Effective Approaches in Leading Patient Safety and
Transcription
Effective Approaches in Leading Patient Safety and
Prepared for the Foundation of the American College of Healthcare Executives Effective Approaches in Leading Patient Safety and Error Reduction Presented By: Gary R. Yates, MD ©Copyright American College of Healthcare Executives 2013 Effective Approaches in Leading Patient Safety & Event Reduction Gary R. Yates, MD Tucson, Arizona May 7, 2013 American College of Healthcare Executives 1 Sentara Healthcare 123-year not-for-profit mission 8 hospitals – 1,935 beds 3,400 medical staff members 10 long-term care/assisted living centers Extended stay hospital 520-physician medical group 432,600-member health plan Sentara College of Health Sciences $3.3B total operating revenues $3.9B total assets 19,225 employees 2 Sentara hospitals & 5 specialties ranked in nation’s Top 50 by U.S. News & World Report Sentara eCare® HIMSS Analytics Stage 7 and HIMSS Davies Award Virginia North Carolina 2 Page 1 Sentara Norfolk General Sentara Leigh Sentara CarePlex 543 beds 250 beds 200 beds Sentara Heart Hospital Sentara Williamsburg Regional Medical Center Sentara Virginia Beach General 112 beds (included in SNGH license) Sentara Obici 150 beds 145 beds 282 beds Sentara Potomac Sentara Princess Anne 183 beds 160 beds 3 HPI – A Reliability Company Methods based on science and facts Science of human error and event prevention Practical experience in high-reliability industries including nuclear power and aviation Experienced-based mentoring Entered healthcare in 2002 Over 450 hospitals Consulting team with HRO experience and healthcare experience (clinicians, non-clinicians, and physicians) 4 Page 2 Introductions Who you are Where you work What you do Why you signed up for this course – what you hope to take away 5 Learning Objectives 1. Identify effective approaches to improve patient safety and reduce human errors 2. Describe approaches from HROs to drive safety improvements 3. Describe the critical role of senior leadership in creating a high reliability culture. 6 Page 3 Course Agenda • Putting a Face on Safety • Behaviors for Error Prevention • The Call for Safety Leadership • High Leverage Leadership Tactics • Lessons from HROs • Engaging Physicians • The Science of Safety • Just Culture • Safety as a Core Value • Summary 7 Putting A Face On Safety 8 Page 4 9 “Make my hospital right; Make it the best.” Abigail Geisinger 1. Don’t harm me 2. Heal me ALWAYS Keep Safe + Evidence-Based Care 3. Be nice to me Promptly and with courtesy and compassion Quality 10 Page 5 Josie King – Medication Error Darrie Eason – Misdiagnosis Sebastian Ferrero – Medication Error 11 Second Victims “The devastated Kimberly Hiatt committed suicide after she gave a baby a fatal overdose of medication at Seattle Children’s. Hiatt was totally destroyed as a nurse after she accidentally overdosed baby Kaia Zautner on 14 September 2010, with ten times too much calcium chloride. Kim Hiatt RN Her error led to the unravelling of her life.” Kaia Zautner 12 Page 6 Please Raise Your Hand If… • YOU have suffered harm as a patient at a hospital or other care facility (an infection, fall, delayed diagnosis causing delay in treatment, other …) • A FAMILY MEMBER has suffered harm in a hospital or other care facility • A FRIEND or COLLEAGUE has suffered harm in a hospital or other care facility 13 The Call for Safety Leadership 14 Page 7 In the News... Hospitals hurt 18 percent of patients, study says • NEJM study of 2,341 patients at 10 hospitals November 25, 2010 • 63.1 % of the injuries were preventable • 2.4 % caused or contributed to a patient’s death “Process changes, like a new computer system or the use of a checklist, may help a bit,” he said, “but if they are not embedded in a system in which the providers are engaged in safety efforts, educated about how to identify safety hazards and fix them, and have a culture of strong communication and teamwork, progress may be painfully slow.” Medical mistakes plague Medicare patients • 780 randomly selected Medicare patients November 16, 2010 • 1 in 7 (13.5%) experienced serious harm • Less serious harm in additional 13.5% of patients “Although hospitals have broadly embraced safety initiatives, the still-high rate of adverse events indicates that far more needs to be done. Hospitals must work faster to adopt evidence-based practices that reduce medical errors.” 15 Success: Hospital-Associated Infections In the United States: between 2008 and 2011: - 42% decrease in CLABSI - 17% decrease in surgical site infections - 7% decrease in CAUTI’s between 2008 and 2010 16 Page 8 HRET/ CMS HEN Progress on Elective Deliveries 355 hospitals have submitted data on Elective Deliveries at >= 37 Weeks and < 39 Weeks (JC PC-1). • There is a 42.40% reduction from baseline rate of 16.29% to a follow-up rate of 9.39% (October to December 2012). • This translates to 5,196 EEDs prevented in 2012, and this represents an estimated cost savings of $21,303,600 for 2012. 17 17 How Safe Is Healthcare? Dangerous (>1/1,000) 100,000 Ultra Safe (<1/100K) Health Care Driving In US Total lives lost per year (1 of ~600) 10,000 Scheduled Commercial Airlines 1,000 100 Mountaineering 10 Bungee Jumping 1 1 10 100 Chartered Flights European Railroads Chemical Manufacturing 1,000 10,000 100K Nuclear Power 1M 10M Number of encounters for each fatality 18 Page 9 Patient Exposure 35 million hospital discharges annually 900 million clinic visits annually Outpatient visits occur 25 times more frequently than hospital admissions 19 American College of Healthcare Executives Announces Top Issues Confronting Hospitals: 2011 Issue 20111,2 20103 20093 Financial challenges Healthcare reform implementation4 Patient safety and quality 62% in 2007 Governmental mandates Care for the uninsured Physician-hospital relations Patient satisfaction Technology Personnel shortages Creating an accountable care organization 2.5 77% 76% 4.5 53% 53% 4.6 31% 32% 4.6 32% 30% 5.2 28% 37% 5.3 30% 25% 5.6 16% 15% 7.2 10% 7% 7.4 11% 13% 8.4 --- --- 1In 2011 the average rank given to each issue was used to place issues in order of concern to hospital CEOs, with the lowest numbers indicating the highest concerns. 