High Reliability How to Significantly Improve Safety Systems Using HRO Methodology Tom Peterson, MD VP, Chief Safety Officer SCL Health April 15, 2015 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved.
No Conflicts of Interest
The Journey to High Reliability in Healthcare 2010-2020 2000-2010 High Reliability Process improvement - Mandated measures -NPSG s,hac s, Never events, VBP, MU Generative Safety is how we do business around here Proactive Safety leadership and values drive continuous improvement 1990 2000 Evidence Based Guidelines Clinical Protocols Core Measures IOM Report Calculative We have safety systems in place to manage all harm events 1980 1990 Regulations Compliance Malpractice - Captive insurance boom Reactive Safety is important, we do a lot every time we have an accident <1980 s Pathological Who cares as long as we re not caught
Naval Aviation Mishap Rate Class A Mishaps/100,000 Flight Hours 60 50 40 30 20 10 776 aircraft destroyed in 1954 0 Angled Carrier Decks Naval Aviation Safety Center NAMP est. 1959 RAG concept initiated NATOPS initiated 1961 15 aircraft destroyed in 2008 Squadron Safety program System Safety Designated Aircraft ACT HFC s 1.64 50 65 80 08 Fiscal Year Source: www.safetycenter.navy/mil ORM Flight Mishap Rate 4
Commercial Aviation
Significant Events at US Nuclear Plants Annual Industry Average, Fiscal Year 1988-2006 Significant Events are those events that the NRC staff identifies for the Performance Indicator Program as meeting one or more of the following criteria: A Yellow or Red Reactor Oversight Process (ROP) finding or performance indicator An event with a Conditional Core Damage Probability (CCDP) or increase in core damage probability (ΔCDP) of 1x10-5 or higher An Abnormal Occurrence as defined by Management Directive 8.1, Abnormal Occurrence Reporting Procedure An event rated two or higher on the International Nuclear Event Scale Source: Nuclear Regulatory Commission Information Digest (1988 is earliest year data is available) Updated: November 2007 6
American Construction Company Worker Injury Rates 12 10 8 6 4 2 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Mortenson RIR 6.55 8.11 6.9 8.18 8.45 7.28 6.89 5.11 5.74 4.47 5.87 3.88 5.06 2.98 1.69 1.28 1.69 1.77 0.64 BLS RIR 11.2 10.1 10.2 9.5 8.9 8.8 7.6 7.1 6.8 6.4 6.40 5.90 5.40 4.70 4.30 4.00 3.90 3.70 BLS DART 4.7 4.2 4.3 4.3 3.9 4.1 3.5 3.8 3.6 3.4 3.40 3.20 2.80 2.50 2.30 2.10 2.10 2.00 Mortenson DART 5.84 4.56 4.3 5.45 6.35 5.34 4.28 2.96 3.49 2.59 3.02 1.91 2.88 1.63 0.70 0.85 1.19 1.04 0.20
Healthcare? We lead in both preventable deaths to our customers (patients) as well as injuries to our employees. Our time is far overdue.. Sisters of Charity of Leavenworth Health System, Inc. All rights reserved.
The Numbers Today Are Daunting. 200-400,000 deaths caused each year to patients in American Hospitals¹ 3 rd leading cause of death in the US 670,000 injuries every year to healthcare workers² Healthcare leads all industries in workers injuries Up to 20-30 times higher than such industries as high rise construction and aluminum plants BLS average RIR for American Hospitals = 6.4, Alcoa Aluminum in 2014 =.98! 1- Jour Patient Saf, 2013;9: 122-128 2- Janocha JA, Smith RT. Workplace Safety and Health in the Health Care and Social Assistance Industry, 2003 07. Washington, DC: US Bureau of Labor Statistics; 2012
Do We Really Want To Be Ultra Safe? Total Lives Lost Per Year Dangerous >1/1,000 100,000 10,000 1000 100 10 1 1 10 Healthcare (1 of ~ 600) Mountain Climbing Bungee Jumping Driving in the US Chartered Flights Chemical Manufacturing 100 1000 10,000 Number of Encounters 100K 1M Ultra-safe <1/100,000 Scheduled Commercial Airlines European Railroads Nuclear Power 10M
Healthcare s Wake Up Call 44,000 to 98,000 patient deaths per year from medical errors (120-268 dead every day) (1 death per every 378 admissions) To Err is Human, Institute of Medicine (1999) Created A Lot of Talk Patient safety publications before and after the IOM report, To Err is Human Quality & Safety in Health Care (2006) Each month,134,00 hospitalized Medicare patients suffer from harm from medical care, while 15,000 of these patients die due to medical mistakes; 44% of all events rendered as preventable. Landrigan, New Eng Jour Med, (2010)
Frankly, there is little guidance in the high reliability science and in the case studies. There s very little guidance on how you get from our pretty mediocre state with quality, with respect to quality and safety. How do you get from low reliability to high reliability? So we have considered that problem and asked the question, how do we create blueprints, roadmaps, assistive devices that allow health care organizations to build toward high reliability? What would it take? Mark Chassin, M.D., President, The Joint Commission 2011
What is an HRO?
