value reliability risky unsafe a proposition where

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What Does All This Mean?Organizing Around 3 Skills for Reliability

Craig Clapper, PE, CMQ/OEChief Knowledge Officer, Health Performance Improvement

© 2012 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.This material is a proprietary document of Healthcare Performance Improvement LLC. Reproducing, copying, publishing, distributing, presenting, or creating derivative work products based on this material without written permission from Healthcare Performance Improvement is prohibited.

Quality An objective appraisal (from a producer perspective) of safety(protection from harm) and effectiveness

Satisfaction A subjective appraisal (from a user perspective) of quality > expectations

Value A subjective appraisal of satisfaction relative to cost and time (to realization).

Reliability A probability that a system will yield a specified result; expressed as a ratio (0.01 or 1:100 or 1%) or a frequency ( 1 per yr)

Risky A proposition where effectiveness > potential harm

Unsafe A proposition where potential harm > effectiveness

Healthcare Reliability Dictionary

“Based on our review of the scant evidence, we believe that preventable medical harm still accounts for more than 100,000 deaths a year… the Centers for Disease Control and Prevention (CDC) estimates that hospital-acquired conditions alone kill 99,000 each year…

In this report, we give the country a failing grade on progress…” Consumers Union (2009)

Death By Numbers44,000 to 98,000 patient deaths per year from medical errorsTo Err is Human, Institute of Medicine (1999)

A Lot of TalkPatient safety publications before andafter the IOM report, To Err is Human

Quality & Safety in Health Care (2006)

Hospitals Are Dangerous Arm yourselves accordingly

What Will It Take?Patient Safety Rounds

+Address TJC Patient Safety Alerts

+Non-Punitive Approach to Reporting

+Crew Resource Management

+Strategies in Targeted Venues(e.g. bundles to reduce VAP or SSI)

But will this produce significant, sustainedreduction in Serious Safety Events and

improved Quality across the organization?

The Swiss-Cheese Effect

Adapted from James Reason, Managing the Risks of Organizational Accidents (1997)

Active Errorsby individuals result in initiating action(s)

EVENTS ofHARM

Multiple Barriers - technology, processes, and people - designed to stop

active errors (our “defense in depth”)

Latent Weaknesses in barriers

PREVENTThe Errors

DETECT & CORRECTThe System Weaknesses

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Influencing Behaviors at the Sharp End

Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994)

Design of

Culture

Outcomes

Behaviorsof Individuals & Groups

Design of

Structure

Design of

Technology & Environment

Design of

WorkProcesses

Design of

Policy &Protocol

© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

“You have to manage a system. The system doesn't manage itself.”

W. Edwards Deming

"A bad system will DEFEAT a good person every time.“

W. Edwards Deming

High reliability organizations (HROs)“operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents.”

Managing the Unexpected (Weick & Sutcliffe)

Risk is a function of probability and consequence.By decreasing the probability of an accident,

HRO’s recast a high-risk enterprise as merely ahigh-consequence enterprise.

HROs operate as to make systems ultra-safe.

10-6

10-5

10-4

10-3

10-2

10-1

Optimizing Reliability

ReliabilityCulture

Safety as the core value Behavior expectations for error prevention Collaborative Interactive Teams Leadership behaviors for reliability

Process, Protocol&Technology Resource allocation

Evidence-based practice (e.g. bundles) Technology enablers

Process, Protocol&Technology

BehaviorAccountability

Human Factors

Design to Optimize Human Performanceat the point of people interface: Easy to do the right thing – impossible to do the wrong thing Intuitive design Mistake proofing by design (i.e. poka yoke)


"At the sharp end, there is almost always a discretionary space into which no system improvement can completely reach. Systems cannot substitute the responsibility borne by individuals within that space."

Sidney DekkerJust Culture: Balancing Safety & Accountability (2007)

Rules About Data

1. Heisenberg Uncertainty Principle : all data is crap (but some data is more useful than other data)

2. Consumer Reports Effect : all crap data is believed

3. Kitty Litter Effect : dig and you will find lumps (bad data invariably is indicative of a real problem)

4. Kubler-Ross Effect : physicians grieve all bad data

1) Denial

2) Anger

3) Bargaining

4) Depression

5) Acceptance

Published Cases

• 89% reduction in 2 years• $ 10 M savings first year• $ 11 M savings second year

• 50% reduction in 18 months• AHA Quest for Quality Award 2004• TJC Eisenberg Quality Award 2005

“Can Your Nurses Stop a Surgeon?”Hospitals & Health Networks, September 2007

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Serious SafetyEventRateSSER

78% Reduction SSER across the System in 29 Months2 Hospitals at Zero Events for over 12 months!