2 In 2011 the survey was confined to CEOs of community hospitals (nonfederal, short-term, nonspecialty hospitals). 3In 2010 and 2009, the percent of CEOs who named an issue among their top three concerns was used to place issues in order of concern to hospital CEOs. 4In 2009 this issue was referred to as “implications of healthcare reform.” 20 Page 10 Sentara Serious Safety Event Rate Sentara Hampton Roads Hospitals 0.75 80% Reduction Since 2003 Event Rate 0.50 0.00 J-03 M-03 M-03 J-03 S-03 N-03 J-04 M-04 M-04 J-04 S-04 N-04 J-05 M-05 M-05 J-05 S-05 N-05 J-06 M-06 M-06 J-06 S-06 N-06 J-07 M-07 M-07 J-07 S-07 N-07 J-08 M-08 M-08 J-08 S-08 N-08 J-09 M-09 M-09 J-09 S-09 N-09 J-10 M-10 M-10 J-10 S-10 N-10 J-11 M-11 M-11 J-11 S-11 0.25 Each monthly data point is a rolling 12-month average of serious events of harm expressed per 10,000 adjusted patient days 21 A deviation from generally accepted performance standards (GAPS) that… Serious Safety Event Serious Safety Events • Reaches the patient • Results in moderate to severe harm or death Precursor Safety Events Precursor Safety Event • Reaches the patient • Results in minimal harm or no detectable harm Near Miss Safety Event • Does not reach the patient • Error is caught by a detection barrier or by chance Near Miss Safety Event © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 22 Page 11 Worker Safety Improvements Workman's Compensation Costs $600,000 1. Represents over 250 employees that have not been $500,000 injured $400,000 2. 80% Reduction in Lost Time Claims 3. 88% Reduction in OSHA$300,000 IIR from 12.2 to 1.5 4. Over $900,00 saved year to date $200,000 $100,000 $0 CY 07 CY 08 CY 09 CY 10 23 Lessons from HRO’s 24 Page 12 Reliability Reliability: The probability that a system, structure, component, process, person will successfully provide the intended function(s). Often a ratio such as 0.96 or 96% Sometimes a frequency such 10-3 per year 25 High reliability organizations (HROs) “operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents.” Managing the Unexpected (Weick & Sutcliffe) Risk is a function of probability and consequence. By decreasing the probability of an accident, HRO’s recast a high-risk enterprise as merely a high-consequence enterprise. HROs operate as to make systems ultra-safe. 26 Page 13 Naval Aviation Mishap Rate 776 aircraft destroyed in 1954 Mishap rates per 100,000 flight hours 60 Angled decks 50 Aviation Safety Center Naval Aviation Maintenance Program (NAMP), 1959 40 15 aircraft destroyed in 2008 RAG concept initiated NATOPS Program, 1961 30 Squadron Safety program System Safety Designated Aircraft 20 ACT ORM 10 USN/USMC, FY50-06 0 50 55 60 65 70 75 80 85 90 95 00 Source: www.safetycenter.navy/mil ORM Flight Mishap Rate 27 28 Page 14 Reliability Journey to improving reliability – the next zero 10 -8 10 -7 10 -6 10 -5 10 -4 10 -3 10 -2 10 -1 Optimized Outcomes Human Factors Integration Intuitive design Impossible to do the wrong thing Obvious to do the right thing Reliability Culture Process Design Core Values & Vertical Integration Hire for Fit Behavior Expectations for all Fair, Just and 200% Accountability Evidence-Based Best Practice Focus & Simplify Tactical Improvements (e.g. Bundles) © 2010 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 29 Descriptive Theories of HRO Karl Weick & Kathleen Sutcliffe 1. 2. 3. 4. 5. Preoccupation with failure Sensitivity to operations Reluctance to simplify interpretations Commitment to resilience Deference to expertise Rene Amalberti 1. 2. 3. 4. 5. Accepting limits on discretionary action Abandoning autonomy Transition from craftsman to equivalent actor Sharing risk vertically in the organization Managing the visibility of risk Admiral Hyman Rickover 1. 2. 3. 4. 5. 6. 7. 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 30 Page 15 Five Principles of HROs Three Principles of Anticipation Preoccupation with Failure Regarding small, inconsequential errors as a symptom that something’s wrong Sensitivity to Operations Paying attention to what’s happening on the front-line Reluctance to Simplify Encouraging diversity in experience, perspective, and opinion Two Principles of Containment Commitment to Resilience Developing capabilities to detect, contain, and bounce-back from events that do occur Deference to Expertise Pushing decision making down and around to the person with the most related knowledge and expertise 31 USS George Washington 32 Page 16 Preoccupation with Failure Operating with a chronic wariness of the possibility of unexpected events that may jeopardize safety by engaging in proactive and preemptive analysis and discussion 33 Counteracting the Risks FOD walkdown Situational awareness – monitoring for anything that “does not fit” expectations of the correct routine Landing Officer – listens to the pilot’s voice to detect subtle cues of tension Every landing graded – used to improve performance Near misses debriefed within the hour Healthcare example: RRT to EWS 34 Page 17 Sensitivity to Operations FOD Walk-Down 35 36 Page 18 “Patients don’t suddenly deteriorate. Healthcare professionals suddenly notice.” Anticipated Recovery Clinical status Admission Assessment Early Warning Score Systematic identification & Mitigation Medical Emergency Team Effort needed to return to recovery CPR Source: Cincinnati Children’s Hospital Medical Center Time 37 Identify Family concerns High risk therapies Mitigate Escalate Bedside Team Unit Team Organization Team Intern Watchstander Senior Resident Medical Response Team (MRT) Bedside nurse Watchstander Charge Nurse Safety Team (Nurse Manager and Safety Officer) Early Warning Score ≥5 Watcher Communication concern Attending 38 Tested on 4 nursing units then spread on 3/22/10 Source: Cincinnati Children’s Hospital Medical Center Page 19 Situation Awareness project go-live Robust plan and prediction 39 Codes Outside the ICU MRT Preventable Codes Outside Critical Care w/ BVMV or CC or Both per 1000 patient days U Chart 0.50 Events per 1000 Hospital Patient Days 0.45 0.40 0.35 0.30 0.25 0.20 0.15 0.10 0.05 19832 18217 17885 17593 19606 19771 19609 19773 21200 19869 20407 21854 21080 19745 20827 18560 20061 