HRO Descriptions Can Be Confusing Sutcliffe and Weicke The 5 Principles Mindfulness TJC Chassin and Loeb Leadership Culture Process improvement Amalberti Accepting limits Abandon autonomy Craftsman to equivalent actors Sharing risk vertically Managing visible risk Health and Safety Executive The 5 Principles Anticipation and Containment Leadership Safety culture Continuous learning Admiral Hyman Rickover Rising standards over time (more than the minimum) Highly capable people trained over a wide range Leaders face bad news (mobilize effort, report up) Healthy respect for dangers Training is constant and rigorous All functions fit together Learning from the past
Journey From Improvement to High Reliability... 10-6 10-5 10-4 10-3 Design to Optimize Human Performance at the point of people interface: Easy to do the right thing impossible to do the wrong thing Mistake proofing/human factors Industry standards The occurrence is viewed as a failure Reliability Culture Mindfulness The Mindset of Failures, Accountability Safety as the core value, Leadership commitment A 1000 safety champions Behavior expectations for error prevention Collaborative Interactive Teams 10-2 Process, Protocol 10-1 &Technology Resource allocation Evidence-based practice (e.g. bundles) Technology enablers The blunt end barriers Reference: HPI, Inc, Sutcliffe and Weick
Things Done Right 99.9% of the Time Means.. Two unsafe landings at O Hare Airport every day 16,000 lost pieces of mail every hour 20,000 wrong drug prescriptions every year 500 incorrect surgical operations a month 50 newborn babies dropped by a doctor every day 32,000 missed heart beats a year 22,000 checks deducted from the wrong account every hour
Quality Improvement is Getting to 99.9% High Reliability is going from the 99.9% to 100%
Safety is One There are not two safety s in HRO s
In An HRO It Does Not Matter If It Is. MSK injuries Sharps/needlesticks CAUTI s Patient falls Employee slips and falls Pressure ulcers Admissions Pressure ulcers Combative patients Hand washing CLABSI s
It Sounds Simple. Do everything you can to prevent it from happening. If it happens, do everything you can to contain the process.. Then do everything you can to correct it, or keep it from happening again. The key is the failure(s) identified are precursors to an actual event.
Safe Patient Handling An unsafe handling is a failure Do Everything to Prevent It From Happening How do you hire? How much training did they get, and do they get? How strict is your screening and policies? Do they all learn error prevention behaviors? Do they all know it is a safe culture they are entering? Do they know safety is a core value? Is there peer checking always? Is there 200% accountability? Can they speak up and question, stop when we see a potential hazard? Are we rewarded for that? Do they report all near miss events and safety hazards? Are they rewarded for reporting? Do they work as a team? Are you always looking for a new way to make it better?
Safe Patient Handling If a failure almost occurs. Do everything you can to contain it if it happens. Did they get the proper equipment? Are you reporting the latent weaknesses always? Did we use leading indicators? Is there continuous training, a need to retrain? Are structures designed appropriately? Did they use the safe behaviors? Is the process standardized? Are you trending the failures? Was there an immediate shared learning? Was there peer checking, where was the team?
