Worlds Collide… - Texas Children's Hospital · When Parallel Worlds Collide… Beautiful Things Happen A Story About High Reliability

When ParallelWorlds Collide…Beautiful Things

Happen

A Story About High Reliability

Principles of a High ReliabilityCollective Mindfulness

Sensitivity to Operations

Commitment to Resilience

Deference to Expertise

Preoccupation with Failure

Reluctance to Simplify

The TSICU Story

Challenges

CollaborationAccomplishments

Great Outcome

The Ethical Dilemma292 Nurse Interactions

The OB Story

Challenges

CollaborationAccomplishments

Great Outcome

The NICU Story

Challenges

CollaborationAccomplishments

Great Outcome

Lessons Learned

Birth Plan

Post Delivery Care

Communication

Debriefing

Our Ultimate Goal

TSICU

NICUOB

Great Outcome

Great Outcomes

Quality Statistics

• Zero Hospital Acquired Infections

Life Gift Statistics

• Double Lung Transplant - 53yo F - waiting 78 days

• Right Kidney - 43yo M - waiting 1,501 days

• Left Kidney - 39yo M - waiting 2,173 days

• Liver - 43yo M - waiting 7 days

• Heart – recovered for research

NinfaMarch 7, 2016

Weight: 4 lbs. 3 oz.

Mother: Pamela

Father: Isaiah

Happy & Healthy

Principles of a High ReliabilityCollective Mindfulness

Sensitivity to Operations

Commitment to Resilience

Deference to Expertise

Preoccupation with Failure

Reluctance to Simplify

Questions?

References

• Weick, K. & Sutcliffe, K. (2007). Managing the unexpected: Resilient performance in the age of uncertainty, (2nd ed.) John Wiley & Sons: San Francisco.