide 15

A deviation from generally accepted performance standards (GAPS) that Serious Safety Event Reaches the patient and Results in moderate harm to severe harm or death Precursor Safety Event Reaches the

16 A deviation from generally accepted performance standards (GAPS) that Serious Safety Event Reaches the patient and Results in moderate harm to severe harm or death Precursor Safety Event Reaches the patient and Results in minimal harm or no detectable harm Serious Safety Events Precursor Safety Events Near Miss Safety Event Does not reach the patient Error is caught by a detection barrier or by chance Near Miss Safety Event 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Slide 16

17 Safety Event Classification(SEC) Flowchart & Guide Deviation from standard of care? Yes Did the deviation reach the patient? Yes Did the deviation cause more than minor or minimal temporary harm to the patient? Yes Serious Safety Event Death, severe or moderate permanent harm, or moderate to severe temporary harm No No No Not a Safety Event Near Miss Safety Event Precursor Safety Event Note: Known complication is defined as an adverse outcome, supported in the literature as a potential risk related to care, and is not present at the time of admission or outpatient encounter. Was there a deviation from standard of care? Was there a deviation from defined policy/procedure (P/P)? Is the P/P substandard compared to other local/national healthcare practice? Is the P/P substandard compared to other industries? If any of the above are answered yes, proceed with the classification. Slide 17

18 Consider Known Complications Four questions: 1. Was the procedure, treatment, or test appropriate and warranted based on nationally recognized standards of care? 2. Was the complication a known risk, was it anticipated, and did the care team plan ahead to take steps to prevent it? 3. Was the complication identified in a timely manner (i.e. at the time of occurrence)? 4. Was the complication treated according to the standard of care and in a timely manner? If the answer to ALL four questions is YES, the event is considered a known complication and not a Safety Event. If the answer to ANY question is NO, the event is a Safety Event. Slide 18

19 Case Studies: Practicing Event Classification Pediatrician performs a circumcision on Baby Boy B after verbally confirming with the nursery nurse that this is correct patient. Postprocedure, the physician discovers that she was to perform the procedure on Baby Boy A. The preprocedure review and time out were not performed. It was discovered that both boys (A & B) were scheduled for circumcision that day. Deviation from standard of care? Yes Did the deviation reach the patient? Yes Did the deviation cause more than minor or minimal temporary harm to the patient? Yes Serious Safety Event Death, severe or moderate permanent harm, or moderate to severe temporary harm No No No Not a Safety Event Near Miss Safety Event Precursor Safety Event Slide 19

20 Case Studies: Practicing Event Classification RN preparing to give Zosyn to patient notes that an allergy to penicillin was documented during the patient s last admission. She talks to the patient who states that she had a severe reaction to penicillin two years prior. The nurse calls the physician who ordered Zosyn. The physician checks his office notes and realizes that the patient did have a documented allergy and orders a different medication. Deviation from standard of care? Yes Did the deviation reach the patient? Yes Did the deviation cause more than minor or minimal temporary harm to the patient? Yes Serious Safety Event Death, severe or moderate permanent harm, or moderate to severe temporary harm No No No Not a Safety Event Near Miss Safety Event Precursor Safety Event Slide 20

21 Case Studies: Practicing Event Classification Elderly patient with CHF and multiple meds determined to be a high falls risk. Policy calls for bed alarm to be placed but RN and tech busy with a new admission. Patient found on floor by respiratory therapist complaining of hip pain. X-ray reveals a fractured hip. Requires surgical repair. Deviation from standard of care? Yes Did the deviation reach the patient? Yes Did the deviation cause more than minor or minimal temporary harm to the patient? Yes Serious Safety Event Death, severe or moderate permanent harm, or moderate to severe temporary harm No No No Not a Safety Event Near Miss Safety Event Precursor Safety Event Slide 21