19052 18143 19275 20957 19545 19909 19860 21253 19983 20268 19828 21404 0.00 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 Q4 FY 2011 Patient Days, Quarter Actual Rate Mean: FY 2004 Q3- FY 2007 Q3 Last Updated 5/3/2011 by J. Barth, James M. Anderson Center for Health Systems Excellence Goal Control Limits Source: Dr. Derek Wheeler, CCHMC Division of Critical Care Medicine/Census Database 40 Page 20 Reliability Culture - Genius of the AND Safety Focus + performed as intended consistently over time Evidence-Based performed as intended + Process Bundles consistently over time Patient Centered + performed as intended consistently over time = No Harm = Clinical Excellence = “Satisfaction” RELIABILITY CULTURE “Failure Prevention” Financial Focus + performed as intended consistently over time = Margin 41 Challenges to Achieving High-Reliability Question whether things could really be that much better Not sure how to get there A piecemeal approach: more tactics than strategy Few healthcare examples 42 Page 21 New Leadership Competencies 43 High Reliability Leadership 1. Create a robust culture of reliability and safety - Be clear about the target and message on the mission - Create commitment, not compliance 2. Learn about high reliability principles and the science of safety - Understand the value of non-technical skills - Leaders as teachers and coaches 3. Implement structures and processes that support high reliability - Daily operating systems for front-line staff and leaders 44 Page 22 The Science of Safety 45 Anatomy of a Safety Event Multiple Barriers - technology, processes, and people - designed to stop active errors (our “defense in depth”) EVENTS of HARM Active Errors by individuals result in initiating action(s) Latent Weaknesses in barriers PREVENT DETECT & CORRECT The Errors The System Weaknesses From James Reason, Managing the Risks of Organizational Accidents, 1997 46 Page 23 Unreliability and Patient Safety Deviations from bestpractice care causing Significant Patient Harm = Serious Safety Event Serious Safety Events include errors that result in death, permanent loss of function, or injury, such as: transfusion reaction medication event misdiagnosis hospital-acquired Infection treatment error delay in treatment wrong site/side surgery or procedure fall with serious injury 47 Common Cause Analysis Data 2010-2011 Top 10 Patient Safety Event Types Comparison based on 1,613 events from72 hospitals in HPI CCA Database HPICompare 23.6% Delay in Diagnosis or Treatment (CM8) 21.3% Medication Error (CM1) 15.2% Other Care Management (CM10) - HAI 10.2% Fall (EE3) 7.4% Other Procedural (PR6) 4.2% Retained Foreign Object (PR4) 2.2% Wrong Site Surgery (PR1) 2.2% Wrong Patient Surgery (PR2) 1.2% Suicide or Attempt (PP3) 1.1% Grade 3 or 4 Pressure Ulcer (CM7) 48 Page 24 "At the sharp end, there is almost always a discretionary space into which no system improvement can completely reach. Systems cannot substitute the responsibility borne by individuals within that space." Sidney Dekker Just Culture: Balancing Safety & Accountability (2007) 49 Human Error – A Symptom, Not Cause Human error is not the cause of failure, but a symptom of failure Human error – by any other name or by any other human – should be the starting point of our investigations, not the conclusion Source: Fitts, P. M., & Jones, R. E. (1947). “Analysis of factors contributing to 460 'pilot error' experiences in operating aircraft controls.” Memorandum Report TSEAA-694-12, Aero Medical Laboratory, Air Material Command, Wright-Patterson Air Force Base, Dayton, Ohio. 50 Page 25 Human Error Classification Based on the Skill/Rule/Knowledge classification of Jens Rasmussen and the Generic Error Modeling System of James Reason Skill Based Rule Based Knowledge Based Activity Type Familiar, routine acts that can be carried out smoothly in an automatic fashion Problem solving in a known situation according to set of stored “rules,” or learned principles Problem solving in new, unfamiliar situation for which the individual knows no rules – requires a plan of action to be formulated Error Types Slips Lapses Fumbles Wrong rule Misapplication of a rule Non-compliance with rule Formulation of incorrect response Self checking – stop and think before acting Educate if wrong rule Think a second time if misapplication Non-compliance – reduce burden, increase risk awareness, improve coaching culture Stop and find an expert Error Prevention Themes Error Probability 1:1000 1:100 3:10 to 6:10 © 2007 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 51 Common Cause Analysis Data 2010-2011 Human Error Types in the GEMS leading to Patient Harm Comparison based on 4,874 acts from 168 hospitals in HPI CCA Database HPICompare 14.3% Skill-based 69.5% Rule-based 16.1% Knowledge-based 52 Page 26 Limitations of Attention 53 Common Cause Analysis Data 2010-2011 Professional Groups Experiencing Acts in Healthcare Safety Events Comparison based on 3,112 inappropriate acts from 72 hospitals in HPI CCA Database HPICompare 39.0% Nurse 30.6% Medical Staff 8.3% Care Team 7.7% Technician/Technologist 3.4% Pharmacist 2.6% Nurse Extender 2.2% Management 1.9% Unit Clerk 1.6% NP + CRNA 1.1% Therapist 54 Page 27 3 Reasons for a Culture of Safety in Support Organizations 1. Harm at their hand – all professional groups in a hospital setting 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. Hospital Readiness – high-reliability support organizations unwind time pressure, distractions (interruption type), and high continuous workload. 55 Common Cause Analysis Data 2010-2011 “How” Data “Why” Data People Causes HPICompare Knowledge & Skill 12.8% Structure (job design) 10.5% Attention on task 15.0% Culture (people & people interaction) 57.3% Process 19.3% Information processing 8.7% Systems Causes HPICompare Critical Thinking 36.0% Policy & Protocol 8.2% Non-Compliance 21.4% Technology & Environment 4.7% Normalized Deviance 6.0% Acts coded for human error 1,820 of 2,845 (64%) Acts coded for system cause Culture Preventable = 2,444 of 3,102 (80%) 76.3% Comparison based on 1,613 events / 3,112 acts from 72 hospitals in HPI CCA Database 56 Page 28 Influencing Behaviors at the Sharp End Design of Policy & Protocol Design of Culture Design of Structure Design of Work Processes Design of Technology & Environment Behaviors of Individuals & Groups “You have to manage a system. The system doesn't manage itself.” "A bad system will DEFEAT a good person every time.