Sean Berenholtz, MD MHS Learning From Defects and Implementing Daily Goals.

Sean Berenholtz, MD MHS

Learning From Defects and Learning From Defects and Implementing Daily GoalsImplementing Daily Goals

Comprehensive Unit-based Safety Comprehensive Unit-based Safety Program (CUSP)Program (CUSP)

1. Educate staff on science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

Learning From DefectsLearning From Defects

ObjectivesObjectives

• To understand the difference between first order and second order problem solving

• To understand how to address each of the 4 questions in learning from defects– What happened, why, what will you do to reduce risk,

and how do you know it worked

Case ExampleCase Example

• 65 yo M s/p lung resection for cancer• Admit to ICU; discharged to floor POD 1• POD 3 develops hypoxia• Admitted to ICU, intubated• CXR shows extensive left lung collapse• Decision to perform broncoscopy

SystemSystem FailureFailure LeadingLeading toto ErrorError

Patient Illness

Bronch cart not stocked

Communication betweenresident and nurse

Fatigue

Patient suffers

Hypoxic arrest

Problem Solving*Problem Solving*

• First Order− Recovers for that patient yet does not reduce risks for future

patients− Example: You go get the supply or you make do

• Second Order− Reduces risks for future patients by improving work

processes− Example: You create a process to make sure supplies are

stocked

*Tucker AL, Edmondson AC. Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics that Inhibit System Change. California Management Review, 2003 ;45(2):55-72.

Learning From Defects ToolLearning From Defects Tool

• Frontline caregivers are eyes and ears of patient safety

• Practical investigative tool• Can be used to investigate events or near misses• Can also be used in Morbidity & Mortality Rounds,

investigations resulting from sentinel events or liability claims

• Involves a 4 step structured process• Guides the user through evaluation of system

factors that may have contributed to an event

4 Questions (steps) to 4 Questions (steps) to Learn from DefectsLearn from Defects

• What happened?– From the view of the person involved

• Why did it happen? – Evaluates the defect

• What will you do to reduce the chance it will recur?– Specific actions needed to reduce the likelihood of

recurrence.

• How do you know that you reduced the risk that it will happen again?

Step 1. What Happened?Step 1. What Happened?

• Construct a brief, concise statement of the “story” surrounding the incident

• Reconstruct the timeline of the incident or near miss. • Put yourself in the place of those involved, in the middle

of the event as it was unfolding• Try to understand what they were thinking when the

event occurred• Try to view the world as they did when the event

occurred• Why did they make the decisions they made and

take the actions they took?

Source: Reason, 1990;

Step 2. Evaluate the DefectStep 2. Evaluate the Defect

• Evaluate the defect by:

– Reviewing and checking all the factors that caused or negatively contributed to patient harm

– Reviewing and checking all positive factors that might have reduced or eliminated harm

Probes to Contributing Factors: Examples

Patient Was the patient acutely ill? Agitated? Anxious? Aged? Language barrier? Personal or social issues?

Task Was a stated policy/protocol or guidelines followed? Were labs available for decision making?

Caregiver Fatigue? Lack of experience by care givers? Any physical or mental health issues with provider?

Team Were handoffs (verbal or written) clear? Was there a clearly identified team leader? Were team members hearing one another’s concerns?

Training and Education Was established protocol followed? Were caregivers knowledgeable and competent?

Step 3. What will you do to reduce Step 3. What will you do to reduce the risk of it happening againthe risk of it happening again

• Prioritize most important contributing factors and most beneficial interventions

• Safe design principles– Standardize what we do

− Eliminate defect

– Create independent check– Make it visible

• Safe design applies to technical and team work

What will you do to reduce risk What will you do to reduce risk

• Develop list of interventions

• For each intervention, rate– How well the intervention solves the problem or

mitigates the contributing factors for the accident– Rates the team belief that the intervention will be

implemented and executed as intended

• Select top interventions (2 to 5) and develop intervention plan– Assign person, task follow up date

Rank Order of Rank Order of Error Reduction StrategiesError Reduction Strategies

Forcing functions and constraintsForcing functions and constraints

Automation and computerizationAutomation and computerization

Standardization and protocolsStandardization and protocols

Checklists and double check systems

Checklists and double check systems

Rules and policiesRules and policies

Education / InformationEducation / Information

Be more careful, be vigilantBe more careful, be vigilant

Step 4. How do you know risks Step 4. How do you know risks were reduced?were reduced?

• Did you create a policy or procedure (weak)

• Do staff know about policy or procedure

• Are staff using the procedure as intended– Behavior observations, audits

• Do staff believe risks were reduced

Summarize and Share FindingsSummarize and Share Findings

• Summarize finds– 1 page summary of 4 questions– Learning from defect figure

• Share within your organizations

• Share de-identified with others in collaborative (pending institutional approval)

Examples of where this was Examples of where this was appliedapplied

• CUSP program

• Critical Care Fellowship Program

• Morbidity and Mortality Conferences

• Anesthesiology residency program

Defect Interventions

Fellow 1 Unstable oxygen tanks on beds Oxygen tank holders repaired or new holders installed institution-wide

Fellow 2 Nasoduodenal tube (NDT) placed in lung Protocol developed for NDT placement

Fellow 3 Medication look-alike Education, physical separation of medications, letter to manufacturer

Fellow 4 Bronchoscopy cart missing equipment Checklist developed for stocking cart

Fellow 5 Communication with surgical services about night coverage

White-board installed to enhance communication

Fellow 6 Inconsistent use of Daily Goals rounding tool Gained consensus on required elements of Daily Goals rounding tool use

Fellow 7 Variation in palliative care/withdrawal of therapy orders

Orderset developed for palliative care/withdrawal of therapy

Fellow 8 Inaccurate information by residents during rounds Developing electronic progress note

Fellow 9 No appropriate diet for pancreatectomy patients Developing appropriate standardized diet option

Fellow 10 Wrong-sided thoracentesis performed Education, revised consent procedures, collaboration with institutional root-cause analysis committee

Fellow 11 Inadvertent loss of enteral feeding tube Pilot testing a ‘bridle’ device to secure tube

Fellow 12 Inconsistent delivery of physical therapy (PT) Gaining consensus on indications, contraindications and definitions, developing an interdisciplinary nursing and PT protocol

Fellow 13 Inconsistent bronchoscopy specimen laboratory ordering

Education, developing an orderset for specimen laboratory testing

Am J Med Qual 2009;24(3):192-5.

