High Reliability Organizing (HRO) in the Ambulatory Setting

High Reliability Organizing (HRO) in the Ambulatory Setting High Reliability Training Sisters of Charity Leavenworth Health System 25 May 2016 2014 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. 1

This activity is jointly-provided by SynAptiv and the Colorado Hospital Association Conflict of Interest Disclosure Statement I have no financial interest or other relationships with the industry relative to the topics being discussed. 2

Clearly 1 Patient Safety preventing harm to patients - is a worthy end in it s own right 2 The system reliability needed to help keep patients safe is a significant success factor in quality, satisfaction, and cost. Slide 5 Less Clear 1 The patient safety culture work accomplished in acute care hospitals is not applicable to the physician s office. 2 The physician s office does not have the need or the time or the resources for patient safety culture. 3 This care setting has not seen the benefits of patient safety culture. Slide 6 3

Non-Technical Skills Non-technical skills describe how people interact with technology, environment, and other people. These skills are similar across a wide range of job functions. These skills include attention, information processing, and cognition. Generic non-technical skills: Situational awareness Attention Communication repeat backs call outs phonetic & numeric clarification clarifying questions inquiry, advocacy, assertion Critical thinking Protocol use Decision-making Flin, O Connor, and Crichton Safety at the Sharp End Slide 7 Safety Culture Interpolation hpiresults.com blog, Safety Interpolation, 2 August 2012 Schimmoller, Power Engineering, 1 October 2002 Slide 8 4

Death By Numbers 44,000 to 98,000 patient deaths per year from medical errors To Err is Human, Institute of Medicine (1999) James Estimate 210,000 to 440,000 patients, each year, suffer from preventable harm that contributes to their death. James, John, A New Evidence-based Estimate of Patient Harms Journal of Patient Safety, September 2013, Volume 9, Issue 3 Slide 9 Darrie Eason Misdiagnosis Sebastian Ferrero Medication Error Patrick Sheridan Misdiagnosis Cal Sheridan - Misdiagnosis Slide 10 5

Patient Exposure 35 million hospital discharges annually 900 million clinic visits annually Outpatient visits occur 25 times more frequently than hospital admissions Slide 11 Outpatient vs. Inpatient Injuries Volume and Severity Patients with Negligent Claims 4500 4000 3500 3000 2500 2000 1500 1000 500 0 Total Moderate Severity High Severity Death Source: Phillips RL Qual Saf Health Care 2004;13:121-126 Slide 12 6

Slide 13 Take Home Points Office-based care has risks of patient injury and physician liability. Diagnostic delays/errors and medication-related errors are particularly common - solutions likely require improvements in both system support and physician practice Research into patient safety in the ambulatory setting lags behind the hospital - There is little formal research on effective interventions in ambulatory care settings, but there are several promising approaches Slide 14 7

Questions for Reflection Do people get well before being discharged from our hospitals? Have I prescribed life-saving meds? Has EMS transported a patient to my office from long-term care? And back? Has my team ever transferred a patient onto an exam table? Have I done procedures in the office that would require a time-out in a hospital? Slide 15 What Will It Take? Patient Safety WalkRounds + Address Patient Safety Alerts + Non-Punitive Approach to Reporting + TeamSTEPPS + Strategies in Targeted Outcomes BUT Will This Produce Significant Sustained Reduction in Serious Safety Events & Culture Change Across the Organization? Slide 16 8

Reliability Culture - Genius of the AND Safety Focus + performed as intended consistently over time = No Harm Evidence-Based Process Bundles + performed as intended consistently over time = Clinical Excellence Patient Centered + Financial Focus + performed as intended consistently over time HIGH RELIABILITY performed as intended consistently over time = Satisfaction = Margin 2010 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Slide 17 More Rules or More Tools? Focused on several known harm events Synergy with policy & protocol Coverage on broad range of harm events Synergy with people, process, and technology Slide 18 9