22 Case Studies: Practicing Event Classification A healthy 26 year old 40 week gestation mother presents in active labor which progresses to the delivery of a 7 lb. baby girl with Apgar s of 10 and 10. Within 2 minutes of delivery the mother experiences escalating respiratory distress and signs of DIC. Despite all interventions, she codes and expires. Autopsy reveals an amniotic fluid embolism. Subsequent physician and nursing review of the case find that care was appropriate during the delivery, post-delivery, and during the code. Deviation from standard of care? Yes Did the deviation reach the patient? Yes Did the deviation cause more than minor or minimal temporary harm to the patient? Yes Serious Safety Event Death, severe or moderate permanent harm, or moderate to severe temporary harm No No No Not a Safety Event Near Miss Safety Event Precursor Safety Event Slide 22

23 Input Identify events from various sources Potential Safety Events JC Sentinel Events IAs/RCAs/RDEs State reportable events Claims and suits Medication Events Falls HAPUs Clinical quality incidents Peer review cases Pt. Complaints/Grievences Readmissions HAI s Others SEC Process Screen events based on organization or individual culpability and level of harm to the patient Output SEC classification & SSER Slide 23

24 Serious Safety Event Examples... Administration of Dilaudid IV rather than po resulting in code Hand-off communication failure resulted in delay in treating spinal contusion resulting in paralysis Wrong site surgery resulting in pneumothorax Arrest due to delay in response to patient s deteriorating CPR condition Demerol overdose resulting in code & transfer to ICU Delay in care for post-op elective breast reconstruction expired from sepsis and shock Extensive delay in treating bilateral chronic hip dislocation due to medical record and imaging switch on patients with same last name Delay in diagnosis/treatment missed rib fractures and hepatic contusions post MVA Slide 24

Rolling 12-month rate of Serious Safety Events per 10,000 adjusted patient days SSER = # SSE during past 12 months # APD for past 12 months X 10,000 Why a 12-month rolling average?

25 Rolling 12-month rate of Serious Safety Events per 10,000 adjusted patient days SSER = # SSE during past 12 months # APD for past 12 months X 10,000 Why a 12-month rolling average? Smoothes the curve for infrequent events Encourages sustainability in reliable safety performance (it takes 12 months for an event to drop out of the average) 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Slide 25

26 Slide 26

27 SSER Serious Safety Event Rate Serious Safety Event Rate 5 Hospital System Slide 27

Putting A Face on Safety, Baseline 2008 Tamika M 4/21/2008 Med Error John B. 9/06/2008 Delay in Dx Baby Girl V. 5/12/2008 Mother s Delay in Tx Ursula H. 2/12/2008 Fall Nicole H.

28 Putting A Face on Safety, Baseline 2008 Tamika M 4/21/2008 Med Error John B. 9/06/2008 Delay in Dx Baby Girl V. 5/12/2008 Mother s Delay in Tx Ursula H. 2/12/2008 Fall Nicole H. 8/12/2008 Post-proced Cx Eugene B. 10/27/2008, 10/28/2008 Med Error, Fall Virginia L. 8/12/2008 Delay in Tx Chantal E. 6/26/2008 Inapprop Touching Shirley H. 12/23/08 Post Proced Death Andrea M. 6/24/2008 Wrong Procedure Ms. L. 2/14/2008 Delay in Tx Robert S. 10/13/2008 Fall Helene C. 9/5/2008 Fall Nancy H. 6/18/2008 Med Error Florita H. 7/03/2008 Delay in Tx Jimmy P. 7/07/2008 Fall Teodur C. 1/29/08, 2/12/2008 Delay in Tx Sandra M. 12/10/2008 Post Procedure Death Mary D. 3/9/2008 Med Error Kathy W. 12/16/2008 Post Proced Loss of Function Gary B. 6/13/2008 Fall Kyle W. 9/13/2008 Delay in Tx Lester J. 9/5/2008 Fall Baby Boy G. 3/25/2008 Med Error Wade W. 7/16/2008 Delay in Tx Joann E. 9/23/2008 Wrong Site Surgery Alvin G. 8/17/2008 Fall Karen G. 8/5/2008 Proced Cx/Delay in Tx Baby Boy S. 8/1/2008 Wrong Pt. Procedure Lorena W. 11/10/2008 Post Procedure Death Cynthia M. 10/27/2008 Med Error Nicole S. 1/4/2008 Delay in Dx Cynthia K. 11/10/2008 Delay in Tx Calvin P. 4/4/2008 Med Error Priscilla W. 8/30/2008 Delay in Tx Mary C. 12/19/2008 Fall Joseph R. 9/08/2008 Delay in Dx. Regina D. 12/9/2008 Wrong Site Surgery Margaret H. 2/6/2008 Med Error Lance D. 10/30/2008 Delay in Tx Dale W. 10/12/2008 Med Error Robert B. 12/2/2008 Post Procedure Death Gwendolyn P. 10/28/2008 Wrong Implant Douglas T. 10/18/2008 Med Error Slide 28

