Promises and Pitfalls STHS Hospital System Network November 12, 2003

1
Promises and PitfallsSTHS Hospital System
NetworkNovember 12, 2003

• Rural and Community Health Institute
• Texas AM University System Health Science Center
• Josie R. Williams, MD, MMM

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Weve Come a Long Wayin Medicine
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and in Nursing and Hospitals
4
Tools, Techniques, and Knowledge Have Changed
5
Are we, being human, being slow to adapt our ways
to change healthcare delivery???
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MetanoiaA Shift of mind

• The most accurate word in Western culture to
  describe what happens in a learning organization
• -P Senge

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Metanonias deeper meaning is to grasp the
meaning of learningLearning is used to be
synonymous with taking in information-----yet
taking in information is only remotely related to
real learning

• P Senge-In Serach of Excellence

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First Do No HarmBasic premise for all
quality of care.It maybe possible to mitigate
harm but it is not possible to be error
free.Lucian Leape
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Did or do you ever wonder why it always feels
like it is NOT as bad as they say??
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Ever Wonder What 99.9 Meant?

• 1 Hour of unsafe drinking water every month.
• 2 Unsafe plane landings per day at OHare
  Airport in
• Chicago.
• 16,000 Pieces of mail lost by the U.S. Post
  Office
• every hour.
• 500 Incorrect operations each week.
• 50 Babies dropped at birth every day.
• 22,000 Checks deducted from the wrong bank
• account each hour.
• 32,000 Missed heart beats per person each year.

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Is 99.9 Were Good Enough

• A major plane crash every three days.
• 12 babies to the wrong parents every day.
• 37,000 ATM errors hourly.
• 20,000 incorrect prescriptions annually.
• The IRS would lose two million documents this
  year.
• 107 erroneous medical procedures every day.
• (Source InSight, Syncrude Canada Ltd,
  Communications Division)

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Lehigh Clinic

• Since we started using FEMA analysis and
  reporting of Near Misses we have so many
  errors, we can only focus on those most likely to
  cause harm.

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HFEMATom Bigley, RPh, MS,Upper Valley Medical
Center, OH
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Tyranny of Small Numbers

• Prescriptions 3,000,000,000
• X 5 error rate
  150,000,000
• X 20 are serious
  15,000,000
• X 10 cause ADE 1,500,000
• X ? 1 are fatal 15,000
• 45,000 Texas physicians wed see one only ever 3
  years
• Adapted from Dr
  Lucian Leape

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Iceberg Model of Accidents and Errors
Actually Occurred
Misadventure Death\severe harm
Actual Harm
No Harm Event Potential for harm is present
Near Miss Unwanted consequences were prevented
because of recovery
Recovery
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Heinreichs Ratio1
It has been proposed that reporting systems could
be evaluated on the proportion of minor to more
serious incidents reported. 2
1

• 1 major injury
• 29 minor injuries
• 300 no-injury accidents

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300
1. Heinreich HW Industrial Accident Prevention,
NY And London 1941.
2. An Organization With a Memory, A report of an
expert group on learning from adverse events in
the NHS chaired by the Chief Medical Officer, The
Stationary Office, London 2000.
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Ways to Improve a Process

• Reduce the number of steps involved or
• Improve the reliability of individual steps.
• Improvement Tip Only Two Ways To Improve a
  Process,Victoria Minden, IHI, 25,May, 2003.

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Hypothetical ProcessImprovement Tip Only Two
Ways To Improve a Process,Victoria Minden, IHI,
25,May, 2003.

• Probability of succeeding only 78
• Step Reliability 
• Step 1 99  
• Step 2 95 
• Step 3 99  
• Step 4 98  
• Step 5 90  
• Step 6 95
• This entire six-step process has a probability of
  succeeding only 78 of the time (0.99 x 0.95 x
  0.99 x 0.98 x 0.90 x 0.95). Or, stated another
  way, the process fails (is defective) 22 of the
  time.

• Probability 87
• Step Reliability 
• Step 1 99  
• Step 2 95  
• Step 3 99  
• Step 4 98  
• Step 6 95

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Improve the Probability of Success by Improving
the Reliability of Individual StepsImprovement
Tip Only Two Ways To Improve a Process,Victoria
Minden, IHI, 25,May, 2003.

• Improve steps 2 and 6, bringing both up to 98
  reliability.

• The overall process would now perform at 83
  reliability much improved from the original 78.

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Combine the Two Improvement Methods Improvement
Tip Only Two Ways To Improve a Process,Victoria
Minden, IHI, 25,May, 2003.

• Remove unnecessary steps AND enhance the
  reliability of individual steps.

