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Healthcare Performance Improvement, LLC Phone: 757.226.7479 Fax: 757.226.7478 www.hpiresults.com Page 1 The Road to Zero Events of Harm: High Reliability as the Chassis to Better Healthcare South Carolina Organization of Nurse Leaders 5 October 2012 © 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. HPI – A Reliability Company Methods based on science and facts Science of human performance in complex systems Practical experience in high reliability organizations Practical experience in high reliability organizations including nuclear power and aviation Experienced-based mentoring Entered healthcare in 2002 Over 400 hospitals Slide 2 Consulting team with HRO experience and healthcare experience (clinicians, non-clinicians, and physicians)

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The Road to Zero Events of Harm:High Reliability as the Chassis to

Better Healthcare

South Carolina Organization of Nurse Leaders

5 October 2012

© 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.

HPI – A Reliability Company

Methods based on science and facts

Science of human performance in complex systems

Practical experience in high reliability organizations Practical experience in high reliability organizations including nuclear power and aviation

Experienced-based mentoring

Entered healthcare in 2002

Over 400 hospitals

Slide 2

p

Consulting team with HRO experience and healthcare experience (clinicians, non-clinicians, and physicians)

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Page 2

Making a Dent – 400+ HospitalsChanging the Culture of the Healthcare Industry

Slide 3

Teamwork Leadership

Slide 4

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Death By Numbers44,000 to 98,000 patient deaths per year from medical errors

To Err is Human, Institute of Medicine (1999)

268 people per day…“a 747 a day”

1 death every 383 admissions (based on AHA Fast Facts on US Hospitals, 2010)

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

Quality & Safety in Health Care (2006)

Slide 5

“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)

Recently in the News...

Hospitals hurt 18 percent of patients, study says

November 25, 2010

• Published in the NEJM• 2,341 patients admitted to 10 hospitals• 63.1 % of the injuries were preventable• 2.4 % caused or contributed to a patient’s death

Medical mistakes plague Medicare patients

“Process changes, like a new computer system or the use of a checklist, may help a bit,” he said, “but if they are not embedded in a system in which the providers are engaged in safety efforts, educated about how to identify safety hazards and fix them, and have a culture of strong communication and teamwork, progress may be painfully slow.”

4 p

• 780 randomly selected Medicare patients

Slide 6

patientsNovember 16, 2010

• 780 randomly selected Medicare patients• 1 in 7 (13.5%) experienced at least one serious instance of harm that prolonged hospital stay• Less serious harm in additional 13.5% of patients

“Although hospitals have broadly embraced safety initiatives, the still-high rate of adverse events indicates that far more needs to be done. Hospitals must work faster to adopt evidence-based practices that reduce medical errors. “

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Lauren Wargo

Lauren Wargo a 19-year-old from Shaker

Sunday, May 23, 2010

Lauren Wargo, a 19 year old from Shaker Heights, Ohio, went to an outpatient surgical center where a plastic surgeon was going to remove a mole from her eyebrow.

The oxygen used during her surgery and an electrical device used to seal blood vessels combined to create a flash flame that left her face, neck and ear badly burned.

Slide 7

How could this have happened? As is too often the case when hospital errors occur, health care professionals weren’t

communicating with each other

The Swiss-Cheese Effect

EVENTS of

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

active errors (our “defense in depth”)

Active Errorsby individuals result in initiating action(s)

HARM

Slide 8

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

in initiating action(s)Latent Weaknesses in barriers

PREVENTThe Errors

DETECT & CORRECTThe System Weaknesses

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Reliability ScienceKnowledge and understanding of human error and

human performance in complex systems

Healing Without HarmDon’t Hurt Me, Heal Me, & Be Nice To Me Will

Reliability Culture

human performance in complex systems Design of

CultureBehaviors for

Error Prevention,Red Rules, CRMDesign of

Structure

Design of

Technology & Environment

Electronic medical record,barcode technology,

smart pumps

Design of

Policies &ProtocolsFocus & Simplify

Design of

WorkProcessesLean, Six Sigma

Means

Execution

LeadershipReinforce & Build Accountability

for performance expectations andFind & Fix system problems

Slide 9

Exceptional OutcomesHealthcare That Is Safe – Zero Events of HarmTimely, Effective, Efficient, Equitable & Patient Centered

© 2009 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Behaviorsof Individuals & Groups

Hi h li bili i i (HRO )High reliability organizations (HROs)“operate under very trying conditions all the time

and yet manage to have fewerthan their fair share of accidents.”

Managing the Unexpected (Weick & Sutcliffe)

Slide 10

Risk is a function of probability and consequence.By decreasing the probability of an accident, HRO’s recast a high-risk

enterprise as merely a high-consequence enterprise.HROs operate as to make systems ultra-safe.

