The Quality Colloquium at Harvard University

The Quality Colloquium at Harvard University Pre-Conference Symposium Patient Safety Officer Certificate Training Paul Barach, MD, MPH Julie K. Johnson, MSPH, PhD Davis Balestracci, MS Gwen Sherwood, PhD, RN, FAAN Monday, August 17, 2009 1

Our Aim To start new and meaningful conversations about quality and safety personally, in our organizations, and with our leaders 2

Learning Objectives By the end of this Patient Safety Officer Training, participants will be able to Reflect on current levels of quality and safety in our organizations Change practitioners everyday conversations about safety and the culture of safety Discuss how to engage the leadership in safety while changing their attitude toward safety 3

Today s s Agenda 9:00 am Welcome and Introduction 9:15 am Mental Models and Framing of Safety and Quality 9:30 am Small Group Discussion about the 5 Pre-Conference Questions 10:00 am The Patient Safety Core Curriculum and Introduction to Lewis Blackman Story 10:15 am Break 10:45 am Small group discussion on Lewis Story (a Pre-Analysis) 11:15 am Debriefing from small group discussion: How are we thinking about safety now? 11:45 am Lunch on Your Own 1:00 pm Data Insanity The silent improvement killer Part 1 4

Today s s Agenda 1:30 pm Group Discussion 2:00 pm Engaging Leaders - From Turf Wars to Appreciative Inquiry, Principles of Leadership for Quality and Safety 2:30 pm Small Group Exercise 2:45 pm Debriefing from small group exercise 3:00 pm Break 3:30 pm Data Insanity The silent improvement killer Part 2 4:00 pm Final discussion about the Lewis Blackman Story 4:15 pm Real World Dilemmas in Quality and Safety 4:30 pm Concluding Comments, Questions and Post- Colloquium Examination Logistics 5:00 pm Adjourn 5

Introductions Introduce yourself to your neighbors Who you are? Where are you from? What is your day-job? What did you give up to be here today? What are your expectations of this session? We will cull expectations from the group 6

What can we learn from the future that will help us create a better present for healthcare? A History of the Future Approach 7

History of the Future Approach Create a scenario fifteen years from now Ask participants to look back at significant events that brought medicine to this point in 2021 Anchor a time horizon in their lives Personal milestones Family members 8

Who Are We? We are an overloaded system We cannot keep up with complex diagnostic and therapeutic technologies We have not changed workflows and roles in the past couple of centuries We have placed most emphasis on sickness control, not on health promotion We face the same challenges everywhere, but are tackling them independently 10

Adverse Event Rates in Healthcare Amalberti, R, Auroy, Y, Berwick, D, Barach, P. Five System Barriers To Achieving Ultra-safe Health Care. Annals of Internal Medicine, 2005;142:756-764. Cardiac Surgery Patient ASA 3-5 Himalaya mountaineering Microlight flights helicopters Fatal Iatrogenic adverse events Medical risk (total) Road Safety Chartered Flight Chemical Industry (total) Blood transfusion Anesthesiology ASA1 Civil Aviation Railways (France) No system beyond this point Nuclear Industry 10-2 10-3 10-4 10-5 10-6 Very unsafe Ultra safe Risk 11

U.S. Adults Receive Half of Recommended Care 80 76 Percent of recommended care received 65 60 55 54 40 39 45 23 20 0 Overall Breast Cancer Hypertension Asthma Pneumonia Hip Fracture Diabetes mellitus Source: McGlynn et al., The Quality of Health Care Delivered to Adults in the United States, The New England Journal of Medicine (June 26, 2003): 2635 2645. 12

Variation in death rates and charges in US hospitals 200 Standardized Mortality Rate 180 160 140 120 100 80 60 40 20 0 0 5,000 10,000 15,000 20,000 25,000 Standardized $ charges per admission 13

CPR Quality During Cardiac Arrest Two companion studies of CPR quality Chest compressions were not delivered half of the time and compressions were too shallow ( out-of-hospital ) Quality of multiple CPR parameters was inconsistent and often did not meet published guidelines ( in( in-hospital ) Abella BS, Alvarado JP, Hyklebust H, et. al. Quality of Cardiopulmonary Resuscitation During In-Hospital Cardiac Arrest. JAMA, January 19, 2005, 293(3):305-310 15

