Post on 21-Sep-2020
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The Quality Colloquium at The Quality Colloquium at Harvard UniversityHarvard University
PrePre--Conference Symposium Conference Symposium Patient Safety Officer Patient Safety Officer Certificate TrainingCertificate Training
Paul Barach, MD, MPHPaul Barach, MD, MPHJulie K. Johnson, MSPH, PhDJulie K. Johnson, MSPH, PhD
Davis Balestracci, MSDavis Balestracci, MSGwen Sherwood, PhD, RN, FAANGwen Sherwood, PhD, RN, FAAN
Monday, August 17, 2009Monday, August 17, 2009
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Our AimOur Aim
To start new and meaningful To start new and meaningful conversations about quality and safety conversations about quality and safety ––personally, in our organizations, and with personally, in our organizations, and with our leadersour leaders
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Learning ObjectivesLearning Objectives
By the end of this Patient Safety Officer By the end of this Patient Safety Officer Training, participants will be able toTraining, participants will be able to–– Reflect on current levels of quality and safety Reflect on current levels of quality and safety
in our organizationsin our organizations–– Change practitionersChange practitioners’’ everyday conversations everyday conversations
about safety and the culture of safetyabout safety and the culture of safety–– Discuss how to engage the leadership in Discuss how to engage the leadership in
safety while changing their attitude toward safety while changing their attitude toward safetysafety
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TodayToday’’s Agendas Agenda9:00 am9:00 am Welcome and IntroductionWelcome and Introduction9:15 am9:15 am Mental Models and Mental Models and
Framing of Safety and QualityFraming of Safety and Quality9:30 am9:30 am Small Group Discussion about Small Group Discussion about
the 5 Prethe 5 Pre--Conference QuestionsConference Questions10:00 am10:00 am The Patient Safety Core Curriculum and The Patient Safety Core Curriculum and
Introduction to Lewis Blackman StoryIntroduction to Lewis Blackman Story10:15 am10:15 am BreakBreak10:45 am10:45 am Small group discussion on LewisSmall group discussion on Lewis’’ Story Story
(a Pre(a Pre--Analysis)Analysis)11:15 am 11:15 am Debriefing fromDebriefing from small groupsmall group discussion: discussion:
How are we thinking about safety now?How are we thinking about safety now?11:4511:45 amam Lunch on Your OwnLunch on Your Own1:00 pm1:00 pm Data Data ““InsanityInsanity””
The silent improvement killer The silent improvement killer —— Part 1Part 1
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TodayToday’’s Agendas Agenda1:30 pm1:30 pm Group DiscussionGroup Discussion2:00 pm2:00 pm Engaging Leaders Engaging Leaders -- From Turf Wars to From Turf Wars to
Appreciative Appreciative Inquiry, Principles of Leadership Inquiry, Principles of Leadership for Quality and Safetyfor Quality and Safety
2:30 pm 2:30 pm Small Group ExerciseSmall Group Exercise2:45 pm2:45 pm Debriefing fromDebriefing from small group exercisesmall group exercise3:00 pm 3:00 pm BreakBreak3:30 pm3:30 pm Data Data ““InsanityInsanity””
The silent improvement killer The silent improvement killer –– Part 2 Part 2 4:00 pm4:00 pm Final discussion about the Lewis Blackman StoryFinal discussion about the Lewis Blackman Story4:15 pm4:15 pm Real World Dilemmas in Quality and SafetyReal World Dilemmas in Quality and Safety4:30 pm4:30 pm Concluding Comments, Questions and PostConcluding Comments, Questions and Post--
Colloquium Examination LogisticsColloquium Examination Logistics5:00 pm5:00 pm AdjournAdjourn
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IntroductionsIntroductions
Introduce yourself to your neighborsIntroduce yourself to your neighbors–– Who you are?Who you are?–– Where are you from?Where are you from?–– What is your dayWhat is your day--job?job?–– What did you give up to be here today?What did you give up to be here today?–– What are your expectations of this session?What are your expectations of this session?
We will cull expectations from the groupWe will cull expectations from the group
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What can we learn What can we learn from the from the futurefuture that will that will help us create a better help us create a better presentpresent for healthcare?for healthcare?
A History of the Future ApproachA History of the Future Approach
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History of the Future Approach•
Create a scenario fifteen years from now
•
Ask participants to “look back”
at significant events that brought medicine to this point in 2021
•
Anchor a time horizon in their lives–
Personal milestones
–
Family members
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Who Are We?Who Are We?
We are an overloaded systemWe are an overloaded systemWe cannot keep up with complex We cannot keep up with complex diagnostic and therapeutic technologiesdiagnostic and therapeutic technologiesWe have not changed workflows and roles We have not changed workflows and roles in the past couple of centuriesin the past couple of centuriesWe have placed most emphasis on We have placed most emphasis on sickness control, not on health promotionsickness control, not on health promotionWe face the same challenges everywhere, We face the same challenges everywhere, but are tackling them independentlybut are tackling them independently
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No system
beyond this point
10-2 10-3 10-4 10-5 10-6
Civil Aviation
Nuclear Industry
Railways (France)
Chartered FlightHimalayamountaineering
Road Safety
Chemical Industry (total)
Risk
Medical risk (total)
Blood transfusionAnesthesiology
ASA1Cardiac SurgeryPatient ASA 3-5
Fatal Iatrogenicadverse events
Microlight flights helicopters
Very unsafe Ultra safe
Amalberti, R, Auroy, Y, Berwick, D, Barach, P. Five System Barriers To Achieving Ultra-safe Health Care. Annals of Internal Medicine, 2005;142:756-764.
Adverse Adverse Event Rates in HealthcareEvent Rates in Healthcare
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U.S. Adults Receive Half of U.S. Adults Receive Half of Recommended CareRecommended Care
Source: McGlynn et al., “The Quality of Health Care Delivered to Adults in the United States,”The New England Journal of Medicine (June 26, 2003): 2635–2645.
