Comprehensive Safe and Reliable Healthcare

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Comprehensive Safe and Reliable Healthcare

• Colorado
• Fall 2005

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Learning Objectives Patient Safety Retreat

• Understand factors contributing to error and harm
• emphasis on teamwork and communication.
• Learn about root cause analysis
• Identify contributing factors in cases discussed
  in breakout sessions
• Consider risk reduction strategies
• Using reliable design and teamwork concepts
• Applying the learning to institutions
• specific actions that might be taken.

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Comprehensive Safe Reliable Design
Using Reliable Design and Human Factors,
enabled by Information Technology
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Using Reliable Design and Human Factors,
enabled by Information Technology
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Outstanding leadership Evidence based optimal
care Sustainable safety culture Enhanced
workforce Marketplace success

• Signature Initiatives
• Investing in quality and utilization
  infrastructure Information systems and other
  resources
• Enhancing patient safety by reducing medication
  errors system-wide
• Enhancing uniform high quality by measuring
  performance and benchmarking for select inpatient
  and outpatient conditions
• Expanding disease management programs patients
  with chronic illnesses
• Improving cost effectiveness through managing
  utilization trends and variance

Using Reliable Design and Human Factors,
enabled by Information Technology
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Reliable Design
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Reliable Design - Evaluation
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Reliable Design - Evaluation

• Chaotic process
• 2 or more failures out of 10 opportunities
• 10-1
• One to two failures out of 10 opportunities
• Performance indicates no articulated common
  process
• Medication management upon discharge
• 10-2
• Five failures or less out of 100 opportunities
• Performance indicates processes with medium to
  high variation
• Warfarin clinics
• 10-3
• Five failures or less out of 1000 opportunities
• Performance indicates a well designed system with
  low variation and cooperative relationships
• Blood banking procedures
• Anesthesia intraoperative management
• 10-4
• Five failures or less out of 10,000 opportunities
  

Roger Resar
Tom Nolan
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Reliable Design - Implementation

• Three types of action
• Prevention
• Stop Metronidazole from being prescribed with
  Warfarin
• Identification
• Notice that the INR is elevated
• Mitigation
• Institute protocol based treatment based on INR
  level

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Model 10-1 Reliability

• Common equipment.
• Standard orders sheets.
• Personal check lists .
• Working harder next time.
• Feedback of information on compliance.
• Awareness and training.

Basic failure prevention Intent, Vigilance and
Hard Work
Roger Resar
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Model 10-2 Reliability

• Decision aids and reminders built into the
  system.
• Desired action the default(based on evidence).
• Standardization of process.
• Takes advantage of habits and patterns.
• Redundancy.
• Scheduling.

Sophisticated failure prevention. Basic failure
identification and mitigation - Human Factors and
Reliability Science.
Roger Resar
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Three Tier Design Reliable design applied to
Outcomes Warfarin ADEs

• Prevent initial failure
• Using intent and standardization
• Paper
• Standardized Warfarin ordering algorithm
• Technology - CPOE
• Dont give Metronidazole with Warfarin
• Identify and/or mitigate failure
• Paper
• Pharmacists find patients not using algorithm
• Protocol for managing elevated INRs
• Technology - LMR, Decision Support
• Adverse Drug Event Surveillance Systems
• Monitor Warfarin users and serial INRs
• Are INRs obtained from Warfarin patients?
• Critical failure mode function
• Identify critical failures and then redesign
• What happens when failures occur?
• Patients are readmitted with GI bleeds or CVA
  identify cause and redesign system.

• 10-1

• 10-2

• 10-3

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• Signature Initiatives
• Investing in quality and utilization
  infrastructure Information systems and other
  resources
• Enhancing patient safety by reducing medication
  errors system-wide
• Enhancing uniform high quality by measuring
  performance and benchmarking for select inpatient
  and outpatient conditions
• Expanding disease management programs patients
  with chronic illnesses
• Improving cost effectiveness through managing
  utilization trends and variance

Using Reliable Design and Human Factors,
enabled by Information Technology
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Just Culture Components

• Essential Human Behaviors
• Amalberti
• Deviation of Behavior
• Park/Salvendy
• Nominal Human Error Rates
• Just Assessment of Behavior
• Reason
• Unsafe Acts Algorithm
• Marx
• Outcome/Rule/Risk Determinants
• Teamwork and Communication
• Helmreich, Leonard, Cooper, Gaba, Salas etc.