Barriers to Significant Quality Improvement Biases/mental model clinicians bring to the table Variation in Clinical Practice High Powered Teams Learning From Our Mistakes Service and Technology Linking Incentives with Report Cards 18

The Cloak Painfully incorporated desire not to appear incompetent Behaviors conferring a sense of protection are greater: The more terrorizing and fatiguing the training or the greater the possibility of catastrophic error on a moment-tomoment basis The problem is we get so used to cloaking our irrational decisions in the guise of wisdom and experience, we confuse good luck with good judgment, and that s where diagnostic errors often begin. Wachter,RM and Shojania,KG: Internal Bleeding: The Truth Behind America s Terrifying Epidemic of Medical Mistakes. 2004. "It is incident to physicians, I am afraid, beyond all other men, to mistake subsequence for consequence. 19 Samuel Johnson, 1756

Meaningful Patient and Family Involvement 20

Transformed Hospitals Have Clear Definitions What do you mean by great performance? Have you established a baseline? Are you improving? If not, why not? How can you improve even faster? Settling upon a consistent and intelligent method of assessing your output results 22

It is Impossible to be Ahead of the Pack if you Think about the Future in Today s Terms Well, lemme think... You ve stumped me, son. Most folks only wanna know how to go the other way. 23

How Do Mental Models Affect Our Work? Exploring Mental Models through Framing and Reframing Julie K. Johnson, MPSH, PhD 24

Learning Objectives By the end of this session, learners will be able to: Describe the concept of mental models Discuss how individuals use mental models to frame issues and how that framing both contributes to and limits our understanding of a situation Consider the implication of frames for patient care and medical education 25

Before We Begin... Choose an opponent for thumb wrestling The goal is for you to win this competition as many times as you can in 15 seconds Winning means pinning your opponent s thumb 26

What happened? How many points did you get? What were the assumptions you brought into this game? How did your assumptions affect your behavior? 27

Mental Models The images, assumptions, and stories we carry in our minds of ourselves, other people, institutions, and every aspect of the world They determine what we see, and most importantly, how we act 28

What Might this Mean for Our Work? Examples from clinical care, education Drug seeking behavior Patient non-compliance Difficult patient/family Born surgeon Born internist Other ideas?? 29

Mental Models None are perfectly accurate Differences in mental models explain how two people can understand the same event differently Are generally invisible to us until we look for them 30

The Ladder of Inference 31

What Happens on the Ladder We pay attention to some data and ignore other data We impose our own interpretations on these data and draw conclusions from them We lose sight of how we do this because we do not think about our own process of thinking Our conclusions feel obvious to us Other people s s conclusions feel obvious to them When people reach different conclusions and disagree, they often hurl conclusions at each other from the tops of their respective ladders This makes it hard to resolve differences and to learn from one another 32

How Can We Surface Our Mental Models? Working with mental models requires surfacing, testing, and improving our internal pictures of how the world works 3 skills can be helpful Reflection understanding your own mental models and the implications Inquiry learning the questions you can ask to help you test others mental model Advocacy making your thinking and reasoning more visible to others 33

Advocacy and Inquiry are Key to High Communication Advocacy One-way Communication (Explaining, Imposing) Two-Way Communication (Mutual Learning) No Communication (Observing, Withdrawing) One-way Communication (Interviewing, Interrogating) Low High Inquiry 34

Relationship of Mental Models to Framing Mental models frame what we see and how we respond Our mental models are internal Framing is the interaction of our mental models and the situation at hand 35

Small Group Exercise Divide into groups of 4 one person from each group will be selected to be the observer and note taker for the group Each group will get a set of 3 postcards Each postcard is covered with a different frame that reveals only part of the postcard Don t t uncover the cards or reveal the frame to the group Discuss these questions: What do you see within the frame? What is the story you can tell? Now, look at the cards and discuss: How did your frame limit what you know? How does someone else s s frame contribute to, or disrupt, your understanding of the issue? 36

Debriefing What was your group s s experience with the exercise? What surprised you? What did you learn? How do your mental models affect the frames you use? How might your professional framework limit what you know? 37