“ W. Edwards Deming W. Edwards Deming Outcomes Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994) © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 57 What is Culture? Culture The shared values and beliefs of individuals in a group or organization Culture = Shared Values & Beliefs Shared Values & Beliefs Our Behaviors Our Behaviors Outcomes 58 Page 29 Job Design EOC Culture Process Policy Protocol Technology Culture makes the other shaping factors work as intended. High Reliability is the right mix of Blunt End behavior shaping factors. Culture is not just one of the spaces Culture is also the space between the other spaces Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994) © 2012 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 59 Complementary Strategies Codes Outside the ICU Surgical Site Infections Hand Hygiene Central Line Infections Culture …and on, and on, and on… © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 60 Page 30 Safety as a Core Value 61 Vive La Différence! Safety as a Priority Safety as a Core Value An objective that is ranked among a list of other objectives Position on the list may shift, based on relative importance at the time A distinctive guiding principle that shapes thinking and decision making Does not change Uncompromisable 62 Page 31 Safety at Norfolk Southern Six Tenets of Safety 1. All injuries can be prevented. 2. All exposures can be safe-guarded. 3. Prevention of injuries and accidents is the responsibility of each employee. 4. Training is essential for good safety performance. 5. Safety is a condition of employment. 6. Safety is good business. 63 “Attention is the currency of leadership.” Ronald Heifetz Director of the Leadership Education Project John F. Kennedy School of Government Harvard University “I’m careful about the questions I ask…” Lee Carter Chair, Board of Trustees Cincinnati Children’s Hospital 64 Page 32 Safety as a Core Value at Riverside Senior leader message Transparent Action-oriented Clear expectations Call for Commitment “I urge you to take this initiative to heart – learn more about it, live it, own it…” 65 Care, Comfort, and Heal …Without Harm Lead with safety… by beginning every meeting with a “safety moment” to keep safety topof-mind in thinking and decision making Call the question… when making decisions by asking, “What impact would this have on safety?” Say “thank you”… when anyone reports an error, mistake, or event. Then, say, “Let’s understand how it happen,” to encourage reporting and to promote transparency and learning from events. 66 Page 33 Actions for Leaders Make Safety an Explicit Core Value Leaders show the way by setting expectations and being good examples. Leaders model, inspire, train and encourage staff to keep themselves and others safe each day. Patient safety message at start of every meeting Link decisions to safety – “what’s best for the patient?” Encourage reporting of events and problems Recognize those who ask the safety question Communicate lessons from safety events Measure preventable harm and make harm visible “There is no priority higher than patient safety. If there is a conflict between safe practice and speed, efficiency or volume, then safety wins – hands down.” James M. Anderson President & CEO Cincinnati Children’s 67 The HRO Difference Harm is visible – Risk is visible 68 Page 34 Making Harm Visible in Healthcare …and more importantly, our efforts to eliminate it! 69 Safety Culture What safety culture sound bites do you hear? Write them down as you watch the video. 70 Page 35 Safety Culture Sound Bites: Safety for the right reasons – not just to meet regulatory requirements Safety is the most important thing we do…if we can’t do it safely, we’re not going to do it Want to understand the hazards and potential hazards before we get to the field Stop Work Ability in the hands of each and every individual – responsibility and moral obligation Culture: consistent, predicable behavior that takes time to develop – have to break old paradigms Not a “check in the box” but something we really believe in Quiz people’s knowledge and their understanding of what’s right and what’s wrong Goal: ZERO lost-time accidents Tout our safety program when we go out to win new work Easy to talk about safety but to actually do something about safety, that’s where the rubber really meets the road 71 Culture Embedding Mechanisms From Organizational Culture & Leadership, by Edgar Schein Secondary Articulation & Reinforcement Mechanisms Primary Embedding Mechanisms • What leaders pay attention to, measure, and control on a regular basis • How leaders react to critical incidents and organizational crises • Observed criteria by which leaders allocate scarce resources • Deliberate role modeling, teaching, and coaching • Observed criteria by which leaders allocate rewards and status • Observed criteria by which leaders recruit, select, promote, retire, and excommunicate organizational members • Organizational design and structure • Organizational systems and procedures • Organizational rites and rituals • Design of physical space, facades, and buildings • Stories, legends, and myths about people and events • Formal statements of organizational philosophy, values, and creed 72 Page 36 Culture Change: It’s Different Work From The Dilemma of Foundation Leadership, by Ronald Heifetz 73 Behaviors for Error Prevention 74 Page 37 Non-Technical Skills “They are not new or mysterious skills but are essentially what the best practitioners do in order to achieve consistently high performance and what the rest of us do “on a good day”.” HRO’s focus on effective, widespread use of NonTechnical Skills Flin, O’Connor, and Crichton Safety at the Sharp End 75 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 76 Page 38 More Rules or More Tools? Coverage on broad range of harm events Synergy with people, process, and technology Focused on several known harm