4/7/2014. SocioTechnical Framework. Patient & Family Centered Care. Improving Safety Requires a Learning System

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1 Improving Safety Requires a Learning System Safety is a characteristic of a SocioTechnical system System level failures occur almost always because of unforeseen combinations of component failures Michael Leonard, MD Adjunct Professor of Medicine Duke University School of Medicine Safety Cultures Evolve Organizational Culture Geneticallywired to produce safety We methodically anticipate prevent problems before they occur Systems being put into place to manage most hazards Safety is important. We do a lot every time we have an accident Where is Yours? We show up, don t we? Chronically Complacent 3 Attribution: Prof. Patrick Hudson, Univ. Leiden SocioTechnical Framework Unmindful Reactive Systematic Proactive Generative Patient & Family Centered Care Leadership Senior and Clinical Effective Teamwork Psychological Safety Organizational Fairness Reliable Processes of Care Learning System Improvement A Culture of Safety Patient & Family Centered Care No one is ever hesitant to voice a concern about a patient Action is taken, feedback Skilled caregivers playing reliably provided, by the rules feel safe to changes are visible for discuss and learn from staff and patients errors Concerns raised by front line caregivers are taken seriously & acted upon Truly patient centered care, a true partnership, all about them Structured process for patients and family at the table, visible results Care process visible, learning and feedback sporadic Customer service is the primary focus Care process built around the convenience of providers 1

2 Patient & Family Centered Care Senior Leadership What is the social experience for patients and their families? How do we know? Do they have predictability as to the care process, or is it a series of surprises? Do we meet or exceed their expectations? Do we manage changes in expectations or outcomes? How do we fail patients and their families? What changes occur in the aftermath of failure? Cyclic flow of information with feedback and organizational learning Systematic engagement with dialogue, support and learning Process for interaction between senior leaders and front line staff They re here something bad must have happened We don t know or see them The Ideal Unit Leadership Characteristics Non Negotiable Mutual Respect, Every Interaction, Every Day. Paul O Neill Once you get used to taking the high road, putting values over expedience, and treating people like people and not the means, it gets easier and easier. Clinical Leadership Leaders create high degrees of psych safety and accountability. Leaders model the desired behaviors to drive culture of safety Training and support exists for building clinical leadership Episodic, completely dependent on the individual clinician Absent for the most part Leaders GENERATE TRUST PROMOTE RESPECT PSYCHOLOGICAL SAFETY JUST CULTURE The associated behaviors: Open; Honest; Approachable Non-negotiable; Non-hierarchical Responsive to team members speaking up about concerns and ideas Clear policy and practice of fair treatment and accountability slide 12 2

3 Effective Leadership Critical Behaviors Set a positive active tone Think out loud to share the plan common mental model Continuously invite people into the conversation for their expertise and concern Use their names 15 Effective Teamwork Teamwork and continuous learning deeply embedded and central to our culture Teamwork methodically taught and modeled across the organization Training and tools available, partial implementation Focus on teamwork awareness / training in response to adverse events If people would just do their jobs we d have no problems Teams WHAT TEAMS DO: The associated behaviors: Critical Language slide 18 Plan Forward Reflect Back Communicate Clearly Manage Conflict Brief (huddle, pause, timeout, check-in) Debrief Structured Communication SBAR and Repeat-Back Critical Language We are going to stop every time and take one minute to make sure we re doing the right thing. I just need a little clarity. I am concerned or unclear. This is unsafe. 17 3

4 Read Backs Ensuring transmission and reception of information is clear and accurate, not assuming All drug names All numbers (patient ID, dosages, etc.) Clinical histories Handoff information Debriefing Linking teamwork and Improvement What did we do well? What did we learn so we can do it better the next time? What got in the way that needs to be fixed? 360 degree View: Identify and Prioritize Highest Risk Units Geriat Target Teamwork Climate Across Michigan ICUs L&D Prioritize Safety Climate Score ORs Lab Med Unit PACU Peds Cardiopulm Surg Unit Admin No BSI = 5 months or more w/ zero No BSI 21% No BSI 31% No BSI 44% Teamwork Climate Score The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care slide 21 Attribution Bryan Sexton CULTURE IS RELATED TO Teamwork Climate Scores Across Facility CCU REHAB OR EMERG 5 WEST 6 WEST PEDS GERI DIALYSIS PERIOP PHARM 3WEST ICU NICU SICU PEDS OB HCAHPS Medication Errors per Month Days between C Diff Infections Days between Stage 3 Pressure Ulcers Illustrative Data: Extracted from Blinded Client Data 4