Safe Patient Handling If a failure caused an event. Do everything you can to correct the defect and keep it from happening again without missing a beat Did you do an immediate ACA on the event? Did you common cause the multiple events to identify a common process? Did you correct the root cause? Was it a system or individual failure, or both? Did you do an immediate huddle (SWARM), with senior execs, to de-brief the event and show your care for the employee and identify the most beneficial information? Have you audited your process recently? Was there an immediate shared learning with everyone? Was the event shared system wide? Was the action plan followed through on? Systems changes implemented?
An HRO High reliability is a mindset Strong responses to all weak signals The occurrence is viewed as a failure High reliability is always learning new ways, new skills. One is always one too many, no excuses Refuses to follow simplified processes High reliability exists only when leadership owns the process, all staff believe in the commitment.. High reliability requires a robust safety culture. There is not one safety officer, there are 2000 of them High reliability is being resilient, and strong infrastructures exist to respond to the needed changes The responses and shared learnings are immediate, and do not alter operations Committed to resilience High reliability is a journey
The High Reliability Mindset - Mindfulness First, we have to view previous norms as failures, or at least extremely dangerous, and be totally preoccupied with preventing it from happening Near misses are highly valued The weak signals are the most important Leading indicators become the norm Not an external mandate, but an internal value Mindfulness is horizontal and vertical The vertical processes are perfected with no defects, while the horizontal culture is always aware if deviations Always new appreciation of current context
CAUTI HAI/HAC Experience 45 The Lean/QI project began here CAUTI HAI/HAC Annual Comparison 40 35 Number of CAUTI Events 30 25 20 15 The new mindset began here CAUTI HAC 10 5 0 2010 2011 2012 2013 2014 2015 0 still in 2015!
The Near Miss Reporting Strong Responses to Weak Signals Many industries use this as accepted practice Airlines, construction, nuclear power, steel, mining, military, petrochemical Near miss reporting has been used in several industries for the last 40 years Near misses, leading indicators, need to be valued by all in the organization Data and skills need to exist to trend, analyze and act on near misses
Leadership Must Own the Process Leadership walks the walk Resources are supported The leader knows every harm event, defect Structures are developed The leader drives accountabilities Safety is a core value
If you want to understand how is doing, you need to look at our workplace safety figures. If we bring our injury rates down, it won t be because of cheerleading or the nonsense you sometimes hear from other CEO s, or some training or new program. It will be because the individuals at this company have agreed to become part of something important: They ve devoted themselves to creating a habit of excellence. Safety will be an indicator that we re making progress in changing our habits across the entire institution. That s how we should be judged. Paul O Neill CEO of Alcoa 1987-1999 15 years later injury rates are their lowest in history!
Always Learning New Ways One is one too many A commitment to zero Always training for new skills Shared learnings Question existing standards, assumptions Continuously changing based on new experiences Willingness to invent new processes
A Robust Safety and Learning Culture Everyone is engaged Clinical and non-clinical A 1000 safety champions Flexible, just, learning, informed and reporting Continuous training and skill building for all Full transparency Physician champions, the hierarchy is flat Stories, awareness, rewards
The Journey The culture and mindsets take years to develop Sustainable commitment is required Not a flavor of the month or a training It should not matter who the leadership is While it can be hard to measure, it is easy to experience when it exists
The Big Questions 1. Structures for culture change 2. Our behaviors are we serious? 3. Are we really reporting everything? 4. Our leaders? 5. Education of staff and physicians 6. Are we really committed? 7. Can we measure our progress? 8. How do we sustain progress?
SCL HRO Program - 2015 Processes Sharps, SPH, Violence and STF s programs Cause analysis and HRO training - > 400 trained Human error prevention trainings 6,000 trained, > 250 trainers Core value Site assessments, apology and disclosure program Safety coach program 100 to train Safety and Physician Safety Committees Lessons learned program Daily huddles unit and hospital wide, executive rounding, Event reporting teams, Regular audits Safety Officers, System Directors Patient and Associate Outcomes Event reporting increased > 100% in 1 year System RIR - 40% in the past 4 years, sharps 25% in past year Current RIR 2.97 Serious safety event rate 20% Workers comp and litigation claims costs decreased over 4 years both by 30%
Questions?
