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Annual NPSF Patient Safety
Congress
May 14 - 16, 2008Gaylord Opryland
Nashville, TN
Maureen Ann Frye, MSN, CS, CRNPDirector, Center for Patient Safety and Health Care Quality
Abington Memorial HospitalAbington PA
High Reliability Demonstration
Project
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Objectives- Outline our journey in applying High Reliability
principles to our organization
- Describe our method of developing, testing and implementing an HRO assessment tool within a microsystem (or two!)
- Share the lessons learned (and “hot off the press” results!)
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Abington Memorial Hospital
- 600 bed independent, nonprofit acute care facility- Northern suburbs of Philadelphia- Level II Trauma Center - 96+ K ETC visits annually- 2nd busiest Maternity Center in Pennsylvania - > 5000 births/year- 5500 employees, 900 physicians, 1200 volunteers
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
-ANCC Magnet Hospital -John M. Eisenberg Award 2003 -AHA Quest for Quality Award 2003-ISMP Cheers Award 2004-Most Wired Hospital Award 2004
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
5 Pillars of ExcellencePatient Safety / Quality - #1Patient SatisfactionEmployee SatisfactionDiversityFinancial/Operational
Defined Patient Safety GoalsReduction of MortalityReduction of HarmFoundational Aspects of Patient SafetyEvidence-Based Care at the Bedside
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Foundational Efforts for Patient Safety
TeamSTEPPS: team practice and communication>2000 physicians/residents/nurses trained FY08Required for medical staff recredentialling
Safety Briefings all units/all shifts
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Our Organizational “HRO” Readiness: Understanding Baldrige
LeadershipCMO is the Chief Patient Safety OfficerBoard is “on Board”11 Physician/Nurse Patient Safety OfficersStrong Physician / Nursing / Ancillary Collaboration
Strategy and StructureGoals defined by Pillar and cascaded down Center for Patient Safety and Health Care Quality
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
•Employee Focus for Patient Safety/Quality
- Alignment to organizational goals
- “Engage Every Employee” (E 3) cards
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Measurement, Analysis and Knowledge Management
Hospital Scorecard with measures of success
Process Management and ImprovementLean Change Acceleration ProcessIHI’s Model for Improvement / PDSA
Patient FocusPatient Satisfaction goals Patient centered care efforts
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Is any of this making us safer or more reliable?
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Why bother developing an HRO tool?
We were intrigued by the idea of
Assessing, Improving & Aligning
a discreet clinical service/microsystem in HRO principles using a Baldrige framework
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Our Participation in the APSF/SCCM HRO Collaborative
November 2006
Utilized the “straw man” example for Cardiac Surgery which included Baldrige Categories
Leadership, Strategic Planning/Deployment, Staff Focus, Process Management, Measurement/Analysis and Knowledge Management; Patient Focus
Developed a tool to elicit high reliability evidence from the stakeholders in a microsystem
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Multidisciplinary Surgical Weight LossService Line: Focus Group
Chose the team to complete the excel tool Engaged Physician Champion & multidisciplinary teamSuccessful FMEA before first bariatric surgeryFirm belief in Drills/Simulations and Teamwork
Incorporated information on ONE ToolSRC Centers of Excellence CriteriaOur Organizational GoalsBaldrige framework
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Attitude / Opinion
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
A = ApproachIs there a standard way (a process) that everyone does this?
D = Deployment Does everyone use/do this or just some of you?
L = LearningAre we learning from this process and using what we learn to improve the process?
I = IntegrationDoes this process work with other processes or feed into other processes? Or does it stand alone and no one else uses it?"
Built in an ‘audit’ component to elicit further Evidence using Baldrige concepts
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
No Process exists- STOPAn informal process exists-NEXTA Process exists but needs improvement-NEXTAn established process exists that guides actionUnable to answer- STOP
Approach
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
No one used/uses the processOnly some team members use the process The process is/was used by all members of the teaThe process is/was used throughout the organizatioUnable to answer
Deployment
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
No learning occurred / occurs as part of the procesWe learn some things We learn from the process and make improvementWe continually learn from the processUnable to answer
Learning
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
This process works independently of other processThis process helped inform/improve other processeThis process is integrated with other improvementUnable to answer
Integration
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
It was “Ex- “hell”Pros
Educated them on the ‘big picture’Content was useful but our deployment was wrong
ConsToo long to explain the tool 2 hours, Q&A, practiceToo long to complete > 3 hours! Not engagingToo difficult to answer the A,D,L,I componentsToo cumbersome in format and data managementDid not capture “WIIFM” and essential elements that reflect the daily function in the service lineDid not reveal anything significant in the data
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Reflection
Asked too much Reached too farWhat were we thinking?What were we asking?
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
HRO Survey Redesign: Labor and Delivery Unit
- Since 1996, 14 area hospitals closed maternity
services.
Increased surge of patients
Increased complexity of patients
- Declining number of practicing obstetricians due to
the unfavorable malpractice climate in PA
Increased production pressures
Increased financial burden to the hospital
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
HRO Survey Redesign: Labor and Delivery Service Line
Burning platform to achieve higher reliability
“Culture is the residue of your past successes…” Edgar Schein
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Engaged Chief Patient Safety Officer and Organizational Support
Patient Safety Officer as Medical Director, Labor and Delivery
Conducting drills, simulationsTeam Training, Safety BriefingsAWHONN trainingLearning from ‘events’ and making system improvements
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Other Microsystem challenges
Private and employed obstetricians
Non-dedicated Anesthesia service
Physical space limitations to manage the surge
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Face an excess of unexpected eventsHave complex technologiesMust coordinate OB, anesthesia, nursing, NICU and anesthesia care under demanding conditionsMultiple simultaneous demands Two patients for every one encounterPatient expectations
“Small moments of inattention and misperception can escalate into serious adverse events…”
Weick and Sutcliffe
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
In Redesigning the Survey, we…Asked the questions that matter most to themFramed questions related to their ‘events’Stopped at Approach & DeploymentFound a better format that engages staff Built the tool for staff to “tell us” what’s really happening in their microsystem…. And they did!
