© Copyright, The Joint Commission The Joint Commission Center for Transforming Healthcare Safe...

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The Joint Commission Center for Transforming Healthcare

Safe Lifting ConferenceNovember 15, 2012

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Objectives

Understand the components of High Reliability.

Identify the influence of nursing and organizational culture on patient-handling practices.

Use safety culture and change management concepts to sustain success in safe-handling programs.

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No Offense but….

Why is the Joint Commission here to talk about Safe Lifting???????

Our Mission: Transform health care into a high reliability industry and to ensure patients receive the safest, highest quality care they expect and deserve

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Helping organizations improve healthcare and achieve high reliability

Donise Musheno, RN, MS, CPHQ

Center Project Lead, Black Belt

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Introduction to CTH-Vision

All people always experience the safest, highest quality, best-value health care across all settings.

One Vision

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Current State of Quality

We have focused intensely for more than a decade on improving quality and safety

Yet, quality problems still surround us

– Health care associated infections

– Medication errors that cause harm

– Failed communication in transitions of care

More than 400,000 harmful, preventable, bad outcomes occur in hospitals every year.

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Source: Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW. The "To Err is Human" report and the patient safety literature. Qual Saf Health Care. 2006;15:174-178.

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High Reliability Organizations

Chassin, M.R. & Loeb, J.M. (2011) The ongoing quality improvement journey: next stop, high reliability. Health Affairs, 30 (4) 559-568.

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Three Crucial Elements of High Reliability

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Robust Process Improvement™(RPI) – A New Way in Delivering ResultsUsual Approaches:

“One-size-fits-all” works well only in very limited circumstances:

•Process varies little from place to place•Causes of failure are few and common

New Generation of Best Practices:Complex processes require RPI to

produce solutions – customized to an organization’s most important causes

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Some Important Causes of Hand Hygiene Failures

1. Faulty data on performance

2. Inconvenient location of sinks or hand gel dispensers

3. Hands full

4. Ineffective education of caregivers

5. Lack of accountability

Each requires a very different strategy to eliminate

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Causes Differ by HospitalEach letter = one hospital

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Develop Solutions with Leading HospitalsAtlantic HealthBarnes-JewishBaylorCedars-SinaiCleveland ClinicExemplaFairviewFloyd Medical CenterFroedtertIntermountainJohns HopkinsKaiser-PermanenteMayo Clinic

Memorial HermannNebraska Medical CenterNY-Presbyterian North Shore-LIJNorthwesternOSF Partners HealthCareSharp HealthcareStanford HospitalTexas Health ResourcesTrinity HealthVirtuaWake Forest BaptistWentworth-Douglass

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Center Operating Model

Project Selection

Create Solutions, Pilot Test, Build Spread

Determine TopicSolve with Participating

Organizations

Pilot Test 1

Pilot Test 2: Integrate Solutions

into TST(Beta-Testing)

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Launch TST

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Confidential ● Easy to Use ● No Extra Cost

Separate from Accreditation• Educational, no jargon, no special

training and no knowledge of RPI methodology needed

• Guides users to customized solutions. Data analysis conducted by the tool, not the user. Tool walks user through process of: Measuring current state Determining root causes Selecting targeted solutions Control of process after

implementation

SPREADMECHANISM

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Introduction to CTH-Projects Project 1 – Hand Hygiene Compliance Project 2 – Wrong Site Surgery Project 3 – Hand Off Communication Project 4 – Surgical Site Infections

– With American College of Surgeons Project 5 – Preventing Avoidable Heart Failure Hospitalizations

– With American College of Physicians Project 6 – Safety Culture Project 7 – Preventing Falls with Injury Project 8 – Reducing Sepsis Mortality Project 9 – Medication Safety

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Memorial Hermann’s Story: Getting to Zero

Leadership commitment to zeroMH Woodlands Hospital was among the 8

Center hospitals that carried out the hand hygiene project and got impressive results

2010: MH committed to use TST to improve hand hygiene system-wide (12 hospitals)

Baseline (150 inpatient units) = 44%– Range (12 hospitals ): from 21% to 65%– Aim: to exceed 90%

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NICU Central Line Associated Blood Stream Infections (CLABSI)

CL

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Memorial Hermann Healthcare SystemNICU Central Line Associated Blood Stream Infections

Source file date: 7/14/2012Generated: 7/14/2012 9:43:21 AM Reporting Months

produced by System Quality and Patient Safety

UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

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UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

0

2

4

6

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10

12

14

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CL

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UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

0

2

4

6

8

10

12

14

16

18

20

CL

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UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