Implementing the HRO Mindset in Healthcare 1/1,000,000 Drive Continuous Learning and Training the Accountabilities View the occurrence as a FAILURE! Human factors Error proofing Industry standards Hire to Fit Leadership accountabilities Leading indicators Performance reviews Create the Reliability Culture Safety stories - Awareness Campaigns Awards/positive feedback Safety Champions Safe environments Videos Increased reporting Safety coaches Unit based expertise - Physician safety champions Safety as a Core Value - Leadership behaviors Build the Foundation Swarms- (Executive) -Weekly Call ins Leadership Commitment - Safety Officers - Daily huddles (hospital and units) Safety Leadership Teams (council) The Right Equipment - Physician Safety Teams Error Behavior Prevention Trainings - Shared Learnings Leadership Ownership 1/100,000 1/10,000 1/1,000 1/100 1/10
. The Vertical Reliability establishes the needed structures and processes to prevent the failures from occurring, while Horizontal Reliability creates the culture for the safety behaviors to prevail... Central Line Infections Questioning attitude Focusing Slips and Falls Safe Patient Handling Bundles Rapid cycle Lean/PI Readmissions Trainings Critical thinking Needle stick injuries High Reliability Safety Culture Speaking up Evidence Based Protocols CAUTI s PDCA Peer checking and on, and on, and on Clear communication..but it only can happen if the mindset exists! 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
We are what we repeatedly do. Excellence, then, is not an act, but a habit. Ἀριστοτέλης 384 BC 322 BC Student of Plato, Tutor to Alexander
High Reliability Patient Safety = Employee Safety Concepts directly apply to caregiver safety Shared values, tools and goals Institutional system for HRO creates framework for all safety initiatives Safe patient handling and mobility directly impacts both patient and caregiver Safety
Entirely In The Same Net Patient Handling Medication Errors Falls Wrong Surgery Site Delay in Diagnosis or Treatment Sharps
HRO Elements = Safe Patient Handling Success Near Miss Reporting Safety Event Follow Up Engaging Leaders about Every Injury Daily Safety Huddles Safety Awareness of each Employee Error Detection & Prevention Skills
Tools to Improve Reliability Crew Resource Management airline industry TeamSTEPPS department of defense Brief execute de-briefs naval aviation Daily Check ins nuclear power Lean Henry Ford, Toyota 42
Obsession With Failure Current Practice: We learn about patient handling issues AFTER an injury has occurred. HRO Practice: Learn about every near miss BEFORE an injury occurs.
Child Proof Your Safe Patient Handling Program and Your Hospital!
Be Prepared for Work Arounds Lets you learn about work-arounds to truly create a successful program!
Near Miss Reporting System Non-Punitive Fast and Easy Meaningful Categories Encourage Reporting! Immediate Management Follow Up
RL6 Reports There is no repositioning/highback slings in the supply room. Linen called and only had two slings available. Pt. needs frequent repositioning in bed, lift room would be safer for pt and staff. Patient unable to do 75% of his own repositioning in bed in a lift room, with a reposition sling underneath him asked me to "boost him up in bed" and requested that his wife help me. I explained to him that we use the overhead lift system with the reposition sling if he is unable to get himself back up in bed.
Are slings available? Is there enough equipment? Do we need different slings or tools? Is everyone adequately trained? Are there clinicians who need specific education? Are assessments accurate?