29 2010 Events.a 76% Improvement! Louis R. 4/16/10 Surgical Fire Martha B. 5/22/10 Post Procedure Death Lonny A. 6/3/10 Med Error Mark C. 1/21/10 Med Error Kate B. 5/12/10 Delay In Tx Frank S. 2/22/10 Surgery Cx Boyd C. 5/25/10 Delay In Dx Rachel B. 5/30/10 Fall Frank T. 8/26/10 Delay In Dx Sara R. 11/9//10 Delay In Tx Donny L. 7/22/10 Med Error Slide 29

30 2012 Events.Three of Five Hospitals at Zero Slide 30

31 January June 2014 All Five Hospitals at Zero Slide 31

32 Safety is Safety Safety = patient safety + personal safety We cannot keep our patients safe if we first cannot keep our employees safe TCIR DART TCIR DART TCIR DART TCIR DART Hosp 1 Hosp 2 All US Hospitals Not Available Not Available TCIR Total Case Incident Rate: the number of OSHA recordable injuries and illnesses per 100 full-time equivalent employees. DART Days Away Restricted or Transferred: the number of injuries and illnesses resulting in days away from work, restricted work activity, and/or job transfer per 100 full-time equivalent employees. Slide 32

33 Worker Safety Improvements (5 hospital system Southern US) Workman's Compensation Costs Monthly Lost Time Claims July 06 - April 2011 $600,000 $500,000 $400,000 Over 300 Serious Injuries prevented 90% reduction in OSHA IIR Over $1, 200,000 saved year to date! $300,000 $200,000 $100,000 Apr-11 Mar-11 Feb-11 Jan-11 Dec-10 Nov-10 Oct-10 Sep-10 Aug-10 Jul-10 Jun-10 May-10 Apr-10 Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 Mar-09 Feb-09 Jan-09 Dec-08 Nov-08 Oct-08 Sep-08 Aug-08 Jul-08 Jun-08 May-08 Apr-08 Mar-08 Feb-08 Jan-08 Dec-07 Nov-07 Oct-07 Sep-07 Aug-07 Jul-07 Jun-07 May-07 Apr-07 Mar-07 Feb-07 Jan-07 Dec-06 Nov-06 Oct-06 Sep-06 $0 CY 07 CY 08 CY 09 CY 10 Slide Month

34 Emerging Common Cause Themes of Serious Safety Events in Healthcare Slide 34

35 Anatomy of a Safety Event Multiple Barriers - technology, processes, and people - designed to stop active errors (our defense in depth ) EVENTS of HARM Active Errors by individuals result in initiating action(s) Latent Weaknesses in barriers PREVENT The Errors DETECT & CORRECT The System Weaknesses From James Reason, Managing the Risks of Organizational Accidents, 1997 Slide 35