events Synergy with policy & protocol 77 Vertically Aligned & Explicit For example: Vision Safest Hospital Mission & Goals Zero events of harm Policy & Programs Infection Prevention Behavior Expectations “Wash Hands Before & After” • Soap & warm water • 15-second scrub (“Happy Birthday”) • Paper towel to turn off faucet Specific Tools & Techniques © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 78 Page 39 Sentara Error Prevention Toolbox 1. Pay Attention to Detail STAR (Stop/Think/Act/Review) 2. Communicate Clearly Repeat Backs & Read Backs Clarifying Questions Phonetic & Numeric Clarifications SBAR 3. Have a Questioning Attitude Validate & Verification 4. Handoff Effectively 5P’s (Patient/Project, Plan, Purpose, Problems, Precautions) 5. Never Leave Your Wingman Peer Checking Peer Coaching 79 Self-Checking Using STAR Stop Pause for 1 to 2 seconds to focus your attention on the task at hand Think Consider the action you’re about to take Act Concentrate and carry out the task Review Check to make sure that the task was done right and that you got the right result The most effective way to avoid slips and lapses. It takes only seconds and reduces the probability of making an error by a factor of 10 or MORE! 80 Page 40 3-Way Repeat Back When information is transferred... Sender initiates communication using Receiver’s Name. Sender provides an order, 1 request or information to Receiver in a clear and concise format. 2 3 Receiver acknowledges receipt by a repeatback of the order, request or information. Sender acknowledges the accuracy of the repeat-back by saying, That’s correct! If not correct, Sender repeats the communication. A Safety Phrase “Let me repeat that back…” 81 Peer Checking Take advantage of working together: Check the accuracy of each other’s work Identify skill-based slips and lapses Point out unusual situations or hazards Impromptu consultation Key to Successful Checking Be willing to check others AND be willing to have others check us 82 Page 41 Peer Coaching Encourage and praise others when they use safe and productive behaviors Discourage and give advice to others when they use unsafe and unproductive behaviors Coaching Tips Look for opportunities to point out the good things – ratio of 5 positives to 1 negative Provide feedback based on observations and facts Use the “lightest touch” possible A Safety Phrase “Thanks for saying something…” 83 Speak Up for Safety using ARCC A responsibility we each have to protect in a manner of mutual respect – an assertion and escalation technique Use the lightest touch possible… Ask a question Make a Request Voice a Concern If no success… Use Chain of Command A Safety Phrase “I have a concern…” 84 Page 42 People Bundle Process Bundle 4 for VAP Prevention 1. Elevation of the head of the bed to between 30 and 45 degrees 2. Daily “sedation vacation” and daily assessment of readiness to extubate 3. Peptic ulcer disease (PUD) prophylaxis 4. Deep venous thrombosis (DVT) prophylaxis (unless contraindicated) Read More: Community Health Network Reduces Deadly Infections Through Culture of Reliability, American Society for Quality (June 2008) 85 Near Misses in Cardiac Surgery Myles Edwin Lee, MD “Mahatma Gandhi propounded the seven deadly sins… I would add an eighth: medicine without teamwork.” “A crucial interdependence exists among the various members of the heart team, making it imperative that they be able to recognize and articulate observations of real or imagined problems that may or may not actually be within the realm of their expertise…It is this system of mutual checks and balances that constitutes the essence of team work.” 86 Page 43 Tenerife Disaster 27 March 1977 Copilot: Wait a minute – We don’t have takeoff clearance Captain: No, I know that – Go ahead! Moments later – Copilot: Is he not clear then? Is he not clear, that Pan American? Captain: Yes! (emphatic and angry) 87 It Always Starts with the Culture Common Themes from Watershed Aviation Accidents Captains treated crewmembers as underlings, creating an environment of “speak only when spoken to” Intimidating atmosphere led to accidents when critical information not communicated among crew 88 Page 44 Power Distance Large Distance Small Distance • Relations are autocratic and paternalistic • Power acknowledged based on formal, hierarchical positions • 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 Reference: Hofestede, Geert. Culture’s Consequences, 2001 (2nd edition). 89 Impact on Individual & Team Behavior *Survey of 2,095 healthcare providers (1,565 nurses & 354 pharmacists) Types of Intimidation: Affects on Safe Practice: (regardless of source) 88% condescending language or tone 87% impatience with questions 79% reluctance or refusal to answer questions or phone calls 48% strong verbal abuse 43% threatening body language 40% who had questions about an order assumed it was correct or asked another professional to interact with the provider 75% asked colleagues to help interpret an order so that they did not have to interact with an intimidating prescriber 34% reported that they found the prescriber's stellar reputation intimidating and had not questioned an order for which they had concerns Source: Institute for Safe Medication Practices. 2003 Survey on Workplace Intimidation, Medication Safety Alert, 11 March 2004 90 Page 45 Collegial Interactive Teams (CIT) = Tone + Tools Setting the tone… “You had me from Hello” - Greetings – include first names - Cordiality, openness - Eye contact and body language Team goals - Use “we” and “us” vs. “I” and “you” - What’s best for the patient… Invite a Questioning Attitude - Leaders set the tone for the flow of information - “If any member of the team sees anything that is unsafe, I expect you to speak up...” 91 Three Sources of Accountability Optimal Accountability Leaders Vertical Accountability Individual Peers Intrinsic Accountability Horizontal Accountability © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 92 Page 46 Safety Culture Accountability Systems Self-driven Hire for it – integrate into job descriptions and hiring practices accountability Convert safety behaviors to individual and team work habits Make them your habits