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Copyright © 2014 Safer Healthcare Partners, LLC. All Rights Reserved. Copyright © 2014 Safer Healthcare Partners, LLC. All Rights Reserved.

High Reliability in Healthcare What It Is. Why You Should Care. And Where to Start. Tom Brooksher and Todd Masten Safer Healthcare Partners

Copyright © 2014 Safer Healthcare Partners, LLC. All Rights Reserved. 2

High Reliability in Healthcare



Chance of Being Killed In Plane Crash

1 in 11 million

Chance of Being Killed In Motor Vehicle Crash

1 in 5,000



•  Published in 1999 •  Low limit: 44,000 deaths/year •  High limit: 98,000 deaths/year •  More deaths from medical

mistakes than AIDS, Breast Cancer or Car Accidents

•  Epidemic proportions •  $39 billion per year

Deaths From Preventable Medical Error



•  Published September, 2013 •  Larger base of studies •  Data 2008 to 2011 •  Low limit: 210,000 deaths

per year •  “True number”: 400,000+

deaths/year •  “Serious harm”: 10x to 20x



•  Complex environments •  Safety super-ordinate goal •  NASA: 70% human error •  Joint Commission: 70% human error •  Highly regulated •  Economic pressures •  Physicians & pilots: very similar

dynamics

Industry Similarities: Healthcare & Aviation



Ability to perform at high levels of safety over long periods of time.

Aviation: High Reliability Industry



Healthcare High Reliability

•  Dr. Mark Chassin, President, Joint Commission

•  Jerod Loeb, PhD, former Exec. VP, Joint Commission



Healthcare’s Three Critical Challenges

1.  Leadership 2.  Culture of Safety 3.  Robust Process

Improvement



Healthcare Crew Resource Management

•  Recognizing human factors cause errors

•  Acknowledging that in complex, high risk endeavors, teams are most effective operating units

•  Cultivating and instilling team-based tools/practices to reduce impact of human factors



The science of effective teamwork and communications

in high risk settings.




•  Team leadership •  Situational awareness •  Standardized communications •  Conflict management •  Decision making •  Checklists •  Briefing and Debriefing •  Assertiveness

Essential Skills Crew Resource Management



•  Promotes Just Culture •  Assumes humans make errors •  Allows team to catch and correct errors •  Promotes reporting adverse and potentially

adverse events •  Makes every mistake a learning experience




•  80% of the work in managing a successful Process Improvement has nothing to do with the tools and everything to do with the perceptions

•  People are prisoners of their own experience – unleashing their creativity takes careful pre-planning prior to any team activity

•  90% of the time, pre-planning never happens – causing false starts and deflated demeanor

Lean Leadership Great Leaders Know



Healthcare Six Aims for Improvement American Healthcare should be: These aims are not new….yet, American Healthcare fails far too often with respect to these aims, despite enormous cost and dedication and good efforts of millions of American Healthcare workers.

•  Safe •  Effective •  Patient-centered

•  Timely •  Efficient •  Equitable



Lean A Path to the Imperatives The IOM Chasm Report gave us the Vision of where to go… …and Womack’s Lean Thinking gives us

the direction (path) to get us there. •  Process Improvement Framework •  Tools and Problem-Solving Skills



Lean Evolution in Healthcare

1910 1930 1940 1950 1960 1970 1980 1990 2000 2010 1920 Time & Motion Studies Methods

Improvement IE Tools, Techniques &

Mgmt Support TQM LEAN

1939 – Shewert, Statistical Method from the Viewpoint of Quality Control 1982 – Deming,

Out of Crisis 1950 – Toyoda visits Ford’s River Rouge Complex

1977 – Sugimori, Toyota Production System & Kanban Systems: Materialization of JIT & Respect-for-Human System

1951 – Juran, Quality Control Handbook

1990 – Womack, Jones & Roos, The Machine That Changed The World

1996 – Womack & Jones, Lean Thinking

1911 – Taylor, Principles of Scientific Management 1950 – Gilbreth

Management Engineering and Nursing 1916 – Gilbreth, Motion Study in Surgery

1999 2001 Healthcare

Manufacturing



•  Value-Stream Mapping •  Workplace Organization (5S) •  Six Sigma •  Visual Management •  Total Preventive Maintenance •  Balanced/Lean Scorecard •  Kaizen Events •  Theory of Constraints •  Workouts •  Kanban •  Reduce Waste •  Improve Efficiency

The Random Acts of Lean •  Heijunka Scheduling •  Standard Work •  Rapid Improvement Events •  Operational Method Sheets •  Changeover Optimization (SMED) •  Case Sequencing •  DMAIC •  Production Preparation Process (3P) •  Process Balancing Tools •  Electronic Kanban Methods •  Benchmarking Practices •  Health Care Execution Systems

•  Green Belts, Black Belts •  Mixed Model Designs •  Drum/Buffer/Rope •  RFID/Bar Code Strategies •  Flow Rate Management •  Cellular Concepts •  Rationalization Practices •  Demand-Driven Metrics •  Flexibility Practices •  Process Mapping •  Velocity Analysis •  Mistake Proofing (Poka-Yoke)

The common problem… •  Pockets of improvement are not tied to nor affect bottom line •  Primarily focused on micro areas with micro results



•  Variability recognizes that processes do not produce identical results every time (inherent in nature)

•  Variability may be caused by identifiable forces acting on the process or by minute fluctuations in the process itself

•  Range (low to high spread), standard deviation (relative dispersion from the mean), and variance (how far a set of numbers is spread out) are common measures of variability

Stop Chasing Averages…

µ = average

σ = variation The Normal

Distribution Curve



How Good Is Good Enough?