116 days since last event across the system

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5 Hospital System – Southern USJanuary 2008- October 2011

Rolling 12 month Serious Safety Events expressed per 10,000 adjusted patient days

)78% Reduction SSER across the System in 29 Months

2 Hospitals at Zero Events for over 12 months!


78% Reduction SSER across the System in 29 Months2 Hospitals at Zero Events for over 12 months!


Personal Safety Improvements(5 hospital system – South Eastern US)

$0

$100,000

$200,000

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CY 07 CY 08 CY 09 CY 10

Workman's Compensation Costs

Over $1, 200,000 savedyear to date!

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Month

Monthly Lost Time ClaimsJuly 06 - April 2011

Over 300 Serious Injuries prevented90% reduction in OSHA IIR

Complementary Strategies


…and on, and on, and on…

Central LineInfections

HandHygiene

Surgical SiteInfections

Codes Outsidethe ICU

Culture

Process Bundle People Bundle

4 for VAP Prevention1. Elevation of the head of the bed to

between 30 and 45 degrees2. Daily “sedation vacation” and daily

assessment of readiness to extubate3. Peptic ulcer disease (PUD) prophylaxis4. Deep venous thrombosis (DVT)

prophylaxis (unless contraindicated)

Read More: Community Health Network Reduces Deadly Infections Through Culture of Reliability, American Society for Quality

(June 2008)

Improving Quality Using High ReliabilityEast Coast System ‐ 8 Hospitals

National Data Source: ASHRM Hospital Professional Liability & Physician Liability 2009 Benchmark Analysis

Finance’s Interest in SafetyMulti-Hospital East Coast System

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RELIABILITYCULTURE

“Failure Prevention”

Evidence‐BasedProcess Bundles

+performed as intendedconsistently over time

= Clinical Excellence

Patient Centered +performed as intendedconsistently over time

= “Satisfaction”

Reliability Culture - Genius of the AND

Safety Focus +performed as intendedconsistently over time

= No Harm

Financial Focus +performed as intendedconsistently over time

= Margin

1. Values & Beliefs About Safety & Reliability

2. Knowledge of Reliability “Science”

Behavior Expectations for

3. High Reliability Leadership

Behavior Expectations for

4. Human Error Prevention

4.2 Collegial Teamwork4.1 Critical Thinking

5. Human Factors Integration

Hierarchy of Reliability Culture

Think your way into a new way of

acting

Challenge:Maintaining

urgency for and monitoring change

Act your way into a new way

of thinking

Challenge:To re-construct from tactics to

principles

Knowing Doing


Three Skills1) WHAT (What is the evidence‐based, best practice?)

Research & literature review

Benchmarking & collaboratives

Positive Deviance

2) HOW (How should a complex system be arranged to do that reliably?)

Human Factors Integration

Focus & Simplify protocol

Error Proofing

3) CHANGE (How to make the change happen and stick?)

Behavior-based model

Sponsors (imperator), Champions (boosters), and Change Agents

Disciplined application of PDCA cycle and plans.

Best Practice?

1. Search first for legal and regulatory

2. Search next for consensus standards

3. Search next for published best practices and studies

4. If nothing available, select benchmarking group and collect data

• Benchmarking group can include sister hospitals, nationally listed top programs, magnet hospitals, other professionally ranked hospitals

• Positive Deviance

What is Human Factors? The science of understanding the properties of human capability

(Human Factors Science).

The application of this understanding to the design and development of systems (Human Factors Engineering).

The practice of applying Human Factors Engineering to a system (sometimes referred to as Human Factors Integration).

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Processes & Procedures Today

How do we transform our work processes and procedure documentation to achieve better outcomes??

Focus & SimplifyTM

Form follows function

Two columns for novice-to-expert application “Required Action Steps” for all

“Supplemental Guidance” when further information is needed

Three columns for multi-actor procedure

Sequential action steps written as clear, concise phrases beginning with an action word

Cautions and Notes placed before the step to which they apply

Job Aids referenced with related action steps

Safety CriticalTask/Activity

(High ReliabilityRequired)

Less-CriticalTask/Activity

(Lower ReliabilityRequired)

ComplexTask/Activity

DetailedProcedure with

VerbatimCompliance

GuidelineWithoutVerbatim

Compliance

CommonSense

or Skill-of-the-Craft

Standing Orderor Checklist

with VerbatimCompliance

SimpleTask/Activity

Minimizing Policy Burden Laboratory Proficiency Testing

Job Aid: External Proficiency Testing ChecklistDivision: Sentara Hospitals Original Date: Rev. 5/05/05

