These Things (Don t Have to) Happen Patient Safety 2013 Tami Minnier Chief Quality Officer Friday, April 5, 2013
Agenda Review the current state of healthcare Define and understand the concept of reliability Grasp three key ingredients to achieve a high reliable health care environment 2
The Current State Headlines 3
US Hospital Care. The Best on Earth, but Not the Best it Could Easily Be! Most American hospitals are safe for the vast majority of patients, the vast majority of time The vast majority of patient care givers are well trained and conscientious Western medicine s ability to save and extend human life is nothing short of miraculous however ~100 K avoidable hospital deaths Hospital medical errors costing between $20 30 billion 2+ million hospital acquired infections 5% to 7% of all hospital admissions involve an adverse drug event (ADE) and another 10% experienced the risk of an ADE
Quality and Patient Safety If the patient is not safe from accidental harm, then highquality healthcare cannot exist
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Our Challenge in Healthcare Medicine used to be simple, ineffective and relatively safe Now it is complex, effective and potentially dangerous Sir Cyril Chantler UK Health Policy Advisor Former Dean, Guy s, King s and St. Thomas Medical and Dental Schools
High Reliability Leadership Trust Process Improvement Improve Report 8 Safety Culture
Key Components to Designing Reliable Care Leadership engagement is a must in a high reliable organization Understanding the Culture of Safety within your organization Identify a Process Improvement method that will reduce variation and increase reliability 9
Reliability Science Principles used to Examine complex systems and processes Calculate overall reliability Develop mechanisms to compensate for limits of human ability Adopting these principles-increase likelihood that the system will perform it s intended functions reliably. In healthcare: Help providers minimize defects in care Increase consistency in care Improve patient outcomes
Useful Reliability Definitions Chaotic process: Failure in greater than 20% of opportunities Unsustainable Design Reliability: (80 or 90%) 1 or 2 failures out of 10 opportunities Final Design Reliability Goal : (95% or better) 5 failures or less out of 100 opportunities (Understanding the reality that perfection is the enemy of reliable process design) 11
Definition: High Reliability (IHI) Reliability Index: Unstable process: Failure in greater than 20% of opportunities 10-1 : 1 or 2 failures out of 10 opportunities 10-2 : 1 failure or less out of 100 opportunities 10-3 : 1 failure or less out of 1,000 opportunities 10-4 : 1 failure or less out of 10,000 opportunities 10-5 : 1 failures or less out of 100,000 opportunities 10-6 : 1 failures or less out of 1,000,000 opportunities Chaotic process: Failure in greater than 20% of opportunities Unsustainable Design Reliability: (80 or 90%) 1 or 2 failures out of 10 opportunities Final Design Reliability Goal : (95% or better) 5 failures or less out of 100 opportunities
Average Rate Per Exposure of Catastrophes and Associated Deaths Per Activity ( Reliability ) Amalberti, et al. Ann Intern Med.2005;142:756-764
The Frontline Test 80% performance lacks consistent clear understanding of the process (5 front line process users can not easily articulate the process) 95% performance has some variation but 5 front line users can easily articulate the process (Articulation demands simplicity) 14
Leadership Board CEO Physicians Quality strategy, quality measures Technology: Tools for supporting ideal processes Patient first mantra Zero is possible 15
Culture of Safety AHRQ Culture of Safety Survey Identifies unsafe conditions and practices Identifies the level of psychological safety I need clarity SBAR Trust and accountability Strengthening systems, measurement 16
2012 Culture of Safety Survey: Fact Sheet 32,267 surveys were administered system wide o 18,721 responses o Received from 773 individual work settings o 58% overall response rate 114 work settings (1,813 surveys) eliminated due to low response; safety attitudes from these settings aren't a valid representation of the setting. Three versions of the AHRQ survey were used: Hospital Version (H) Hospitals Cancer Centers Beacon ISMETT (translated) Medical Office Version (MO) PSD Horizon OP Nursing Home Version (NH) Senior Communities (Skilled) NOTE: Mercy took different approach (used different survey & a rolling administration (in progress)
Dimensions of the Patient Safety Survey Communication Openness (NH, H, MO) Feedback & Communication About Error (NH, H, MO) Teamwork Across Units (H) Teamwork Within Units (H, MO) Frequency Of Event Reporting (H) Handoffs & Transitions (NH, H) Management Support For Safety (NH, H, MO) Compliance With Procedures (NH) Training & Skills (NH, MO) List of Patient Safety and Quality Issues (MO) Nonpunitive Response To Error (NH, H) Information Exchange With Other Settings (MO) Organizational Learning (NH, H, MO) Overall Perceptions Of Safety (NH, H, MO) Work Pressure and Pace (MO Office Processes and Standardization (MO) Staffing (NH, H) Patient Care Tracking/Follow-up (MO) Supervisor Actions Promoting Safety (NH, H) H=Hospital; NH=Nursing Home; MO=Medical Office 18
Hospitals (Pgh) Overview of System Results: % Positive Responses Strengths and Opportunities Medical Offices Nursing Homes
Process Improvement Systems and processes drive outcomes Identify methods Lean Six Sigma Toyota PDSA Human Factors Training Spread 20
Process Improvement Human Factors Error Reduction Strategies incorporated into processes and systems Avoid reliance on memory Standardization Checklists Forcing Functions Checklists Eliminate look-alikes Create redundancy
Why has this been so difficult in Healthcare? Other high risk industries have gotten it There is a business case for them Airlines build time into schedules for forced safety Little direct financial impact to hospitals and physicians until recently
23 Questions?