36 Retained Foreign Object Barriers to prevent event fail. Pt. developed infection and required an additional surgery to remove sponge Additional Surgery Circulator performed sponge count alone Scrub Tech did not participate in or require independent verification of sponge count Circulator performed final sponge count alone because Scrub Tech was assisting surgeon Surgeon did not support Circulator and Scrub Tech in performing final sponge count Slide 36

37 Common Cause Analysis A collective examination of past events for common causes (not common outcomes) E1 E2 E3 E4 E5 E6 Event (E): a condition that results from a deviation from practice expectations or standard of care IA1 IA2 IA3 IA4 IA5 IA6 IA7 IA8 IA9 IA10 IA11 IA12 IA13 IA14 IA15 Inappropriate Act (IA): a human error that violates performance expectations or takes a task outside acceptable limits Analyze by: Profession, Organization, Key Process, Key Activity, System Failure Mode, Individual Failure Mode, Human Error Type Common Causes 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Slide 37

38 168 Client Hospitals Aggregate Baseline CCA Professional Group: N = 7627 EE = 1% (80% CF) Professional Group Key Process Key Activity Human Error Type (Skill, Rule, Knowledge) Individual Failure Mode (20) System Failure Mode (26) Slide 38

39 168 Client Hospitals Aggregate Baseline CCA Key Activity: N = 7652 EE = 1% (80% CF) Professional Group Key Process Key Activity Human Error Type (Skill, Rule, Knowledge) Individual Failure Mode (20) System Failure Mode (26) Slide 39

40 As Humans, We Work in 3 Modes Skill-Based Performance Auto-Pilot Mode Rule-Based Performance If-Then Response Mode Knowledge-Based Performance Figuring It Out Mode Slide 40

41 168 Client Hospitals Aggregate Baseline CCA Human Error Type Human Error Type: N = 4874 EE = 1% (80% CF) Department/Professional Group Key Process Key Activity Human Error Type (Skill, Rule, Knowledge) Individual Failure Mode (20) System Failure Mode (26) Slide 41

42 Causal Factors of Inappropriate Acts System & Management Failure Modes (26) Structure (5 modes) Culture (8 modes) Policy & Protocol (4 modes) Process (5 modes) Technology & Environment (4 modes) Individual Failure Modes (20) Competency (3 modes) Consciousness (6 modes) Communication (3 modes) Compliance (4 modes) Critical Thinking (4 modes) Inappropriate Act 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Slide 42

43 Individual Failure Modes Baseline CCA Individual Failure Modes (IFM) Baseline CCA Findings 168 Recent HPI Clients Competency 21% Consciousness 13% Communication 9% Critical Thinking 34% Compliance 22% Department/Professional Group Key Process Key Activity Human Error Type Individual Failure Mode (20) System Failure Mode (26) Slide 43

44 System Failure Modes Baseline CCA System Failure Modes (SFM) Baseline CCA findings 168 Recent HPI Clients Structure 12% Culture 55% Processes 18% Policy & Protocol 10% Technology/Environment 5% Department/Professional Group Key Process Key Activity Human Error Type Individual Failure Mode (20) System Failure Mode (26) Slide 44

45 Observations from Healthcare CCAs It s not communication! (However opportunities exist in handoffs and communication culture.) ~77% of the inappropriate acts causing SSEs are failures in Critical Thinking, Compliance or Competency. Error prevention behaviors should emphasize stopping in the face of uncertainty, teamwork and 200% accountability Leaders need to take accountability to monitor and observe for what is expected and daily connect with the sharp end In the long-term, policies and processes must be simplified to address non-compliance and make it easier to do the right thing Slide 45

46 Three Things We Must Do To Eliminate or Reduce Events Find holes by DETECTION Reduce the size or eliminate the holes by CORRECTION Reduce Initiating Actions by PREVENTION Slide 46