0

2

4

6

8

10

12

14

16

18

20

CL

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UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

0

2

4

6

8

10

12

14

16

18

20

CL

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UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

0

2

4

6

8

10

12

14

16

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CL

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UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

0

2

4

6

8

10

12

14

16

18

20

CL

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UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

0

2

4

6

8

10

12

14

16

18

20

CL

AB

SI

Ra

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UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

0

2

4

6

8

10

12

14

16

18

20

CL

AB

SI

Ra

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UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

0

2

4

6

8

10

12

14

16

18

20

CL

AB

SI

Ra

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UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

0

2

4

6

8

10

12

14

16

18

20

Mean = 1.85

Mean = 1.07

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Ventilator Associated Pneumonias (VAP)

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System Adult VAPDo No Harm

Ventilator Associated Pneumonia



UCL = 4.30

Mean = 2.19

LCL = 0.07

UCL = 3.12

Mean = 1.37

UCL = 2.47

Mean = 0.72

2006 2007 2008 2009 2010 2011 2012

0.00

2.00

4.00

6.00

Mean = 0.95

Mean = 0.5

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Woodlands: Zero Hospital Central Line Blood Stream Infections

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Improving Transitions

Hand-off communication failed to include adequate information 41% of the time

Interventions reduced this rate to 17%One hospital focused on the transition

from its inpatient units to a nursing home

Baseline Improve

Inadequate hand-offs 29% <1%

30-day readmissions 21% 10%

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Safety Culture and Safe Lifting

Coleen Smith, RN, MBA, CPHQ

Center Project Lead, Black Belt

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HealthCare

HighReliability

RPI

Leadership

Safety Culture

ReportImprove

Trust

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Why is culture important?

Lack of an optimal safety culture allows unsafe behaviors/conditions to be present, but not always identified or acted upon, before they cause harm [to patients].

“Culture is what people do when no one is looking.”

Herb Kelleher, Chairman

Southwest Airlines24

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What is the impact?The price of avoidable harm1:

– $17.1 billion in 2008 – On average, the cost per medical error was

$11,366.

The price of unsafe patient handling:– Direct and indirect costs associated with

only back injuries: Estimated to be $20 billion annually2

1Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1 Billion Problem: The Annual Cost of Measurable Medical Errors. Health Affairs 30 (4): 596-603, April 2011

2United States Dept. Of Labor Statisticshttp://www.osha.gov/SLTC/healthcarefacilities/safepatienthandling.html

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What is the impact?

In 2010, nursing aides, orderlies, and attendants had the highest rates of MSDs3:– 27,020 cases--which equates to an

incidence rate (IR) of 249 per 10,000 workers

– More than seven times the average for all industries.

3United States Dept. Of Labor Statisticshttp://www.osha.gov/SLTC/healthcarefacilities/safepatienthandling.html

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The myth:

For decades, we were persuaded that we could avoid back injuries simply by using “ergonomic” manual lifting techniques and performing abdominal strengthening exercises.

We now know better, but….

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The Safety Culture Project

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Project GoalsIncrease recognition

– And reporting, triage, action and communication

Increase the quality and effectiveness of the communication– What happened to our report?

Increase the effectiveness of the actions– Is this going to prevent a recurrence?

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“The adult human form is an awkward burden to lift or carry. [I]t has no handles, it is not rigid, and is susceptible to severe damage if mishandled or dropped.”1

1 Anonymous. The nurse’s load (editorial). Lancet 1965; II:422-3.

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How does culture relate to safe lifting?Acceptance and buy-in of the

technological and procedural Recognition of errors, close calls and

disregard of procedures– Barriers to use– Policy adherence– Learn from close calls

Change in focus to prevention – Errors will never be completely eliminated

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How Have Others Done It?

“High reliability organizations” manage very serious hazards extremely well

– Commercial aviation, nuclear powerWhat do they all have in common?

– Highly effective process improvement

– Fully functional safety cultureDiscover and fix unsafe conditions early“Collective mindfulness”

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Swiss Cheese theory of causation 33

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Success in Safe HandlingFollow solid, well-understood policies

Partial or optional buy-in will not lead to success

BUT—education and training are not enough

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Success in Safe Handling

Leaders establish a safety-oriented culture that supports caregivers to perform safe handling.– Peer safety leaders/Lift champions

Ability to report injuries/errors/near misses without fear of being blamed.– Learning Culture– Leadership then follows up and

communicates

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And don’t forget…

Change management techniques are crucial.