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76
65
54
39
23
45
0
20
40
60
80
Overall BreastCancer
Hypertension Asthma Pneumonia Hip Fracture Diabetesmellitus
Percent of recommended care received
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Variation in death rates and Variation in death rates and charges in US hospitalscharges in US hospitals
0
20
40
60
80
100120
140
160
180
200
0 5,000 10,000 15,000 20,000 25,000
Standardized $ charges per admission
Stan
dard
ized
Mor
talit
y R
ate
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CPR Quality During CPR Quality During Cardiac ArrestCardiac Arrest
Two companion studies of CPR qualityTwo companion studies of CPR quality–– Chest compressions were not delivered half of Chest compressions were not delivered half of
the time and compressions were too shallow the time and compressions were too shallow ((““outout--ofof--hospitalhospital””))
–– Quality of multiple CPR parameters was Quality of multiple CPR parameters was inconsistent and often did not meet published inconsistent and often did not meet published guidelines (guidelines (““inin--hospitalhospital””))
Abella BS, Alvarado JP, Hyklebust H, et. al. Quality of Cardiopulmonary Resuscitation During In-Hospital Cardiac Arrest. JAMA, January 19, 2005, 293(3):305-310
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17
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Barriers to Significant Quality Improvement
•
Biases/mental model clinicians bring to the table
•
Variation in Clinical Practice•
High Powered Teams
•
Learning From Our Mistakes•
Service and Technology
•
Linking Incentives with Report Cards
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The Cloak•
Painfully incorporated desire not to appear incompetent
•
Behaviors conferring a sense of protection are greater:
–
The more terrorizing and fatiguing the training or the greater the possibility of catastrophic error on a moment-to-
moment basis
•
“The problem is we get so used to cloaking our irrational decisions in the guise of wisdom and experience, we confuse good luck with good judgment, and that’s where diagnostic errors often begin.”
Wachter,RM and Shojania,KG: Internal Bleeding:
The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. 2004.
"It is incident to physicians, I am afraid, beyond all other men, to mistake subsequence for consequence.“
Samuel Johnson, 1756
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Meaningful Patient andFamily Involvement
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Transformed Hospitals Have Clear Definitions
What do you mean by great performance?Have you established a baseline?Are you improving?If not, why not?How can you improve even faster?Settling upon a consistent and intelligent method of assessing your output results
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It is Impossible to be Ahead of the Pack if you Think about the Future in Today’s Terms
““Well, Well, lemme lemme think... Youthink... You’’ve stumped me, son. Mostve stumped me, son. Mostfolks only folks only wanna wanna know how to go the other way.know how to go the other way.””
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How Do Mental Models How Do Mental Models Affect Our Work?Affect Our Work?
Exploring Mental Models through Exploring Mental Models through Framing and ReframingFraming and Reframing
Julie K. Johnson, MPSH, PhDJulie K. Johnson, MPSH, PhD
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Learning ObjectivesLearning Objectives
By the end of this session, learners will be By the end of this session, learners will be able to:able to:–– Describe the concept of mental modelsDescribe the concept of mental models–– Discuss how individuals use mental models to Discuss how individuals use mental models to
frame issues and how that framing both frame issues and how that framing both contributes to and limits our understanding of contributes to and limits our understanding of a situationa situation
–– Consider the implication of frames for patient Consider the implication of frames for patient care and medical educationcare and medical education
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Before We Begin . . .Before We Begin . . .
Choose an opponent for thumb wrestlingChoose an opponent for thumb wrestlingThe goal is for you to win this competition The goal is for you to win this competition as many times as you can in 15 secondsas many times as you can in 15 secondsWinning means pinning your opponentWinning means pinning your opponent’’s s thumbthumb
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What happened?What happened?
How many points did you get?How many points did you get?What were the assumptions you brought What were the assumptions you brought into this game?into this game?How did your assumptions affect your How did your assumptions affect your behavior?behavior?
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Mental ModelsMental Models
The images, assumptions, and stories we The images, assumptions, and stories we carry in our minds of ourselves, other carry in our minds of ourselves, other people, institutions, and every aspect of people, institutions, and every aspect of the worldthe worldThey determine what we see, and most They determine what we see, and most importantly, importantly, how we acthow we act
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What Might this Mean for What Might this Mean for Our Work?Our Work?
Examples from clinical care, educationExamples from clinical care, education–– Drug seeking behaviorDrug seeking behavior–– Patient nonPatient non--compliance compliance –– ““DifficultDifficult”” patient/familypatient/family–– Born surgeonBorn surgeon–– Born internistBorn internist
–– Other ideas??Other ideas??
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Mental ModelsMental Models
None are perfectly accurate None are perfectly accurate Differences in mental models explain how Differences in mental models explain how two people can understand the same two people can understand the same event differently event differently Are generally invisible to us Are generally invisible to us –– until we look until we look for themfor them
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The Ladder The Ladder of Inferenceof Inference
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What Happens on the LadderWhat Happens on the LadderWe pay attention to some data and ignore other dataWe pay attention to some data and ignore other dataWe impose our own interpretations on these data and We impose our own interpretations on these data and draw conclusions from themdraw conclusions from themWe lose sight of how we do this because we do not think We lose sight of how we do this because we do not think about our own process of thinkingabout our own process of thinkingOur conclusions feel obvious to us Our conclusions feel obvious to us Other peopleOther people’’s conclusions feel obvious to thems conclusions feel obvious to themWhen people reach different conclusions and disagree, When people reach different conclusions and disagree, they often hurl conclusions at each other from the tops they often hurl conclusions at each other from the tops of their respective laddersof their respective laddersThis makes it hard to resolve differences and to learn This makes it hard to resolve differences and to learn from one anotherfrom one another
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How Can We Surface Our How Can We Surface Our Mental Models?Mental Models?
Working with mental models requires surfacing, testing, Working with mental models requires surfacing, testing, and improving our internal pictures of how the world and improving our internal pictures of how the world worksworks3 skills can be helpful3 skills can be helpful–– Reflection Reflection –– understanding your own mental models and the understanding your own mental models and the
implicationsimplications–– Inquiry Inquiry –– learning the questions you can ask to help you test learning the questions you can ask to help you test
othersothers’’ mental modelmental model–– Advocacy Advocacy –– making your thinking and reasoning more visible to making your thinking and reasoning more visible to
others others
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Advocacy and Inquiry are Key to Advocacy and Inquiry are Key to CommunicationCommunication
High
Low High
Adv
ocac
y
Inquiry
OneOne--way Communicationway Communication(Explaining, Imposing)(Explaining, Imposing)
TwoTwo--Way Way Communication Communication
(Mutual Learning)(Mutual Learning)
No Communication No Communication (Observing, Withdrawing)(Observing, Withdrawing)
OneOne--way Communication way Communication (Interviewing, Interrogating)(Interviewing, Interrogating)
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Relationship of Relationship of Mental Models to FramingMental Models to Framing
Mental models frame what we see and Mental models frame what we see and how we respondhow we respondOur mental models are internalOur mental models are internalFraming is the interaction of our mental Framing is the interaction of our mental models and the situation at handmodels and the situation at hand
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Small Group ExerciseSmall Group ExerciseDivide into groups of 4 Divide into groups of 4 –– one person from each group will be one person from each group will be selected to be the observer and note taker for the groupselected to be the observer and note taker for the groupEach group will get a set of 3 postcards Each group will get a set of 3 postcards –– Each postcard is covered with a different frame that reveals onlEach postcard is covered with a different frame that reveals only y
part of the postcardpart of the postcardDonDon’’t uncover the cards or reveal the frame to the groupt uncover the cards or reveal the frame to the groupDiscuss these questions:Discuss these questions:–– What do you see within the frame?What do you see within the frame?–– What is the story you can tell?What is the story you can tell?
