Lessons from the Frontlines

1
Lessons from the Frontlines

• CCS/CCHA NICU Improvement Community of Practice
• In collaboration with CPQCC
• Paul Kurtin, MD

2
Our Reality!

• When an ever increasing amount of information
  has to be squeezed into the relatively constant
  amount of time each of us has at our disposal,
  the span of attention necessarily decreases
• social anthropologist Thomas Eriksen

3
High Reliability Organization

• Preoccupation with failure
• Reluctance to simplify interpretations
• Sensitivity to operations
• Deference to expertise

4
Mindfullness

• We are faced with an overwhelming amount of
  information
• What we pay attention to filters and limits the
  information we have
• We then use that limited information as the
  basis of our decision making and action

5
Mindfullness

• How do we maintain continuing alertness
• We can forestall catastrophic outcomes through
  mindful attention to ongoing operations

6
Mindlessness

• There are always surprises, but we ignore or
  discount contradictory information

7
Mindlessness

• Mindlessness is more likely when people are
  distracted, hurried, or overloaded. To deal with
  production pressures people ignore discrepant
  clues and cut corners
• Also occurs when people feel they can not act
  upon their concerns

8
Mindfullness

• Continuing efforts to update actions and
  expectations by always checking if new
  information fits current expectations and plans

9
Sustaining Mindfullness

• Create a climate where it is safe to report and
  question assumptions
• Conduct incident reviews soon after the event
• View close calls as sign of potential danger not
  success
• Maintain situational awareness of current
  practices and changes in those practices
• Make knowledge about the system transparent and
  widely known (process measures)

10
Sustaining a Culture of Safety

• Reporting culture protection of people who
  report
• Just culture acceptable and unacceptable
  behaviors
• Flexible culture adapt to changing conditions
  system endangered until proven safe
• Learning culture seek out and adopt best
  practices dont explain away contradictory
  evidence

11
Sustaining Focus

• Develop and implement tools to assess and share
  adherence to standardized approaches
• Build decision aids into the process. Make it
  easy to do the right thing.

12
Organizing for Quality

• Relatively small number of similar challenges
  with a potentially large number of solutions
• Must address all common challenges
• Must find local answers that are appropriate
  contextually
• Must build these solutions into ongoing
  improvement processes

13
Six Challenges

• Organizational culture
• Structural processes
• Political processes
• Organizational learning
• Emotional processes to engage people
• Technology and infrastructure to support
  improvement

14
Six Challenges

• Structure committees, roles, data monitoring, QI
  training
• Politics Whats in it for me?
• Culture key to sustainability, mindset about
  quality

15
Six Challenges

• Learning both accumulate and pass on new
  knowledge. Key to sustainability
• Emotion quality as a cause, social movement
• Infrastructure reliably deliver quality, safe
  care everyday

16
Non-sustainability

• Structure Fragmentation
• Political Disillusionment
• Cultural Evaporation (gains vanish)
• Education Frustration as skills and knowledge
  dont keep up with goals
• Emotion Loss of energy
• Infrastructure Too hard to do

17
Solutions

• Solutions may travel poorly because of context,
  most broadly defined
• Solutions must be home grown, bottom-up
• Solutions lay in effectively connecting the right
  people, the right leader, the right tools
• Solutions in relationships among processes, among
  people (micro, meso, macro, system)

18
Solutions

• Structure Put in place
• Culture Build team work
• Politics Deal with conflicts
• Learning Learn from mistakes
• Emotion Share passion for being the best and
  being for the kids
• Infrastructure Avoid distractions of high tech
  solutions

19
Solutions

• Organizing for quality is about fallible
  people who keep going Quality is human and
  organizational, not technical or mechanical.

20

• Patient care quality Qsystem
• Qsystem Q1 Q2 Q3(the quality
• within each microsystem
• the quality of the hand-offs
• between microsystems)

21
Toyota

• Long-term philosophy the right processes will
  produce right outcomes
• Add value to the organization by developing
  people and partners
• Continuously solving root problems thus driving
  organizational learning

22

• Learn and Learn about learning.
• Generalisable scientific knowledge
  organizational context measurement improvement
  modalities execution
• Be the best at getting better

23
Our Reality!

• Everyone in healthcare really has 2 jobs when
  they come to work everyday to do their work and
  to improve it!
• Paul Bataldan, MD