Cover Holes in the Swiss Cheese C.N.A. is develops a back injury. Other Caregivers Do Not Speak Up & Suggest Using Lift Patient Develops Deep Tissue Injury and Stage 4 Pressure Ulcer Caregivers Not Using Available Lift To Reposition Patient Sling is not under patient, training inadequate, low par levels
Lift Team Safe Patient Handling Committee Super Users, Coaches, Champions Simple Policy & Procedure with Concise Language Organization support for caregiver safety when moving patients. Access to Equipment Sling Flow Super Users, Coaches, Champions Equipment that meets needs Easy access to equipment Correct amount of equipment Distraction Critical Thinking Time pressure Assumptions The blunt end structures cannot prevent all errors, so the sharp end behaviors must exist always Correct Equipment is used to reduce injury and improve patient outcomes every time. Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994)
3 Ways We Learn 30 in 10,000 errors per day 0.3% forget to hook up one sling loop 1% Error Rate choose to boost and not use lift 30% Error Rate do not know how to use new equipment but try without asking for help
Type of Error: Skill Based- Auto Pilot Rule Based- Performance How we re taught or noncompliance Knowledge Based- Lack of knowledge Action Error Prevention Strategy: Focus Stop on proper and Think technique for sling loop placement Education, risk or burden reduction Create better location for slings Enforce management expectations Stop and find an expert Find Lift Champion or Site Safe Patient Handling Coordinator
Near Miss Follow Up Pertinent Information From Reporting System February 9, 2015 Specific Event Type: Patient Handling Type of Person Affected: Associate Injury Incurred? No Equipment Involved/Malfunctioned? No Was lift equipment used? No If no, why wasn't this used? (Explain): the nurse didn't seem to think it mattered. As i used my voice about concern, she again didn't seem to think it matter. Brief Factual Description: I went up to image the patient in room ####. the patient was in a room with a lift however there was no sling under the patient. The patient could not move at all. I told the nurse the patient need a sling and she didn't seem to care. Again i spoke up when the nurse asked me to help boost the patient up that this patient needs a sling. No one was injured today but this patient cant move and someone will eventually get injured or injury to the patient. Immediate Actions Taken: I voiced my concern about this patient not having a lift, she didn't seem to think it mattered. again i voiced my concern about this situation. I asked the nurse. i used CUS but it didn't matter.
Goal = 24 Hours Follow Up (All occurred in first 24 hours following near miss) Email to Unit Manager Unit Manager investigated and learned nurse involved was in float pool Email to float pool educator Float pool educator met with nurse and emailed all involved managers Lesson Learned: Float pool education was needed Lesson Learned: Processes and tools need to be better utilized Lesson Learned: Policy was not followed and chain of command not utilized
Meeting Attendance Meeting Scheduled February 11, 2015 Attendance: 1. On-Site SPH Leader 2. System SPH Leader 3. Imaging Director 4. Float Pool Educator 5. Float Pool Manager 6. Wound Care Nurse 7. Department Manager of Unit where event occurred Agenda: 1. Review of incident focusing on patient mobility status 2. Identify best practice 3. Plan training and follow up
Near Miss Reporting System Example Meeting Scheduled February 11, 2015 Outcome: Patient had been on unit 3 days so sling should have been placed prior to this incident. Lack of mobility may be a contributing factor to patient s pain and low grade fever. SBAR written by unit manager. PM&R manager, Float manager and Surgical manager will review incident with all staff. Work is being done with PACU for sling placement on patients prior to transfer to the floor. Incident also discussed in Daily Safety Huddle, SPH committee, Email, Department huddles Results: 1.Employee who spoke up was rewarded and supported 2.Departmental issue learned and addressed from a near miss event with no harm 3.Late adopters are held accountable after initial attempt to ignore incident 4.Closed some holes in the Swiss cheese 5.SSC on Unit understands proper practice and support 6.Blunt End strategies were developed and implemented to support sharp end Long Term: 1.Culture is changed from bottom up and top down with each incident properly addressed.
A bad system will DEFEAT a good person every time. W. Edwards Deming Every system is perfectly designed to get the results it gets. Dr. Paul Batalden
Culture Will Not Change Without Manager Knowledge and Accountability
Rapid reporting directly to front line managers. Follow up meetings with leadership Ideally, there is personal knowledge of each employee injury by CEO! Written leadership follow up with details of corrective actions
Power Distance in Health Care 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 Safety Culture Goal: Use organizational culture to reduce the power distance between groups Adapted from G. Hofstede s Culture s Consequences (2001)
Daily Check-in for Safety Patient Handling Examples Chair removed from patient room contributed to fall Sling loops need to be tucked in No lift room available during high census Report out standard patient handling metrics Report that nurse was asked to boost patient with sling under them Sling par issue poorly managed
Associate Safety Tip: What Should I do if no Blue Reposition Slings are available? 1.Call Materials Management and request a disposable sling. 2.Call Materials Management and request a Gold reposition sling if leg support is not needed. Follow up promotes more reporting!! 3.Please let your manager know there was a par issue so that our Safe Patient Handling Committee can work to solve this issue. 4.Consider using a limb lifter
Announcing a Good Catch for Safety! We re celebrating those who identify, correct and report potential safety issues before harm reaches a patient, associate or other staff person. Thank you for keeping our patients and each other safe from harm. Good Catch for Safety!