• Now the system succeeds 92 of the time, with
  defects only 8 of the time. A leap of 14 from
  our original performance of 78.

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Given the Implications of Tolerating Unreliable
System Performance

• Organizations/individuals seeking quality must
  ask
• What steps could be removed?
• How could each step be made more reliable?
• These simple questions are paramount in the drive
  toward perfection.
• Improvement Tip Only Two Ways To Improve a
  Process,Victoria Minden, IHI, 25,May, 2003.

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Complexity and Performance

• Number of steps
• 1
• 10
• 20
• 50
• 100
• 1000

• Defect - free
• .99
• .90
• .82
• .49
• .36
• .0004

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B James
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• Its not what we know to do.
• Its not what we try to do.
• Its not what we think we do.
• Its what we know to do that for whatever the
  reason doesnt get done.
• Its what we know to do that we think we do
  doesnt get done.

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Patient Safety The Old Look

• Clinicians are Supposed to be Infallible.
• Bad Things Happen Only when People Make Mistakes.
• People/Organizations that Fail are Bad.
• Blame Punishment Sufficiently Motivate
  Carefulness.

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Judgment vsLearning
Judgment - Based approaches ask WHO? Learning -
Based approached ask WHY? or
WHAT? or
HOW? (The Japanese Five Whys) (Concept of
Drill Down)
B James
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Vigilance is Necessary but not Sufficient
Condition for Appropriate Clinical Decision
Making

• David Gaba, M.D., Assistant Professor, Department
  of Anesthesiology, Stanford University,
  emphasized that

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Vigilance

• Vigilance is sustained tension toward the
  occurrence of a signal to which one is expected
  to respond.
• A signal is an event to which one is to respond.
  
• "Vigilance" Discussed by ASA Panel,by David W.
  Edsall, M.D., Vol 8 No. 1, Spring, 1993.

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Vigilance Decrement Example

• Repetitive vital signs would be events.
• A vital sign in an unsafe range would be a
  signal.
• The ability to sustain attention toward the
  signal decreases with time and is called the
  vigilance decrement.
• Decrement completes itself in about 30 minutes
  with ½ the decrement in about 15 minutes.
• "Vigilance" Discussed by ASA Panel,by David W.
  Edsall, M.D., Vol 8 No. 1, Spring, 1993.

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Classic Vigilance Paradigm

• Classic vigilance paradigm occurs when
• (1) The task is prolonged and continuous
• (2) The signal is infrequent and aperiodic
• (3) The signal is easily recognizable
• (4) The observer's response cannot affect
  
  the future signal rate.
• Vigilance" Discussed by ASA Panel,by David W.
  Edsall, M.D., Vol 8 No. 1, Spring, 1993

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P f (M,S,U,B,C)

• Where P Performance
• M Sensory Modality (i.e., visual vs. auditory
  signals)
• S Signal Salience (i.e., volume of auditory
  signal)
• U Stimulus Uncertainty (i.e., where or when a
  signal will appear during the watch)
• B Background Event Rate (i.e., frequency of
  vital signs, background noise levels, etc. The
  more one has to look for signals, the less likely
  one is to detect them)
• C Signal Complexity (the task can be either too
  complex or too simple, either of which will
  result in an increased vigilance decrement).
• Vigilance" Discussed by ASA Panel,by David W.
  Edsall, M.D., Vol 8 No. 1, Spring, 1993

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Negative Vigilance Factors

• Stress.
• Fatigue.
• High or low work load.
• Emotional depression.
• Noise.
• Extreme temperatures.
• Many other stress inducing task environments
  which have been shown to increase the vigilance
  decrement.
• Vigilance" Discussed by ASA Panel,by David W.
  Edsall, M.D., Vol 8 No. 1, Spring, 1993

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Negative Vigilance Factors

• Human short-term memory capacity is quite small.
• Five to ten items maximum lasting 15 to 20
  seconds.
• Automation can help reduce the stress of
  overloaded short-term memory or excessive
  short-term to long-term memory consolidation.
• Trend displays, if appropriately used, can reduce
  short-term memory workload and increase
  vigilance.
• Vigilance" Discussed by ASA Panel,by David W.
  Edsall, M.D., Vol 8 No. 1, Spring, 1993

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Automation and Vigilance

• Negative issues resulting from automation are
• (1) Decreased manual skills for the operator.
• (2) Decreased human-to-human communication if the
  work situation requires a team approach.
• (3) Increased complacency as the automated system
  continues to enhance its performance.
• As reliability of an automated system
  increases, complacency increases.
• Vigilance Discussed by ASA Panel,by David W.
  Edsall, M.D., Vol 8 No. 1, Spring, 1993