The Pre-Conference Questions 38

Small Group Discussion The 5 Pre-Conference Questions What are the most important patient safety issues facing yourinstitution? institution? How does the culture of your institution affect your ability toimplement change? What are 3 patient safety initiatives that you've read about, heardabout, about, or seen that you believe will make an impact in your institution? What are 3 patient safety initiatives you would like to implement inthe next year? Describe the composition of the team that will be necessary toaccomplish each of those initiatives in your institution 39

Debriefing 40

The Patient Core Curriculum and Introduction to the Lewis Blackman Story Paul Barach, MD, MPH 41

Institute of Medicine November 1999 Human Error and performance limitations Establish near miss voluntary reporting systems and protect from discovery Creating Safety systems in health care organizations Errors lead as major cause of death, injury Create a safety culture Create and inculcate a safety curriculum Team training and simulation Establish national safety authority Anesthesiology only only clinical domain to make patient safety central to its mission Altman, et al. 2004--- ---five years later-- IOM most important report in 2 decades Wachter,, 2006--- ---C+ grade on report card 42

THE PATIENT SAFETY CORE CURRICULUM Patient Safety Domains Knowledge, Skills, Attitudes 1. Theoretical Foundations Microsystems, historical trends, chaos, complexity, competency and learning 2. Behavioral Aspects of Medical Professionalism Ethics, patient quality of life, resolution of conflict 3. Interpersonal Issues Communication, stress and coping 4. Human Factors and Ergonomics Design history, error taxonomies, safety tools, decision support systems, fatigue factors, user centered design 5. Systems Analysis Usability criteria, organizations and learning disasters, place for human error 6. QI Learning Pareto/flow charts, and other QI tools, best practices, act cycles 7. Injury Epidemiology Workplace hazards, worker safety, phases of injury, medico-legal aspects 8. Medication Safety Adverse and near-miss reporting, ISMP tools and website, look/sound-alikes 9. Crisis Management Tools Team work, shared decision making, situational awareness 10. Simulations Micro-, macro-, debriefing, immersion levels, scripting, role playing Gilula, M. and Barach P. Creating a Patient Safety Curriculum: Purposive Sampling of Patient Safety Experts. 79th Clinical and Scientific IARS Congress. S-143. Honolulu, Hawaii. March 12, 2005.; Gilula, Barach, 2009. 43

Case I: The Role of Human Factors in an Unexpected MI A 45-year year-old women for parathyroidectomy with no past medical history, under general anesthesia After uneventful induction of anesthesia, the patient became hypotensive Resident gave 1 cc of phenylephrine HR went to 150 s s and VT CPR required Epinephrine given ST changes; TEE-severe LV hypokenesis 44

Similar Vials: Atropine & Phenylephrine 45

Elements of Organizational Failure Incompatible Goals Organizational Structural Deficiency Inadequate Communications Poor Planning and Scheduling Inadequate Control and Monitoring Design Failures Deficient Training Inadequate Maintenance Management JT Reason 1993 46

Elements of Organizational Accidents Task and Environmental Conditions Individual Unsafe Acts Organizational Processes Failed Defenses James T. Reason. The Human Factor in Medical Accidents. Medical Accidents. Vincent C, Ennis M, and Audley R. Oxford University Press 1993 48

Human Error Rates Error of commission (misreading a label) 3/1000 Error of omission (item embedded in procedure) 3/1000 Error of omission (without reminders) 1/100 Error in simple arithmetic (with self check) 3/100 Personnel on different shift fail to check conditions unless directed by a checklist Errors under very high stress when dangerous activities are occurring rapidly 1/10 25/100 Adapted from: Park, K. Human Error. In Salvendy, G, ed. Handbook of Human Factors and Ergonomics, New York. John Wiley & Son, Inc. 1997: 163. 49

Human vs. Design Flaws Human errors (7%) can be reduced by rigorous practices, standardization, simulation training, building a safety culture, etc. 51

The 93% vs. 7% Rule Human Error (People) Reckless Conduct (People) Organizational Design 93% Negligent Conduct (People) Knowing Violations (People) 52

Performance Shaping Factors Affecting Human Vigilance Fatigue Environmental Conditions/Built Environment Task Design Psychological Conditions Competing Demands Hand offs/sign outs 53