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00 h

ours

Reliability – U.S. Nuclear Power

Scr

ams

per

7,00

Slide 11

YearThe unplanned automatic scrams per 7,000 hrs critical indicator tracks the median scram (automatic shutdown) ratefor approximately one year (7,000 hrs) of operation. Unplanned automatic scrams result in thermal and hydraulictransients that affect plant systems. The scram rate has been significantly reduced since 1980. In 2000, 59% of operating plants had zero automatic scrams.

Source: Statistics Show US Nuclear Power Plants Always Improving, Nuclear News, May 2001

Reliability – Commercial Aviation

Slide 12

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776 aircraftdestroyed in

1954

60

ht

Ho

urs

Reliability – Naval Aviation

1 64

15 aircraftdestroyed in

2008

10

20

30

40

50

Mis

hap

s/10

0,00

0 F

ligh

Slide 13

Fiscal Year

1.640

10

50 65 80 08Cla

ss A

M

Source: www.safetycenter.navy/mil ORM Flight Mishap Rate

Reliability Culture - Genius of the AND

Safety Focus +performed as intendedconsistently over time

= No Harm

RELIABILITY

Patient Centered +performed as intendedconsistently over time

= “Satisfaction”

Evidence-BasedProcess Bundles

+performed as intendedconsistently over time

= Clinical Excellence

Slide 14

RELIABILITYCULTURE

“Failure Prevention”

Financial Focus +performed as intendedconsistently over time

= Margin

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Preoccupation with FailureOperating with a chronic wariness of the possibility of unexpected events that may jeopardize safety by engaging in proactive and preemptive analysis and discussion

Sensitivity to Operations

Five Principles of HROs

– We regard small, inconsequential errors as a symptom something’s wrong– We spend time identifying activities we do not want to go wrong– We discuss what to look out for when giving report to an oncoming shift‒ We take time to attend to important details

Sensitivity to OperationsPaying attention to what’s happening on the front-line – Ongoing interaction and information-sharing about the human and organizational factors that determine the safety of a system as a whole

Reluctance to Simplify interpretationsTaking deliberate steps to question assumptions and received wisdom to create a more complete and nuanced picture of ongoing operations

C i R ili

Slide 15

Commitment to ResilienceDeveloping capabilities to detect, contain, and bounce back from errors that have already occurred, before they worsen and cause more serious harm

Deference to ExpertiseDuring high-tempo operations, decision-making authority migrates to the person or people with the most expertise with the problem at hand, regardless of rank

From Vogus & Sutcliffe, The Safety Organizing Scale, Medical Care, 45/1, Jan 2007, p. 46-54.

Regarding small, inconsequential errors as a symptom that something’s wrong…

Slide 16

Preoccupation with Failure

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Serious Safety Event• Reaches the patient• Results in moderate to severe harm or death,

SeriousSafety

Regarding small, inconsequential errors as a symptom that something’s wrong…

Preoccupation with Failure

Precursor Safety Event• Reaches the patient• Results in minimal harm or no detectable harm

PrecursorSafetyEvents

yEvents

Slide 17

Near Miss Safety Event• Does not reach the patient• Error is caught by a detection barrier

or by chance

Near Miss Safety Event

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

1000 Bed Midwest HospitalSSER JAN 2005: 1.21SSER JAN 2007: 0.34 71.9% reduction

Serious SafetyEventRateSSER

SM

Slide 18

Start of Safety Culture Engagement

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Boeing Model 299“Too Much Plane for One Man to Fly”

We spend time identifying activities we do not want to go wrong…

y

Slide 19

B-17 Flying Fortress

Slide 20

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We spend time identifying activities we do not want to go wrong…

Slide 21

Preoccupation with Failure

High Reliability – 1 out of a Million

Slide 22

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Self-Check Using STAR

Stop Pause for 1 to 2 seconds to focus our attention on the task at hand

We take the time to attend to important details…

Think Consider the action you’re about to take

Act Concentrate and carry out the task

Review Check to make sure that the task d tl d th t

Slide 23

was done correctly and that yougot the correct result

STOP is the most important step. It gives your brain a chance to catch up with what your

hands are getting ready to do.

Clear

Complete

Accurate

When giving report, we discuss what to look out for…

Accurate

Sent and Received

“I am ready to relieve you Sir”“I am ready to be relieved”

• Base Course and Speed

Slide 24

Base Course and Speed• Engineering Data / Equipment Casualties• Expected Weather / Navigation• When to wake CO / XO

“I relieve you Sir”“I stand relieved”“This is ____, _____ has the Deck”

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A Repeat-Back Failure

27

527

“The Same”

29

Slide 25

“The Same”

Preoccupation with FailureOperating with a chronic wariness of the possibility of unexpected events that may jeopardize safety by engaging in proactive and preemptive analysis and discussion

Sensitivity to OperationsPaying attention to what’s happening on the front line Ongoing

Five Principles of HROs

L d t t d l k f th h l i th S i ChPaying attention to what’s happening on the front-line – Ongoing interaction and information-sharing about the human and organizational factors that determine the safety of a system as a whole

