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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

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    High Reliability in Healthcare

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    High Reliability in Healthcare

  • Copyright © 2014 Safer Healthcare Partners, LLC. All Rights Reserved. 4

    High Reliability in Healthcare

  • Copyright © 2014 Safer Healthcare Partners, LLC. All Rights Reserved. 5

    High Reliability in Healthcare

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

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    High Reliability in Healthcare

  • Copyright © 2014 Safer Healthcare Partners, LLC. All Rights Reserved. 8

    High Reliability in Healthcare

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    High Reliability in Healthcare

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    High Reliability in Healthcare

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    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  

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    High Reliability in Healthcare

    •  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

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    High Reliability in Healthcare

    •  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

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    High Reliability in Healthcare

    •  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

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    High Reliability in Healthcare

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

    Aviation: High Reliability Industry

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    High Reliability in Healthcare Healthcare High Reliability

    •  Dr. Mark Chassin, President, Joint Commission

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

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    High Reliability in Healthcare

    Healthcare’s Three Critical Challenges

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

    Improvement

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    High Reliability in Healthcare

    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

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    High Reliability in Healthcare

    The science of effective teamwork and communications

    in high risk settings.

    Healthcare Crew Resource Management

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    High Reliability in Healthcare

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

    Essential Skills Crew Resource Management

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    High Reliability in Healthcare

    •  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

    Healthcare Crew Resource Management

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    High Reliability in Healthcare

    •  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

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    High Reliability in Healthcare

    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

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    High Reliability in Healthcare

    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

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    High Reliability in Healthcare

    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

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    High Reliability in Healthcare

    •  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

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    High Reliability in Healthcare

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

    •  Variability may be caused by identifiable forces acting on the pro

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