Tools and Methods of Analysis Numerous methods and tools are available for analyzing adverse events, near misses, and the context of care Regardless of the tool used, the goal is to determine at the organizational level how to prevent errors from occurring in the future 54

Latent Errors Types of Tools Incident Reporting Active Errors Autopsies and M&M Conferences Chart Review Administrative Data Analysis Direct Observation Adverse Events Clinical Surveillance Malpractice Claims Files Analysis Information Technology Peterson et al. 55

Tools and Methods of Analysis Retroactive Analysis Root Cause Analysis (RCA) is a thorough retrospective investigation to identify factors that contributed to the occurrence of an error Proactive Analysis Failure mode and effects analysis (FMEA) identifies potential contributing factors to potential adverse events 56

Consider the Microsystem Small group of clinicians and staff working together with a shared clinical purpose to provide care for a defined set of patients The clinical purpose defines the essential parts of the microsystem Clinicians and support staff Information and technology Care processes Source of excellence in health care organizations Mohr(Johnson) J, Batalden P, Barach P. Qual Saf Health Care 2004;13 Suppl 2:34-8. 57

What Are the Essential Elements of a Microsystem? Core team of health professionals Defined population of patients they care for Information & information technology Support staff, equipment, environment Processes, activities specific to accomplishing the aim 58

A Microsystem Framework for Analyzing Events One method that we have found to be useful for systematically looking at patient safety events builds on Haddon s overarching framework on injury epidemiology 59

The Haddon Matrix Human Vehicle Environment Pre-event event Alcohol intoxication Braking capacity Visibility of hazards Event Resistance to injury insults Sharp, pointed edges and surfaces Flammable materials Post-event Hemorrhage Rapidity of energy dissipation Emergency medical response Source: Haddon, W. A Logical Framework for Categorizing Highway Safety Phenomena and Activity. J. Trauma 1972; 12:197. 60

Haddon Matrix adapted to Patient Safety in the Microsystem Patient/ Family Health Care Professional Systems/ Environment Pre-event event Event Post-event 61

Debriefing Patient/ Family Health Care Professional Systems/ Environment Pre-event event Orientation to the process Probablistic Risk Assessment (PRA) Scenario Building Hazard Analysis Checklists Failure Modes Effects Analysis (FMEA) Human Factors Engineering Event Interview Crew Resource Management (CRM) Checklists Root Cause Analysis (RCA) Post- event Interview, Focus Group Interviews Microsystem Analysis Morbidity and Mortality Conference (M&M) Root Cause Analysis (RCA) 62

Organizational Accident Causation Model Organization Workplace Person/team Defenses Management Decisions & Organisational process Accidents Latent conditions pathway 63

Organization Accident Causation Model Organization Workplace Person/team Defenses Management Decisions & Organisational process Error & Violation Producing conditions Accidents Latent conditions pathway 64

Workplace Conditions Promoting Unsafe Acts High Workload Inadequate Knowledge, Ability or Experience Inadequate Supervision or Instruction Stressful Environment Mental State Change 65

Workplace Error Producing Conditions Unfamiliarity(x17) Time Shortage(x11) Poor Human-System Interface (x8) Information Overload (x6) Negative Transfer(x5) Misperception of Risk (x4) Inexperience Not Lack of Training (x3) Inadequate Checking (x3) Poor Instructions(x3) Educational Mismatch (x2) Disturbed Sleep (x1.6) 66

Work Environment Violation Producing Conditions Lack of Safety Culture Management/Staff Conflict Poor Morale Poor Supervision Condones Violations Misperception of Hazard Lack of Management Concern Little Pride in Work Macho Culture Bad outcomes Won t t Happen Low Self-Esteem License to Bend Rules Ambiguous or Meaningless Rules 67

Organizational Accident Causation Model Organization Workplace Person/team Defenses Management Decisions & Organisational process Error & Violation Producing conditions Errors & violations Accidents Latent conditions pathway 68

Person /Team Individual Unsafe Acts Errors Attentional Slips and memory lapses (Intrusions, omissions) Mistakes Rule based Knowledge-based Violations( deliberate deviation from regulation) Routine ( shortcuts) Optimizing Violations Exceptional Deliberate 69