Reluctance to Simplify interpretationsTaking deliberate steps to question assumptions and received wisdom to create a more complete and nuanced picture of ongoing operations

Commitment to Resilience

– Leaders get out and look for the holes in the Swiss Cheese– We’re able to give real-time guidance and resource allocation– We have a good “map” of each other’s talents and skills on the unit

Slide 26

Co t e t to es e ceDeveloping capabilities to detect, contain, and bounce back from errors that have already occurred, before they worsen and cause more serious harm

Deference to ExpertiseDuring high-tempo operations, decision-making authority migrates to the person or people with the most expertise with the problem at hand, regardless of rank

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Accountability

Building intrinsic motivation of the individual to meet the individual to meet performance expectations

Slide 27

NOT just about punishing the person

FOD Walkdown

Leaders get out and look for the holes in the Swiss Cheese…

Slide 28

Sensitivity to Operations

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Rounding to Influence

It’s not about being seen.It’s about what you see what you ask and what you say

Leaders get out and look for the holes in the Swiss Cheese…

What It Is A technique for reinforcing behaviors or performance expectations

Why It Works Connects expectations to core

values

Assesses knowledge of expectations

Identify problems impacting the

It s about what you see, what you ask and what you say.

Slide 29

Identify problems impacting the ability of people to follow expectations

Engages commitment to practice expectations

Sensitivity to Operations

The RTI Conversation…

Connect to a core value ♥Assess knowledge and reinforce the

specific behavior expectations

Identify problems impacting abilityto follow the behavior expectations

Slide 30

Ask about commitment actions

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RTI Script – Prepare to Influence

Core Value Relate to our core value of safety protecting patients

and employees from harm

Greeting Hello! Do you have a few minutes for a brief conversation about ___________”

Tell a story or share facts

Can Do’s Review practice expectations and share facts

Concerns Ask, “What makes this hard to do?”

Slide 31

Commitment

Questions to foster commitment actions:

What will you do to make this your habit?

How will you help others do it?

STOP if you see a safety risk.

RTI: Hand Washing for HAI Prevention

C V l

Hand washing is very important to keeping our patients – and you –safe. It’s one of the most important things we can do to prevent the spread of MRSA and other hospital acquired infections.

Greeting Hello! Do you have a few minutes for a brief conversation about hand washing?

Core Valuespread of MRSA and other hospital acquired infections.

Did you know that there are nearly 19,000 deaths each year (CDC) from hospital acquired MRSA? In 2008, we had ___ cases of MRSA in our own hospital…

Can Do’s

In addition to washing in and out of every patient room, I’d like to ask you to help others build good hand washing habits, too. Give a thumbs up when you see them doing it, and remind when you see them forget.

Slide 32

Concerns Are there things that make this difficult in your department?

Commitment Will you try it out today? Leave a message for me and let me know how it goes. Thanks!

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RTI: Improving Customer Satisfaction

Core ValueDelivering a remarkable patient experience to our customers is at the heart of everything we do. Our ultimate goal is to keep our patients safe while exceeding their expectations in the delivery of care.

Greeting Hello! Do you have a few minutes for a brief conversation about service excellence?

safe while exceeding their expectations in the delivery of care.

Can Do’s

We have a number of Standards of Excellence that focus on customer service. In order to demonstrate a Willingness to Help, we

1. Conclude every conversation with an offer of further assistance, such as “What else may I do for you?”

2. Take personal ownership of the customer’s needs and take responsibility to follow up.

Slide 33

Concerns What makes doing these things this difficult in your department?

Commitment

Can I count on you to meet these expectations relative to our Standards for Excellence? Please use them in your patient and family interactions every day and let me know how it goes by sending me an email with your feedback. Thanks!

Your Turn!

Core Value Why is this so important to us (me)?

Sample topics:• Kids using their manners• Teenagers not drinking and driving• Husband doing his honey-do’s• Reducing patient falls with injury

Core Value Why is this so important to us (me)?

Can Do’s What is the expectation?

Concerns What makes it hard for you to do this?

Slide 34

Concerns y

Commitment Can I count on you to do this? Here’s how I’m going to follow-up:

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Admiral’s Daily Update 9:00-9:30 am, everyday at sea

All department heads and warfare commanders

We’re able to give real-time guidance and resource allocation…

commanders

Held via video tele-conference call

100% attendance expected

Entire day’s schedule (Battle Rhythm) revolves around update

Slide 35

Sensitivity to Operations

Daily Check-In at Community 9:00-9:15 AM, Monday-Friday

All departments directors

We’re able to give real-time guidance and resource allocation…

Held via conference call

Facilitated by senior leader

90% attendance expectation – send a representative if you can’t participate

Barbara Summers, PresidentCommunity Hospital North

Sensitivity to Operations

Slide 36

Community Hospital North

Daily Check-in is a huddle of the leader and direct reports at the start of the day to maintain awareness of operations and to give direction about

priority and responsibility for problem resolution.

p

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Daily Huddle at Baptist

What benefits of a Daily S f U d d h ?Safety Update do you hear?