Now, look at the cards and discuss:Now, look at the cards and discuss:–– How did your frame limit what you know?How did your frame limit what you know?–– How does someone elseHow does someone else’’s frame contribute to, or disrupt, your s frame contribute to, or disrupt, your
understanding of the issue?understanding of the issue?
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DebriefingDebriefing
What was your groupWhat was your group’’s experience with the s experience with the exercise?exercise?–– What surprised you?What surprised you?–– What did you learn?What did you learn?
How do your mental models affect the frames you How do your mental models affect the frames you use?use?How might your professional framework limit what How might your professional framework limit what you know?you know?
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The PreThe Pre--Conference Conference QuestionsQuestions
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Small Group DiscussionSmall Group Discussion
The 5 PreThe 5 Pre--Conference QuestionsConference Questions––
What are the most important patient safety issues What are the most important patient safety issues facing yourfacing your��institution?institution?��
––
How does the culture of your institution affect your How does the culture of your institution affect your ability toability to��implement change?implement change?��
––
What are 3 patient safety initiatives that you've read What are 3 patient safety initiatives that you've read about, heardabout, heard��about, or seen that you believe will about, or seen that you believe will make an impact in your institution?make an impact in your institution?����
––
What are 3 patient safety initiatives you would like to What are 3 patient safety initiatives you would like to implement inimplement in��the next year?the next year?��
––
Describe the composition of the team that will be Describe the composition of the team that will be necessary tonecessary to��accomplish each of those initiatives in accomplish each of those initiatives in your institutionyour institution
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Debriefing Debriefing
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The Patient Core Curriculum The Patient Core Curriculum and Introduction to the and Introduction to the LewisLewis Blackman StoryBlackman Story
Paul Barach, MD, MPHPaul Barach, MD, MPH
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Institute of Medicine Institute of Medicine November 1999November 1999
Human Error and performance Human Error and performance limitationslimitationsEstablish near miss voluntary reporting Establish near miss voluntary reporting systems and protect from discoverysystems and protect from discoveryCreating Safety systems in health care Creating Safety systems in health care organizationsorganizationsErrors lead as major cause of death, Errors lead as major cause of death, injuryinjuryCreate a safety cultureCreate a safety cultureCreate and inculcate a safety Create and inculcate a safety curriculumcurriculumTeam training and simulationTeam training and simulationEstablish national safety authorityEstablish national safety authorityAnesthesiologyAnesthesiology——only clinical domain to only clinical domain to make patient safety central to its make patient safety central to its missionmissionAltman, et al. 2004Altman, et al. 2004------five years laterfive years later----IOM most important report in 2 IOM most important report in 2 decadesdecadesWachterWachter, 2006, 2006------C+ grade on report C+ grade on report cardcard
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Patient Safety Domains Knowledge, Skills, Attitudes
1. Theoretical Foundations Microsystems, historical trends, chaos, complexity, competency and learning
2. Behavioral Aspects of Medical Professionalism
Ethics, patient quality of life, resolution of conflict
3. Interpersonal Issues Communication, stress and coping4. Human Factors and
ErgonomicsDesign history, error taxonomies, safety tools, decision support systems, fatigue factors, user centered design
5. Systems Analysis Usability criteria , organizations and learning disasters, place for human error
6. QI Learning Pareto/flow charts, and other QI tools, best practices, act cycles7. Injury Epidemiology Workplace hazards, worker safety, phases of injury, medico-legal
aspects8. Medication Safety Adverse and near-miss reporting, ISMP tools and website,
look/sound-alikes9. Crisis Management Tools Team work, shared decision making, situational awareness10. Simulations Micro-, macro-, debriefing, immersion levels, scripting, role playing
THE PATIENT SAFETY CORE CURRICULUM
Gilula, M. and Barach P. Creating a Patient Safety Curriculum: Purposive Sampling of Patient Safety Experts. 79th Clinical and Scientific IARS Congress. S-143. Honolulu, Hawaii. March 12, 2005.; Gilula, Barach, 2009.
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Case I: The Role of Human Case I: The Role of Human Factors in an Unexpected MIFactors in an Unexpected MI
A 45A 45--yearyear--old women for parathyroidectomy old women for parathyroidectomy with no past medical history, under general with no past medical history, under general anesthesia anesthesia After uneventful induction of anesthesia, the After uneventful induction of anesthesia, the patient became patient became hypotensivehypotensiveResident gave 1 cc of Resident gave 1 cc of phenylephrinephenylephrineHR went to 150HR went to 150’’s and VTs and VTCPR requiredCPR requiredEpinephrine givenEpinephrine givenST changes; TEEST changes; TEE--severe LV hypokenesissevere LV hypokenesis
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Similar Vials: Atropine & Similar Vials: Atropine & Phenylephrine Phenylephrine
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Elements of Organizational Elements of Organizational FailureFailure
Incompatible GoalsIncompatible GoalsOrganizational Structural DeficiencyOrganizational Structural DeficiencyInadequate CommunicationsInadequate CommunicationsPoor Planning and Scheduling Poor Planning and Scheduling Inadequate Control and MonitoringInadequate Control and MonitoringDesign FailuresDesign FailuresDeficient Training Deficient Training Inadequate Maintenance ManagementInadequate Maintenance Management
JT Reason 1993
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Elements of Organizational Elements of Organizational AccidentsAccidents
James T. Reason. The Human Factor in Medical Accidents. Medical Accidents.
Vincent C, Ennis M, and Audley R. Oxford University Press 1993
Task and Environmental
Conditions
Individual Unsafe Acts
Organizational Processes
Failed Defenses
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Human Error RatesHuman Error Rates
Error of commission (misreading a label)Error of commission (misreading a label) 3/10003/1000
Error of omission (item embedded in Error of omission (item embedded in procedure)procedure)
3/10003/1000
Error of omission (without reminders)Error of omission (without reminders) 1/1001/100
Error in simple arithmetic (with self check)Error in simple arithmetic (with self check) 3/1003/100
Personnel on different shift fail to check Personnel on different shift fail to check conditions unless directed by a checklistconditions unless directed by a checklist
1/101/10
Errors under very high stress when Errors under very high stress when dangerous activities are occurring rapidlydangerous activities are occurring rapidly
25/10025/100
Adapted from: Park, K. Human Error. In Salvendy, G, ed. “Handbook of Human Factors and Ergonomics”, New York. John Wiley & Son, Inc. 1997: 163.