47 Typical Improvement Themes Overall Goal: Establish Safety as a Core Value Create a highly reliable environment for safe practices with global safety metrics and control loops to ensure continuous improvement 1. Leadership Methods Learn, adopt, and practice leader skills for building and sustaining a culture of safety and performance excellence 2. Error Prevention Implement behavior expectations for error prevention, targeted at common causes of past events. 3. Cause Analysis Implement the philosophy and methods of a state-of-the-art cause analysis program to accelerate learning from events. 4. Lessons Learned Implement a robust lessons-learned program for events, safety metrics and great catches aimed at eliminating events. 5. Simplify Policies and Procedures Focus and simplify policies and procedures and leverage the use of job-aids to help individuals do the right thing and minimize the burden to compliance. Slide 47

48 Creating a Safe Day, Everyone Has a Role Slide 48

49 Safety is a dynamic non-event. James Reason So, what made it a safe day? What do I do to create a safe day? Everyone has a role the Board, hospital Leaders, staff and physicians. Slide 49

50 Leadership An Evolution in Perspective If you do the things you ve always done, you ll get the results you ve always gotten. From Externally driven safety focus (e.g. Joint Commission, CMS) Safety is a priority We are creating a safety culture The board and senior leader support culture change Medical staff support culture change To Internally driven safety focus (first, do no harm it s the right thing to do) Safety is a core value that cannot be compromised We are shaping a reliability culture that creates safety The board and senior leader own and manage the culture Medical staff own and promote safety culture 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Slide 50

51 The High Reliability Operating System Human Factors Integration Resilience Engineering Non-Technical Skills for Individuals & Teams Mutual Respect High Reliability Leadership Method Knowing Doing Reliability Principles as an Operating System Knowledge of Reliability Science Safety As The Precondition & Core Value 2010 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. (Revision 2, April 2014) Slide 51

52 A Attention Boards and Executives The ATM of Safety Management Attention is the currency of leadership. T Transparency and Trust Transparency = learning. Trust is the enabler of transparency. M Measure, Measure, Measure from Lee Carter, Chairman of the Board Cincinnati Children s Hospital Medical Center Slide 52

53 Safety as an Explicit Core Value "Safety is not a priority at Alcoa, it is a precondition." There is no priority higher than patient safety. If there is a conflict between safe practice and speed, efficiency or volume, then safety wins hands down. James M. Anderson President & CEO Cincinnati Children s Hospital Medical Slide 53

54 What about staff, physicians and operational leaders? People Bundle for High Reliability proven error prevention techniques Leader Bundle for High Reliability evidence-based leadership methods Slide 54

55 Shaping Behaviors at the Sharp End Design of Structure Design of Work Processes Design of Culture Design of Policy & Protocol Design of Technology & Environment Behaviors of Individuals & Groups Outcomes Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994) 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Slide 55

56 Leadership Triple Threat for Performance Reliability Set the set point 1. Define and demonstrate safety as a core value and adopt reliability as an operating system Prevent, detect & correct drift 2. Reinforce and build accountability for behavior expectations at the sharp end 3. Find problems and fix causes in systems and processes Design of Policy & Protocol Design of Structure Design of Culture Behaviors of Individuals & Groups Outcomes Design of Work Processes Design of Technology & Environment Slide 56

57 First-Focus Leadership Methods 1. Define and demonstrate safety as a core value A. Safety Moment at the start of every meeting B. Link decisions to safety C. Encourage reporting of events/problems D. Recognize, protect and thank those who ask the safety question E. Tell Stories F. Actively involve patients 2. Reinforce and build accountability for behavior expectations at the sharp end. A. Rounding To Influence with 5+:1- Feedback B. Fair and Just Culture 3. Find problems and fix causes in systems and processes A. Safety Huddle/Check-In B. Top 10 Reliability Problem List with Level 1 & 2 Action Plans Patient Safety Employee Safety Patient Experience 168 Hospital Composite CCA System Failures Structure 12% Culture 55% Process 18% Policy & Protocol 10% Technology & Environment 5% % Slide 57

58 Creating Vertical Alignment Vision For example: Safest Hospital in America Mission & Goals Zero events of harm Policy & Programs Communications required by processes and protocols Behavior Expectations Communicate Clearly Specific Actions Repeat & Read backs Clarifying questions Phonetic & numeric clarifications Slide 58

Process Design Reliability Culture 4 for VAP Prevention 1.