Write them down as you watch the video.

Slide 37

Bernie SherryPresident & CEO, Baptist Hospital

Preoccupation with FailureOperating with a chronic wariness of the possibility of unexpected events that may jeopardize safety by engaging in proactive and preemptive analysis and discussion

Sensitivity to OperationsPaying attention to what’s happening on the front line Ongoing

Five Principles of HROs

Paying attention to what’s happening on the front-line – Ongoing interaction and information-sharing about the human and organizational factors that determine the safety of a system as a whole

Reluctance to Simplify interpretationsTaking deliberate steps to question assumptions and received wisdom to create a more complete and nuanced picture of ongoing operations

Commitment to Resilience

– We discuss alternatives on how to go about our normal work activities– We’re not afraid to ask questions and voice safety concerns

Slide 38

Co t e t to es e ceDeveloping capabilities to detect, contain, and bounce back from errors that have already occurred, before they worsen and cause more serious harm

Deference to ExpertiseDuring high-tempo operations, decision-making authority migrates to the person or people with the most expertise with the problem at hand, regardless of rank

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Page 20

We discuss alternatives on how to go about our normal work activities…

We’re not afraid to ask questions and voice safety concerns…

Slide 39

Reluctance to Simplify

Power DistanceGeert Hofstede’s Power Distance• Extent to which the less powerful expect and accept

that power is distributed unequally• Leads to strong Authority Gradients, which is the

perception of authority as perceived by theperception of authority as perceived by the subordinate

United States• Moderate to low Power Distance

(38th of 50 countries)

In Healthcare• High between certain professional groups:

Slide 40

• Some physicians and nurses• Some nurses and other clinical staff• Some leaders and staffCultural differences are a nuisance at best and often a

disaster."Geert Hofstede, Emeritus Professor, Maastricht University

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Korean Airlines Flight 801

High

Bad Weather

Minor Technical FailureFatigue

gPower Distance

Slide 41

Cross-Checking in Health Care

Individual reliability is limited:1 defect per 1000 opportunities

Slide 42

1/1000 (my error probability)x 1/1000 (your error probability)= 1/1,000,000 (our combined reliability!!)

We are bettertogether…

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ARCC technique – a responsibility to protect in a manner of mutual respect – an assertion and escalation technique

We’re not afraid to ask questions and voice safety concerns…

Ask a question

Make a Request

Voice a Concern

Use the lightest touch possible…

Use Chain of Command

Slide 43

A Safety Phrase – “I have a Concern…”

Use Chain of Command

Preoccupation with FailureOperating with a chronic wariness of the possibility of unexpected events that may jeopardize safety by engaging in proactive and preemptive analysis and discussion

Sensitivity to OperationsPaying attention to what’s happening on the front line Ongoing

Five Principles of HROs

Paying attention to what’s happening on the front-line – Ongoing interaction and information-sharing about the human and organizational factors that determine the safety of a system as a whole

Reluctance to Simplify interpretationsTaking deliberate steps to question assumptions and received wisdom to create a more complete and nuanced picture of ongoing operations

Commitment to Resilience

Slide 44

Co t e t to es e ceDeveloping capabilities to detect, contain, and bounce back from errors that have already occurred, before they worsen and cause more serious harm

Deference to ExpertiseDuring high-tempo operations, decision-making authority migrates to the person or people with the most expertise with the problem at hand, regardless of rank

– We talk about mistakes and ways to learn from them – When errors happen, we discuss how we could have prevented them

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Developing capabilities to detect, contain, and bounce back from errors that have already occurred, before they

worsen and cause more serious harm

Slide 45

Commitment to Resilience

We talk about mistakes and ways to learn from them… When errors happen, we discuss how we could have prevented them…

Cause analysis

Slide 46

Cause analysis

Transparency

Story telling

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1) Failures Modes of people

2) 20 Failure Modes in Five

Individual Human Failure Modes

Categories:• Competency• Consciousness (Inattention

to Detail)• Communication• Compliance

Slide 47

• Compliance• Critical Thinking

3) Internal Factors affecting Human Performance

Individual Failure ModesHOW the individual experienced the error

CompetencyThe person does not have the knowledge of how to perform the task or a well-developed skill in performing the task.

Consciousness

The person knows exactly what to do and how to do it, yet they fail to carry out the task or they do it incorrectly because their thoughts are not on – or fully on – the task at hand.

CommunicationThe person receives information and hears it incorrectly or ascribes incorrect meaning to the information.

C iti l Thi kiThe person fails in the cognitive processing of information

Slide 48

Critical ThinkingThe person fails in the cognitive processing of information or in decision making based on information.