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Human vs. Design FlawsHuman vs. Design Flaws
Human errors (7%) can be reduced by Human errors (7%) can be reduced by rigorous practices, standardization, rigorous practices, standardization, simulation training, building a safety simulation training, building a safety culture, etc.culture, etc.
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Organizational Organizational Design Design 93%93%
The 93% vs. 7% RuleThe 93% vs. 7% Rule
Negligent Conduct
Knowing ViolationsReckless
Conduct
Human Error
(People)
(People)
(People)
(People)
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Performance Shaping Factors Performance Shaping Factors Affecting Human Vigilance Affecting Human Vigilance
FatigueFatigueEnvironmental Conditions/BuiltEnvironmental Conditions/BuiltEnvironmentEnvironmentTask DesignTask DesignPsychological ConditionsPsychological ConditionsCompeting DemandsCompeting DemandsHand offs/Sign outsHand offs/Sign outs
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Tools and Methods of AnalysisTools and Methods of Analysis
Numerous methods and tools are available Numerous methods and tools are available for analyzing adverse events, near misses, for analyzing adverse events, near misses, and the context of careand the context of careRegardless of the tool used, the goal is to Regardless of the tool used, the goal is to determine at the organizational level how determine at the organizational level how to prevent errors from occurring in the to prevent errors from occurring in the futurefuture
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Types of ToolsTypes of ToolsLatent Errors
Latent Errors
Active Errors
Active ErrorsAdverse Events
Adverse EventsDirect Direct ObservationObservation Clinical Clinical
SurveillanceSurveillance
Incident Incident ReportingReporting
Autopsies and Autopsies and M&M ConferencesM&M Conferences
Malpractice Malpractice Claims Files Claims Files AnalysisAnalysis
Administrative Administrative Data AnalysisData Analysis
Information Information TechnologyTechnology
Chart ReviewChart Review
Peterson et al.
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Tools and Methods of AnalysisTools and Methods of Analysis
Retroactive AnalysisRetroactive Analysis–– Root Cause Analysis (RCA) is a thorough Root Cause Analysis (RCA) is a thorough
retrospective investigation to identify factors retrospective investigation to identify factors that contributed to the occurrence of an errorthat contributed to the occurrence of an error
Proactive AnalysisProactive Analysis–– Failure mode and effects analysis (FMEA) Failure mode and effects analysis (FMEA)
identifies potential contributing factors to identifies potential contributing factors to potential adverse eventspotential adverse events
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Consider the MicrosystemConsider the Microsystem
Small group of clinicians and staff working Small group of clinicians and staff working together with a shared clinical purpose to together with a shared clinical purpose to provide care for a defined set of patientsprovide care for a defined set of patientsThe clinical purpose defines the essential parts The clinical purpose defines the essential parts of the microsystemof the microsystem–– Clinicians and support staffClinicians and support staff–– Information and technologyInformation and technology–– Care processesCare processes
Source of excellence in health care organizationsSource of excellence in health care organizations
Mohr(Johnson) J, Batalden P, Barach P. Qual Saf Health Care 2004;13 Suppl 2:34-8.
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What Are the Essential Elements What Are the Essential Elements of a Microsystem?of a Microsystem?
Core team of health professionalsCore team of health professionalsDefined population of patients they care Defined population of patients they care forforInformation & information technologyInformation & information technologySupport staff, equipment, environmentSupport staff, equipment, environmentProcesses, activities specific to Processes, activities specific to accomplishing the aimaccomplishing the aim
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A Microsystem Framework for A Microsystem Framework for Analyzing EventsAnalyzing Events
One method that we have found to be One method that we have found to be useful for systematically looking at patient useful for systematically looking at patient safety events builds on Haddonsafety events builds on Haddon’’s s overarching framework on injury overarching framework on injury epidemiologyepidemiology
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The Haddon MatrixThe Haddon Matrix
HumanHuman VehicleVehicle EnvironmentEnvironment
PrePre--eventevent
EventEvent
PostPost--eventevent
Source: Haddon, W. A Logical Framework for Categorizing Highway Safety Phenomena and Activity. J. Trauma 1972; 12:197.
Alcohol intoxication
Braking capacity
Visibility of hazards
Resistance to injury insults
Sharp, pointed edges and surfaces
Flammable materials
Hemorrhage Rapidity of energy dissipation
Emergency medical response
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Haddon Matrix adapted to Patient Haddon Matrix adapted to Patient Safety in the MicrosystemSafety in the Microsystem
Patient/Patient/ FamilyFamily
Health Care Health Care ProfessionalProfessional
Systems/Systems/EnvironmentEnvironment
PrePre--eventevent
EventEvent
PostPost--eventevent
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DebriefingDebriefing
Patient/Patient/ FamilyFamily
Health Care Health Care ProfessionalProfessional
Systems/Systems/EnvironmentEnvironment
PrePre--eventevent
Orientation to the Orientation to the processprocess
ProbablisticProbablistic Risk Risk Assessment (PRA)Assessment (PRA)Scenario BuildingScenario BuildingHazard AnalysisHazard AnalysisChecklistsChecklists
Failure Modes Failure Modes Effects Analysis Effects Analysis (FMEA)(FMEA)Human Factors Human Factors EngineeringEngineering
EventEventInterviewInterview Crew Resource Crew Resource
Management (CRM)Management (CRM)ChecklistsChecklists
Root Cause Root Cause Analysis (RCA)Analysis (RCA)
PostPost-- eventevent
Interview, Interview, Focus Group Focus Group InterviewsInterviews
Microsystem Analysis Microsystem Analysis Morbidity and Mortality Morbidity and Mortality Conference (M&M)Conference (M&M)
Root Cause Root Cause Analysis (RCA)Analysis (RCA)
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ManagementDecisions
& Organisational
process
Accidents
DefensesPerson/teamWorkplaceOrganization