Team video 71

What are important team competency requirements? 72

Medical Team Training Team Competencies Knowledge Competencies The principles and concepts that underlie a team s effective performance Skill Competencies The learned capacity (psychomotor and cognitive) to interact with other team members Attitude Competencies Internal states that influence team members to act in a particular way 73

The TeamSTEPPS Framework Knowledge Shared Mental Model Attitudes Mutual Trust Team Orientation Performance Adaptability Accuracy Productivity Efficiency Safety Baker D, Salas E, Battles J, King H, Barach P, 2005, 2007 74

Miller s s Pyramid Does 75 Shows How Knows How Knows

See Handout with Lewis Story QuickTime and a decompressor are needed to see this picture. 77

Break 78

Small Group Discussion A Pre-Analysis of the Lewis Blackman Story In small groups discuss the case Discuss how you would approach the analysis (e.g., the types of tools you are familiar with in analyzing adverse events) Prepare to report back 79

Debriefing How are we thinking about safety now? 80

Disclosure of Adverse Events: What Do You Do When Bad Things Happen? Paul Barach,, MD, MPH 81

Adverse Event Management Plan Containment Plan Render care to pt Staff Support Contain risk of harm/recurrence Notification Securing scene Recovery Monitoring Restitution Event Activation Crisis Mgt Team Investigation & RCA Corrective Action & Prevention Communication Plan Patient Disclosure/ External Audience Organizational Internal Audience Recovery Notify Billing to hold bills Immediate Response Follow up Response 82

Disclosure Process Identify incidence of patient harm or a potentially compensable event Initial disclosure and apology Case Review Follow-up disclosure Discuss restitution 83

What do patients want? 1. To know what happened 2. To receive an apology 3. To know what is being done to prevent it from happening again 84

Disclosing Adverse Events Disclosure is required when Has a perceptible effect on the patient not discussed in advanced with patient Necessitates a change in patient care Poses risk to patient s s future health Involves non-consented treatment or procedure Reduces chances of being sued Transparency in process helps the team address guilt New laws in 22 states requiring disclosure Cantor M, Barach P, et al. Jt Comm Qual Patient Saf 2005;31:5-12. Barach, P, Cantor M, 2007 85

Disclosure Conversation Planning Review disclosure principles Decide who, when, where Decide who will be point contact person for patient/family What to say and how to say it Anticipate questions Planning next steps Debriefing/emotional support for the individual(s) doing the disclosing 86

Disclosure Conversation Learn to effectively communicate and explain the facts Expression of concern/responsibility Discuss present/future needs Describe actions taken and explain specific process for finding the answers 87

Risk Management Support Manage contact with patient and/or family Coordinate regulatory/accreditation requirements Managing reputation risks Media/Crisis communication Internal and external Managing complaints and claims Early non litiginous settlement 88

Resources Cantor M, Barach P, Derse A, et al. JCAHO 2005;31:5-13. Kramam SS, Hamm G. Ann Intern Med 1999;131:963-967. Clinton H, Obama B. NEJM 2006. Gallagher T, et al. NEJM 2007. http://www.sorryworks.net Risk Management Pearls on Disclosure of Adverse Events. American Society for Healthcare Risk Management at http://www.ashrm.org 89

Lunch Reconvene at 1 pm 90

Data Insanity - The Silent Improvement Killer Part I Davis Balestracci,, MS 91

Group Discussion 1. How does your organization react to, report, and analyze incidents? incidents? 2. Have you ever considered safety in a process- oriented context? 3. Have you, with the best of intentions, been using special cause strategies? Could you plot the dots to see whether you have been successful? 4. Does this material suggest situations in your organizations that might respond better to common cause strategies? 92

Debriefing 93

Engaging Leaders - From Turf Wars to Appreciative Inquiry, Principles of Leadership for Quality and Safety Gwen Sherwood, PhD, RN, FAAN 94

Engaging Leaders: From Turf Wars to Appreciative Inquiry Principles of Leadership for Quality and Safety Harvard Safety Certificate Program 2009 Gwen Sherwood, PhD, RN, FAAN 95