ComplianceThe person knows the performance expectation, thinks about it at the time, and makes a choice to act differently.

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1) Failure Modes of systems, programs and processes)

System Failures Modes

2) 26 Failure Modes in Five Categories: Structure Culture Policy & Protocols Processes & Procedures

Slide 49

Processes & Procedures Technology & Environment

3) External factors to human performance

System Failure ModesWHY the individual experienced the error

StructureThe organization did not provide the people, resources, or oversight to support the process or activity being performed.p

Culture

The organization’s values and behavior expectations for leaders, physicians, and staff serve as a counter-influence to safe, reliable individual and team performance.

ProcessThere are deficiencies in the design of the expectations or flow of the work process expectations

There are deficiencies in the documents – policies,

Slide 50

Policy & Protocolp ,

procedures, and job aids – that are intended to support the work process and guide individual decision making.

Technology & Environment

The design of the workplace, equipment, and information systems makes it difficult for the person to carry out the task at hand.

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• Structure• Culture• Process• Policy & Protocol• Environment &

Technology

WHY did they experience the error

(system failure mode)

Anatomy of anInappropriate Act

• Competency• Consciousness• Communication• Critical Thinking• Compliance

and…

HOW did they experience the error

(individual failure mode)

Slide 51

WHO did WHAT because…

What went wrong…

© 2009 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Pharmacy Tech sees Warfarin interaction

RN gives patient Bactrim

63 y/o F with history of DVT and on Coumadin. Bactrim was ordered for a UTI. The next day the patient’s INR was 5.2. Her Coumadin (Warfarin) was held for several days and she was monitored closely for bleeding. She had

no further problems.

Intern orders Bactrim for patient on

Warfarin interaction alert but fills order

anywayPharmacist “clicks through” Warfarin interaction alert when entering

order

SafetyEvent

Patient INR next

Slide 52

for patient on Warfarin

Patient INR next day was 5.2.

Coumadin was held for 3 days, no

further problems

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4) WhyNo formal orientation for interns on high-risk drug interactions

• Structure• Culture• Process• Policy & Protocol• Environment &

Technology

3) HowWas rotating through medical unit and didn’t know about Warfarin/Bactrim interaction

Prescribes Bactrim despite because…

• Competency• Consciousness• Communication• Critical Thinking• Compliance

and…

Slide 53

The Inappropriate Act Statement

2) Whatp

Warfarin interaction potential

1) Who Intern

4) WhySelf-checking and no-interruption zone at order entry not observed in department

• Structure• Culture• Process• Policy & Protocol• Environment &

Technology

3) HowWas distracted when another pharmacist asked for clarification of a physician order

“Clicks through” drug because…

• Competency• Consciousness• Communication• Critical Thinking• Compliance

and…

Slide 54

The Inappropriate Act Statement

2) Whatg g

interaction alert when entering order

1) Who Pharmacist

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4) WhyPharmacists in department “get aggravated” by questions, so Techs don’t bother to ask

• Structure• Culture• Process• Policy & Protocol• Environment &

Technology

3) HowSaw Pharmacist had approved order and didn’t ask for verification

Fills order despite noting

because…

• Competency• Consciousness• Communication• Critical Thinking• Compliance

and…

Slide 55

The Inappropriate Act Statement

2) What Fills order despite noting the interaction alert

1) Who Pharmacy Tech

• Structure• Culture• Process• Policy & Protocol• Environment &

Technology4) Why

Orientation program didn’t cover all drug interactions and medication documentation system doesn’t integrate all interactions.

• Competency• Consciousness• Communication• Critical Thinking• Compliance

3) HowShe was a new grad and didn’t know about the interaction between Bactrim and Warfarin

Gave the Bactrim to patient because…

and…

Slide 56

The Inappropriate Act Statement

2) Whatp

and didn’t question drug interaction

1) Who RN

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Preoccupation with FailureOperating with a chronic wariness of the possibility of unexpected events that may jeopardize safety by engaging in proactive and preemptive analysis and discussion

Sensitivity to OperationsPaying attention to what’s happening on the front line Ongoing

Five Principles of HROs

Paying attention to what’s happening on the front-line – Ongoing interaction and information-sharing about the human and organizational factors that determine the safety of a system as a whole

Reluctance to Simplify interpretationsTaking deliberate steps to question assumptions and received wisdom to create a more complete and nuanced picture of ongoing operations

Commitment to Resilience

Slide 57

Co t e t to es e ceDeveloping capabilities to detect, contain, and bounce back from errors that have already occurred, before they worsen and cause more serious harm

Deference to ExpertiseDuring high-tempo operations, decision-making authority migrates to the person or people with the most expertise with the problem at hand, regardless of rank– We take advantage of the unique skills of our colleagues– When a patient crisis occurs, we rapidly pool our collective expertise to resolve it