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Solutions

• The solution may be to incorporate an
  unreliability factor in a controlled and safe
  manner.
• In other words, keep the human being in the loop
  with a certain frequency of manual and problem
  solving tasks.
• These tasks could be real or simulated events.
• Vigilance Discussed by ASA Panel,by David W.
  Edsall, M.D., Vol 8 No. 1, Spring, 1993

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Example

• It was suggested that an anesthetist may be
  awake and alert but because of signal complexity,
  high work load, distractions, or inappropriate
  signal display, the anesthetist may not address
  the correct problem.
• Similarly, a problem may be detected but the
  response time may be slowed because of difficulty
  in deciding what to do about the problem.
• The use of an anesthesia simulator, as in the
  aviation industry, has been invaluable in
  identifying some of these issues.
• Beyond vigilance issues of leadership, education,
  action planning, resource allocation, and
  communication are other conditions required of
  the anesthetist in order to provide good patient
  care.
• David Gaba, M.D., Assistant Professor, Department
  of Anesthesiology, Stanford University,
  emphasized that

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Health Care Systems

• Were more than 2000 percent more complex than
  their general business counterparts.
• 31 percent of hospital workers reported wasting
  inordinate amounts of time and productivity
  overcoming system roadblocks.
• Where there was downsizing without addressing
  this time and productivity concern, there was
  increased morbidity and mortality.
• Physician buy-in during this time of change was
  also a big challenge.
• Steven Kairys cited a study by E.C. Murphy, Ltd.,
  in 1993, Chaos and Complexity CyberForum, ACPE
  Webpage, Leader Roy E. Gilbreath, M.D. Tampa,
  Fla., Abstractor Philip J. Aliotta, MD, MSHA
  Main Urology Associates, P.C. Williamsville, N.Y.

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Challenge of Redesign

• Retaining the best of all theories and avoiding
  the pitfalls.
• Change in healthcare works only when clinical
  teams own lead the process.
• Incremental testing of improvements, with lateral
  thinking that looks beyond existing processes and
  addresses system wide issues.
• Early successes gain interest acceptance.
• Use common sense redesign.
• Adapted from Healthcare redesign meaning origins
  application,L Locock, Quality Safety in
  Health Care,V 12, 1, February, 2003

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BUILDING A CLINICAL LAB
. . . how does one structure a health system so
that every patient treated routinely contributes
to valid safe clinical knowledge . . .
B James
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ICU at Baptist Memorial Hospital-DeSoto in
Southaven, Mississippi46 Decrease VAP in 6
Months IHI Newsletter, October 30,2003
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Compelling Improvement Results

• Dramatic improvements in ICU outcomes by
• Consistently applying systematic methodologies.
• Teams participating in Critical Care.
• Compulsive adherence to formulaic standards.
• Bundle Up, mechanical ventilationIHI
  Newsletter, October 30,2003

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Ventilator-Associated Pneumonia (VAP)IHI
Newsletter, October 30,2003

• A leading cause of morbidity and mortality in the
  ICU.
• Estimates 30- 50 mortality rate higher when
  virulent strain of infection.
• LOS 13 days on ave.
• 3,000 to 6,000/episode.

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Five Basic Precautionary Steps Rigidly Applied
IHI Newsletter, October 30,2003

• Most hospitals likely follow some of the steps
  some of the time.
• Critical care consumes some 30 of a hospitals
  expenses, for just 8 of its population.

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Forcing Function For TeamworkIHI Newsletter,
October 30,2003

• Over-stressed providers often accept poor
  outcomes and high costs of treating ICU patients
  on mechanical ventilation as inevitable.
• A number of effective strategies are not
  consistently followed in most institutions.
• Hence the design, honing and embracing of the
  ventilator bundle.

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Five Basic Precautionary Steps Rigidly Applied
IHI Newsletter, October 30,2003

• Elevating the head of the patients bed (HOB) to
  30 degrees or higher.
• Prophylactic treatment for deep venous thrombosis
  (DVT).
• Prophylactic treatment for peptic ulcer disease
  (PUD).
• Conducting a daily sedation vacation.
• Daily screening of respiratory function, followed
  by trials of spontaneous breathing.

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What is New? IHI Newsletter, October 30,2003

• No dazzling new research or technical wizardry
  but a system to ensure that each of the best
  treatment steps is taken for every patient on a
  unit.
• These interventions, when executed at the same
  time and place, bring better results than when
  performed separately. Through them one by one and
  check them off Yes or No.
• The package itself!

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Manoj Jain, MD, MPHBaptist Memorial Health
Center IHI Newsletter, October 30,2003

• These are things that every physician and nurse
  knows need to be done the problem is that we
  werent doing them consistently.
• Having a system that forces you to do the steps
  100 of the time, to follow up on the details and
  constantly evaluate the data this is whats
  new.
• Its not rocket science, but it makes a huge
  difference.