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Systemic Migration of Boundaries Deviation is
Normal
VERY UNSAFE SPACE
LOW Individual Benefits HIGH
ACCIDENT
HIGH Production Performance
LOW
Rene Amalberti, MD, PhD
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Nominal Human Error Rates
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Unsafe Acts
Were the actions as intended?
Unauthorized Substance?
Knowingly violated safe operating procedures?
Pass substitution test?
History of unsafe acts?
no
no
no
yes
yes
yes
yes
yes
no
no
no
Medical Conditions?
Were the consequences as intended?
Were procedures available, workable, intelligible
and correct?
Deficiencies in training and selection, or
inexperienced?
Blameless Error
yes
yes
yes
yes
no
no
no
Substance Abuse without mitigation
System induced violation
Blameless Error, but corrective training or
counseling indicated
Possible reckless violation
System Induced Error
Sabotage, malevolent damage, suicide, etc.
Substance Abuse with mitigation
Possible Negligent Behavior
From James Reason Managing the risks of
organizational accidents
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The Choices in Managing Risk

• Outcome
• Rule
• Risk
• Normal Errors
• At-Risk Behaviors
• Reckless Behaviors

David Marx
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Teamwork Science
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Team Definition

• A group of individuals each assigned specific
  roles or functions, interacting together
  dynamically, interdependently, and adaptively
  towards a common goal.

Fowlkes JE, Norman EL, Salas E et al 1994
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WalkRounds is about leading by example

• Hospital Leadership manifesting
• teamwork behavior.

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History

• Institute for Healthcare
• 1997
• Collaboratives - Hospital teams work on rapid
  cycle improvement
• Leadership support
• Determines success of teams
• Determines longevity of teams
• 1999
• WalkRounds concept is born in IHI Idealized
  Design meeting
• Many hospitals in IHI Collaboratives begin to
  implement
• 2000
• Brigham and Womens Hospital
• Pilot of rigorous WalkRounds discussed and begin
  January 2001
• Johns Hopkins Hospital (Peter Pronovost)
• Incorporates concept into ICU CUSP
  Comprehensive Unit-based Safety Program
• 2001
• Health Research Services Administration funds
  AHAs HRET and Partners to evaluate 10
  Massachusetts Hospitals
• Bryan Sextons Attitudinal Survey Instrument
  bundled with WalkRounds concept
• 2002
• Kaiser Permanente pilots WalkRounds concept
  nationally.

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What is a WalkRounds?

• A carefully choreographed discussion between
  Frontline Staff and
• A hospital leader (or two)
• A Patient Safety Manager/Director/Specialist
• A scribe.
• Other (Managers, Pharmacists, Students)
• lasting about one hour and regularly repeated
• As frequently as weekly, but at a minimum
  monthly,
• located wherever frontline staff do their work,
• fully supported by back office quality analysis,
• fully integrated into Operations committees,
• requiring rigorous application to detail in every
  step.

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WalkRounds is NOT

• Solely about safety.
• Parading senior leadership around the hospital.
• A relaxed conversation with frontline employees.
• Specifically about employee or patient
  satisfaction.
• Designed to solely address safety issues.
• Risky conversations.
• Always scintillatingly interesting.
• A soapbox for voicing opinions.
• An opportunity for Leadership to showcase.
• Usually conversations with patients (so far).
• However, these may periodically be attributes of
  WalkRounds

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In WalkRounds,

• safety quality, efficiency, effectiveness,
  timeliness, and equity
• are equal parts of the conversation.
• their exists a comprehensive management tool
  designed to
• Help Leaders lead better,
• Ensure ever safer and more reliable systems,
• Help align frontline and leadership perspectives.