3,660 Patients With Misplaced Personal Items

Every Day

340 Patients With Misplaced

Personal Items Every Day


Personal Items Every Day


Personal Items Every Month

770 Coding Errors Every Day Require

Correction

72 Coding Errors Every Day

Require Correction

13 Coding Errors Every Week

Require Correction

During The Year, Only 10 Coding Errors Require

Correction

257 Calls Each Day Exceed The Two Minute On-Hold

Time

24 Calls Each Day Exceed The Two Minute On-Hold

Time

5 Calls Each Week Exceed The Two Minute On-Hold

Time

During The Year, 3 Calls Exceed The

Two Minute On-Hold Time

66,800

6,210

230

3.4

93.32000%

99.34900%

99.97700%

99.99966%

3σ

4σ

5σ

6σ

Sigma Level

Personal Items

Misplaced

Coding Processing

Errors

On-hold Time

Exceeded

Defects Per Million

Oppty % Yield



Traditional Push Versus The Power of Pull Push Facility

vs.

Pull Facility

vs. Originally built to push or batch product

Originally built to pull

to customer demand



•  The 90/10 Rule of Value •  Often, the same amount of effort applied to the non-value

added activity (the 90%) as the value-added activity (the 10%) yields significantly greater results

•  However, most improvements focus solely on the 10%

•  In health care, this applies to both paper process(ing) and patient process(ing)

Lean Value and Non-Value Add

10%!90%!Time!

Non-value added activity! Value added activity!

Typical NVA Ac,vi,es: •  Coun,ng •  Handling •  Wai,ng •  Stocking/Storing •  Signoffs •  Mul,ple Order Entry/Processing

•  Moving

VA activity is defined as anything the customer is willing to pay for



Lean Separating Waste from Value

Time Start Finish

Waiting Wait Move Wait Move/Wait = Value Added Time (VA)

= Non-Value Added Time (NVA)

Tests Treat Triage

Traditional Focus ! Improve the VA processes Process Focus ! Eliminate the NVA processes



•  Scope creep •  Any change not in the original project plan •  Team member adds on additional items to target area/project •  Often done with the best intentions •  Can cloud team focus and cause delays •  Major challenge… knowing when to raise the flag

•  Hope creep •  Not having clear view of end state •  Do not have clear understanding, so just go through the motions •  Hoping someone knows what they’re doing and where they’re headed •  Major challenge… waiting to catch up (procrastination)

•  Effort creep •  Moves project to 80%+ complete and then stalls out •  Major challenge… crossing the finish line continues to push

Lean Leadership Know Your “Creeps”



Lean Leadership Getting Started

To be completed PRIOR to getting the team assembled

Names of key people or units/departments that will have influence over or be affected

by the changes in the target area.

Stakeholders can be internal or external…senior or junior levels.

Onboarding New Staff

PeriOp 07 09 XX Mary Smith Scope: Scrub Techs – Top 20 Procedures

Team Leads Scrub Techs Dr Jones RN Johnson HR RN Staff Physicians Grp Educator Manager

Plot the numbers of each of the listed stakeholders…

…based on their level of Power and Interest

related to the transformation.

Manage Closely Keep Satisfied Keep Informed

Monitor



1

2

3

4

5 6

7

8 9


List the primary (key) activities for the project down the left side.

Then indicate the appropriate designation

for the individuals from the stakeholder list:

Responsible Accountable Consulted Informed



1

2

3

4

5 6

7

8 9


Identify Top Procedures

Select Software Vendor

Take Supply Pictures

Solidify Curriculum

Determine Training Sched

Create Rounding ?s

R A R

C R A

C A C I I I I C I I I I

R I A R C I R I I R R A C C C C I I R C A I C I I I I R R A C C I R I I

Use this Communication Grid to detail the various communication methods required

throughout the transformation.



1

2

3

4

5 6

7

8 9

Keep Satisfied

Manage Closely

Keep Informed

10min weekly

10min Weekly

Tammy Face-to- Face

No Surprises

Major Milestones Manager

Manager Dr Jane Face-to- Face Alignment Milestones

Obstacles

Huddle Susie Scrub

Face-to- Face Update Top 3

Activities Manager


Identify Top Procedures

Select Software Vendor

Take Supply Pictures

Solidify Curriculum

Determine Training Sched

Create Rounding ?s

R A R

C R A

C A C I I I I C I I I I

R I A R C I R I I R R A C C C C I I R C A I C I I I I R R A C C I R I I

What is the specific name or number of the element or issue(s) under review?