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Health Care Facilities Attribute Medication
Errors to Multiple Causes

• Source Medmarx 2001.

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Average Medication Error
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BALANCING THE CORE VALUES AND TENSIONS IN CYCLES

• KNOWLEDGE

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Easing the Burden of Input
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What I Want

• Not to have to wade through papers.
• Not to have to go on line with Medline.
• To have an index of the strength of evidence.
• To have a one word answer.
• To see questions that already have answers.
• 15 seconds to medical knowledge.

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Arent We Doing OK Anyway?

• In 1994 17 of family Practitioners thought that
  aspirin had no effect on the survival of patients
  having an MI (evidence 1988).
• Variation in prescribing, diagnostic tests,
  supervision of chronic conditions.
• Dr Martin Dawes,University of Oxford,June 2001.

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Increasing KnowledgeDr Martin Dawes,University
of Oxford,June 2001.
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Where do we get knowledge?

• Reported Observed
• Print Source 62 27
• General/speciality textbooks 25 3
• Pharmaceutical textbooks 14 9
• Journals 18 7
• Drug Company Information 1 1
• Self Made Compendia 4 7
• Human Sources 33 53
• Gorman P et al. Bull Med Libr Assoc 1994 82(2)
  140-6

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How Much Do We Read in Clinical Practice?

• 1/2 hour or less/week 3
• 1 hour 46
• 1 1/2 hours 23
• 2 hours 20
• 3 hours or more 8
• Dr Martin Dawes,University of Oxford,June 2001.

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How Many Do We See

• 100 - 200 consultations a week.
• 5,000 - 10,000 per year.
• It is difficult to be sure that one is doing the
  right thing for all these cases.
• One relies on experience.
• Use 2 million pieces of information - stored in
  your memory.
• Dr Martin Dawes,University of Oxford,June 2001.

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Why Evidence Based Health Care?

• Too many patients.
• Too many problems.
• Too many journals.
• Information overload.
• No time to read.
• Read what I am familiar with.
• Avoid difficult issues
• Dr Martin Dawes,University of Oxford,June 2001.

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Structured Question - Why Bother?

• What do you think about ACE inhibitors and heart
  disease.
• You know about EBHC - can you look it up?
• ACE Heart Disease 2,755 articles on Medline
  through PubMed.
• Need structure to my question.
• Dr Martin Dawes,University of Oxford,June 2001.

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Foreground Questions
Background Questions
Experience with Condition
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How Can You Recognize and Formulate Clinical
Questions as they Occur?

• Pay careful attention to the questions that
  spontaneously occur to you.
• Listen for the question behind the question
• What can I use for a sprain.
• Might become.
• Is a topical NSAID like aspirin more effective
  than paracetamol at enabling resumption of sport
  at 1 week?
• Dr Martin Dawes,University of Oxford,June 2001.

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What is the Best Evidence?

• Friend once told me.
• Group of old Professors.
• Case series.
• Systematic Review.
• RCT.
• Case control trial.
• Case.
• http//cebm.jr2.ox.ac.uk/docs/levels.html

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Appraise using JAMA Guide Evidence-Based
Medicine Working Group

• Are the results valid?
• What are the results?
• Will the results help me in patient care?
• http//medicine.ucsf.edu/resources/guidelines/user
  s.html

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Current Information

• Source Access Quality
• Experiential Fast Fast Dubious
• Colleagues Variable Fast Unclear
• Patients Fast Fast hmmm
• Guidelines Lost Buried Good
• Books Fast Lengthy Variable
• Research Slow Lengthy Variable

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Types of Health Care Professional
Evidence Generator
Evidence Users
Evidence Finders
Evidence Ignorer
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Analysis By Paralysis
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Modified Reason Error Model
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Richard Cooks Hindsight Bias
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BIG PICTURE
BIG PICTURE
PRACTICE
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Bridging the Quality Chasm
Where
Where We We Are
Want To Be
Implementation
Innovation
Education
Diffusion
Adoption
TRIP
Partners for Quality,Carolyn Clancy, M.D.,
Director, Agency for Healthcare Research and
Quality, March 20, 2003
75
Metanoia Understanding

• Culture.
• Communication.
• Change Management.
• Proactive Adaptation.