Learning From Defects to Enhance Morbidity and Mortality Conferences

EvaluationsEvaluations

• “one of the most valuable parts of [their] fellowship”

• ...their project “improved [their] understanding of safe systems”

• “it was great to work with colleagues from other disciplines to improve patient care”

• “changing a system can be difficult, but [they] are better prepared to address patient safety defects after fellowship”

Learning from Defects in M&M Learning from Defects in M&M ConferenceConference

• Select 1 or 2 meaningful cases• Invite everyone who touches the process

including administrators• Summarize event• Identify hazardous systems• Close the Loop (issue, person, F/U)• Share what you learn

Sources of Defects

• Adverse event reporting systems• Sentinel events• Claims data• Infection rates• Complications• How is the next patient going to be harmed

Staff Identify Defects

• Survey staff; establish a collection box or envelope• Identify and group common defects (such as communication,

medications, patient falls, supplies, etc.) • Summarize as frequencies (i.e., what percent of responses

were for communication) • QI team reviews data, set the agenda for discussion with

executive partner

Key LessonsKey Lessons

• Focus on systems not people• Prioritize• Use Safe design principles• Go mile deep and inch wide rather than mile wide

and inch deep• Pilot test• Learn form one defect a month/quarter• Answer the 4 questions

ReferencesReferences

• Bagian JP, Lee C, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv 2001;27:522-32.

• Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf 2006;32(2):102-108.

• Reason J. Human Error. Cambridge, England: Cambridge University Press, 2000.

• Vincent C. Understanding and responding to adverse events New Eng J Med 2003;348:1051-6.

• Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008;299:685-87.

• Berenholtz SM, Hartsell TL, Pronovost PJ. Learning From Defects to Enhance Morbidity and Mortality Conferences. Am J Med Qual 2009;24(3):192-5.

Implementing Daily GoalsImplementing Daily Goals

Learning ObjectivesLearning Objectives

• To understand the importance of having daily goals

• To understand basics of communication

• To learn how to implement daily goals in your ICU

• To understand that daily goals is a tool to improve teamwork and communication AND supports interventions to reduce CLABSI and VAP

Importance of Daily GoalsImportance of Daily Goals

•People and organizations who create explicit goals and provide feedback toward goals achieve more than those who do not

•Rounds generally provider rather than patient centered

•Discussion on rounds is divergent (brainstorming) rather than convergent (explicit plan)

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ICU Physicians and ICU RN ICU Physicians and ICU RN CollaborationCollaboration

ICUSRS Data

Communication ErrorsCommunication Errors

• Communication errors most common contributing factor for all types of sentinel events reported to The Joint Commission

• Over 80% of staff responding to the question, “how will the next patient be harmed” list communication failure

Basic Components and Process of Basic Components and Process of CommunicationCommunication

Elizabeth Dayton, Joint Commission Journal, Jan. 2007

Daily GoalsDaily Goals

• Standardizes communication and creates independent checks

• Helps ensure diverse input

• Adds convergent thinking to often divergent rounds

• Reduces encoding and decoding errors

Sample Sample Daily GoalsDaily Goals

J Crit Care 2003;18(2):71-75

How to Use Goals?How to Use Goals?

• Be explicit

• Important questions– What needs to be done for discharge– What will we do today– What is patients greatest safety risk

• Completed on rounds and nurse reads back

• Stays with bedside nurse

• Modify to fit your hospital

Percent UnderstandingPercent UnderstandingPatient Care GoalsPatient Care Goals

Pronovost daily goals

Implemented patient Implemented patient goals sheetgoals sheet

Impact on ICU Length of Impact on ICU Length of StayStay

654 New Admissions: 7 Million Additional 654 New Admissions: 7 Million Additional RevenueRevenue

Daily GoalsDaily Goals

N Engl J Med 2006;355:2725-32; BMJ 2010;340:c309.

Michigan Keystone ICUMedian and Mean CRBSI Rate

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Time (months)

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Median CRBSI Rate Mean CRBSI Rate

Infect Control Hosp Epidemiol. 2011;32(4): 305-314

Michigan Keystone ICU

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Action PlanAction Plan

• Present the idea to your local team• Draft a daily goals form• Obtain support from one or more physicians• Monitor number of time physicians are paged

(WIFM)– Daily goals reduced pages by 80%

• Pilot test on one patient• Expand

ReferencesReferences

• Pronovost PJ, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care 2003;18(2):71-5.

• Dayton E, Henriksen K. Teamwork and Communication: Communication Failure: Basic Components, Contributing Factors, and the Call for Structure. Jt Comm J Qual Patient Saf 2007;33(1):34-47.

• Schwartz JM, Nelson KL, Saliski M, Hunt EA, Pronovost PJ. The daily goals communication sheet: A simple and novel tool for improved communication and care. Jt Comm J Qual Patient Saf 2008;34(10):608-13.

• Timmel J, Kent PS, Holzmueller CG, Paine L,et.al. Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf 2010;36:252-60.

Sean Berenholtz, MD MHS Learning From Defects and Implementing Daily Goals.

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