Department: Laboratory Services Review/Revision Date:

Category: Quality Management Approved By: Medical Director

Locations: SBH, SCH, SLH, SNGH, SVBGH, SWCH Owner: Clinical Specialist, POCT

Checklist:

Required Action Steps: Completed by: 2nd Checks

1. Receive kit. Initiate ExternalProficiency TestingChecklist.

Tech No._________

Date:____________

2. Date & store kit. Tech No._________

3. Notify appropriate person.Hand off checklist toProcess Owner.

Tech No._________

Notified (name):_________

4. Make copy of paperwork. Tech No._________

5. Order in Cerner. Tech No._________

6. Assign to testing personnel.Schedule follow/up withtesting personnel.

Date due:_________

Assigned to (name):______




Scheduled f/u (date)_________

7. Prepare & perform testing. Tech No._________

8. Enter test results on forms.Deliver to Process Owner.

Tech No._________

9. Transcribe results to Masterforms.

On-line: Enter results, Print,Review, Submit.

Paper: Transcribe to Master,Error Check, Submit by fax.

Tech No._________

10. Validate transcribed results.(2nd independent check)

Second check (name):_________________________________

11. File result forms withchecklist.

Tech No._________

References:

Policy List primary guiding Policy

Procedures External Proficiency Testing

Key Process, If Applicable:Key Process

6 department procedures…

to 1 procedure and job aid

E X T E R N A L P R O F IC IE N C Y T E S T IN G

F or ex terna l p ro f icienc y tes ting , S en ta ra L abo rato ry S erv i ces P O C T p rog ram is en ro lledin the a pp rop r iate ava ila b le g rade d C A P su rve ys o r C A P-app ro ved a ltern ative p ro fici enc ytesting p ro g ra m s fo r pa tie n t tes ting pe rfo rm ed . Fo r those a nalytes w he re g rade dp ro f icienc y te sting is no t a vailab le , an in te rna l p ro fic ienc y tes ting p rog ram is e s tab lishedan d is exe rcise d sem i-a nnua lly.

P ro fic ienc y spec im ens a re re ceive d on a re gu lar sc he du le th rou ghou t the c ale ndar yea r. Itis the responsib ility o f all s ta ff to a ssu re th at the spe cim e ns are p roper ly s to red w he nre ce iv ed ; tha t the date o f rec eip t is ind ica ted on the pap erw o rk ; a nd that the P O C T sta ff isin fo rm ed o f th e a rriva l o f the su rve y m ate rial.

A ll in s truc tions nee ded to pe rfo rm the su rve y are include d w ith ea c h sh ipm en t.S pec im ens w ill be designate d to a spe cif ic nu rs in g u n it to e nsu re that a ll te s ting p ersonnelpa rticipate in the p ro ficie nc y p rog ra m . In som e in stanc es du e to the la rge num ber o f un itspe rfo rm in g te s ting , it m ay be nec essa ry fo r m u ltip le un its to pe rfo rm the sam e su rve y . Inth is ca se, a s in g le un it w ill be d esignate d as the p rim ary un it and the ir resu lts w ill besubm itted to the p rov ide r. T he n add itiona l un its w ill te s t the sam p le s and tho se re su ltsw ill be retaine d in the P O C T o ffic e. P ro f icien c y su rve y sp ecim e ns are to be hand le d inthe sa m e m a nner as pa tie n t spe cim ens. N o p ro f icienc y tes ting spe cim e ns m ay be re fe rre dto an o th er la bo ra to ry. F o r e ac h an aly te pe rfo rm e d , the a pp rop r iate in fo rm a tion is to b ere co rd ed on th e P ro fic ienc y S u rve y In fo rm ation S he et. T h e hea lthca re p ro fess ionalpe rfo rm in g th e p ro ficie nc y te s tin g m ust s ign the attes ta tio n s tatem e n t on the o r ig in aldoc um en tation tha t verif ies that the spec im ens w ere tre ated in the sa m e m anne r a s patie n tsam p le s . T he resu lts a re tran sc ribed and rev ie w e d by the P O C T S e n io r T e chno lo g is tp rio r to send ing the o rig inal fo rm s to the p rov ide r. T he tra nscribe d re su lts are doub le -ch eck ed b y on e o ther pe rson . T h e M e d ical D irec to r o r designe e s igns the fina ldoc um en tation be fo re be ing m ailed . A ll o rig inal su rve y resu lts m ust be m ailed /fa xe d tothe p rov ider w ith in the tim e f ram e ind ica ted fo r the ana lyt e. T he re m ust no t be a nyin ter la bo ra to ry c om m un ica tion on p ro f ic ien cy tes ting da ta be fo re resu lts are subm itted .C op ies o f the re su lts are file d in the P O C T o f fic e. T he re m ain ing spe cim ens sho u ld besto re d app rop ria tely base d on the type o f spec im en ( fro ze n o r re fr igerated ) in thede signa ted f re ez er o r re fr igerato r un til re su lts are ob tain ed from the p rov ider and it isde te rm ined th at no fu r ther ana ly sis is ne ce ssa ry . T he ind iv idual tha t m a ils th e su rve y isre sponsib le fo r m ak in g su re th at the spe cim e ns are s to re d p rop erly.