On the flight deck: Rank has no privilege

Junior sailors can shut down the flight deck

We take advantage of the unique skills of our colleagues…

Everyone “owns” the mission

Slide 58

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We need to take advantage of the unique skills of our colleagues…

Institute for Safe Medication Practices 2003 Survey- 2095 healthcare providers (1565 nurses, 354 pharmacists)

- 88% condescending language or tone

- 87% impatience with questions

- 79% reluctance or refusal to answer questions or phone calls

- 48% strong verbal abuse

Slide 59

- 43% threatening body language

We need to take advantage of the unique skills of our colleagues…

Institute for Safe Medication Practices 2003 Survey- 2095 healthcare providers (1565 nurses, 354 pharmacists)

- 88% condescending language or tone

- 87% impatience with questions

- 79% reluctance or refusal to answer questions or phone calls

- 48% strong verbal abuse

- 43% threatening body language

Slide 60

Denigrates SubordinatesIntimidating

Poor for moraleAtmosphere inhibits the flow of information

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• 49% altered their handling of order clarifications or questions

• 34% felt the highly respected reputation of the prescriber was intimidating and avoided clarification

Impact on Individual and Team Behavior

order clarifications or questions

• 75% used avoidancetechniques to clarify orders

Slide 61

• 49% felt pressure to accept, dispense or administer a medication despite concerns

• 31% allowed physician to give medication despite reservations

Can We Function as a Team?

75% of surgeons rated teamwork “High”

Others on the team “not-so-much”

When a patient crisis occurs, we need to rapidly pool our collective expertise to resolve it…

Others on the team not so much- 39% of anesthesiologists

- 28% of surgical nurses

- 25% of anesthesia nurses

- 10% of residents

Slide 62

Source: Internal Bleeding, Whachter & Shojania, 2004

50% of surgeons felt junior team members should not question the

decisions of senior physicians

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Miracle on the Hudson

Slide 63

We MUST Function as a Team

I am very happy to know that, unlike at other appearances we’ve made, I don’t have to explain here what ‘crew’

Slide 64

The crew of US Airways Flight 1549 receiving ALPA’s first-ever Distinguished Safety Award in August of 2009

means.”– Captain Chesley “Sulley” Sullenberger, in remarks after an emotional, 2-minute standing ovation at the ALPA 55th Air Safety Forum Awards Banquet in Washington, DC

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BREAK

Slide 65

Define & Demonstrate Core Valuesat the “blunt end”

Leadership Triple Threatfor Performance Reliability

Set the set point

Find Problems & Fix Causesin systems and processes

Manage to prevent, detect and manage drift

Slide 66

Reinforce & Build Accountabilityfor behaviors at the “sharp end”

detect, and manage drift

© 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

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Just culture (Fair and Just Accountability)

An atmosphere of trust in which people are encouraged to provide, and even rewarded for providing essential safety-related information but in

Slide 67

even rewarded for providing, essential safety related information but in which they are clear about where the line must be drawn between acceptable and unacceptable behavior.

James ReasonManaging the Risks of Organizational Accidents (1997)

Skill Based Rule Based Knowledge Based

Activity

Human Error ClassificationBased on the Skill/Rule/Knowledge classification of Jens Rasmussen and the Generic Error Modeling System of James Reason

Familiar, routine acts that can b i d t thl i

Problem solving in a known situation according to set of

Problem solving in new, unfamiliar situation for which th i di id l k l

y

Type

Error

Types

Error

Prevention Self checking – stop and think

Slips

Lapses

Fumbles

be carried out smoothly in an automatic fashion

Educate if wrong rule

Think a second time if misapplication

Wrong rule

Misapplication of a rule

Non-compliance with rule

gstored “rules,” or learned principles

St d fi d t

Formulation of incorrect response

the individual knows no rules – requires a plan of action to be formulated

Slide 68

Prevention

Themes

Error

Probability

© 2007 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Self checking stop and think before acting

1:1000

Non-compliance – reduce burden, increase risk awareness, improve coaching culture

1:100

Stop and find an expert

3:10 to 6:10

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Non-CompliancePerson knew the rule, had the skill and ability to perform according to the rule, made a choice to disregard the ruleg

Usually, a conscious decision, made after weighing the pros and cons, that it is better choice to not comply

Slide 69

Also known as risk-taking

The Drivers of Non-Compliance

Non-Compliance = Perceived Burden

PerceivedRisk + Coworker

Coaching

Slide 70

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Building Compliance

If burden to comply is high

- Reduce physical burden through work redesign

- Reduce mental/emotional burden

If positive coworker feedback is low

- Develop team commitment to observe and coach for compliance

If risk awareness is low

Slide 71

- Educate on risk to the patient or coworkers

- Educate on risk to self (physical or discipline)

Intuitive Work ProcessesOur responsibility as leaders…

To design work processes that make it easy for our employees to do the right thing

Slide 72

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Building Compliance

If burden to comply is high

- Reduce physical burden through work redesign

- Reduce mental/emotional burden

If positive coworker feedback is low

- Develop team commitment to observe and coach for compliance

If risk awareness is low

Slide 73

- Educate on risk to the patient or coworkers

- Educate on risk to self (physical or discipline)

Slide 74

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Good Habits for Coaching – 5:1 Feedback

5 positive bits of feedback for every

1 bit of negative feedback

Why It Works:• Positive is a more powerful influencer in managing

resistance and building habits

• Builds a relationship of trust and respect

• Enables individuals to more effectively give and

Slide 75

y greceive negative reinforcement for a behavior that needs to be changed –

It’s like “building money in the bank!”