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Patient Safety - Human ErrorProcess Design
Organizational Change

• Process Design
• Reduce Reliance on Memory Vigilance
• Simplify
• Standardize
• Checklists
• Forcing Functions
• Eliminate Look and
• Sound-alikes

• Organizational
• Increase Feedback
• Teamwork
• Drive Out Fear
• Leadership Commitment
• Improve Direct
• Communication

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Systems Approach to Patient SafetyThe New Look

• Risk of Failure is Inherent in Complex Systems.
• Risk is always Emerging.
• Not All Risk is Foreseeable.
• People are Fallible No Matter How Hard They Try
  Not to Be.
• Systems are Fallible.
• Alert, Well-trained Clinicians are Crucial.

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Three Types of Measures

• Outcome Measures (voice of the customer or
  patient).
• Process Measures (voice of the workings of the
  system).
• Balancing Measures (looking at a system from
  different directions/dimensions) Measures,
  QualityHealthCare.org

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System Accidents The Operating Model
Three sets of factors are typically implicated
when organizations have accidents or incidents

• Human factors.

2. Technical factors.
3. Organizational factors.
Adapted from Managing the Risk of Organizational
Accidents, J. Reason, 1997
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Systems Approach to Patient SafetyThe New Look

• Risk of Failure is Inherent in Complex Systems.
• Risk is always Emerging.
• Not All Risk is Foreseeable.
• People are Fallible No Matter How Hard They
• Try Not to Be.
• Systems are Fallible.
• Alert, Well-trained Clinicians are Crucial.
• Reports Should Emphasize Narratives.
• Interdisciplinary Review Teams.
• About Identifying Vulnerabilities NOT
• Statistics.
• Prompt Feedback.
• Open to All Comers.

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Error in Medicine

• Wus Definition
• A Medical Error is a commission or omission
  with potentially negative consequences for the
  patient that would have been judged wrong by
  skilled and knowledgeable peers at the time it
  occurred, independent of whether there were any
  negative consequences.
• (Wu, 1997)

New York Medical College Department of Family
Medicine
82
Error in Medicine

• An Adverse Event
• An injury caused by medical management rather
  than the underlying condition of the patient. An
  adverse event attributable to error is a
  preventable adverse event.

New York Medical College Department of Family
Medicine
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Error in Medicine

• Why Errors Occur
• Lack of Standardization.
• Failure to design with error in mind.
• A medical culture that resists admitting to error
  and so cannot work to prevent error.
• Reference Schenkel S. 2000 Promoting safety and
  preventing medical error in emergency
  departments. Academic Emergency Medicine, Nov 7
  11, 1204-1222.

New York Medical College Department of Family
Medicine
84
Error in Medicine

• Who Makes Errors?
• The reality is that most errors are made by good
  people with good training, skills, and intentions
  who inadvertently commit errors despite their
  best efforts because of an unfortunate confluence
  of individual, workplace, communication,
  technologic, psychological, and organizational
  factors.
• Reference Annals of Emergency Medicine, July
  2000, 59

New York Medical College Department of Family
Medicine
85
James Reason in Human Error

• Two kinds of failures
• Error of Execution - Correct action does not
  proceed as intended.
• Error of planning - Original intended action is
  not correct.

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Skill-based Performance Failures

• Inattention
  Overattention
• Double - capture slips Omissions
• Omissions p interruptions Repetitions
• Reduced intentionality Reversals
• Perceptual confusions
• Interference errors

87
Rule-Based Performance Failures

• Misapplication of Good Rules Application
  of Bad Rules
• First exceptions
  Encoding deficiencies
• Countersigns and non-signs Action
  deficiencies
• Informational overload Wrong rules
• Rule strength
  Inelegant rules
• General rules
  Inadvisable rules
• Redundancy
• Rigidity

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Knowledge-Based Performance Failures

• - Selectivity -
  Overconfidence
• - Workspace limitations - Biased
  reviewing
• - Out of sight out of mind - Halo
  effects
• - Confirmation bias -
  Illusory correlation
• - Problems w causality - Delayed feed-back
• - Problems with complexity
• - Insufficient consideration of processes in time
• - Difficulties with exponential developments
• - Thinking in causal series not causal nets
• - Thematic vagabonding
• - Encysting

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Definitions

• Slips--errors that occur during actions governed
  by familiar impulses.
• Mistakes--errors of judgment.
• Rules and the familiar patterns of habit do not
  apply.
• Near misses--Stopped in the process.

