ecri patient safety organization hfacs and healthcare diller 2015-10-15... · ecri patient safety...

©2015 ECRI INSTITUTE

Thomas W. Diller, MD, MMMVP System Chief Medical OfficerCHRISTUS Health

October 15, 2015

ECRI Patient Safety OrganizationHFACS and Healthcare


Learning Objectives

Understand the human factors errors for a large health system.

Understand lessons learned from the roll out of HFACS across two healthcare systems.


Current Quality Approach Good Quality is Assumed to Equal Safe Patient Care Quality Improvement is Project Based

■ Examples … Core Measures, CLABSI, Hand Hygiene, etc.■ Too Many Things to Do!!! Not Sustainable!!!

PI Methods are Inadequate■ Copy what someone else did and replicate it.■ Use of simple PI methods (PDCA, Best Practice, etc.).■ Failure to identify specific causes for performance and fix

them. Reactive, rather than Proactive

■ We will be talking about the same errors with the next case.■ Punitive approach, rather than a system’s based approach.


The pursuit of mediocrity is

always successful.

Karl Albrecht


Event Opportunity Continuum Customer Complaints

■ Patient driven reporting■ Focus is on immediate mitigation and patient satisfaction■ Currently difficult to obtain systematic information

Occurrences■ Staff reported events and near misses■ Identifies areas for process improvement■ Captured in database, but <10% of events are reported

Adverse Events■ Intense investigation of adverse events■ Identifies both process and behavioral root causes

Malpractice Claims■ Limited data with several year lag time■ Generally it is about money, not about process or behavior


Traditional Healthcare Root Cause Analysis

Heavily focused on TJC “Sentinel Events”■ Focused primarily on actual harm, rather than the risk of harm.

Facilitates a Culture of Blame■ Find out “Who” did “What”, rather than “Why” an event occurred.

Flawed Investigation Process■ Identification of risk events is not optimal.■ The RCA process is not standardized leading to inconsistent investigation processes and thus findings.

The Root Causes are Usually High Level and Not Actionable■ Events are managed individually without a systematic assessment of risk.■ We can’t improve “poor communication”.

Corrective Actions Do Not Solve the Problems, which then Recur■ Many corrective actions are relatively weak.

Find who is at fault and punish them. Change a policy or process with variable outcomes. More education and training. “Try Harder!!!”


Error Causation James Reason … University of Manchester

■ Organizations create redundant system defense barriers to prevent error.

■ Each defense barrier has its own inherent weakness.■ Failure or error occurs when the system defense barrier weaknesses

accumulate and align. ■ The failures can be due to “latent” or system failures, or can be due to

“active” or human failures.■ Thus, usually adverse events have more than one cause.

Used with Permission of HPI


Greenville Health SystemP9

• 5 Medical Campuses with 1268 Beds• GMH = 750 Bed Tertiary Center• 2 Community Hospitals• Acute Surgical Hospital • LTACH

• > 10,000 Employees• > 1,250 Medical Staff• 731 Employed / Contracted Physicians

• $1.5B Net Revenue• > 42,000 Discharges• > 2.3 M Outpatient Visits• ~ 170,000 ETS Visits

• USC School of Medicine – Greenville• 7 Residencies / 7 Fellowships• > 5,000 Health Care Students


Greenville Health System Process Centralized Risk Management Department

■ Fully trained in methodology (helped develop it)■ Monitored occurrence reports to identify potential and actual harm

events■ Led investigations and analytics

Academic Health System■ Vice Chairs of Quality all trained in HFACS■ 2 Vice Chairs of Quality assisted in the development of the

methodology■ Vice Chairs of Quality partnered with Risk Management in the

conduction of the investigation and review of findings■ They were typically accountable for fixes