A pprox im ate ly fou r to s ix w ee ks afte r the re su lts are re ce ived b y the p rov ide r, a sum m aryo f resu lts and in te rlab o ra to ry com p arison is retu rne d to the labo ra to ry fo r rev ie w a nd an yne cessa ry c o rrective ac tion . A t th is tim e, the PO C T staff w ill also ev aluate th e resu lts o fan y add itional un its tha t perfo rm ed th e su rve y a nd de te rm ine if co r re ctive action isre qu ired .

T he acc red it in g p ro g ra m assig ns to e ac h re sul t a s ta nd a rd d ev ia tio n ind e x to d e scrib e ho w far a re sul t isfro m th e gro u p m ea n a s m ea sure d in sta nd ard d ev ia tio n u n its . R e sul ts a re rev ie w ed an d

Mistake Proofing by Designa.k.a. Poka-Yoke (ポカヨケ)

Eliminate: Redesign so error prone task is no longer necessary

Replace: Automate a manual task

Prevent: Design components so that a mistake is impossible

Facilitate: Provide visual cues and reminders

Detect: Add requirements designed to detect mistakesChecklists

Second checks and double checks

Mitigate: Add redundancy to mitigate the impact of a process failure

Lower

Reliability

Higher

Poka-Yoke from Home to Healthcare

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Error Proofing Tactics

Constraints Provide design features that compel or exclude actions. Constraints may be physical, semantic, cultural, or logical .

Affordances Provide guidance for operation of device by providing features that allow certain actions.

Natural Mappings Design one‐to‐one correspondence between controls and device being controlled.

Visibility Make operation of the device visible.

Feedback Give each action an immediate and obvious effect.

Norman’s Tactics for Knowledge in the Environment

Agency for Healthcare Research and QualityPrepared by John Grout (Berry College)

Changing Behaviors

Set Expectations

Educate & Build Skill

Reinforce & Build

Accountability


Non-Technical SkillsNon-technical skills describe how people interact with technology, environment, and other people. These skills are similar across a wide range of job functions. These skills include attention, information processing, and cognition.

Flin, O’Connor, and CrichtonSafety at the Sharp End

Generic non-technical skills:

Situational awareness Attention Communication

repeat backs call outs phonetic & numeric clarification clarifying questions inquiry, advocacy, assertion

Critical thinking Protocol use Decision-making

Power Distance

Large Distance• Relations are autocratic and

paternalistic• Power acknowledged based on

formal, hierarchical positions

The perceived distance – not necessarily the real difference –as seen by the subordinate

Small Distance• Relations are consultative and

democratic• Relate as equals regardless of

formal positions

Reference: Hofestede, Geert. Culture’s Consequences, 2001 (2nd edition).

Collegial Interactive Teams (CIT) = Tone + ToolsContext• Patient focused – like we’re

caring for a loved one

Collegiality• Greetings & introductions• Eye contact &

open body language• Relationships• Team goals – use “we”

and “us” vs. “I” and “you”

Coordination• Who’s in charge• Roles & responsibilities• Brief>Execute>Debrief

– pocket card in-hand

Communication• Information – ready

& in hand• 3-way repeat backs• Clarifying questions• Phonetic/numeric

clarifications• SBAR for requestsConfidence in Speaking Up

• Cross Monitoring – peer checking & peer coaching• “If anyone – regardless of role or experience – senses a

problem that would compromise safe, quality care, I expect you to speak up.”