Latent conditions pathway
Organizational Accident Causation Organizational Accident Causation ModelModel
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ManagementDecisions
& Organisational
process
Accidents
DefensesPerson/teamWorkplaceOrganization
Latent conditions pathway
Error &Violation
Producingconditions
Organization Accident Causation Organization Accident Causation ModelModel
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Workplace Conditions Workplace Conditions Promoting Unsafe ActsPromoting Unsafe Acts
High WorkloadHigh WorkloadInadequate Knowledge, Ability or ExperienceInadequate Knowledge, Ability or ExperienceInadequate Supervision or InstructionInadequate Supervision or InstructionStressful EnvironmentStressful EnvironmentMental StateMental StateChangeChange
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WorkplaceWorkplace Error Producing ConditionsError Producing Conditions
Unfamiliarity(x17)Unfamiliarity(x17)Time Shortage(x11)Time Shortage(x11)Poor HumanPoor Human--System System Interface (x8)Interface (x8)Information Overload (x6)Information Overload (x6)Negative Transfer(x5)Negative Transfer(x5)Misperception of Risk (x4)Misperception of Risk (x4)
Inexperience Not Lack of Inexperience Not Lack of Training (x3)Training (x3)Inadequate Checking (x3)Inadequate Checking (x3)Poor Instructions(x3)Poor Instructions(x3)Educational Mismatch (x2)Educational Mismatch (x2)Disturbed Sleep (x1.6)Disturbed Sleep (x1.6)
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Work EnvironmentWork Environment Violation Producing ConditionsViolation Producing Conditions
Lack of Safety CultureLack of Safety CultureManagement/Staff Management/Staff ConflictConflictPoor MoralePoor MoralePoor SupervisionPoor SupervisionCondones ViolationsCondones ViolationsMisperception of HazardMisperception of HazardLack of Management Lack of Management ConcernConcern
Little Pride in WorkLittle Pride in WorkMacho CultureMacho Culture““Bad outcomes Bad outcomes WonWon’’t Happent Happen””Low SelfLow Self--EsteemEsteemLicense to Bend License to Bend RulesRulesAmbiguous or Ambiguous or Meaningless RulesMeaningless Rules
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Organizational Accident Causation Organizational Accident Causation ModelModel
ManagementDecisions
& Organisational
process
Accidents
DefensesPerson/teamWorkplaceOrganization
Latent conditions pathway
Error &Violation
Producingconditions
Errors &violations
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Person /TeamPerson /Team Individual Unsafe ActsIndividual Unsafe Acts
ErrorsErrors–– AttentionalAttentional Slips and memory lapses (Intrusions, omissions)Slips and memory lapses (Intrusions, omissions)–– MistakesMistakes
Rule Rule ––basedbasedKnowledgeKnowledge--basedbased
Violations( deliberate deviation from regulation)Violations( deliberate deviation from regulation)–– Routine ( shortcuts)Routine ( shortcuts)–– Optimizing Violations Optimizing Violations –– ExceptionalExceptional–– DeliberateDeliberate
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ManagementDecisions
& Organisational
process
Accidents
DefensesPerson/teamWorkplaceOrganization
Latent conditions pathway
Error &Violation
Producingconditions
Errors &violations
Organizational Accident Causation Organizational Accident Causation ModelModel
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Team videoTeam video
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What are important What are important team competency team competency
requirements?requirements?
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Medical Team TrainingMedical Team Training Team CompetenciesTeam Competencies
Knowledge Competencies Knowledge Competencies –– The principles and concepts that underlie a teamThe principles and concepts that underlie a team’’s s
effective performanceeffective performance
Skill CompetenciesSkill Competencies–– The learned capacity (psychomotor and cognitive) to The learned capacity (psychomotor and cognitive) to
interact with other team membersinteract with other team members
Attitude CompetenciesAttitude Competencies–– Internal states that influence team members to act in Internal states that influence team members to act in
a particular waya particular way
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The The TeamSTEPPSTeamSTEPPS FrameworkFramework
KnowledgeKnowledge–– Shared Mental ModelShared Mental Model
AttitudesAttitudes–– Mutual TrustMutual Trust–– Team OrientationTeam Orientation
PerformancePerformance–– AdaptabilityAdaptability–– AccuracyAccuracy–– ProductivityProductivity–– EfficiencyEfficiency–– SafetySafety
Baker D, Salas E, Battles J, King H, Barach P, 2005, 2007
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MillerMiller’’s Pyramids Pyramid
Does
Shows How
Knows How
Knows
76
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See Handout with LewisSee Handout with Lewis’’ StoryStory
QuickTime™ and a decompressor
are needed to see this picture.
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BreakBreak
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Small Group DiscussionSmall Group Discussion
A Pre-Analysis of the Lewis Blackman Story–
In small groups discuss the case
–
Discuss how you would approach the analysis (e.g., the types of tools you are familiar with in analyzing adverse events)
–
Prepare to report back
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DebriefingDebriefing
How are we thinking about safety now?
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Disclosure of Adverse Disclosure of Adverse Events: What Do You Do Events: What Do You Do
When Bad Things Happen?When Bad Things Happen?
Paul Paul BarachBarach, MD, MPH, MD, MPH
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Adverse Event Management PlanAdverse Event Management Plan
ActivationEvent Crisis Mgt Team
Containment Plan• Render care to pt• Staff Support• Contain risk of
harm/recurrence• Notification• Securing scene
Investigation & RCA
Communication Plan•Patient•External Audience•Internal Audience•Notify Billing to hold bills
Corrective Action & Prevention
RecoveryMonitoringRestitution
Disclosure/OrganizationalRecovery
Immediate Response Follow‐up Response
8383
Disclosure ProcessDisclosure Process
Identify incidence of patient harm or Identify incidence of patient harm or a potentially compensable event a potentially compensable event Initial disclosure and apologyInitial disclosure and apologyCase ReviewCase ReviewFollowFollow--up disclosureup disclosureDiscuss restitutionDiscuss restitution
8484
What do patients want?
