The Tolerated Defects in Healthcare

Introducing a new approach to safety in hospitals

June, 2013Roger Resar MD Senior IHI Fellow

1

The Task

• Despite current approaches to prevention, analysis and improvement hospitals continues to experience serious adverse events

2

3

The Small Hospital Challenge

• Large scale projects promoted for large hospitals frequently do not apply (either by volume or nature)

• Staff time for team meetings is much less available

• Improvement skills are less available

• Resources are frequently very limited (travel, consultants, etc)

4

A New Concept

1-Projects are small with the entire emphasis on frontline driven identification .(meaning not top down)

 

2-All work on the project is done by a dyad in a dyadic fashion (meaning no teams)

 

3-There are no team meetings (meaning work takes place on the project as work takes place on the unit)

 

4-Has no relationship to a large change package (meaning every unit will have unique projects with little chance of sharing ideas unless the finished project is spread to other units in the organization)

 

5-The cost in resources to design the improvement is essentially nothing (meaning even small hospitals, clinics etc can afford the methodology)

 

6-Measurement is local with pencil and paper and emphasis is based on bimodal simplicity (meaning data collection is simple without need for IT)

 

7-Emphasis on JIT teaching rather than more formal quality improvement modules (meaning less cost, less time lost and better application of what QI knowledge the organization currently has)

8-Projects are finished in less than 30 days

5

Frontline Structured

Conversation

Frontline Structured

Conversation

FrontlineDefects

Clinical Non-clinical

CollectData

CollectData

Suggest Strategie

s

Suggest Strategie

s

Identify

DefectsIdentify

Defects

Frontline Engagement

Small TestsLeadingToProjectSuccess

Frontline Defect Driven Project Model

Surface DefectsSurface Defects

Scope DefectsScope

Defects ValidateValidateSelect specific work

Select specific work

Design StrategyDesign

StrategyFinish

ProjectFinish

ProjectActions

DesignBenefits

Timeline 90 min 2 Days 1 day

60 min 60 min 30 days

FrontlineEngagement

LeadershipEngagement

FrontlineEngagement

Tester Engagement

FrontlineEngagement

DesignBasics of theActions

ConversationSpecificMethodology

Anchoring Questions

Frontline Feedback

Align work

Gauge Capacity

ArticulateImplications

Study the next defect

Y/N FrontlineData Collection

Determinefrequency

DefineBoundaries

Determine Simplemeasures

Frontline Input

SmallTests

Frontline Defect Driven Project Framework

R Resar

The Framework

• Multidisciplinary Team• 90 Minute Visits

─Intro

─Identification of “defects” Normalization of Deviation

• Non-threatening & blame free environment

8

Check List for setting up the Conversation

• Pre-arrange for a 90 minute conversation (preferably the conversation occurs on the unit)

• Pre-arrange a time for the conversation (chose a time when a representative group of frontline staff can participate)

• Invite a leadership representative

9

Technique to Start the Conversation

• Make introductions

• Have one lead person (others can participate later) initiate the conversation by asking individual frontline staff to describe their daily routine (without questions or interruption)

• Spend about 15-20 minutes in the start of the conversation (to allay fears)

10

Technique to Surface Defects

• Use anchoring questions to start to surface defects Examples:1-We all have good and bad days at work, describe the last difficult day you

recall?

2-Things have to be adjusted in work flow to make the day smooth, describe how you make adjustments to accomplish getting the work done?

3-What clinical diagnoses are most common on this unit, describe the most difficult cases you work with?

4-The unexpected is bound to occur from time to time, describe the last unexpected event that occurred in your work?

11

The Defects

• Each anchoring question usually surfaces at least one defect

• Most 90 minute conversations surface from 12-20 defects

• Avoid spending time on possible solutions (that will come later)

• Have a scribe write down each of the defects with as much detail as possible

• Finish the conversation by listing the defects surfaced, assure the frontline staff one or more of these will be solved and then thank the team

12

Some Observations

• Daily interruptions are commonly viewed as normal, so little or no attempt is currently made to change processes

• The units function primarily at an artisan level of work. Staff pride themselves in their unique ability to deal with defects (scrambling).

• “Victimized” by external factors. Most areas described problems with a system “out there”—units, physicians, scheduling systems, a physician’s preference and they are viewed as beyond their control

13

Cedars-Sinai Examples

• CVIC

─ Patients arrive for a procedure still on anti-coagulation

─ Daily search for equipment

• OR/PACU

─ Cases delayed due to wrong equipment

• Radiation Oncology

─ Add-ons

─ Missing information

14

Cedars: Initial learnings

• It became clear that the seeds for the next event have already been sown in the day-to-day missteps described as “normal” by staff.

• Start small with the creation of small islands of stability. An island of stability represents an area of work that has been reviewed and changed to create a new standardized way to organize workflow.

• Build unit-based learning, reflection on work, measurement, and change leadership systems to support work at the local level.

15

MAYO CLINIC EXAMPLE

A Defect is Surfaced

Can we fix it in 30 days?

Study next occurrence of the defect

Is it a re-surfaced defect?

Document the defect

Is the defect critical to patient safety?

Are there resources to fix at unit level?

Scope project > 30 days

Is there interest in fixing the problem?

No

No

No

No

No Yes

Can we fix it in 30 days?No

Are there nowinterest, resources to fix ?

Yes

Surface Defect Process

Three one-hour conversations with the frontline

Participants: • Hospitalists • Nurses • Social worker • Discharge planners • Dietitian • Pharmacists

39 defects surfaced during 3 conversations

Results

18/39 (46%) of surfaced defects moved on to improvement projects

– 15/18 (83%) of surfaced defects that moved on to improvement projects were resolved in less than 30 days

2 projects qualified for ABIM/ABP MOC part IV (performance improvement) credit

CEDARS-SINAI EXAMPLE

One Week33 Defects Identified

21

I

Examples

What Was Learned

It became clear that the seeds for the next event have already been sown in the day-today missteps described as “normal” by staff.

• Start small with the creation of small islands of stability. An island of stability represents an area of work that has been reviewed and changed to create a new standardized way to organize workflow.

• Build unit-based learning, reflection on work, measurement, and change leadership systems to support work at the local level.

22

Advantages

Projects are accomplished by a dyad

No team meetings

No training other than JIT

No data collection other than pencil and paper

Creates enthusiasm for improvement

23

Session Objectives

Understand how integral the harm measurement is to the mission and values of a hospital

Explore the reasons for the lack of any significant improvement in safety in our hospitals

Appreciate the key calibrations in the safety trajectory for a hospital

Surface

Defects

Surface

Defects

Scope DefectsScope Defects

Validate

Validate

Select specific work

Select specific work

Design StrategyDesign

Strategy

Finish Projec

t

Finish Projec

t

Actions

DesignBenefits

Timeline 90 min 2 Days 1 day

60 min 60 min 30 days

FrontlineEngagement

LeadershipEngagement

FrontlineEngagement

Tester Engagement

FrontlineEngagement

DesignBasics of theActions

ConversationSpecificMethodology

Anchoring Questions

Frontline Feedback

Align work

Gauge Capacity

ArticulateImplications

Study the next defect

Y/N FrontlineData Collection

Determinefrequency

DefineBoundaries

Determine Simplemeasures

Frontline Input

SmallTests

Frontline Defect Driven Project Framework

R Resar