first! Connect the dots – here’s how the behavior expectations apply to the work in our department Cues and reminders integrated into work processes Observe and coach using 5:1 feedback Aligning goals and incentives Integrate into performance appraisals Leader-driven accountability Safety Success Story Program Safety Coach Program Peers “check each other” and “coach each other” Peer-driven accountability 93 Share Safety Success Stories Environmental Services Associate Speaks Up For Safety While going about her daily duties of cleaning a patient room, Janice, an Environmental Services Associate observed a physician and nurse enter the room and prepare to perform a minor procedure. She knew the hospital’s rule about site verification before a procedure, yet noticed that the team was about to proceed without the verification. Janice politely questioned the physician and nurse, “Shouldn’t we verify the site before the procedure?” The physician and nurse thanked the Associate and verified the site. By being aware of what was going on around her and being willing to speak up, Janice helped ensure that the procedure was performed on the correct site. What Makes a Great Story Great??? Everyday excellence – not just the great saves Language we can all understand More Clever: Use the number of Name names to recognize published safety success stories as Link to a behavior expectation a real-time metric. 94 Page 47 High Leverage Leadership Tactics 95 High Reliability Leadership Method Evidence Based Leadership = Best-Practice Tools & Techniques adopted and practiced as Leadership Habit resulting in Predictable Leadership & Reduced Variation in Operational Outcomes 96 Page 48 Leveraging Senior Leaders lev·er·age the use of a small initial investment to gain a very high return in relation to one's investment, to control a much larger investment, or to reduce one's own liability for any loss High • Core Value • Daily Check-In • Rounding to Influence (RTI) • Top 10 Safety List High Leverage Tools & Techniques for Senior Leaders Impact Visibility, Relevance Degree of Influence Low Low Investment High Time, Money, Other Resources © 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 97 Daily Check-In 98 Page 49 Plan of the Day (POD) Meeting in the Nuclear Power Industry 30-minute meeting of operational leadership to provide situational awareness of plant operations and command and control for issue prioritization, ownership, and resolution Agenda Emergent safety issues Status of Top 10 Problem List Routine reports (operations priorities, operations workarounds, alarms not working, alarms locked-in, temporary modifications) Priorities for the day Critical questions Palo Verde Nuclear Generating Station Pressurized water reactor 99 The “Daily Safety Call” at Community Hospital North What It Is A deliberate, intentional, purposed report and conversation among leaders about safety events and potential safety risks so we can assign resources to follow-up appropriately on what has occurred and assign resources to reduce the risk of potential events of harm to patients, families, caregivers and care supporters. 100 Page 50 “Talking about safety should not be an event.” Barbara Summers, President Community Hospital North 9:00-9:15 AM, Monday-Friday Held via conference call All departments directors 90% attendance expectation – “step out of meeting to attend” or send a representative if you can’t participate Facilitated by senior leader Prepare to participate… 101 How To Do It Include direct reports and others who know the status of operations in your areas of responsibility. Establish a standing time. Schedule the time on your calendar and stick to it. Keep it short – 10 to 15 minutes at the most – and hold it as a “stand-up” meeting. Keep it focused. Follow a routine, 3-point agenda: Daily Check-In Agenda 1. LOOK BACK – Significant safety or quality issues from the last 24 hours/last shift 2. LOOK AHEAD – Anticipated safety or quality issues in next 24 hours/next shift 3. Follow up on Start-the-Clock Safety Critical Issues 102 Page 51 Look Back – Any Events of Harm? Patient Safety Events Serious Safety Events & Precursor Safety Events Employee Safety Events Real-Time Harm Intelligence!!! Injuries to patients Assessment or treatment delays or deficiencies Falls Medication errors Incidents of skin breakdown Incidents of VAP Etc., etc., etc. Slips/trips/falls Exposures to infectious disease Assaults Injuries to non-clinical staff – Maintenance – equipment incidents – Environmental Services – chemical incidents – Food Services – burns, cuts 103 Look Ahead – Any Threats to Safety? Procedures we have never done before New piece of equipment Very critical patient, especially one moving between departments New high-risk medication Issues that are causing staff to develop workarounds – POC testing access, lack of equipment, staffing shortage, etc. Equipment failures or concerns Change in communication capabilities Change in computer process or level of function Facility/environmental issue that poses a safety hazard Social safety issue – can involve patients, family members, employees and others Deficiencies in staffing, resources, or information Anything new or different that increases the probability of error 104 Page 52 Start the Clock for Safety Fault Exposure Time Window of potential for harm HRO Lesson: Leaders need structure. 105 Risk Awareness Curve Risk Awareness High Complacency How do you increase risk awareness without having to have an event? Event Low Time © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 106 Page 53 Risk Awareness Leveling Strategies “Talking about safety and risk should be a everyday occurrence.” Barbara Summers, President Community Hospital North Risk Awareness High Leadership Methods for Maintaining Organizational Risk Awareness Complacency Rounding-to-Influence Daily Check-In Pre-Job Briefs & After Action Reviews Safety Success Stories Events of Harm Stories Event Low Time © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 107 Daily Check-In at Cincinnati Children’s Hospital 108 Page 54 Daily Check-In at Baptist Hospital Ascension Saint Thomas Health 109 Rounding to Influence (RTI) 110 Page 55 Rapid Cycle Feedback Do Optimal Feedback PERFORMANCE Learning is doing with feedback Decrease cycle time for feedback Traditional TIME © 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 111 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. 