1999 Institute of Medicine study estimated that as many as 98,000 people die in any given year from medical errors that occur in hospitals. To Err is Human To Delay is Deadly Ten years later, a million lives lost, billions of dollars wasted Ten years ago the Institute of Medicine (IOM) declared that as many as 98,000 people die each year needlessly because of preventable medical harm, including healthcare-acquired infections. Ten years later, we don t know if we ve made any real progress, and efforts to reduce the harm caused by our medical care system are few and fragmented. With little transparency and no public reporting (except where hard fought state laws now require public reporting of hospital infections), scarce data does not paint a picture of real progress.
Providence St. Joseph Medical Center (PSJMC) Located in Northwest Montana on the Flathead Indian Reservation 22 bed Critical Access Hospital Joint Commission Accredited Hospital Full array of medical services (ED, Rural Health Clinic, Walkin Clinic, Inpatient, Obstetrics, Orthopedics, General Surgery, visiting Specialist, and a robust Tele-health platform) Average daily in patient census is 7 140 births delivered per year on average 5,500 ED visits per year and 10,000 Walk-in visits per year
What is a High Reliability Organization? A high reliability organization (HRO) is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity.
Our HRO Journey Partnered with Healthcare Perormance Improvement (HPI) Analyzed safety data over a two year period to identify trends and opportunities Opportunities identified in two categories: Critical Thinking Culture
A typical Improvement Curve
Culture Culture is shared values and beliefs of an organization. Culture is important because culture determines behavior and, in humanbased systems, behavior determines outcomes. Patient safety culture is demonstrated through people who think safety is important, have the knowledge and skills to perform their tasks with high reliability, are mindful to anticipate harm, are resilient to take action to prevent harm.
The Swiss Cheese Effect
Culture Transformation Plan
Patient Safety Safety is protecting patients from harm. Harm is defined as any bad outcome caused by and or allowed to occur in the course of helping patients to their best possible outcome.
Reliability Culture
Sustaining a Culture
Leadership is the Key
Safety Message A two-minute communication about safety Start each meeting with a safety message Sets the tone of the meeting Utilize the art of story telling to describe a safety opportunity within the organization Discuss the importance for speaking-up for safety Thank staff for participating/working safely
Ministry Safety Huddle Occurs at 0830 daily with leadership from the organization Enhances leadership awareness of safety concerns and potential concerns Early identification of problems Creates a culture of accountability and transparency.
Ministry Safety Huddle cont. A look back-report significant safety or quality issues from the last 24 hours A look ahead-report any potential safety or quality concerns for the next 24 hour Follow up and make safety a priority for the day
Daily Department Huddles A look back and look ahead Follow up on critical issue Maintains awareness of daily operations and safety concerns Enhances transparency and responsibility
Top 10 Safety List Outlines and identifies the safety priority needs of the organization Individual safety concerns assigned to leaders Action plan and documentation specific to the safety concerns Improves tracking and follow up/cpmpletion status
PSJMC Top 10 List # Problem Title Problem Owner Add Date Days on List 1 Staff unprepared to handle disruptive patients and visitors Nikki 9/7/16 131 2 Lack of Standardized Timeout Process on Med Surg Erin 10/31/16 77 3 Caregivers parking in patient parking spots. Landon 10/31/16 77 4 Antibiotics started before blood culture drawn (Incomplete Administration of Sepsis Bundle) Erin 4/26/16 265 5 Delays in Outpatient Blood Transfusion from External Providers Landon 5/18/16 243 6 7 Confusion on handoffs of direct admitted patients from Clinic (Direct Admit Process) High patient acuity not detected when presenting to walk in clinic (Delay in moving patient from walk in to ED) Ben 9/7/16 131 Ben 6/30/16 200 8 No mechanism for ensuring competences in a division Ben 9/21/16 117 9 On call sheet is often inaccurate Landon 10/27/16 81 10 Chemistry Analyzer tests are unavailable regularly Landon 8/11/16 158
5:1 Feedback 5 positives to 1 negative Timely Observation and expectation setting around safety behaviors
Round to Influence Purposeful, Enhances communication Designed to go out to the work where it is occurring, essentially meeting staff where they are at Assess staff knowledge on a safety topic Asks for commitment, again reinforcing accountability
Round to Influence
Fair and Just Culture Instill confidence that managers will respond fairly Improved identification and correction of system problems that contribute to performance issues More event and near-miss reporting
Performance Management Decision Guide Adapted from James Reason s Decision Tree for Determining Culpability of Unsafe Acts and the Incident Decision Tree of the National Patient Safety Agency (UK National Health Service) Use the guide to step through questions that a manager needs to ask when a person s acts deviate from performance expectations The guide will lead to the appropriate actions to take with that individual Consistent use by all of us is the best way to move forward
The Fair and Just Accountability Tool Helps Leaders: Differentiate an Honest Mistake from Knowing Violations Shifts thinking from Who is to blame? to Why did he/she act this way? What were the causal factors? Helps to define effective corrective actions and promotes and environment where employees are treated fairly and consistently
Caregiver Implementation of HRO at SJMC Education and training All staff attended a 4 hr training on the Toolbox Toolbox education included education on tones and behaviors Every month we utilize and showcase the tool of the month STAR (Stop, Think, ACT, Review) Peer Check SBAR (Situation, Background, Assessment, Recommendation) Three-way Repeat-Back and Read-Back Phonetic and Numeric Clarification Clarifying Questions Validate and Verify Know Why and Comply Brief, Execute, and Debrief Escalation using CUS (Concerned, Uncomfortable, Stop)
PSJMC Current State of HRO
Top 10 Action Plan Completion To date 22 actions plans have been completed Action plans have ranged from unsafe Labor and Delivery nursing staff to Security presence on nightshift Utilize FMEA scoring to escalate safety concerns to the top 10 list
UOR Reporting Increase in UOR reporting Precursory and Near miss type events increased over the 249 events reported from 2012-2014 431 events reported from 2015-current
Rural Facility Challenges Bench strength within each department Patient facing working supervisors/leadership Resource allocation Leadership Maturity Staff turnover Culture shift
Key to Success Leadership and Culture