DESIGNING RELIABLE SYSTEMS AILSA BROTHERTON PROGRAMME DIRECTOR SLIDES KINDLY SUPPLIED BY: KEVIN STEWART MEDICAL DIRECTOR SAFE CARE WORK STREAM QIPP, DEPARTMENT.

DESIGNING RELIABLE SYSTEMS

AILSA BROTHERTONPROGRAMME DIRECTOR

SLIDES KINDLY SUPPLIED BY:KEVIN STEWART

MEDICAL DIRECTORSAFE CARE WORK STREAM

QIPP, DEPARTMENT OF HEALTH

QIPP SAFE CARE

ABOUT ME

Career Focus: improving nutritional care for patients

Since June 2010Programme Director, QIPP Safe Care, Department of Health

2005-2010Senior Research Fellow: University of Central Lancashire

1991-2004Clinical DieteticsHead of Acute DieteticsAssistant Director of Operations

THE 4 PRINCIPLES OF GOOD NUTRITIONAL CARE

1. Identify those with malnutrition or at risk of malnutrition through screening and assessment e.g. the MUST Tool

2. Implement ‘individualised’ care pathways for the malnourished and those at risk appropriate to the care setting

3. Provide training on the importance of nutritional care for all care staff appropriate to care setting, profession and responsibilities

4. Ensure multidisciplinary structures to manage and monitor nutritional care

STANDARDS AND GUIDELINES IN NUTRITIONAL CARE

Patient Environment Action Teams (PEAT), 2000 Better Hospital Food, 2001 Essence of Care, 2001 National minimum standards, 2001 Nutrition and Patients; A doctor’s responsibility, RCP London, 2002 Council of Europe Resolution, 10 key characteristics of good nutritional care, 2003 NICE guidance on nutrition support in adults, 2006 Delivering Nutritional Care through Food and Beverage Services, 2006 Malnutrition among Older People in the Community. Policy recommendations for change, 2006 Malnutrition, what nurses working with children and young people need to know and do, 2006 Good Practice Guide, Healthcare Food and Beverage Service Standards: A guide to ward level services,

2006 Improving nutritional care. A joint action plan from the DH & Nutrition Summit stakeholders, 2007 Nutrition Now, 2007 Care Services Improvement Partnership factsheet 22; Catering arrangements in Extra Care Housing,

2007 NICE Guidance on maternal and child nutrition, 2008 NPSA factsheets on the 10 key characteristics of good nutritional care, 2009 Social Care Institute for Excellence Guide: Dignity in Care; Nutritional Care and Hydration, 2009 Improving nutritional care and treatment. Perspectives and recommendations from population groups,

patients and carers, 2009 Appropriate Use of Oral Nutritional Supplements in Older People, 2009

Malnutrition Matters: Meeting Quality Standards in Nutritional Care

PREVALENCE AND CONSEQUENCES OF MALNUTRITION IN THE UK

SECONDARY CARE complications length of stay readmissions mortality

CARE HOMES30-42% of recently admitted residents

HOSPITAL28% of admissions

PRIMARY CARE

hospital dependency GP visits prescription costs

SHELTERED HOUSING10-14% of tenants

HOMEGeneral population

(adults)BMI <20kg/m2 : 5%BMI <18.5kg/m2 : 1.8%

Elderly: 14% Prevalence of malnutrition

RELIABILITY

Is not; about what clinical care should be given (we know that)

Is; about the process of ensuring that patients get care

Reliably Consistently On time

MEASURING RELIABILITY

= number of processes which achieve the desired result….

..divided by total number of processes

HOW RELIABLE IS THIS PROCESS?

Mum Cold Perfect Perfect Perfect

Dad Perfect Perfect Perfect Perfect

Daughter Perfect Cold Perfect Perfect

Son Perfect Perfect Cold Perfect

Grandma Perfect Perfect Perfect Cold

IS IT…?

4 cold dishes out of a possible 20 = 20% failure

Or 1 person out of 5 got a perfect lunch (80% failure)

HOW RELIABLE IS HEALTHCARE?

McGlynn et al; NEJM June 26 2003 6712 patients 30 chronic care processes 55% were receiving all indicated care

Most healthcare processes are currently implemented with between 50 and 80% reliability, which is generally described as chaotic.