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Internet-Based Tool
User FriendlyPoint & click
Likert questions + “tell me more” text featuresOpen ended / Fill-in Questions Baldrige “Process Questions” (Approach & Deployment)
Anonymous for participants Confidential for Unit Leaders
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Labor and Delivery Focus GroupInvited all who ‘touch’ the unit to participate.
Random selection of 20% from each role
Intro session 30 min Done “on the unit” with all staffDescribed an HRO: “All Unit” Assessment
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Focus Group
Voluntary participationCMEs/CEUs offeredToken of appreciationPromise of feedback
Deployed March 5 - April 15, 200862 interdisciplinary focus group members (97%)
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Brief Peek at the Tool
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Introduction to the Tool and Why
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Allowed us to Sort Responses by Profile
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Allowed us to assess current environmental conditions affecting the survey
What risks are occurring in the environment?
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Questions elicited their ‘Opinion”
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
And told us how well they know our processes
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Baldrige questions drill down for A= Approach (Process) and
Do we have an approach/process?
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D = Deployment (extent that the process is used)
Is the Process being deployed/used?
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We can get culture questions….
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and “Pop Up” boxes clarify terms
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Allows the difficult conversations to be aired anonymously
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Running bars allow the respondent some sense of ‘where they are’ in the tool
Enjoyed
Seeing
Photos of
Their
Team
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Staff cannot progress without answering key questions
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Pros
Easier ‘on the eyes’Less time to complete
(~90 min)Running progress barCan come ‘in/out”;
paced completionDone Online “Pop Ups” for clarityStaff were informed while eliciting responses
Cons
160 questionsTakes ~90 min to completeSome questions were “fuzzy”Intranet tool requires significant data management on the “back end”Not statistically validated
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Managing the DataCategorized by
Question typeLikertOpen Ended (Text Responses)Process Questions
Role of respondent
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
160 questions aligned with 14 Dimensions
Strategic Emphasis on Pt SafetyLeadership “Setting the Tone”Just CultureSocial Milieu of the UnitEducational Infrastructure for Safe PracticeAdaptive Factors / Learning OrganizationSystem Design and TechnologyRisk Perception
Human Factors Mindset & DesignStaff Alignment to Organizational and Unit GoalsTeamwork Skills and BehaviorsConflict ResolutionEvidence-Based Perinatal Care and Reliable Standards of PerformancePatient Centered Care
AND
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
9 15 16 30 32 33 34 39 40 78 83 88 89 90 97
107 109 11
0111
114
117
118
120
134
136
158
Deference to Expertise Defer to those
with most experience, flattening of the hierarchy,
freely share information and concerns
12 16 25 26 38 41 78 119
120
132
21 23 44 57 63 88 101
105
106
110
114
117
120
122
124
125 128 12
9130
133
134
136
137
139
143
160
161
5 6 8 12 15 26 29 35 41 44 57 63 79 83 87
89 90 91 96 97 98 100
101
113
114
117
123
130
132
134
139 140 14
2145
146
147
148
149
150
151
12 15 16 19 25 30 32 33 34 35 36 37 38 40 41
44 52 63 88 89 90 97 101
110
117
118
124
125
131
139
134 135 14
0158
161
Reluctance to Simplify Search for true causes of error/near
misses; recognize the range of things that could go wrong.
Seek the meaning not the obvious. Diverse teams in
decision making
Sensitivity to Operations Quick
resolution of problems, situational awareness, error identification and addresses.
How long staff on duty, needed resources, potential
distractions to care.
Commitment to Resilience Quickly contain errors after they
happen, improvise, perform quick situational
assessments. Drill, huddle
Preoccupation with Failure Focused on
predicting and eliminating catastrophies before they happen. Near misses are opportunities to improve.
Mindfulness
HRO Characteristics Mindsets
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Early Findings
Variation exists between likert and text responses. What does this mean?
Respondents did “tell us more” in the text fields. They told scenarios and often changed their likertresponse in their narratives.
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Text Responses are identifying…
- Gaps in shared values between different groups related to flow/unit priorities.
- That residents need more safety education, situational awareness and to “speak up” for help
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Unit leaders struggle with managing the patient safety message and budget/finance issues.
There’s a need for shared mental modeland a better strategy for situational awareness embraced by everyone – how to get them all “in the same movie” Michael Leonard, MD
Learning from near misses/events occursJust culture/safe social milieu is improvingTeamSTEPPS strategies are being implemented
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Early lessons learned
Begin with the microsystem to build reliability
Are attitudinal surveys enough to understand the microsystem?
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2008 NPSF Patient Safety Congress Connect, Communicate, Commit
Next Steps
Continue to analyze & understand the resultsFeedback to the MicrosystemObservational analysis to assess behaviorsReview of policies, job descriptions, etc for alignment with survey answersDevelop specific intervention strategiesNarrow the tool and resurvey