Be as specific as possible so as to allow

others to easily identify this element.

Anticoagulation Patient Management Process

PeriOp 08 27 XX Mary Smith

Review Dose Amount

What is the specific manner in which a component, system or function could

possibly fail while being used?

Essentially, ask the question: “How can this element fail?”



Review Dose Amount

Dose change made when not needed

Patient took wrong dose

amount

For each mode of failure, what will the likely effect be? How would the failure affect

different stakeholders? What will be the likely outcomes if the system or component

fails?

An individual failure more may have many possible effects.



Review Dose Amount


Bleeding, clot


amount Bleeding, clot, adverse event

Each failure effect can be judged for it’s potential seriousness. This value should be discussed and

negotiated by all members of the team.

Severity Rating: 1 – low impact (minor event – patient unharmed) 3 – med impact (moderate event – stay extends) 9 – high impact (major event – surgical intervention)



Review Dose Amount


Bleeding, clot X

X

X


amount Bleeding, clot, adverse event X

X

X

Each failure mode will have an underlying root cause. Thus, it is important to spend time

to establish the potential root causes or mechanisms of failure.

Ask… “what is the likely cause of the failure

mode?”



Review Dose Amount


Bleeding, clot X Patient did not

communicate diet on day of test

X Lab error in calibration

X Patient went to

different lab then usual


amount Bleeding, clot, adverse event X Wrote down

wrong dose

X Selected the wrong pills

X Forgot they took

dose already that day

Assign a value of the likelihood of the potential failure occurring. The entire team

should agree as to the probability.

Occurrence Rating: 1 – low likelihood (remote – once per 5yrs) 3 – med likelihood (occasional – 2+ per2yrs) 9 – high likelihood (frequent – 5+ per 6mos)



Review Dose Amount




X

X Lab error in calibration X

X Patient went to


X



wrong dose X

X Selected the wrong pills X

X Forgot they took


X

Indicate here if there are any specific design controls which can reduce or eliminate the

potential failure.

These could include labels, barriers, work instructions or a total redesign of a given

process.



Review Dose Amount




X INR test

X Lab error in calibration X INR test

X Patient went to


X Different than

listed in system, INR test



wrong dose X INR test

X Selected the wrong pills X INR test

X Forgot they took


X INR test

Rate the likelihood that the design controls listed will enable the detection of the potential

failure.

Occurrence Rating: 1 – high likelihood (almost certain it will occur) 3 – med likelihood (moderate chance) 9 – low likelihood (very remote chance)



Review Dose Amount




X INR test X

X Lab error in calibration X INR test X

X Patient went to


X Different than


X



wrong dose X INR test X

X Selected the wrong pills X INR test X

X Forgot they took


X INR test X

Follow through is essential and identifying specific actions to reduce the impact or

likelihood of the potential failure are essential.

These actions should be specific and measurable. Attentions should be given to

actions that address the root cause and not just the symptoms.



Review Dose Amount




X INR test X Standardize questions to patient, training

X Lab error in calibration X INR test X Weekly sample

checks

X Patient went to


X Different than


X Patient training



wrong dose X INR test X Patient repeats dose to care practitioner

X Selected the wrong pills X INR test X Pills are color

coded

X Forgot they took


X INR test X Pill dispenser container by day

All actions should be unambiguously assigned or allocated to an individual, department and/or

an organization.

A date should be assigned by which time all assigned actions have been accomplished and

approved.



Review Dose Amount




X INR test X Ron Black 10/10/XX Standardize questions

to patient, training

X Lab error in calibration X INR test X Jane

Brown 09/16/XX Weekly sample checks

X Patient went to


X Different than


X Sue Jones 11/23/XX Patient training



wrong dose X INR test X Ron Smith 10/10/XX Patient repeats dose

to care practitioner

X Selected the wrong pills X INR test X Jane

Brown 09/16/XX Pills are color coded

X Forgot they took


X INR test X Mary Gomez 11/23/XX Pill dispenser

container by day

Multiply the scores from the “Severity,” “Occurrence” and “Detection” columns to

create an objective measure of potential risk.

The higher the Risk Priority Score, the higher the assumed risk that needs to be mitigated.

Conduct another FMEA on same process once actions are completed to calculate risk mitigation %.



Review Dose Amount




X INR test X 81 Ron Black 10/10/XX Standardize questions

to patient, training

X Lab error in calibration X INR test X 27 Jane

Brown 09/16/XX Weekly sample checks

X Patient went to


X Different than


X 9 Sue Jones 11/23/XX Patient training



wrong dose X INR test X 243 Ron Smith 10/10/XX Patient repeats dose

to care practitioner

X Selected the wrong pills X INR test X 81 Jane

Brown 09/16/XX Pills are color coded

X Forgot they took


X INR test X 81 Mary Gomez 11/23/XX Pill dispenser

container by day



Lean Leadership Communication

The single biggest problem with communication is the illusion that it has taken place.

George Bernard Shaw



Tom Brooksher Email: [email protected] Todd Masten Email: [email protected]

high reliability in healthcaree4enterprise.com/charm/charm presentation - safer...copyright © 2014...

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