Building Compliance

If burden to comply is high

- Reduce physical burden through work redesign

- Reduce mental/emotional burden

If positive coworker feedback is low

- Develop team commitment to observe and coach for compliance

If risk awareness is low

Slide 76

- Educate on risk to the patient or coworkers

- Educate on risk to self (physical or discipline)

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Page 39

U.S. Inaction Lets Look‐Alike Tubes Kill PatientsBy GARDINER HARRIS

Robin Rodgers Died July 31, 2001

By GARDINER HARRISAugust 20, 2010

Died, with her unborn child, after a bag of tube feeding

formula was mistakenly connected to an existing

intravenous line

Slide 77

“The death of Robin and her unborn child were among hundreds of deaths or serious injuries that researchers have traced to tube mix-ups. But no one knows the real toll, because this kind of mistake, like medication errors in general, is rarely reported. A 2006 survey of hospitals found that 16 percent had experienced a feeding tube mix-up.

Perceived Risk to Self

Risk = Probability x Consequence

Probability of being observed – rounding, daily huddle, peer checking

Consequence of actions – Rules of Conduct,

Slide 78

progressive discipline, Red Rules, performance review

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Unintended Human Errorvs. Non-Compliance

In a fair, or just, culture…- No punishment for unintended error or mistakes driven o pu s e t o u te ded e o o sta es d e

by system problems

- Fair consequence for intended decisions to act against the rule

It’s the leader’s responsibility to differentiate, and

Slide 79

we can differentiate…

We Can Differentiate

James Reason’s “Decision Tree for Determining the C lpabilit of Unsafe Acts” from Managing the

Slide 80

The United Kingdom’s National Health Service’s “Incident Decision Tree,” adapted from James Reason’s decision tree

the Culpability of Unsafe Acts” from Managing the Risks of Organizational Accidents (2007)

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Slide 81

It is important for employees to know that a leader will respond and treat an employee fairly when performance does not meet expectations

How Leaders Respond

If employees perceive that individuals are unfairly punished:

• Reduced likelihood to report events, errors, and mistakes

• Missed opportunities to find and fix problems impacting performance and outcomes

This is your management “moment of 

truth”

Slide 82

If employees see management tolerance when there is intentional, disregard for work rules:

• Performance of other individuals and of the team as a whole will decline over time

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Practical Case Studies

Slide 83

In 2006, nurse Julie Thao mistook a bag of epidural painkiller for penicillin and hooked it up to an IV line that pumped the painkiller—meant to be injected into the spine later—into the bloodstream of Jasmine Gant, a 16-year-old who was about to deliver a baby at St Mary's Hospital in Madison Wis The teen's

Case Study #1

at St. Mary s Hospital in Madison, Wis. The teen s heart collapsed. Her baby was delivered successfully by emergency Caesarean section, but Ms. Gant didn't survive.

Ms. Thao failed to put an identification bracelet on her patient or use the hospital's bar-coding system, designed to match the right medication to the right patient. But the bar-coding system had glitches, and nurses hadn't been adequately trained on it, so they often bypassed it.

Slide 84

Both medications—which looked alike—were brought into the patient's room before orders were given, a violation of policy. Fatigue increased Ms. Thao's likelihood of making a mistake. Ms Thao had worked two consecutive eight-hour shifts the day before and then slept in the hospital before coming on duty again the next morning, but there were no rules at the hospital to prevent her from being overworked.

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Slide 85

A staff nurse working on an oncology unit reported to the charge nurse that she had called the Internal Medicine resident for an order of morphine for a terminally ill patient in severe pain. She reported that the physician had asked her to administer the drug, saying that he would be coming by in an hour to write the order.

Th h th ht thi dd i th ti t h d b tti i

Case Study #2

The charge nurse thought this was odd since the patient had been getting pain medication all along and seemed to be doing OK. She didn’t ask any questions however and the patient was given the medication. An hour later, the patient was discovered non-responsive and expired.

The following day it was discovered that the staff nurse had not telephoned the doctor at all for an order. Initially she lied about this, but subsequently admitted she had not even tried to call because: “You can never get hold of him and this patient was in pain”

Slide 86

patient was in pain .