112 Page 56 RTI – What’s the Difference? Sensitivity to Operations Threshold Genchi Genbutsu “Go and see for yourself” Walking Rounds Rounding To Influence Low - Moderate Low - Moderate Moderate High How do your shoes feel? Shine your shoes Take a few steps in their shoes Walk a mile in their shoes Adopt-a-Unit Time 30 minutes 5 to10 minutes > 30 minutes Recurring visit boluses Theme General awareness Specific focus Blunt end to sharp end translation of performance expectations Practical knowledge and experience of unit work Purpose •Identify problems that need to be fixed •Build relationships •Influence a specific behavior expectation •Identify problems impacting a specific performance expectation •Empathy for sharp end realities •Identify performance deviations and conditions impacting performance that need remediation •Sympathy for sharp end realities •Identify performance deviations and conditions impacting performance that need remediation Implementing Detail Global questions Targeted questions Observation of behaviors and environment Participation in work and work life Location Work environment or other Work environment or other Work environment Work environment © 2009 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 113 RTI: Hand Washing for HAI Prevention Greeting Hello! Do you have a few minutes for a brief conversation about hand washing? Core Value Hand washing is very important to keeping our patients – and you – safe. It’s one of the most important things we can do to prevent the spread of MRSA and other hospital acquired infections. Did you know that there are nearly 19,000 deaths each year (CDC) from hospital acquired MRSA? In 2010, we had 10 cases of MRSA in our own hospital… Can Do’s In addition to making hand washing your habit, I’d like to ask you to help others build good hand washing habits, too. Give a thumbs up when you see them doing it, and remind when you see them forget. Concerns Are there things that make this difficult in your department? Commitment Will you try it out today? Leave a message for me and let me know how it goes. 114 Page 57 VCU Health System Spectrum Health – Helen DeVos Children’s Hospital 115 Rounding To Influence Lectionary Provides uniform schedule Forces leaders to take on tough topics – not just the easy messages Aids in sharing resources and insights while preparing to influence Cycle Rounding-To-Influence (RTI) Topic 1 Speak Up for Safety Using ARCC 2 Reporting of Safety Events, Errors, & Unsafe Conditions 3 Safety Practice: Time outs 4 SBAR 5 Red Rule: Patient Identification 6 Communicating Clearly by Asking & Encouraging Clarify Questions 7 Hand Hygiene for HAI Prevention 8 Staffing Shortages: Crisis or Chronic? 116 Page 58 Engaging Physicians 117 Blunt End Influencer Sharp End Provider © 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 118 Page 59 Managing Your Strengths… ASSETS RELIABILITY LIABILITIES UNRELIABILITY PERSONAL ATTRIBUTES Derived from Overcoming Your Strengths, by Lois P. Frankel, PhD © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 119 The Disruptive Path Attributes Liabilities Unreliability Intelligence Elitest Condescending Independence Team averse Abrasive Objectivity Impersonal Belligerent Analytic Capability Critical Blaming Sense of Urgency Impatient Insensitivity Influence Aggressive Sabotage Derived from Overcoming Your Strengths, by Lois P. Frankel, PhD 120 Page 60 The Success Path Attributes Strengths Reliability Intelligence Competence Independence Confidence Objectivity Thinking Critically Analytic Capability Problem Solving Sense of Urgency Safety First Influence Team Building Preoccupation with failure Sensitivity to operations Reluctance to simplify Commitment to resilience Deference to expertise 121 Aviators & Physicians – Some Observations Aviators o o o o o o o o o o o Highly Skilled Confident & Decisive Self-sufficient High need to achieve Seeks responsibility More concerned with modifying their environment than changing their own behavior Low tolerance for imperfections Crave excitement Use humor to cope with stress Have difficulty with ambiguous situations Don't handle failures well Physicians o o o o o o o o o o o o o o Highly Skilled Confident & Decisive Self-sufficient High need to achieve Seeks responsibility More concerned with modifying their environment than changing their own behavior Low tolerance for imperfections Crave excitement Use humor to cope with stress Have difficulty with ambiguous situations Don't handle failures well Empathetic Compassionate Altruistic - sometimes 122 Page 61 What Aviators Had to Learn the Hard Way… We created Power-Distance Authority Gradient and shunned speaking up for safety We poorly managed the Advancement of Technology We developed additional individual roles but simultaneously created the Absence of Teamwork We vehemently resisted Standardization Self-Imposed Stressors were only what you worried about at home We failed to understand Aviators were more than pilots; we didn’t accept Leadership by Default 123 Why It’s Important Better for you…and for your patient Contributors to harm in healthcare - #2 professional group experiencing 31% of errors and mistakes associated with safety events (HPICompare) Longer tenure – lower turnover - Boards – every 3 to 6 years Hospital CEOs – 18% (in 2009; ACHE) RNs – 21% (in 2000; AONE) Physicians in Medical Groups – 7% (in 2006; AMGA) Impact on individual and team behavior…for better or for worse! 