Daily sedation vacation and daily assessment of readiness to extubate 3.

Deep venous thrombosis (DVT) prophylaxis (unless contraindicated)

59 Process Design Reliability Culture 4 for VAP Prevention 1. Elevation of the head of the bed to between 30 and 45 degrees 2. Daily sedation vacation and daily assessment of readiness to extubate 3. Peptic ulcer disease (PUD) prophylaxis 4. Deep venous thrombosis (DVT) prophylaxis (unless contraindicated) Clinical Bundle Leadership Bundle People Bundle Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Slide 59

60 Best-Practice Error Prevention Toolkit Safety Behaviors for Everyone EXPECTATIONS: I am accountable for and commit to: Personal, Patient & Team Safety I will demonstrate an open, personal and team (200%) commitment to safety Clear & Complete Communications I am responsible for professional, accurate, clear and timely verbal, written, and electronic communication. TECHNIQUES: I will: 1. Practice Team Member Checking and Team Member Coaching using ARCC (Ask a question, Request a change, voice a Concern, invoke Chain of Command) 1. Include the 5 Ps as part of standardized structured hand-off process when transferring & sharing patient care or other work responsibilities (Patient/Project, Plan, Purpose, Problems, Precautions) 2. Use SBAR to communicate issues or concerns requiring action (SBAR = Situation, Background, Assessment, Recommendation) 3. Use Repeat-Backs and Read-Backs with 1 or 2 Clarifying Questions Have A Questioning Attitude I will think it through, and ensure that my actions are the best. 1. Stop and resolve when questions arise (validate & verify) Pay Attention To Detail I focus on the details at hand to avoid unintended errors. 1. Practice Self-Checking with STAR (Stop, Think, Act, Review) Slide 60

Changing Behaviors Set Expectations Educate & Build Skill Reinforce & Build

62 Sources of Accountability Optimal Accountability Leaders Vertical Accountability Individual Intrinsic Accountability Peers Horizontal Accountability Patient Personal & Caregiver Accountability Slide 62

63 Unique Role of Medical Staff in an HRO Slide 63

64 Medical Staff as Leaders Physicians hold a peculiar trump card they do not make safety transformation happen, but they can prevent it from happening. James Reinertsen MD HPI has come to believe after working with over 600 hospitals to improve safety and reliability: No hospital can achieve a state of high reliability without the full engagement of the medical staff. True physician leadership, optimally from the outset, is required to achieve and sustain a safe environment for patients. Slide 64

65 Critical Impact of Physicians on Safety Transformation Significant contribution to errors associated with patient injury Unequaled impact on hospital morale through their considerable influence on hospital staff and leaders Strengths may become liabilities if left unchecked Profound impact on long-term hospital culture sustained improvements require physician support There is no one else to do it! Slide 65

66 Sharp End Provider to Blunt End Influencer Proportion of time by: Residents? Attendings? Division chiefs? Department chairs? CMO? Slide 66

Vive la Difference Blunt End Leader Demonstrate in word and actions safety as a core value that cannot be compromised at any time Find and fix causes of system and process problems that challenge

67 Vive la Difference Blunt End Leader Demonstrate in word and actions safety as a core value that cannot be compromised at any time Find and fix causes of system and process problems that challenge safe, high quality care Reinforce and build accountability for behavior expectations for error prevention Sharp End Provider Know and comply with behavior expectations for error prevention make them personal work habits Encourage the practice of behavior expectations for error prevention in others Slide 67