IMPROVING RELIABILITY

A hospital finds that only 60% of patients admitted to the wards are having nutritional screening completed. Of those found to be at high risk, only 40% had a nutritional care plan and only 10% of these had the care plan implemented

..resulting in; Increased infection rates Increased pressure ulcers Prolonged length of stay

CHAT BOX DISCUSSION

Thought to be mostly due to; Delays in using the MUST screening tool Delays in referral to the Dietician and SALT for detailed

assessments Confusion about when and how to complete the MUST

tool and whose responsibility it is to develop a nutritional care plan

Poor management structures / nutritional care pathways – especially when patients move between care settings

Type in the chat box how might we go about addressing this issue?

RELIABILITY DEFINITIONS

Reliability levels

Number of failures

Percentage success

Chaotic More than 2 in 10 Less than 80%

Level 1 1 failure in 10 90%

Level 2 1 failure in 100 90-99%

Level 3 1 failure in 1000 99-99.9%

etc

DESIGNING FOR RELIABILITY

Level 1 Intent, vigilance, hard work, audit

Level 2 Design of processes informed by reliability science and

knowledge of human factors Level 3

System-wide focus on becoming a highly reliable organisation

LEVEL 1 TECHNIQUES; INTENT, VIGILANCE, HARD WORK

Standard equipment Feedback Training and education Reminders Standard order sets Personal checklists

LEVEL 1 TECHNIQUES

…are only ever likely to achieve around 90% reliability, because; This is probably the limit of human reliability when working

with complex systems Vigilance is highly dependent on uncontrollable external

factors

FACTORS AFFECTING VIGILANCE

Fatigue Stress Competing demands Environmental conditions Task design

LEVEL 2 TECHNIQUES

Moving from level 1 (90% reliable) to level 2 (99% reliable) usually requires an understanding of human factors and reliability science

LEVEL 2 TECHNIQUES

LEVEL 2 TECHNIQUES

LEVEL 2 TECHNIQUES

LEVEL 2 APPROACHES

Making the desired action the default Decision aids and reminders in the system Design changes Take advantage of habits and patterns Build in redundancy

SOME OTHER EXAMPLES?

In everyday life?

In healthcare?

EXAMPLES

Different coloured vials for drugs which are often confused

Connectors; for intravenous access Automated alerts for allergies, drug interactions etc

on electronic systems Default options for drug doses Pre-printed drug charts

LEVEL 3 AND BEYOND

To improve reliability beyond level 2 usually requires fundamental system redesign

Based on Failure Modes and Effects analysis which analyse process failures in detail and changes the systems accordingly

This will be the focus of Next Week’s Webex

LEVEL 1 CHANGE CONCEPTS

Strategy (Tier)

Level Prevent Identify Redesign

1

Vigilance

Common equipment

Personal check lists

Working harder next time

Education

Awareness

Compliance feedback

Standard order sets

Focus is mostly on initial failure prevention

LEVEL 2 CHANGE CONCEPTS

Strategy (Tier)

Level Prevent Identify Redesign

2

Standardization

Decision aids

Reminders

Desired action = default

Opt-out versus opt-in

Automate scheduling of tasks

Forcing functions

Redundancy

Automatic checks

Others?

Analysis of failure modes and root causes (but mostly ad hoc)

Focus is on: (1) initial failure prevention and also (2) catching some early failures. Some failure mode work.

WHY DO WE FAIL?

Current systems in healthcare are highly dependent on level 1 measures; intent, vigilance, hard work

We focus on outcomes, so only measure the process where there is catastrophic failure

We miss process defects where the patient does well despite the system (rather than because of it)

We don’t really analyse failures and learn from them systematically

CHAT BOX DISCUSSION

Think about the last RCA or incident investigations in which you were involved

List the outcomes/recommendations if you can remember them

How confident are you that the incident won’t happen again

SO WHAT CAN I DO?

•Go back to your last RCA....or use a Safety Express topic•Look at a few examples of the process to identify;

Crucial points where things go wrongSuggestions to improve reliability beyond the usual level 1 stuff

SUMMARY

At best, most healthcare processes deliver level 1 reliability (i.e. around 90% success)

Hard work, vigilence, training & audit is unlikely to make our systems more reliable than this

Level 2 changes, which rely on a knowledge of human factors, can deliver up to 90-99% success

To get more reliable than this requires organisation-wide change

(btw; there are no quick fixes or easy answers here!)

ACKNOWLEDGEMENTS AND REFERENCES Frank Federico & Carol Haraden, IHI IHI white paper “Improving the reliability of

healthcare” at www .ihi.org Nolan T “System change to improve patient safety”

BMJ 2000;320. 771-3