• We know what to do, but do it wrong or poorly.
• In unfamiliar situations we must make a decision
  on inadequate information.
• Adapted from
• First Do No Harm A Practical Guide to
  Medication Safety and JCAHO Compliance,1999 Opus
  Communications

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Causes of slips

• Anger
• Anxiety
• Boredom
• Fear

• Habit
• Interruptions
• Hurry
• Fatigue

91
Model of Error Process

• Should aid identification of
• Types of errors committed.
• Deficiencies in training and knowledge.
• Ineffective, lacking or potential error
  detection strategies.
• Effective error mitigation or management
  strategies.
• Threat detection and management strategies.
• Systemic threats.
• The University of Texas Threat and Error
  Management Model Components and Examples, Robert
  L. Helmreich, PhD, David M Musson, MD,BMJ
  WebSite(www.BMJ.com) At www.bmj.com/misc/bmj
  320.7237.781/

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Denial

• Is my decision making as good during medical
  emergencies as during routine situations?
• 70
• Error, stress, teamwork in medicine and
  aviationcross sectional surveys, JBryan Sexton,
  Eric J Thomas, Robert L Helmreich, BMJ 320, 18
  March 2000, www.bmj.com

93
Indignant Rejection

• What definitions are you using-----!
• Where did you get this---!
• Youre comparing apples and oranges.
• You need to make this a level playing field.
• This isnt fair!
• My/our patients are sicker!
• I dont believe the data..!

94

• Error, stress, teamwork in medicine and
  aviationcross sectional surveys, JBryan Sexton,
  Eric J Thomas, Robert L Helmreich, BMJ 320, 18
  March 2000, www.bmj.com

95
Error, stress, teamwork in medicine and
aviationcross sectional surveys, JBryan Sexton,
Eric J Thomas, Robert L Helmreich, BMJ 320, 18
March 2000, www.bmj.com
96
The most common recommendation for improving
patient safety --- in the operating theatre was
to improve communication.

• Error, stress, teamwork in medicine and
  aviationcross sectional surveys, JBryan Sexton,
  Eric J Thomas, Robert L Helmreich, BMJ 320, 18
  March 2000, www.bmj.com

97
The Gold Standard
98
Many Errors are Never Acknowledged or Discussed
Because
Error, stress, teamwork in medicine and
aviationcross sectional surveys, JBryan Sexton,
Eric J Thomas, Robert L Helmreich, BMJ 320, 18
March 2000, www.bmj.com
99
Deny Fatigue Effects Performance
100
Believe True Professionals Leave Personal
Problems Behind When Working
Error, stress, teamwork in medicine and
aviationcross sectional surveys, JBryan Sexton,
Eric J Thomas, Robert L Helmreich, BMJ 320, 18
March 2000, www.bmj.com
101
Junior Team Members Should Not Question The
Decisions Made By Senior Team Members
Error, stress, teamwork in medicine and
aviationcross sectional surveys, JBryan Sexton,
Eric J Thomas, Robert L Helmreich, BMJ 320, 18
March 2000, www.bmj.com
102

• Paradigms change when anomalies between existing
  theory and observation occur,
• When an alternative paradigm is available, and
• When a critical mass of people have changed their
  beliefs.
• New paradigms represent a change in a collective
  world view.
• Chaos and Complexity CyberForum, ACPE Webpage,
  LeaderRoy E. Gilbreath, M.D. Tampa, Fla.,
  Abstractor Philip J. Aliotta, MD, MSHA Main
  Urology Associates, P.C. Williamsville, N.Y.

103
Hierarchy of Research Impact
IMPROVES ACCESS, OUTCOMES, EFFICIENCY
Level 4
IMPROVES DELIVERY AND PRACTICE
Level 3
Level 2
IMPROVES PROCESSES AND POLICIES
Level 1
IMPROVES OTHER RESEARCH
Partners for Quality,Carolyn Clancy, M.D.,
Director, Agency for Healthcare Research and
Quality, March 20, 2003
104
Implementation of Research Findings Debunked
Assumption
Question
Hypothesis
Study
Publications
Changes in Practice
Partners for Quality,Carolyn Clancy, M.D.,
Director, Agency for Healthcare Research and
Quality, March 20, 2003
105
--Innovation is real workDrucker

• Essential ingredients
• Takes talent.
• Ingenuity.
• Knowledge.
• Diligence.
• Persistence.
• Commitment.

106
Beyond Blame The System

• Its impossible to separate the chance of good
  from the risk of ill.
• -David Hume
• Healthcare is a high risk industry.
• Errors/potential errors are everywhere.

107
Beyond Blame The System

• Borrow from others disciplines and industries.
• High Reliability Organizations Risk can be
  controlled and system can be made safer.

108
Attributes ofHigh Reliability Organizations (1
OF 2)

• Acknowledgement of Risk.
• Auditing Risk.
• Process Control.
• Leadership.
• Appropriate Rewards.

109
Attributes of High Reliability Organizations (2
OF 2)

• Process Control
• Rules Procedures
• Training, Training, Training
• Strategic Redundancies
• Teamwork Development
• Migrating Decision-Making

110
Strength of Changes (in rank order)

• 1. Forcing function
• 2. Automation, computerization
• 3. Protocols and preprinted orders
• 4. Checklists
• 5. Rules and double-checking
• 6. Education
• 7. Information

111
Some New Terms

• Authority gradient.
• Work-around.
• Diffusion of responsibility.
• Sharp end.
• Force function.
• HROs.