1. To know what happened
2. To receive an apology
3. To know what is being done to prevent it from happening again
8585
Disclosing Adverse EventsDisclosing Adverse Events
Disclosure is required whenDisclosure is required when–– Has a perceptible effect on the patient not Has a perceptible effect on the patient not
discussed in advanced with patientdiscussed in advanced with patient–– Necessitates a change in patient careNecessitates a change in patient care–– Poses risk to patientPoses risk to patient’’s future healths future health–– Involves nonInvolves non--consented treatment or procedureconsented treatment or procedureReduces chances of being suedReduces chances of being suedTransparency in process helps the team address guiltTransparency in process helps the team address guiltNew laws in 22 states requiring disclosureNew laws in 22 states requiring disclosure
Cantor M, Barach P, et al. Jt Comm Qual Patient Saf 2005;31:5-12. Barach, P, Cantor M, 2007
8686
Disclosure Conversation PlanningDisclosure Conversation Planning
Review disclosure principlesReview disclosure principlesDecide who, when, whereDecide who, when, where–– Decide who will be point contact person for patient/familyDecide who will be point contact person for patient/family
What to say and how to say itWhat to say and how to say itAnticipate questionsAnticipate questionsPlanning next stepsPlanning next stepsDebriefing/emotional support for the individual(s) doing Debriefing/emotional support for the individual(s) doing the disclosingthe disclosing
8787
Disclosure ConversationDisclosure Conversation
Learn to effectively communicate and Learn to effectively communicate and explain the factsexplain the facts
Expression of concern/responsibilityExpression of concern/responsibility
Discuss present/future needsDiscuss present/future needs
Describe actions taken and explain specific Describe actions taken and explain specific process for finding the answersprocess for finding the answers
8888
Risk Management SupportRisk Management Support
Manage contact with patient and/or family Manage contact with patient and/or family
Coordinate regulatory/accreditation Coordinate regulatory/accreditation requirementsrequirements
Managing reputation risksManaging reputation risks–– Media/Crisis communication Media/Crisis communication –– Internal Internal and and externalexternal
Managing complaints and claims Managing complaints and claims –– Early Early non non litiginous settlementlitiginous settlement
8989
ResourcesResourcesCantor M, Cantor M, Barach Barach P, P, Derse Derse A, et al. JCAHO 2005;31:5A, et al. JCAHO 2005;31:5--13.13.Kramam Kramam SS, SS, Hamm Hamm G. G. Ann Ann Intern Intern Med Med 1999;131:9631999;131:963--967.967.Clinton Clinton H, H, Obama Obama B. NEJM 2006.B. NEJM 2006.Gallagher Gallagher T, et al. NEJM 2007.T, et al. NEJM 2007.http://http://www.sorryworks.netwww.sorryworks.netRisk Management Pearls on Disclosure of Adverse Risk Management Pearls on Disclosure of Adverse Events. American Society for Healthcare Risk Events. American Society for Healthcare Risk Management at Management at http://www.ashrm.orghttp://www.ashrm.org
9090
LunchLunchReconvene at 1 pmReconvene at 1 pm
9191
Data Data ““InsanityInsanity”” -- The Silent The Silent Improvement KillerImprovement Killer
Part IPart I
Davis Davis BalestracciBalestracci, MS, MS
9292
Group DiscussionGroup Discussion1.1. How does your organization react to, report, and How does your organization react to, report, and
analyze analyze ““incidents?incidents?””2.2. Have you ever considered Have you ever considered ““safetysafety”” in a processin a process--
oriented context?oriented context?3.3. Have you, with the best of intentions, been using Have you, with the best of intentions, been using
““special causespecial cause”” strategies? Could you strategies? Could you ““plot the dotsplot the dots”” to see whether you have been successful? to see whether you have been successful?
4.4. Does this material suggest situations in your Does this material suggest situations in your organizations that might respond better to organizations that might respond better to ““common common causecause”” strategies?strategies?
9393
DebriefingDebriefing
9494
Engaging Leaders Engaging Leaders -- From Turf Wars to From Turf Wars to Appreciative Appreciative Inquiry, Inquiry,
Principles of Leadership for Principles of Leadership for Quality and SafetyQuality and Safety
Gwen Sherwood, PhD, RN, FAAN Gwen Sherwood, PhD, RN, FAAN
95
Engaging Leaders: From Turf Wars to Appreciative Inquiry
Principles of Leadership for Quality and Safety
Harvard Safety Certificate Program 2009
Gwen Sherwood, PhD, RN, FAAN
96
Gwen Sherwood, PhD, RN, FAAN
Professor and Associate Dean for Academic Affairs
The University of North Carolina at Chapel Hill
School of Nursing
gwen.sherwood@unc.edu
97
Framing new roles and skills
Appreciative Inquiry to build culture
Reflection for transformation
98
Changing conversations, Changing minds, Changing culture
Creating transformation
99
Quality and safety have moral, ethical, and economic considerations that require examination of contextual factors: work force preparation,
culture, and transformative leaders.
100
Considering QualityHealth care is value based; quality is an essential value.
When quality erodes, joy in work diminishes, contributes to disengagement and departure.
Health professionals are willing to help improve systems when they have what is needed to make quality improvement a part of daily work
101
Working in systems with poor quality lowers satisfaction: American Association of Critical-
Care Nurses (AACN), CQ HealthBeat
Retention
Quality impacts the work force
102
Framing new roles and skills
Complexity of care means no one discipline can provide care, need to clarify and understand roles
Patients and families partnering in care
New RN graduates need different skills for emerging system redesigns
Longer and costly orientations
103
104
Nurses’ Role in Quality and SafetyQuality and Safety Education for Nurses (QSEN)
www.qsen.org (funded by RWJ)
National expert panel defined quality and safety competencies and knowledge, skills and attitudes required for nurses in health care organizations
Based on IOM competencies for all health professions education
Adopted by nursing education credentialing agencies
105
Cronenwett et al, Nursing Outlook, May-June 2007 (special topic issue)
Patient centered careTeamwork and collaborationEvidence base practiceQualitySafetyInformatics
Updates due in Nov. 2009
New views of familiar
concepts require curricula
transformation
106
Example: 2 definitionsQuality improvement: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems
Safety: Minimize risk of harm to patients and providers through both system effectiveness and individual performance
107
Selected: Quality Improvement KSAsKnowledge Skills Attitudes
Describe strategies for learning about the outcomes of care in the setting in which one is engaged in practice-----------------------------*Describe strategies for improving outcomes of care in the setting in which one is engaged in practice
**Explain common causes of variation in outcomes of care in the practice specialty
Seek information about outcomes of care for populations served in care setting------------------------------*Use a variety of sources of information to review outcomes of care and identify potential areas for improvement
**Assert leadership in shaping the dialogue and providing leadership for the introduction of best practices
Appreciate how unwanted variation affects care-----------------------------*Appreciate the importance of data that allows one to estimate the quality of local care
**Appreciate that all improvement is change but not all change is improvement
108
Selected: Safety KSAsKnowledge Skills Attitudes
Discuss effective strategies to reduce reliance on memory---------------------------*Evaluate effective strategies to reduce reliance on memory
**Describe best practices that promote patient and provider safety in the practice specialty
Participate appropriately in analyzing errors and designing system improvements-----------------------------*Design and implement microsystem
changes in response to identified hazards and errors
**Report errors and support members of the health care team to be forthcoming about errors and near misses
Value own role in preventing errors------------------------------
*Value own role in reporting and preventing errors
**Appreciate the importance of being a safety mentor and role model
**Value the use of organizational error reporting systems
109
Shaping organizational contextWork takes place in a given context which influences our responses.Culture is the behavior and beliefs/values of the groupCulture is built from the connection of consequences with behavior, what is valued and rewarded.Leaders create and manage the culture, and deconstruct when needed to change outcomes.