5 AND UNFAVORABLE EMPLOYEE OUTCOMES Teamwork Climate Scores Across Facility CCU REHAB OR EMERG 5 WEST 6 WEST PEDS GERI DIALYSIS PERIOP PHARM 3WEST ICU NICU SICU PEDS OB <60% Score = Danger Zone Using Cultural Data and Teamwork to Drive Improvement Employee Satisfaction Employee Injury per 1000 days Employee Absenteeism per 1000 days RN Vacancy Rate 9 1 Illustrative Data: Extracted from Blinded Client Data 2009 Percent Favorable 2010 Percent Favorable 2010 Hospital Partner Psychological Safety Primary responsibility of leaders, continuously modeled everywhere. Leaders model and expect the behaviors that promote psychological safety In some units it feels safe to speak up and voice a concern Personality dependent it depends who I m working with Fear based keep your head down and stay out of trouble Psychological Safety Is Local 2012 Pascal Metrics Psychological Safety Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes. A shared sense of psychological safety is a critical input to an effective learning system. Psychological Safety We are our own image consultants and best image protectors To protect one s image, if you don t want to look STUPID Don t ask questions INCOMPETENT NEGATIVE Don t ask for feedback Don t be doubtful or criticize Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, Vol. 44, No. 2 (Jun., 1999), pp Amy Edmondson DISRUPTIVE Don t suggest anything innovative PSYCHOLOGICAL SAFETY CHANGES THIS PARADIGM slide 30 Source: Amy Edmondson 5

6 Organizational Fairness / Just Culture Real events are shared by leaders, true culture of accountability and learning Clear ways to differentiate individual v. system error, safe to discuss mistakes Well understood algorithm, learning is the priority Depends who the boss is, blame and punishment are common Nothing good will come from talking about mistakes 3 2 Inherent Human Limitations Perspectives on Human Error Sidney Dekker Old View New View Limited memory capacity 5 7 pieces of information in short term memory Negative effects of stress error rates Tunnel vision Negative influence of fatigue and other physiological factors Limited ability to multitask cell phones and driving Human error is a cause of trouble You need to find people s mistakes, bad judgments and inaccurate assessments Complex systems are basically safe Unreliable, erratic humans undermine system safety Make systems safer by restricting the human contribution Human error is a symptom of deeper system trouble Instead, understand how their assessments and actions made sense at the time context Complex systems are basically unsafe Complex systems are tradeoffs between competing goals safety v. efficiency People must create safety through practice at all levels Drift = Risk Little Things Can Cause Big Problems LOW Individual Benefits HIGH VERY UNSAFE SPACE 100% Agreement Nonacceptable ACCIDENT Usual Space Of Action Illegal normal Real Life standards 60-90% Safety Reg s & good practices, accreditation standards HIGH Production Performance LOW 100% Expected safe space of action as defined by professional standards Attribution: Dr. Rene Amalberti Room 20 Look out the window A simple knee scope He s OK he s not too sedated you go home What it says on the box is not what s in the box 6