Gwen Sherwood, PhD, RN, FAAN Professor and Associate Dean for Academic Affairs The University of North Carolina at Chapel Hill School of Nursing gwen.sherwood@unc.edu 96

Framing new roles and skills Appreciative Inquiry to build culture Reflection for transformation 97

Changing conversations, Changing minds, Changing culture Creating transformation98

Quality and safety have moral, ethical, and economic considerations that require examination of contextual factors: work force preparation, culture, and transformative leaders. 99

Considering Quality Health care is value based; quality is an essential value. When quality erodes, joy in work diminishes, contributes to disengagement and departure. Health professionals are willing to help improve systems when they have what is needed to make quality improvement a part of daily work 100

Quality impacts the work force Working in systems with poor quality lowers satisfaction: American Association of Critical- Care Nurses (AACN), CQ HealthBeat Retention 101

Framing new roles and skills Complexity of care means no one discipline can provide care, need to clarify and understand roles Patients and families partnering in care New RN graduates need different skills for emerging system redesigns Longer and costly orientations 102

103

Nurses Role in Quality and Safety Quality and Safety Education for Nurses (QSEN) www.qsen.org (funded by RWJ) National expert panel defined quality and safety competencies and knowledge, skills and attitudes required for nurses in health care organizations Based on IOM competencies for all health professions education Adopted by nursing education credentialing agencies 104

Cronenwett et al, Nursing Outlook, May-June 2007 (special topic issue) Patient centered care Teamwork and collaboration Evidence base practice Quality Safety Informatics Updates due in Nov. 2009 New views of familiar concepts require curricula transformation 105

Example: 2 definitions Quality improvement: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems Safety: Minimize risk of harm to patients and providers through both system effectiveness and individual performance 106

Selected: Quality Improvement KSAs Knowledge Skills Attitudes Describe strategies for learning about the outcomes of care in the setting in which one is engaged in practice ----------------------------- *Describe strategies for improving outcomes of care in the setting in which one is engaged in practice **Explain common causes of variation in outcomes of care in the practice specialty Seek information about outcomes of care for populations served in care setting ------------------------------ *Use a variety of sources of information to review outcomes of care and identify potential areas for improvement **Assert leadership in shaping the dialogue and providing leadership for the introduction of best practices Appreciate how unwanted variation affects care ----------------------------- *Appreciate the importance of data that allows one to estimate the quality of local care **Appreciate that all improvement is change but not all change is improvement 107

Selected: Safety KSAs Knowledge Skills Attitudes Discuss effective strategies to reduce reliance on memory --------------------------- *Evaluate effective strategies to reduce reliance on memory **Describe best practices that promote patient and provider safety in the practice specialty Participate appropriately in analyzing errors and designing system improvements ----------------------------- *Design and implement microsystem changes in response to identified hazards and errors **Report errors and support members of the health care team to be forthcoming about errors and near misses Value own role in preventing errors ------------------------------ *Value own role in reporting and preventing errors **Appreciate the importance of being a safety mentor and role model **Value the use of organizational error reporting systems 108

Shaping organizational context Work takes place in a given context which influences our responses. Culture is the behavior and beliefs/values of the group Culture is built from the connection of consequences with behavior, what is valued and rewarded. Leaders create and manage the culture, and deconstruct when needed to change outcomes. 109

Positive approach to building culture, Appreciative Inquiry (AI) Discovers and builds on what works in the organization, a system perspective consistent with quality and safety Positive perspective change management to manage context to influence work that happens Flexible process to engage people in building an organization and world they want to live in Reflective, generative and life-enriching through collaborative, inclusive discovery into what gives life 110 to the organization to vision the future

Magnet Hospitals for nursing excellence Developed by identifying successful strategies at hospitals with no nursing vacancies to replicate at other hospitals: positive work environments, nurse leadership, continuous quality improvement academic and practice partnerships. Higher satisfaction Lower staff vacancy Improved patient outcomes 111

Problem Solving: See organization as a problem to be solved Felt need, problem identification Analysis of causes Analysis of possible solutions Action planning, treatment Appreciative Inquiry: View organization as a mystery to embrace Appreciate and value the best of what is Envision what might be Dialogue what should be Innovate what will be Solution oriented Seeks transformation 112