110
Positive approach to building culture, Appreciative Inquiry (AI)
Discovers and builds on what works in the organization, a system perspective consistent with quality and safety
Positive perspective change management to manage context to influence work that happens
Flexible process to engage people in building an organization and world they want to live in
Reflective, generative and life-enriching through collaborative, inclusive discovery into what gives “life”to the organization to vision the future
111
Magnet Hospitals for nursing excellenceDeveloped by identifying successful strategies at hospitals with no nursing vacancies to replicate at other hospitals:
positive work environments, nurse leadership, continuous quality improvementacademic and practice partnerships.
Higher satisfaction Lower staff vacancyImproved patient outcomes
112
Problem Solving:See organization as a problem to be solved
Appreciative Inquiry: View organization as a mystery to embrace
Felt need, problem identification
Appreciate and value the best of what is
Analysis of causes Envision what might be
Analysis of possible solutions
Dialogue what should be
Action planning, treatment Innovate what will be
Solution oriented Seeks transformation
113
Appreciative InquiryAppreciate: Value
Energizes by recognizing the best Affirming past or present strengths, successes, and potentials which give life to living systems
Inquire: QuestionQuestion are the first part of changeExplores new possibilities based on successful events
114
AI is a reflective process that allows participants to own their world by sharing what works.
Clarify what is desiredAsk for what is wantedListen to what is attainedRecycle to maintain goals
4 D Cycle of
115
The 4-D Cycle of AIDiscovery— “What gives life (for topic)?”appreciating and valuingDream—“What might be?” envisioningDesign— “How can it be?” co-creating the futureDestiny— “What will be?” learning, empowering, and improvising to sustain the future
116
Reflection: Critically consider one’s beliefs or knowledge in light of supporting evidence.Raise awareness about what one does to be able to make better choices in the future.Bridge actual and desired practice/actions.Monitors reactions to lead to intentional, conscious, deliberate actions.Learn from successful and unsuccessful events.
117
Reflective Leadership: journey of the self towards transformation
Begins with uncomfortable feeling about the way one does something or reacts.Critically reflect on the action.Discover meaning within what happened.Integrate into context as one changes perspective.Act from one’s internal compass of what is right.Emotional intelligence is building block of reflection.
118
Self-Reflection:In your usual day, do you spend more time with a focus on what is working or what is not working? Cite specific examples.
119
Discovery: Changing conversationsIdentify and appreciate the best of “what is”
Share stories of accomplishments and success, when people have experienced (the topic) at its best.
Create Meaning through sharing story.
What is the common mission or purpose that unites the group? How is this communicated and nurtured?
120
Dream: Changing mindsChallenge the status quo by envisioning potential results and bottom line contributions to the world
Through collective sharing, images of the future emerge out of grounded examples from the positive past
Give life to the organization through positive history (can be expressed in multiple ways such as story boards)
It is the opportunity to Dream Big!
121
Design: Changing cultureCreate ways to replicate themes in successful stories and events to expand potentialDevelop together a plan for a transformed approach (to the topic) with integration of quality and safety.
122
The conversations we have shape how we see the world, how we behave, and what we see as reality.
Inquiry is change. The first question we ask is fateful.
We create our reality by the stories we tell.
We act according to perceptions of our current reality AND what we anticipate/imagine will happen in the future; we move toward the reality we imagine.
Moving to Change: Creating Transformation
123
Creating our realityBuilding and sustaining momentum for change requires large amounts of positive affect . . . . Hope, excitement, inspiration, camaraderie, urgent purpose.Wholeness (inclusiveness) brings out the best in people and organizations.
To really create change, we must “be the change we want to see.”
124
There is a time and place for multiple ways of examining quality issues.
It depends on what you are trying to see, what you are trying to change, and how you want to shape the culture and context.
125
Opening to new ways of viewing context
Changing conversationsChanging mindsChanging cultureCreating transformation
126
Get Out of the Box to Build Quality and Safety
127
Additional ReferencesSherwood & Horton-Deutsch. (2008). Reflective practice: The route to nursing leadership. In Freshwater, D., Taylor, B., & Sherwood, G. International textbook of reflective practice in nursing. Oxford, England: Blackwell Publishing & Sigma Theta Tau Press. Pp. 157-176.
Hammond, S. (1998).The Thin Book of Appreciative Inquiry. Bend, OR: The Thin Book Publishing Co.
Bolman & Deal. (2004). Leading with Soul.
128128
Small Group ExerciseSmall Group ExerciseReflect on the time you have been in your current organization. Reflect on the time you have been in your current organization. What gives life to this organization? Why do you want to belong?What gives life to this organization? Why do you want to belong?Think for a moment about what you value deeplyThink for a moment about what you value deeplyWithout being humble, describe what you value most about your Without being humble, describe what you value most about your self, your work and your contribution to the organizationself, your work and your contribution to the organizationLocate a high point when you felt most effective and engaged in Locate a high point when you felt most effective and engaged in contributing to the life of the organizationcontributing to the life of the organizationDescribe how you felt and what makes this possibleDescribe how you felt and what makes this possibleHow does this contribute to a culture of safety?How does this contribute to a culture of safety?How do you individually add value to the safety culture of your How do you individually add value to the safety culture of your organization?organization?What are your three concrete wishes for insuring a culture of saWhat are your three concrete wishes for insuring a culture of safety fety in your organization?in your organization?What are the forces and factors that can make these best practicWhat are the forces and factors that can make these best practices es happen?happen?
129129
DebriefingDebriefing
130130
BreakBreak
131131
Data “Insanity”: The silent improvement
killer –
Part 2 Davis Balestracci, MS
132132
The Lewis Blackman The Lewis Blackman Story revisitedStory revisited
What have we learned today that would What have we learned today that would help us approach this event differently?help us approach this event differently?
133133
Facilitated DiscussionFacilitated Discussion
Real World Dilemmas in Quality and Safety
What are the day-to-day issues that members of the audience face?
