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7/16/2012
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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
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)
“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."
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)
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
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
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
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
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Source: Brandeis University Center for Youth & Communities
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Rapid Cycle FeedbackLearning is “doing” with “feedback”