112
Surgical care revolves around a predictable event
(the surgical operation) with an expected outcome

• Jennifer Daly,Institute for Health Policy
  MGH/Partners HealthCare System and the Department
  of Veteran Affairs

113
Clinicians Begin to Accept Credibility of the
NSQIP Information

• Slow gradual process of testing reliability and
  validity of the data.
• Exploring best practices and opportunities for
  improvement.
• Sharing blinded data with each other.
• Threatened by release of data to administrative
  and senior clinical leaders.
• Experiments in improvement.
  Jennifer Daly

114

• Jennifer Daly

115
VA National Surgical Quality Improvement Program
(1991-1999)

• 27 decline in post-operative mortality.
• 55 decline in post-operative morbidity.
• Median post-operative LOS declined from 13 days
  to 4 days.
• Volume and complexity of surgery unchanged.
• Risk profiles of patients unchanged.
• Patient satisfaction improved.
• 
  
• 
  Jennifer Daly

116
What Makes the NSQIP Possible?

• Commitment and participation of VA surgeons.
• VHAs informatics infrastructure.
• Trained dedicated clinical nurse reviewers.
• Standard definitions of risk factors and
  outcomes.
• Commitment from the top (clinical and
  administrative).

117
Reflections on Risk Adjustmentand Performance
Improvement

• The road to improvement is slow and gradual.
• Reliable clinically credible information is
  necessary but not sufficient for improvement.
• Sustained improvement requires continuous
  education and reinforcement.
• Dont lose sight of the goalimprovement, not
  risk adjustment!
• 
  
• 
  Jennifer Daly

118
NSQIP Lessons Learned From Site Visits to
Centers of Concern

• Poor coordination of care across the entire
  surgical episode.
• Poor or conflicted relationships with the
  affiliated university and/or teaching program.
• Poor monitoring of quality.
• Lack of state-of-the-art equipment/ technology.
• Failure of surgical leadership to create a sense
  of team work and to marshal the support and
  attention of senior clinical and administrative
  leadership.
• Jennifer Daly

119
What This Means

• This is not the end. This is not the beginning
  of the end. It is, however, the end of the
  beginning.
• Winston Churchill

120
IF WE DO NOT CHANGE OUR DIRECTION, WE ARE VERY
LIKELY TO END UP EXACTLY WHERE WE ARE
HEADED.Anonymous
121
8 STEPS TO TRANSFORMATIONAL CHANGE

• Establish a Sense of Urgency.
• Form Powerful Guiding Coalitions.
• Create a Vision.
• Communicate the Vision.
• Empower Others to Act on the Vision (Remove the
  barriers).
• Plan for and Create Short-Term Wins.
• Consolidate Improvements Produce still more
  Change. (Dont declare victory too soon)
• Institutionalizing New Approaches. (CULTURE)
• John P. Kotter, Leading Change Why
  Transformation Efforts Fail, HBR, March-April
  1995

122
Put Aside Ego-

• One of the hardest things about innovation is
  getting people to accept that the way they work
  just might not be the best.
• Thomas Fogarty, Cardiovascular Surgeon,Stanford

123
DEEP CHANGE OR SLOW DEATH ??

• DO WE HAVE THE COURAGE TO WALK NAKED INTO THE
  LAND OF UNCERTAINITY??
• Robert Quinn----Deep Change

124
The Culture of Safety
New Leadership Challenges
How Each of us adds value Knowledge Networking
New Types of Information
125
BALANCING THE CORE VALUES AND TENSIONS IN CYCLES

• COMMUNICATION

126
Communications

• All problems tend to be attributed to bad
  communications
• Considerable complexity lies behind this
  seemingly universal assumption.
• What specifically, causes communications to go
  badly?

127
Communications Blocking Presumptions

• Our beliefs are the truth.
• The truth is obvious.
• Our beliefs are based on real data.
• The data we select are the real data.
• Richard D Hayes, Oct, 1997, EMMM 635

128
Three Primary Communication Skills

• Recognizing - leaps of abstraction (jumps from
  observation to generalization).
• Exposing - articulation of our actual meaning
  more often of things we do not normally say.
• Inquiring - about the assumptions and motivations
  of others for better understanding.
• Richard D Hayes, Oct, 1997, EMMM 635

129
Mary, If I die I will die making an
impactLessonLet the patient guide your
listening and learning and meet them at their
need.
130
Large family practice residency

• 35 Physicians of four clinics of a large
  University-affiliated, multi-specialty group
  practice.
• Patients aged 65 and older.
• Compared their medical records with the way they
  reported taking their medications at home.
• Overall medication discrepancy prevalence of 87.
  