Appreciative Inquiry Appreciate: Value Energizes by recognizing the best Affirming past or present strengths, successes, and potentials which give life to living systems Inquire: Question Question are the first part of change Explores new possibilities based on successful events 113

AI is a reflective process that allows participants to own their world by sharing what works. Clarify what is desired Ask for what is wanted Listen to what is attained Recycle to maintain goals 4 D Cycle of 114

The 4-D Cycle of AI Discovery What gives life (for topic)? appreciating and valuing Dream What might be? envisioning Design How can it be? co-creating the future Destiny What will be? learning, empowering, and improvising to sustain the future 115

Reflection: Critically consider one s beliefs or knowledge in light of supporting evidence. Raise awareness about what one does to be able to make better choices in the future. Bridge actual and desired practice/actions. Monitors reactions to lead to intentional, conscious, deliberate actions. Learn from successful and unsuccessful events. 116

Reflective Leadership: journey of the self towards transformation Begins with uncomfortable feeling about the way one does something or reacts. Critically reflect on the action. Discover meaning within what happened. Integrate into context as one changes perspective. Act from one s internal compass of what is right. Emotional intelligence is building block of reflection. 117

Self-Reflection: In your usual day, do you spend more time with a focus on what is working or what is not working? Cite specific examples. 118

Discovery: Changing conversations Identify and appreciate the best of what is Share stories of accomplishments and success, when people have experienced (the topic) at its best. Create Meaning through sharing story. What is the common mission or purpose that unites the group? How is this communicated and nurtured? 119

Dream: Changing minds Challenge the status quo by envisioning potential results and bottom line contributions to the world Through collective sharing, images of the future emerge out of grounded examples from the positive past Give life to the organization through positive history (can be expressed in multiple ways such as story boards) It is the opportunity to Dream Big! 120

Design: Changing culture Create ways to replicate themes in successful stories and events to expand potential Develop together a plan for a transformed approach (to the topic) with integration of quality and safety. 121

Moving to Change: Creating Transformation The conversations we have shape how we see the world, how we behave, and what we see as reality. Inquiry is change. The first question we ask is fateful. We create our reality by the stories we tell. We act according to perceptions of our current reality AND what we anticipate/imagine will happen in the future; we move toward the reality we imagine. 122

Creating our reality Building and sustaining momentum for change requires large amounts of positive affect.... Hope, excitement, inspiration, camaraderie, urgent purpose. Wholeness (inclusiveness) brings out the best in people and organizations. To really create change, we must be the change we want to see. 123

There is a time and place for multiple ways of examining quality issues. It depends on what you are trying to see, what you are trying to change, and how you want to shape the culture and context. 124

Opening to new ways of viewing context Changing conversations Changing minds Changing culture Creating transformation 125

Get Out of the Box to Build Quality and Safety 126

Additional References Sherwood & Horton-Deutsch. (2008). Reflective practice: The route to nursing leadership. In Freshwater, D., Taylor, B., & Sherwood, G. International textbook of reflective practice in nursing. Oxford, England: Blackwell Publishing & Sigma Theta Tau Press. Pp. 157-176. Hammond, S. (1998).The Thin Book of Appreciative Inquiry. Bend, OR: The Thin Book Publishing Co. Bolman & Deal. (2004). Leading with Soul. 127

Small Group Exercise Reflect on the time you have been in your current organization. What gives life to this organization? Why do you want to belong? Think for a moment about what you value deeply Without being humble, describe what you value most about your self, your work and your contribution to the organization Locate a high point when you felt most effective and engaged in contributing to the life of the organization Describe how you felt and what makes this possible How does this contribute to a culture of safety? How do you individually add value to the safety culture of your organization? What are your three concrete wishes for insuring a culture of safety in your organization? What are the forces and factors that can make these best practices happen? 128

Debriefing 129

Break 130

Data Insanity : The silent improvement killer Part 2 Davis Balestracci, MS 131

The Lewis Blackman Story revisited What have we learned today that would help us approach this event differently? 132

Facilitated Discussion Real World Dilemmas in Quality and Safety What are the day-to-day issues that members of the audience face? 133