Make Reliability a Reality

Collegial

Interactive

Team

Critical Thinking

Safety Culture

Critical ThinkingQuestioning AttitudeProactive hindsightSTEPSORT(Train using case study in modules)

Culture of SafetyPatient first, every timeSafety firstImportance of attention (self‐check)Importance of compliance (Red Rules)Cross monitoringSpeaking‐up for safety as a concept(Train using leader modules)

Collegial Interactive TeamsSituational awarenessCommunication bundle:• Repeat‐back• Call out• Phonetic & numeric clarification• Clarifying questionsSpeak‐up (inquiry‐advocacy‐assertion)Brief‐Execute‐Debrief(Train in teams using simulation)

STEP = Story, Test story, Eliminate gaps in story, Plan to proceedSORT = Statement of problem, Options, Rule-out options, Test and take action

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Questioning Attitudewith Validate & Verify Technique

Validate: Does it make sense to me?

Verify: Check with an independent, qualified source

Patient

Technology

Professionals

Medical RecordDocumentation Procedures &

References

Peer CheckingWatching-out for each other. Peers share situational awareness and provide on-the-spot second opinions.

Peer CoachingInvolves feedback. Peers provide a 5:1 ratio of positive to negative feedback to reinforce good habits, extinguish poor habits, and build better practice habits.

Multiply Your Error Probability0.001 x 0.001 = 10-6

Cross Monitoring

Making it Stick:“It’s Hawthorne Until Habit”

20%

Eve

nt R

ate

Awareness

Skill Acquisition

Habit Formation

Performance

Time

100%

2 Years


Novice ‐ Advanced Beginner ‐ Competent ‐ Proficient ‐ ExpertSource: Patricia Benner, From Novice to Expert (1984)

Unconsciously incompetent ‐ Consciously incompetent ‐ Consciously competent ‐ Unconsciously competent"Four Stages of Learning," a theory posited by 1940's psychologist Abraham Maslow

Leading Causes of Action Failure

Hidden non-commitment(there seems to be agreement, but managers later back out)

Soft cost – benefit analysis(the best root solution is always the cost effective solution)

Medical Staff resistance(Involve physicians early in the process and rely on tactful diplomacy)

Poor implementation accountability(Corrective Action Plan should have responsible parties by name and date)

From Maximize Patient Safety with Advanced Root Cause Analysis; Corbett, Clapper, & Johnson; 2004.

Plan the Work – Work the PlanA4 Action Plans

One-page, problem, causes, and actions with names & due dates

“A4” refers to the size of the paper. The plan is intended to fit on a single page. A4 is a letter-

sized page; A3 is legal.

Managing Complex ChangeVision Skills Incentives Resources Action Plan

Effective Change

Confusion

Anxiety

Gradual Change

Frustration

False Starts

Skills Incentives Resources Action Plan

Vision Incentives Resources Action Plan

Vision Skills Resources Action Plan

Vision Skills Incentives Action Plan

Vision Skills Incentives Resources

=

=

=

=

=

=

Source: Brandeis University Center for Youth & Communities

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Rapid Cycle FeedbackLearning is “doing” with “feedback”


Do

Feedback

TraditionalFeedback Cycle

OptimalFeedback Cycle

Time

Per

form

ance

Technical SkillsTechnical +

Non‐Technical Skills

Non‐Technical Skills

(Individual & Team)

Simulation in the Lab

Pre‐JobBriefing

Real‐Time SimTeachingon the Spot

Simulation at the Line

Is there any technical skill that does not also require non‐technical skills? NO! Eliminatetechnical simulation in

isolation!

Off‐Line Education & Training Real‐Time Simulation

Best UseInitial education on new concepts; intensive skill development

Reinforcement and application of known concepts; development of critical thinking and analytical problem solving

Location Classroom, training lab, meeting On‐the‐job

Nature Objective‐bound Time‐bound

Prep Time Longer Short to none

Touch Time Longer (>30 minutes, typically hours) Short (30/60/90 seconds; typically <5 minutes)

Frequency Episodic; longer time between sessions Often; shorter time between touches

Facilitator Trained instructors or manager Manager or coworker

Costs Salary of instructors/learners; supplies None

To build and reinforce technical skills and critical thinking skills

To build and reinforce technical skills and critical thinking skills

Build real-time simulation as a leadership competency!


Simulation Continuum

Sim Center Sim Center In‐Situ Sim

Technical skills Team skills

EnvironmentProtocolEBM + human factors

Technical+ CIT skills

A fool’s choice:o technical skills in isolation, oro team skills in isolation

Perfect practice makes perfect.

Practice only makes permanent.

“What you do every day is what you do in an emergency.” Joe Martin, Battalion Chief - LAFD

A Triple Play

Craig Clapper, PE, CMQ/OEPartner & Chief Knowledge Officer

Healthcare Performance Improvement, LLC5041 Corporate Woods Drive, Suite 180

Virginia Beach, VA 23462(757) 226-7479 www.hpiresults.com

value reliability risky unsafe a proposition where

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