The staff nurse said she did not regret her actions and had administered drugs without an order before. She was fully aware that she was breaching protocols. By contrast, the charge nurse was shocked by the incident and appalled that she had accepted the staff nurse’s explanation without asking any questions.

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Slide 87

It was a very busy evening shift in the hospital. The security guard in charge that night had been having some difficult family problems and had gotten very little sleep over the past few days.

A th h ffi ki th t hift h h d th t k th t d

Case Study #3

As the charge officer working that shift, he had the master key that opened every door in the building. He was called to open an office off the main lobby. After he completed the task, he received a STAT call to the ED to help with a violent patient.

He left right away to go to the ED, but left the key in the door. When he realized 3 minutes later that he had done this, he went back to the lobby office, but the key was gone. As a result, they had to re-key the whole building

Slide 88

building.

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Slide 89

A clerk in the Registration Department was having problems with attendance. He had been working in the department for about two years, but in recent months had developed a pattern of tardiness, arriving late to work. The problem had started gradually, every couple of weeks and only a few minutes late.

Over the past two weeks however he was late by anywhere from 15 30

Case Study #4

Over the past two weeks, however, he was late by anywhere from 15 – 30 minutes at least twice a week. The manager had counseled him during the earlier episodes, but was now concerned that this employee could be headed toward termination.

This employee’s performance other than the tardiness was good and he had been recognized recently in two different safety success stories. Problems with tardiness were not uncommon in this department, but the manager had tried to address each one as it had arisen.

Slide 90

A subsequent conversation with the employee brought out the information that he was going through some domestic issues and he was having to be the responsible adult to get his two children to day care.

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Slide 91

A hospital, which had achieved remarkably low fall rates in all units, suddenly saw an increase in falls. Leadership re-emphasized the expectation of compliance with the normal fall prevention protocols – falls assessments, hourly rounding, side-rails up, pink armband identifiers, signs on the door and effective handoffs.

The next month there were 3 falls with injury:

Case Study #5-7

The next month there were 3 falls with injury:

1. A fall occurred when the nursing aide took the patient to the bathroom. The patient wanted privacy so the aide left her alone. The patient went to get up using the IV pole as a support, the pole slid and the 70 year old woman fell and split her head open from forehead to nose.

2. One patient came back from X-ray and told the transporter they wanted to sit in the chair, but no handoff was given to the nurse nor was a chair alarm set. Later he went to get up without assistance, fell and broke his hip.

Slide 92

3. Another patient had just returned from cardiac. The cardiac team put him in the bed, set the bed alarm, and handed off to the nurse. The nurse made hourly rounds for most of the day but wasn’t able to check on the patient for two hours when she got busy with an admission as well as a unit code. During that time the patient tried to get out of bed on their own and fell, breaking his arm.

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Slide 93

Just Culture Challenges

Leader epiphany – “We have found the enemy, and the enemy is us.”

“But (s)he’s such a good employee…”

“But there was no bad outcome…”

Turn the learning for one into learning for all

“If thi ‘ ’ th i th d bl b

Slide 94

“If everything ‘goes,’ then in the end no problem may be seen anymore as safety critical – and people will stop

talking about them for that reason.”

Sidney Dekker, Just Culture: Balancing Safety & Accountability (2007)

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Two Important Messages

Employees have a responsibility to report events

L d ’ h ibilit t Leader’s have a responsibility to- Identify and fix system problems

- Handle the individual fairly while using opportunity to build accountability

Slide 95

Recommended ReadingsSidney Dekker, Just Culture: Balancing Safety & Accountability, Ashgate (2007).

David Marx JD “Patient Safety and the ‘Just Culture’: A Primer for HealthDavid Marx, JD, Patient Safety and the Just Culture : A Primer for Health Care Executives,” Columbia University (2001).

Donald Norman, The Design of Everyday Things, Basic Books (2002 edition).

James Reason, Managing the Risks of Organizational Accidents, Ashgate (1997).

Slide 96

Sandra Meadows, et. al., “The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents,” National Patient Safety Agency, United Kingdom (2003). (http://www.npsa.nhs.uk/site/media/documents/760_IDT%20Information%20and%20Advice%20on%20Use.pdf)

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Page 49

Georgia Tech vs Wake Forest

March 19 2010

Low flyover lands two Oceana pilots in hot water

March 19, 2010

Slide 97

“I think one’s feelings waste themselves in words; they ought all to be distilled into actions which bring results.”

Fl Ni hti l- Florence Nightingale

Slide 98

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Steve Kreiser CDR (USN Ret ) MBA MSM

Contact Information

Steve Kreiser, CDR (USN Ret.), MBA, MSMSenior ConsultantTel: 757.353.7833

Email: [email protected]

Slide 99

Healthcare Performance Improvement5041 Corporate Woods Drive, Suite 180 • Virginia Beach, VA 23462

Phone: (757) 226-7479 • Website: www.hpiresults.com