Improving Safety, Implementing Change Creating a Patient Safety Plan Paul Barach,, MD, MPH 134

Patient Safety Plan High Reliability Organization Culture/ Leadership 2 Identify Failures Patient Centeredness Teamwork / Human Factors Knowledge Sharing Manage Failures Reliable Design Adapted from Kaiser Permanente 135

Getting Started Self-assessment Alignment with organizational strategy Program Infrastructure Inventory of current patient safety activities Resource allocation Capacity Results 136

Safety Program Linkage with Leadership/Organizational Culture Oversight responsibility/infrastructure Stakeholder Engagement Work Plan Development Execution Model(s) Monitoring/Measurement Participation/accountability Spread/Sustainability 137

Creating a Patient Safety WorkPlan AIM: Safest Hospital Objective: Zero incidence of harm Tactics Crew resource management (CRM) SBAR Rapid response teams Source: Institute for Healthcare Improvement at http://www.ihi.org 138

Resources Advanced Training Program, Intermountain Healthcare, Salt Lake City. http://intermountainhealthcare.org/xp/public/institute/courses/atp/ tp/ #objectives Leadership Guide to Patient Safety from the Institute for Healthcare Improvement at http://www.ihi.org The University of Michigan Healthsystem Patient Safety Toolkit at http://www.med.umich.edu/patientsafetytoolkit/ 140

Concluding comments, questions, and Post Test logistics 141

What do you think is on the horizon for patient safety in the next 5 years? 142

What s s on the Horizon for Patient Safety? The role of the built environment Patient centered processes Smart automation Adaptive informatics Focus on the team and simulation Full disclosure Telemedicine/remote care 143

THE PATIENT SAFETY CURRICULUM Patient Safety Domains Knowledge, Skills, Attitudes 1. Theoretical Foundations Microsystems, historical trends, chaos, complexity, competency and learning 2. Behavioral Aspects of Medical Professionalism Ethics, patient quality of life, resolution of conflict 3. Interpersonal Issues Communication, stress and coping 4. Human Factors and Ergonomics Design history, error taxonomies, safety tools, decision support systems, fatigue factors, user centered design 5. Systems Analysis Usability criteria, organizations and learning disasters, place for human error 6. QI Learning Pareto/flow charts, and other QI tools, best practices, act cycles 7. Injury Epidemiology Workplace hazards, worker safety, phases of injury, medico-legal aspects 8. Medication Safety Adverse and near-miss reporting, ISMP tools and website, look/sound-alikes 9. Crisis Management Tools Team work, shared decision making, situational awareness 10. Simulations Micro-, macro-, debriefing, immersion levels, scripting, role playing Gilula, M. and Barach P. Creating a Patient Safety Curriculum: Purposive Sampling of Patient Safety Experts. 79th Clinical and Scientific IARS Congress. S-143. Honolulu, Hawaii. March 12, 2005.; Gilula, Barach, 2007. 144

Rules for Health Care Design in the 21st Century Current Approach Do no harm is an individual responsibility Information is a record Secrecy is necessary The system reacts to needs Professional autonomy drives variability New Approach Safety is a system property Knowledge is shared and information flows freely Transparency is necessary Needs are anticipated Decision making is evidence-based IOM. Crossing the Quality Chasm. National Academy Press, 2001. 145

What You Should Ask About Quality and Patient Safety Do staff feel safe about reporting health care errors or care related injuries and deaths? If not, what are we doing to create a culture of safety a just culture? What happens when a heath care error occurs? What serious care related adverse events have occurred during the past year? What did we learn from these events? What did we do? What systems related quality and patient safety improvements have occurred during the past year? 146

Barriers To Achieving Ultra-safe Healthcare Acceptance of limitations on maximum performance Abandonment of professional autonomy Transition from mindset of craftsman to that of an equivalent actor Develop a culture of safety Simplify professional rules and regulations Amalberti R, Berwick D, Barach P. Annals of Internal Medicine 2005;142:756-764. 147

Getting Serious About Hospital Quality There are known knowns.. These are things we know that we know. There are known unknowns. That is to say, these are things we know we don t t know. But there are also unknown unknowns. These are things we don t t know we don t know -- Donald Rumsfeld Oct 3, 2006 148

Adjourn 149