Human Factors Analysis Classification System (HFACS) Framework

Organizational Influences

Resource Management

Organizational Climate

Organizational Process

Supervision

Inadequate Supervision

Inappropriate Planned

Operations

Failure to Address a Known

Problem

Supervisory Violation

Preconditions for Unsafe Acts

Environmental Factors

Physical Environment

Technological Environment

Personnel Factors

Communication / Coordination /

PlanningFitness for Duty

Conditions of the Operator

Adverse Mental State

Adverse Physiological

State

Chronic Performance

Limitation

Unsafe Act

Errors

Skill-Based Error

Decision Error

Perceptual Error

Violations

Routine Exceptional


HFACS

P14

434

372

183

97

62

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0

50

100

150

200

250

300

350

400

450

500

Personnel,Communication,

Coordination, Planning

Error, Decision Violation, Routine Operator, Adverse MentalState

Error, Skill-Based

Perc

ent o

f Cas

es

Num

ber o

f Cas

es

General Causal Category

Causal Categories Most Common in Adverse Events

105 coded cases


HFACS

P15

50

3633

30 2623

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0

10

20

30

40

50

60

Environment, Physical Organization,Organizational

Climate

Environment,Technical

Supervision,Inadequate

Organization,Organizational

Processes

Supervision,Inappropriate planned

operations

Perc

ent o

f Cas

es

Num

ber o

f Cas

es

General Causal Category

Causal Categories Most Common in Adverse Events

105 coded cases


Organizational Influences


Supervision


Preconditions for Unsafe Acts


Unsafe Acts


Findings ComparisonSource Pt. Safety Survey Occurrence Reports HFACS

Adverse Mental State

No No Yes

Communication Yes Yes Yes

Errors (Decision / Skill Based)

No No Yes

Handoffs and Transitions

Yes Yes Yes

OrganizationalLearning

Yes No No

Staffing (Resource Management)

Yes +/- +/-

Violations No No Yes

P20


Findings Comparison• Prior to HFACS

– No preceding cause

– Lack of sufficient information

– May have failed to address root causes

– Non-actionable Root Causes

• With use of HFACS– Actionable Common Causes identified

– Avoid unintended consequences

– Identify commonalities across departments/services/units

– System solutions

P21


Lessons Learned• HFACS required refining for the healthcare industry

– Resource intensive and took over two years of adjustments– Future refinements should be expedited

• Retrospective application of HFACS was ineffective– Traditional reviews failed to address multiple failure modes or

preceding causes

• Training for key staff (physician leaders and risk managers) is essential

• Excel database works well• Identification of causes is only the beginning; appropriate

solutions are essential

P22


CHRISTUS Health

Catholic Health Care System Top 15 Health System by Size

■ ~25 Hospitals in the U.S. in TX, LA, NM■ ~11 Hospitals in Mexico / Chile

$4.5B in Net Revenues ~30,000 Employees Non-academic, community based


Root Cause Analysis Transition Roll out HFACS as the system-wide standard for the conduction

of RCAs.■ Standardize the process for the conduction of an RCA.■ Requires substantial education and reinforcement.■ Focus RCAs on events with both harm and the potential risk of harm.

Develop an HFACS database to analyze adverse events / potential events and identify specific opportunities for system-wide and local mitigation of risk.

Link performance improvement activity, training including simulation and clinical policies to system-wide risk mitigation.


CHRISTUS Health System Roll Out Process 4 – Two day training sessions with Dr. Shappell.

■ Focus on Regional CMOs / CNOs / Quality / Risk / Clinical Education■ System office key clinical leaders (CCO / CMO / CNO / CQO / CMIO)■ ~130 key individuals trained

Clinical Risk Management■ Developed a Go Team to assist regions in processes

Senior Clinical Leadership■ Introduced over time as part of a cultural transformation discussion■ Reinforced including in novel settings … capital equipment

acquisition


CHRISTUS Health Adverse Event Workflow

Potential

Risk Event Occurs

Actual Risk Event

Occurs

Front Line Staff Enter Event into Event

System

Service Recovery / Mitigation

Identifies as High Risk Event

Mgr. Reviews Event (24 hrs.)

Service Recovery / Mitigation

Investigates, Clarifies &


CRM Reviews … Risk Based

Prioritization (48 – 72 hrs.)


Track and Trend

Patient Safety Officer Reviews

RCA2 Process Initiated

Assign a Team

Conduct Investigation

Review Findings

Implement Corrective Action Plan

Track and Trend

Low

High


CHRISTUS Health Lessons Learned Roll Out

■ Training was spread out over 4 months, needed to be more compact

■ Have regional people come in teams, rather than as individuals■ Training of senior clinical leaders (CMOs, CNOs) was critical

~12 Adverse Event Investigations To Date■ All have numerous decision and skill based errors■ Resource management (staffing) is a concern■ Fitness for duty (primarily sleep deprivation from more than 1

job)

©2015 ECRI INSTITUTE©2015 ECRI INSTITUTE

Questions / Discussion

Tom Diller, MD, [email protected]

mailto:[email protected]

ecri patient safety organization hfacs and healthcare diller 2015-10-15... · ecri patient safety...

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