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Through WalkRounds,

• Awareness of safety and reliability increase.
• Safety and reliability become a high priority.
• Staff are educated about safety concepts.
• Information about barriers to care is obtained.
• Actions are taken to improve reliability.
• Feedback improves - to frontline providers and
  leadership.

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Clinicians Report -spontaneous reporting Walkaroun
ds -stimulated reporting
validation
Leadership feedback to clinicians/employees
Contributing Factors Identified
Report to Leadership
ACTION
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A WalkRounds Described

• A WalkRounds team.
• At least one, perhaps two, senior executives
• Senior Executives should take turns participating
  in the WalkRounds.
• A patient safety officer/manager
• A scribe (usually a member of patient safety or
  administrative staff)
• Usually the manager or director of a unit to be
  visited on the rounds
• Engaging in a discussion with providers and
  employees about safety, reliability and their
  perceptions of their environment of care
• Asking specific open ended questions
• Engaging in a dialogue that is
• Mutually educational
• Facilitates the collection of useful information
• Ensures that frontline staff and employees feel
• Empowered
• They are participating in organizational
  improvement

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Who Participates?

• Senior Executive (President, CMO, CNO, COO,
  Board, Clinical Chairs)
• Pt. Safety, Quality, Risk Mgmt
• Managers/Administrators/Physician leaders/VPs
• Frontline Staff
• Physicians
• Nurses
• Pharmacists
• Students
• Whoever is available and involved in clinical care

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Asking the right questions

• How will the next patient be harmed in your
  area?
• How does the environment fail you?
• The last patient who was hurt as a result of how
  we delivered care what happened?

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Three Tier Design Reliable design applied to
Environment Just Culture

• Prevent initial failure
• Using intent and standardization
• Hire intelligently
• Develop Citizenship criteria for behavior
• Reasons Unsafe Acts Algorithm
• Teach middle management
• Reporting Systems
• Identify and/or mitigate failure
• Teamwork and Communication Training, Metrics and
  Feedback
• WalkRounds supported by cyclical information flow
• Coordinate Safety and Quality and Risk functions
  in institution
• Attitudinal surveys and reported events
• Critical failure mode function
• Identify critical failures and then redesign
• What to do when a middle manager is critical of
  an RN or MD for 3rd medication error?
• Multidisciplinary Root Cause Analyses for
  learning and system redesign.
• Reported data evaluated in Operations Committees,
  assignment of actions with timelines.

• 10-1

• 10-2

• 10-3

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Outstanding leadership Evidence based optimal
care Sustainable safety culture Enhanced
workforce Marketplace success

• Signature Initiatives
• Investing in quality and utilization
  infrastructure Information systems and other
  resources
• Enhancing patient safety by reducing medication
  errors system-wide
• Enhancing uniform high quality by measuring
  performance and benchmarking for select inpatient
  and outpatient conditions
• Expanding disease management programs patients
  with chronic illnesses
• Improving cost effectiveness through managing
  utilization trends and variance

Using Reliable Design and Human Factors,
enabled by Information Technology
37

• Signature Initiatives
• Investing in quality and utilization
  infrastructure Information systems and other
  resources
• Enhancing patient safety by reducing medication
  errors system-wide
• Enhancing uniform high quality by measuring
  performance and benchmarking for select inpatient
  and outpatient conditions
• Expanding disease management programs patients
  with chronic illnesses
• Improving cost effectiveness through managing
  utilization trends and variance

• Signature Initiatives
• Investing in quality and utilization
  infrastructure Information systems and other
  resources
• Enhancing patient safety by reducing medication
  errors system-wide
• Enhancing uniform high quality by measuring
  performance and benchmarking for select inpatient
  and outpatient conditions
• Expanding disease management programs patients
  with chronic illnesses
• Improving cost effectiveness through managing
  utilization trends and variance

Using Reliable Design and Human Factors,
enabled by Information Technology