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Change Management Application for Safety: Yours and Others

Dawn Allbee

Director of Corporate Robust Process Improvement

Master Change Agent

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“Change is good.

You go first.” — Dilbert

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Robust Process Improvement (RPI)

Six SigmaLeanChange Management

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To Get Effective Results

Consider the solution and the human side of change:– How will people accept the change?

–What if they don’t?– How will people be accountable for the

change?–What if they aren’t?

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Change Management Challenges

Lack of team engagementLack of key stakeholder supportResistanceLack of buy-inHow do we sustain the gains?

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Why do we need to change?

Why is the change important?

Demonstrate the need to change

– What does the data show?

– Who or what is driving the initiative?

– What are the threats if we do nothing?

– What are the opportunities with success?

Create a sense of alignment

– Do we all see the same problem?

– Do we all share the same goals?

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Demonstrate the Need Six Sigma Performance

99.99966% Good (6 Sigma)

Unsafe drinking water for almost 15 minutes each day

52 incorrect site surgeries for every 5,000 surgeries

Two short or long landings at a major airport each day

10,000 wrong drug prescriptions per 1 million filled each year

Unsafe drinking water for one minute every seven months

1.7 incorrect site surgeries every 500,000 surgeries

One short or long landing every five years at a major airport

3.4 wrong prescriptions per 1 million filled each year

99% Good (3.8 Sigma)

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What will the future state look like? If you had a crystal ball and could go into the future,

what would you see?– What behaviors would we see more of?– What behaviors would we see less of?

Create a vision for the direction you want to move– A picture paints 1,000 words

Develop key words and phrases for the team to use when describing the vision– To motivate and energize

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Engaging Key Stakeholders

Identify key stakeholders and gauge their support

Utilize early adopters to build additional support

Identify resistance early and have a plan of action to address

– Where is resistance coming from?

– Why is there resistance?

– Understand stakeholder concerns and identify wins

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Identifying Resistance

What Resistance Do You Hear/See?

Know who your key stakeholders are

and what’s important to them!

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Sustain the GainsIf You Don’t Actively Make the Change Last, It Won’t

What will happen here if someone lets go?

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Keys to Sustaining the Gains

Energize your key stakeholders

Know where resistance may be hiding

Actively make change last

Align management practices with the change

Ensure continued leadership support

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Can we operationalize the change?It looks good on paper, but do we have

the structure in place to support the change?

– Right people and skill sets

– Right incentives

– Right message and medium to communicate

– Right technologies

– Right organization structure

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Leadership Commitment and Support Ever hear the phrase “Follow the Leader”?

– Leadership commitment and support is crucial to any change initiative

– Leadership support is maintained throughout the project

Leadership’s involvement in change initiatives– Shows importance of change– Helps others move through change initiatives– Helps reduce resistance

People focus their time, passion, and energy on things that are important to them

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Celebrate Success!The First Step in Sustaining the Gains

Remember where you started

Relive the journey

Capture the lessons learned along the way

Compare the “before” and “after”

Celebrate success!

Don’t be afraid to ask, “So now what…?”

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To Get Effective Results

Consider the solution and the human side of change:– How will people accept the change?

–What if they don’t?– How will people be accountable for the

change?–What if they aren’t?

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This is about...

Introducing a new concept focused on Personal Accountability

Discussing the concept and how it applies in your daily work

Focusing on what you can do (self-management)

Ownership, Solving Problems and Taking Action !!

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This is NOT ...

An interpersonal skill intervention!!

About banishing the words “Why?” “When?” and “Who?” from our vocabulary (its about knowing when to use them).

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Overview of QBQ concepts

QBQ Definition:

Personal Accountability is about each of us holding ourselves accountable for our own thinking and behaviors and the results they produce.

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QBQ Concepts

Lack of personal accountability results in:– an epidemic of blame– complaining– procrastination

No organization or individual can achieve goals, compete in the marketplace, fulfill a vision, or develop people and teams without personal accountability.

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QBQ – Question Behind the Question

Ask “what” or “how” not “why” or “when”Use the word “I”Include some action

Source: QBQ – The Question Behind the Question by John G. Miller

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QBQ Examples...

When is somebody going to train me? What can I do to develop myself?

When is that department going to do its job right? What can I do to better support my team and

organization?

Why do we have to go through all of this change? How can I adapt to the changing environment and

world so that I am successful?

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Call to Action

Learning is really about translating knowing what to do into doing what we know....its about changing so....

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Call to Action

What is the single most important idea for me in this session?

What will I start doing, stop doing or do differently to bring this idea to life?

What rewards will come from my efforts?

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