68 Power Distance Large Distance Relations are autocratic and paternalistic Power acknowledged based on formal, hierarchical positions Small Distance Relations are consultative and democratic Relate as equals regardless of formal positions The perceived distance not necessarily the real difference as seen by the subordinate Reference: Hofestede, Geert. Culture s Consequences, 2001 (2 nd edition). Slide 68

Collegial Interactive Teams (CIT) = Tone + Tools Setting the tone You had me from Hello - Greetings include first names - Cordiality, openness - Eye contact and body language Team goals - Use we and

69 Collegial Interactive Teams (CIT) = Tone + Tools Setting the tone You had me from Hello - Greetings include first names - Cordiality, openness - Eye contact and body language Team goals - Use we and us vs. I and you - What s best for the patient Invite a Questioning Attitude - Leaders set the tone for the flow of information - If any member of the team sees anything that is unsafe, I expect you to speak up... Slide 69

Physician Safety Champions Concept select a respected, influential group of physician leaders to mold a high-reliability medical staff culture, beginning with patient

70 Physician Safety Champions Concept select a respected, influential group of physician leaders to mold a high-reliability medical staff culture, beginning with patient safety Not necessary to influence everyone to tilt the culture, only a segment equivalent to the square root of the number of participants Edwards Deming, Ph D Slide 70

71 Sustainability Slide 71

72 SSER Serious Safety Event Rate Case A Single Hospital Jan 02 Mar 02 May 02 Jul 02 Sep 02 Nov 02 Jan 03 Mar 03 May 03 Jul 03 Sep 03 Nov 03 Jan 04 Mar 04 May 04 Jul 04 Sep 04 Nov 04 Jan 05 Mar 05 May 05 Jul 05 Sep 05 Nov 05 Jan 06 Mar 06 May 06 Jul 06 Sep 06 Nov 06 Jan 07 Mar 07 May07 Jul 07 Sep 07 Serious Safety Event Rate Slide 72

73 Common Causes of Losing the Gains 1. Organizational Complacency - Senior leaders do not own and actively lead. 2. Changes in senior leadership. Safety/reliability is driven by an individual (not by the organization). 3. Safety/reliability is silo-ed and exists as a competing, one-among-many priority. 4. Medical staff is not meaningfully engaged they support safety rather than own safety. 5. Leader practices don t change they aren t leading for high reliability so error prevention techniques are never really hardwired as practice habits. Slide 73

74 In Closing Slide 74

75 Closing Thoughts 1. Safety is fundamental to our mission. 2. Harm happens on our watch, in our hospital. 3. Serious harm events are preventable and a continuous journey towards ZERO is the only acceptable goal. 4. We improve reliability and safety by the right mix of process, people and system design. 5. It will take everyone: Board, senior leaders, operational leaders, staff and physicians. Slide 75

76 Slide 76

77 Four Key Points 1. Create Safety as an uncompromisable core value - It starts at the top the ATM of safety management - Give people the license to put safety first - Personally demonstrate safety as a core value 2. Adopt Reliability Principles as an Operating System - Expect positive outcomes in all domains not just safety - Build high reliability as a step-wise approach (you can t skip steps) 3. Create alignment in leadership perspective - Board, C-Suite, Medical Staff Leaders 4. Actively detect drift to sustain the journey towards zero - Recognize reliability culture transformation is an Adaptive Change - Avoid Organizational Complacency - Harm Early Warning System Slide 77

78 Is Patient Safety a Core Value or just another priority? Slide 78

79 Camp Rules 1. Lights out at 10 PM 2. No food in the cabins 3. Safety first 4. No cohabitation Slide 79

80 Kerry Johnson Founding Partner Mobile: Healthcare Performance Improvement 5041 Corporate Woods Drive, Suite 180 Virginia Beach, VA Tel: (757) Slide 80

High Reliability Organizations Healing Without Harm by 2014

Please click your mouse or use the enter button to move onto the next slide High Reliability Organizations Healing Without Harm by 2014 1.1 Stand up if You have suffered harm as a patient at a hospital