Getting Started 1. Authentic safety first leadership 2. Safety Culture or Safety Climate assessment (to confirm a firm foundation) 3. Common Cause Analysis: a. Rule-out broken process(es) and knowledge & skill deficiencies as majority causes b. Select behaviors/skills indicated by study 4. Culture design leaders, staff, and medical staff 5. Educate leaders, staff, and medical staff Slide 19 Physician Practice Sites Common Cause Analysis Data Comparison 2010-2011 Top 10 Patient Safety Event Types Comparison based on systems comprising 72 hospitals in HPI database 1 2 3 4 Compare 17.8% 21.7% 38.1% 23.7% 23.6% Delay in Diagnosis or Treatment (CM8) 44.4% 52.2% 23.8% 28.9% 21.3% Medication Error (CM1) 6.7% 4.3% 19.0% - 15.2% Other Care Management (CM10) - HAI 8.9% 4.3% 4.8% 10.5% 10.2% Fall (EE3) 4.4% - - 5.3% 7.4% Other Procedural (PR6) - - - 5.3% 4.2% Retained Foreign Object (PR4) - - - 5.3% 2.2% Wrong Site Surgery (PR1) 13.3% 9.0% - - 2.2% Wrong Patient Surgery (PR2) - - - 2.6% 1.2% Suicide or Attempt (PP3) - - - - 1.1% Grade 3 or 4 Pressure Ulcer (CM7) 45 23 21 38 1,1613 Slide 20 10

Professional Groups Experiencing Acts in Healthcare Safety Events Comparison based on systems comprising 72 hospitals in HPI CCA Database 1 2 3 4 Compare Physician Practice Sites Common Cause Analysis Data Comparison 2010-2011 45.9% 48.5% 12.5% 19.7% 39.0% Nurse 39.1% 36.3% 46.9% 36.3% 30.6% Physician + PA 8.2% - 9.4% 9.1% 8.3% Care Team 2.0% 1.5% - 18.2% 7.7% Technician/Technologist 0 - - 3.0% 3.4% Pharmacist 0.3% - 25.0% - 2.6% Nurse Extender 0.3% 9.1% 3.1% 3.0% 2.2% Management 1.4% 4.5% 3.1% - 1.9% Unit Clerk 0.3% - - 1.5% 1.6% NP + CRNA 1.0% - - - 1.1% Therapist 294 66 32 69 3,112 Slide 21 3 Reasons for a Culture of Safety in Support Organizations 1. Harm at their hand all professional groups in a healthcare have been the direct cause of harm. 2. Cross Monitoring if support organizations are not always part of the problem, they can still always be part of the solution. 3. Readiness high-reliability support organizations unwind time pressure, distractions (interruption type), and high continuous workload. Slide 22 11

Physician Practice Sites Common Cause Analysis Data Comparison 2010-2011 Top 10 Acts Leading to Patient Harm Comparison based on systems comprising 72 hospitals in HPI CCA Database 1 2 3 4 Compare 12.6% 30.3% 41.0% 14.9% 18.0% Checking/Verifying/Identifying 22.1% 15.1% 12.8% 14.9% 15.6% Coordinating care 13.3% 6.1% 7.7% 6.0% 10.0% Assessing 3.4% 6.1% 2.6% 1.5% 6.7% Administering 6.1% 16.7% 10.3% 11.9% 6.4% Physician ordering 13.6% 1.5% - 3.0% 5.7% Interpreting 5.1% 4.5% - 1.5% 4.8% Notifying 2.7% 4.5% - 9.0% 3.1% Performance technique 1.7% 1.5% 2.6% 6.0% 3.1% Data Entry & Documenting 3.4% - - 2.0% 3.0% Monitoring/Observing 294 66 39 67 3,112 Slide 23 Human Error Classification Based on the Skill/Rule/Knowledge classification of Jens Rasmussen and the Generic Error Modeling System of James Reason Activity Type Error Types Error Probability Skill Based Rule Based Knowledge Based Familiar, routine acts that can be carried out smoothly in an automatic fashion Slips Lapses Fumbles Problem solving in a known situation according to set of stored rules, or learned principles Wrong rule Misapplication of a rule Non-compliance with rule Problem solving in new, unfamiliar situation for which the individual knows no rules requires a plan of action to be formulated Formulation of incorrect response 1:1,000 1:100 3:10 to 6:10 Compare 25% 60% 15% 1 - - - 2 40.9% 52.3% 6.8% 3 42.9% 57.1% - 4 31.4% 54.3% 14.3% Slide 24 12