• Survey response rate of 92.

131
Root Cause Analysis JCAHO Sentential Event

• 1----Communication Failure (over 70 of root
  cause).
• 2----Inadequate Orientation (over 50 of root
  cause).

132
I dont understand why you dont understand. I
speak perfect English. You must be listening in
dingbat. Archie Bunker
133
BALANCING THE CORE VALUES AND TENSIONS IN CYCLES

• CULTURE

134
"The culture is an impediment to acknowledging
error. Peer group pressure is the biggest
impediment to talking about itwhat your peers
will think of you for making a mistake. You are
taught that losing your credibility is the worst
thing that can happen to you". K Kizer,
Trustee, Feb, 2000
135

• The medical profession demands perfection and
  punishes imperfection. In such a culture of
  blame, then, who will step forth to admit a
  mistake? And without full knowledge of what the
  mistakes are, how can we learn to stop making
  them?
• K Kizer, Trustee, Feb, 2000

136
Percentage of Pilots and Doctors Endorsing
Unrealistic Attitudes about Personal Capabilities

• Decision making the same in
  
• emergencies.
• Effective pilot/doctor leaves behind
• personal problems.
• Performance same with
• inexperienced team.
• Dont make more errors in
• emergency.
• Perform effectively when
• Fatigued.
• Helmreich Merritt,
• Culture at Work in Aviation and medicine

137
CULTURE EATS STRATEGY FOR BREAKFAST EVERY
MORNINGAuthor Unknown- at AHSR June 2000
138
Virginia Mason

• Western Washington State
• 336 Beds
• gt 1 million outpatients/yr
• 1600 inpatients/yr
• STOP THE LINE

139
ORGANIZATIONAL CHANGE

• More historical failures than successes.
• A difficult process requiring solid insight,
  planning, multiple tools, exceptional skill,
• But, a good technology of change exists.
• Richard D Hayes, Oct, 1997, EMMM 635

140
The Change Continuum

• Developmental Change incremental, improves on
  the present state, tends to preserve the status
  quo-1970s.
• Strategic Change moves organization from one
  state to a new state. Produces marked change,
  involves altered organizational structures and
  directions. 1980s.
• Transformational Change forces organizational
  reemergence from period of chaos into a new state
  not known during the initial phase of the change
  process. 1990s beyond.
• V. Cocowitch,The Turnaround Imperative

141
MAIN REASONS FOR FAILURES

• The need to change not felt strongly enough.
• Understanding of the existing situation is too
  shallow.
• Attempting a tuning fix when only a
  transformational change will succeed.
• Insufficient time effort spent in unfreezing
  the old ways.
• Insufficient solidification (refreezing)
  following the change.
• Richard D Hayes, Oct, 1997, EMMM 635

142
External Environment Factors

• Knowledge of the entire situation
• Knowledge tools to improve safety
• Strong visible professional leadership
• Legislative regulatory initiatives
• Actions of purchasers consumers

143
Bake Knowledge into Knowledge Work

• Keys to success Brigham Womens - Partners
  Healthcare-
• Develop a system.
• Develop support of knowledge workers ie Docs,
  Nurses, Pharmacists, etc.
• Expert and Up-to-date Knowledge Base.
• Prioritized Processes Knowledge Domains.
• Final Decisions by Experts.
• A Culture of Measurement.
• Just in Time Delivery Comes to Knowledge
  ManagementThomas H Davenport, John Glaser,
  Best Practice July 2000

144
THE SAFE HEALTHCARE DELIVERY SYSTEM

• The System
• WHICH ACKNOWLEDGES AND MEASURES NUMBER OF
  COMMISSIONS OR OMMISSIONS
• WHICH HAS A PROCESS TO EVALUATE, CATEGORIZE, AND
  ELIMINATE THOSE COMMISSIONS OR OMMISSIONS
• WHICH MINIMIZES NUMBER OF COMMISSIONS OR
  OMMISSIONS OR THEIR IMPACT ON PATIENTS AND STAFF

145
Make It Meaningful Daniel Vasella, Physician,
CEO, Novartis

• People do a better job when they believe in what
  they do and in how the company behaves, when they
  see that their work does more than enrich
  shareholders.

146
Tell the Stories!In Memory of Cari Jo
147
In Expectation of Improved Care For Sam, Nichole,
and Michayla
148
Helpful Websites

• http//webmm.ahrq.gov
• http//ahrq.gov
• http//npsf.org
• http//ismp.org
• http//ihi.org