134134
Improving Safety, Improving Safety, Implementing ChangeImplementing Change
Creating a Patient Safety PlanCreating a Patient Safety Plan
Paul Paul BarachBarach, MD, MPH, MD, MPH
135135
Patient Safety PlanPatient Safety Plan
Reliable Design
Teamwork / Human Factors
High Reliability Organization Culture/Leadership
2
PatientCenteredness
Knowledge Sharing
Identify Failures
Manage Failures
Adapted from Kaiser Permanente
136136
Getting StartedGetting Started
SelfSelf--assessmentassessment–– Alignment with organizational strategyAlignment with organizational strategy–– Program InfrastructureProgram Infrastructure–– Inventory of current patient safety activitiesInventory of current patient safety activities
Resource allocationResource allocationCapacityCapacity
–– ResultsResults
137137
Safety ProgramSafety Program
Linkage with Leadership/Organizational Linkage with Leadership/Organizational CultureCultureOversight responsibility/infrastructureOversight responsibility/infrastructureStakeholder EngagementStakeholder EngagementWork Plan DevelopmentWork Plan DevelopmentExecution Model(s)Execution Model(s)Monitoring/MeasurementMonitoring/MeasurementParticipation/accountabilityParticipation/accountabilitySpread/SustainabilitySpread/Sustainability
138138
Creating a Patient Safety WorkPlanCreating a Patient Safety WorkPlan
AIM: Safest HospitalAIM: Safest Hospital
Objective: Zero incidence of harmObjective: Zero incidence of harm
TacticsTactics–– Crew resource management (CRM)Crew resource management (CRM)–– SBARSBAR–– Rapid response teamsRapid response teams
Source: Institute for Healthcare Improvement at http://www.ihi.org
139
Transformed Hospitals Have Clear Definitions
What do you mean by great performance?Have you established a baseline?Are you improving?If not, why not?How can you improve even faster?Settling upon a consistent and intelligent method of assessing your output results
140140
ResourcesResources
Advanced Advanced Training Program, Training Program, Intermountain Intermountain HealthcareHealthcare, , Salt Lake Salt Lake City. City. http://intermountainhealthcare.org/xp/public/institute/courses/ahttp://intermountainhealthcare.org/xp/public/institute/courses/atp/tp/#objectives#objectives
Leadership Guide to Patient Safety from the Leadership Guide to Patient Safety from the Institute for Healthcare Improvement at Institute for Healthcare Improvement at http://www.ihi.orghttp://www.ihi.org
The University of Michigan Healthsystem Patient The University of Michigan Healthsystem Patient Safety Toolkit at Safety Toolkit at http://www.med.umich.edu/patientsafetytoolkit/http://www.med.umich.edu/patientsafetytoolkit/
141141
Concluding comments, Concluding comments, questions, and Post Test questions, and Post Test
logisticslogistics
142142
What do you think is on the horizon What do you think is on the horizon for patient safety in the next 5 for patient safety in the next 5
years?years?
143143
WhatWhat’’s on the Horizon for Patient s on the Horizon for Patient Safety?Safety?
The role of the built environmentThe role of the built environmentPatient centered processesPatient centered processesSmart automationSmart automationAdaptive informaticsAdaptive informaticsFocus on the team and simulationFocus on the team and simulationFull disclosureFull disclosureTelemedicine/remote careTelemedicine/remote care
144144
Patient Safety Domains Knowledge, Skills, Attitudes
1. Theoretical Foundations Microsystems, historical trends, chaos, complexity, competency and learning
2. Behavioral Aspects of Medical Professionalism
Ethics, patient quality of life, resolution of conflict
3. Interpersonal Issues Communication, stress and coping4. Human Factors and
ErgonomicsDesign history, error taxonomies, safety tools, decision support systems, fatigue factors, user centered design
5. Systems Analysis Usability criteria , organizations and learning disasters, place for human error
6. QI Learning Pareto/flow charts, and other QI tools, best practices, act cycles7. Injury Epidemiology Workplace hazards, worker safety, phases of injury, medico-legal
aspects8. Medication Safety Adverse and near-miss reporting, ISMP tools and website,
look/sound-alikes9. Crisis Management Tools Team work, shared decision making, situational awareness10. Simulations Micro-, macro-, debriefing, immersion levels, scripting, role playing
THE PATIENT SAFETY CURRICULUM
Gilula, M. and Barach P. Creating a Patient Safety Curriculum: Purposive Sampling of Patient Safety Experts. 79th Clinical and Scientific IARS Congress. S-143. Honolulu, Hawaii. March 12, 2005.; Gilula, Barach, 2007.
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Rules for Health Care Design in Rules for Health Care Design in the 21st Centurythe 21st Century
Current ApproachCurrent Approach–– Do no harm is an individual Do no harm is an individual
responsibilityresponsibility–– Information is a recordInformation is a record–– Secrecy is necessarySecrecy is necessary–– The system reacts to needsThe system reacts to needs–– Professional autonomy Professional autonomy
drives variabilitydrives variability
New ApproachNew Approach–– Safety is a system Safety is a system
propertyproperty–– Knowledge is shared Knowledge is shared
and information flows and information flows freelyfreely
–– Transparency is Transparency is necessarynecessary
–– Needs are anticipatedNeeds are anticipated–– Decision making is Decision making is
evidenceevidence--basedbased
IOM. Crossing the Quality Chasm. National Academy Press,
2001.
146
•
Do staff feel safe about reporting health care errors or care related injuries and deaths? If not, what are we doing to create a “culture of safety”
–
a “just culture”?
•
What happens when a heath care error occurs?
•
What serious care related adverse events have occurred during the past year?
•
What did we learn from these events? What did we do?
•
What systems related quality and patient safety improvements have occurred during the past year?
What You Should Ask About Quality and Patient Safety
147147
Barriers To Achieving UltraBarriers To Achieving Ultra--safe safe HealthcareHealthcare
Acceptance of limitations on maximum Acceptance of limitations on maximum performanceperformanceAbandonment of professional autonomyAbandonment of professional autonomyTransition from mindset of craftsman to Transition from mindset of craftsman to that of an equivalent actorthat of an equivalent actorDevelop a culture of safetyDevelop a culture of safetySimplify professional rules and regulationsSimplify professional rules and regulations
Amalberti R, Berwick D, Barach P. Annals of Internal Medicine 2005;142:756-764.
148
““There are known There are known knownsknowns. These are . These are things we know that we know. There things we know that we know. There are known unknowns. That is to say, are known unknowns. That is to say, these are things we know we donthese are things we know we don’’t know. t know. But there are also unknown unknowns. But there are also unknown unknowns. These are things we donThese are things we don’’t know we dont know we don’’t t know know ””
-- Donald Rumsfeld Oct 3, 2006
Getting Serious About Hospital Quality
149149
AdjournAdjourn