7 Drawing the Bright Line Accountability Malicious Substance Use Conscious Unsafe Repeat Events? Act Substitution Test could 2 3 others make the same mistake? Organizational Fairness Differentiate between: Unsafe individuals Reckless behaviors Risky behaviors Unsafe systems System Derived Error Safe Harbor Reason, James LEONARD M, FRANKEL A; PAT EDUC COUNSELING, 80 (2010) The Fair Evaluation and Response Chart 1. First, exclude individuals with impaired judgment or whose actions might be malicious. (These cases must be managed using other appropriate avenues i.e. employee assistance programs for substance abuse and psychosocial problems, legal authorities for cases with possible criminal intent.) IMPAIRED JUDGMENT The caregiver's thinking was impaired - by illegal or legal substances - by cognitive impairment - by severe psychosocial stressors Discipline is warranted if illegal substances were used. The caregiver's mindset and performance should be evaluated to determine whether a temporary work suspension would be helpful. Help should be actively offered to the caregiver. MALICIOUS ACTION The caregiver wanted to cause harm. Discipline and/or legal proceedings are warranted. The caregiver's duties should be suspended immediately. The Fair Evaluation and Response Chart 2. Second, use best judgment to categorize each action as either Reckless, Risky or Unintentional based on the definitions in the Chart. The categorization determines the general level of culpability and possible disciplinary actions, however these general categories require further analysis as below prior to making a final decision. RECKLESS ACTION The caregiver knowingly violated a rule and/or made a dangerous or unsafe choice. The decision appears to be self serving and to have been made with little or no concern about risk. The caregiver is accountable and needs re-training. Discipline may be warranted The caregiver should participate in teaching others the lessons learned. RISKY ACTION The caregiver made a potentially unsafe choice. Their evaluation of relative risk appears to be erroneous. The caregiver is accountable and should receive coaching. The caregiver should participate in teaching others the lessons learned. UNINTENTIONAL ERROR The caregiver made or participated in an error while working appropriately and in the patients' best interests The caregiver is not accountable. The caregiver should participate in investigating why the error occurred and teach others about the results of the investigation. Partially adapted from David Marx. slide-39 slide-40 The Fair Evaluation and Response Chart 3. Third, perform a Substitution Test by asking at least 3 others with similar skills if they, in a similar situation, would act similarly. If the answer is No the individual is accountable. If the answer is We do it all the time or answers are divided, assign accountability per below - and remember that an important goal is to ensure others perceive responses as fair: The system supports reckless action and requires fixing. The caregiver is probably less accountable for the action, and system leaders share in the accountability. The system supports risky action and requires fixing. The caregiver is probably less accountable for the action, and system leaders share in the accountability. The system supports error and requires fixing. The system's leaders are accountable and should apply error-proofing s. 4. Fourth, evaluate whether the individual has a history of unsafe or problematic acts. If they do, this may influence decisions about the appropriate responsibilities for the individual i.e. they may be in the wrong job. Organizations should have a reasonable and agreed upon statute of limitations for taking these actions into account. The Substitution Test is a concept of James Reason. Reliable Processes of Care Safety is built at all levels of the organization, continuous risk assessment and learning Active situational awareness leads to early problem detection and resolution Healthcare systems are complex, risk must be actively managed Adverse events stem from human error who did it? If smart people try hard and know what they re doing, they won t make mistakes slide-41 7

8 Annotations 4/7/2014 The Quality of Healthcare in America 30 evidenced based practices: ACE inhibitors for CHF Beta blockers / ASA for post MI The chance of an average patient receiving appropriate care was 55% Avoidable Patient Harm 30% of hospitalized patients have something happen to them you and I wouldn t want to happen to us 6% are harmed seriously enough to stay in the hospital longer and go home with a disability >200,000 Medicare patients die every year from medical harm Process Improvement Unit level learning systems, continuous learning aligned with organizational goals Robust unit level learning and is the norm Knowledge of testing, process, collaborative work We try harder after process failures or adverse events Lots of first order problem solving, simple things don t get fixed Debriefing Linking teamwork and Improvement What did we do well? What did we learn so we can do it better the next time? What got in the way that needs to be fixed? The Ideal Unit ICU Percent of Patients Receiving all Four Aspects Of Ventilator Bundle 1: Marked beds at 30 degree angle 2: Fact Sheet for staff education 3: Poster with weekly data feedback 4: Vent bundle posted in all vent patient rooms 5: Began initial trials of Daily goal sheet and pre-extubation sheet 6: Initiated Powerpoint education for RT/RN 7: Initiated Clinical Pharm rounds 8: 1st test of multidisciplinary rounds 9: Expanded use of Pre-extubation sheet 10: Staff education on Goal sheet; mini inservices on unit on SBT and Preextubation sheet 11: Incorporated Goal Sheet into Multidisciplinary Rounds 12: Impact Extravaganza (staff/md education) 13: Expanded multidisciplinary rounds to include additional disciplines 14: Check compliance on night shift past 2 weeks 15: New sign at HOB, 16: One on one follow up by Nursing & RT managers on collaboratiion in weaning process 8

9 Acute Medicines Unit, Ninewells Hospital, Dundee, Scotland Arun Chaudhuri, Medical Director The Learning Board O2 Prescribing DVT Prescribing Compliance Bld Culture Contamination Hand Hygiene Early Warning Scores Bundle Compliance with Med. Reconciliation Pressure Ulcer Prevention Bundle 50 Mercy Andersen Hospital, Catholic Health Partners Melissa 9