124 Page 62 Just Culture 125 Just Culture creates an atmosphere of trust in which people are encouraged to provide, and even rewarded for providing, essential safety-related information but in which they are clear about where the line must be drawn between acceptable and unacceptable behavior. James Reason Managing the Risks of Organizational Accidents (1997) 126 Page 63 Striking the Right Balance Human Error Rate Blame-Free (post-1990) “Fair or Just Culture” Blame & Punishment (pre-1990) 127 Unintended Human Error vs. Non-Compliance In a fair, or just, culture… - No punishment for unintended error or mistakes driven by system problems - Fair consequence for intended decisions to act against the rule “If everything ‘goes,’ then in the end no problem may be seen anymore as safety critical – and people will stop talking about them for that reason.” Sidney Dekker, Just Culture: Balancing Safety & Accountability (2007) It’s the leader’s responsibility to differentiate, and we can differentiate… 128 Page 64 The Drivers of Non-Compliance Non-Compliance = Perceived Burden Coworker Perceived + Coaching Risk © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 129 Culpability Assessment Tools James Reason “Decision Tree for Determining the Culpability of Unsafe Acts” from Managing the Risks of Organizational Accidents (1997) United Kingdom’s National Health Service “Incident Decision Tree,” adapted from James Reason’s decision tree (2003) P. Hudson Refined Just Culture Model from the Shell Hearts & Minds Project (2004) David Marx “Just Culture Algorithm” (2005) 130 Page 65 Performance Management Decision Guide Adapted from James Reason’s Decision Tree for Determining the Culpability of Unsafe Acts and the Incident Decision Tree of the National Patient Safety Agency (United Kingdom National Health Service) Start Deliberate Act Test Incapacity Test D1 Compliance Test C1 I1 No Did the individual intend the act? Is there evidence of ill health or substance abuse? Yes No Yes Did the individual depart from policies, procedures, protocols, or generally accepted performance expectations? Yes Substitution Test S1 No Would individuals in the same profession and with comparable knowledge, skills, and experience act the same under similar circumstances? No Yes C2 Were the policies, procedures, protocols, or performance expectations available, understandable, workable, and in routine use? No Yes D2 Did the individual act with malicious intent (i.e. to cause individual harm or other damage)? C3 I2 No Did the individual have a known medical condition? No Is there evidence that the individual chose to take an unacceptable risk OR has a trend in poor performance or decision making? Yes Yes S2 No Were there deficiencies in related training, experience, or supervision? Yes No Yes C4 Were there significant mitigating circumstances? Yes No Malevolent or Willful Misconduct (Consult Human Resources) Disciplinary action Report to professional group or regulatory body Law enforcement referral Identify Contributing System Factors Medical Condition and/or Substance Abuse (Consult Human Resources) Occupational health referral Adjustment of duties Leave of absence If substance abuse: Substance abuse testing Disciplinary action Identify Contributing System Factors Possible Reckless or Negligent Behavior (Consult Human Resources) Disciplinary action Job-fit consideration Identify Contributing System Factors 131 What Senior Leaders Can Do To Promote a Just Culture Possible Unintended Human Error (Consult Human Resources) Console Coaching Mentor assignment Increased supervision Performance improvement plan Adjustment of duties Possible System Induced Error Console and/or Coach the Individual AND Find & Fix Process Problems Identify Contributing System Factors Revision 3, April 2009 © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Set the tone: • When you hear about an event, count to 5 before responding…Stop & Think before you speak! • Say, “Thank you” when someone reports an event or error. Then say, “Let’s understand how that happened…” • Ask your direct reports to let you know when one of their employees reports and event or error – go thank that person. • Ask about events and errors during Daily Check-In. • Round-To-Influence on the importance of reporting and learning from errors and events. • Observe and coach operational leaders in their response What Make it “safe” to report and demonstrate the value of reporting: Operational Leaders • Share great catches – a.k.a. Safety Success Stories Can Do To Promote a Just Culture • Reward reporting of Near Misses & Precursor Safety Events • Diagnoses the cause of human error…and respond in a fair and just way: Fix system and management problems causing error Console and coach for unintended human error Apply fair consequence for non-compliance • Communicate improvements made as a result of reporting What Personal commitment to safety: Staff & Physicians Can Do To Promote a Just Culture • • • • Report events, errors, and mistakes Encourage others to report Offer suggestions for improving the systems and processes Be eager to learn and apply lessons from events and the experience of others 132 Page 66 References & Recommended Readings Sidney Dekker, Just Culture: Balancing Safety & Accountability, Ashgate (2007). David Marx, JD, “Patient Safety and the ‘Just Culture’: A Primer for Health Care Executives,” Columbia University (2001). James Reason, Managing the Risks of Organizational Accidents, Ashgate (1997). Sandra Meadows, et. al., “The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents,” National Patient Safety Agency, United Kingdom (2003). (http://www.npsa.nhs.uk/site/media/documents/760_IDT%20Information%20and%20Advice%20on%20Use.pdf) Gary R. Yates, MD gryates@sentara.com 133 Key Points 1. Safety is a science. Ultra-high levels of safety can be achieved by employing High Reliability principles. 2. “Attention is the currency of leadership.” The role of senior leaders is absolutely critical to HRO success. 3. Safety is a “dynamic, non-event.” Everyone has a role in creating and maintaining a high reliability, safe culture. 4. The medical staff is critical to sustain safety as a core value. 5. Everyone makes errors – serious patient harm events are almost always a result of the “system” failing – not an individual human error. 6. Staff, physicians and leaders must make proven error prevention strategies practice habits. 134 Page 67 March 22, 1966 “The measure of success is not whether you have a tough problem to deal with, but whether it is the same problem you had last year.” John Foster Dulles 135 135 Thank you Gary Yates, MD gryates@sentara.com 136 Page 68 NOTES NOTES NOTES