Physician Practice Sites Common Cause Analysis Data Comparison 2010-2011 System Causes - Why Data 1 2 3 4 Compare Structure (job design) 8.9% 4% - 5.8% 10.5% Culture (people & people interaction) 57.4% 62% 100% 57.7% 57.3% Process 15.8% 12% - 19.2% 19.3% Policy & Protocol 5.9% 10% - 7.7% 8.2% Technology & Environment 11.9% 12% - 9.6% 4.7% Acts coded for system cause 101 66 12 52 2,444 Culture Preventable = 72.7% 75% 100% 74.0% 76.3% Slide 25 Physician Practice Sites Common Cause Analysis Data Comparison 2010-2011 People Causes - How Data 1 2 3 4 Compare Knowledge & Skill 3.9% 5.2% 8.3% 9.1% 12.8% Attention on task 19.5% 24.2% 25.0% 24.2% 15.0% Information processing 16.9% 10.6% 8.3% 7.8% 8.7% Critical Thinking 29.9% 24.2% 16.7% 33.3% 36.0% Non-Compliance 15.6% 10.6% 33.3% 18.2% 21.4% Normalized Deviance 14.3% 25.2% 8.3% 9.1% 6.0% Acts coded for human error 77 66 12 33 1,820 Slide 26 13

Tools can be the same as other care settings in the system Novant Medical Group 1. Questioning attitude 2. Clear communications 3. Know & comply with Red Rules 4. Self-checking 5. Support others Slide 27 Tones can also be the same as other care settings in the system Sentara Martha Jefferson 1. Smile and greet others 2. Use preferred names 3. Listen with empathy and intent 4. Communicate positive intent 5. Provide for questions Slide 28 14

Training May Be Different Novant Medical Group Main Line Health System Summa Healthcare Riverside Health System Sentara Martha Jefferson Swedish Medical Group Group Health Cooperative Format Practical Trainers Two 1 hour sessions One 3 hour session One 3 hour session One 3 hour session One 3 hour session One 2 hour session One 4 hour session Video examples Experiential learning Experiential learning Experiential learning Experiential learning Experiential learning Video plus simulation Lead clinicians Staff Lead clinicians Lead clinicians Staff Leaders Staff Slide 29 Leadership Should be the Same Slide 30 15

Safety Message A safety message is a two-minute dose of safety: 1. Share your convictions relative to patient safety or personal safety 2. Explain how safety contributes to our mission 3. Explain how our policy & practice contribute to safety 4. Tell a story about something good that we did 5. Tell a story about something bad that happened to us 6. Tell a story about harm in another healthcare system 7. Tell a story about another system preventing harm 8. Read a Safety Success Story from your people 9. Read a Safety Success Story from the group 10. Review our safety behaviors 11. Teach applications of our safety behaviors to our jobs 12. Discuss the importance of reporting problems 13. Discuss the importance of speaking-up for safety 14. Ask staff to be safe, and explain how 15. Thank staff for practicing / working safely Slide 31 The Safety Huddle Football teams have hours of practice, hours of film, hours running plays and they still huddle before each play. Safety Huddle Agenda 1. LOOK BACK Significant safety or quality issues from yesterday 2. LOOK AHEAD Anticipated safety or quality issues for today 3. Follow up on Start-the-Clock Safety Critical Issues Daily Check-In for Safety, PS&QH September/October 2011 Slide 32 16

Rounding to Influence (RTI) a High Impact/Low Investment Leadership Method A technique for reinforcing a vital behavior or performance expectation linked to a core value Connect to a core value Assess knowledge and reinforce the specific behavior expectations Identify problems impacting ability to follow the behavior expectations Ask about commitment actions 2009 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Slide 33 Local Learning System Tools Cause Solving Process mapping, task analysis, ask why five times, A3 Acton Plan Process Improvement Guide Solutions for human error in the Generic Error Modeling System (GEMS), human factors, protocol, and process Learning Boards Visual management of new, working, and solved problems Slide 34 17

Measurement Should be Different 1. Use Serious Safety Event Rate (SSER) with denominator of 100,000 patient visits 2. Consider including Precursor Safety Events (PSE) 3. Consider an automated Global Trigger Tools (GTT) for outpatient care settings 4. Baylor Health Care performed a demonstration project and found same fidelity with top 5 triggers Slide 35 Rolling 12-month rate of Serious Safety Events Per 100,000 visits SSER = # SSE during past 12 months # APD for past 12 months X 100,000 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 36 18

System A 12-month moving range per 100,000 patient visits Slide 37 System B 12-month moving range per 100,000 patient visits Slide 38 19

Habit Formation Should be the Same Slide 39 The HPI Team Craig Clapper PE, CQM/OE Partner & Chief Knowledge Officer Healthcare Performance Improvement 5041 Corporate Woods Drive, Suite 180 Virginia Beach, VA 23462 Tel: (757) 226-7479 www.hpiresults.com Slide 40 20