Connecticut Hospital Association HRO Creating …...Creating Sustainability for High Reliability...

Friday, April 15, 2016

Connecticut Hospital Association HROCreating Sustainability for High Reliability Organizations

8:30 a.m. – 9:00 a.m. Registration and Continental Breakfast

9:00 a.m. – 10:30 a.m. Creating Sustainability for High Reliability Organizations

10:30 a.m. – 10:45 a.m. Program Break

10:45 a.m. – 12:00 p.m. Creating Sustainability for High Reliability Organizations (continued)

12:00 p.m. – 12:15 p.m. Program Wrap-up and Evaluations

Creating Sustainability for High Reliability Organizations held at

The Connecticut Hospital Association 110 Barnes Road Wallingford, CT

Friday, April 15, 2016 9:00 a.m. – 12:15 p.m.

Please circle the extent to which these objectives were met: POOR FAIR GOOD EXCELLENT N/A

1. Amount of useful information and ideas provided: 1 2 3 4

2. Learning Environment and Circumstances (e.g., room, AV, accessibility of the site):

1 2 3 4

3. Usefulness to my hospital of the information and ideas provided: 1 2 3 4

4. Chance that the information and ideas provided will improve my effectiveness and results:

1 2 3 4

POOR BELOW EXPECT-ATIONS

SATIS- FACTORY

GOOD EXCELLENT

5. This activity’s impact on improving your job performance: 1 2 3 4 5

6. Relevance of learning objectives to purpose/goals of activity The purpose of this continuing education activity is to provide healthcare professionals with concepts and tips to prevent High Reliability from becoming a “flavor of the month.”

1 2 3 4 5

7. Appropriateness of audiovisual and teaching aids: 1 2 3 4 5

8. The pace of the activity: 1 2 3 4 5

9. The conference room was conducive to learning and networking: 1 2 3 4 5

10. The program met my overall expectations: 1 2 3 4 5

11. The teaching effectiveness of the speaker: Steve Kreiser 1 2 3 4 5 12. The effectiveness of the teaching strategies: 1 2 3 4 5

I will use the information from today’s session to (please check all that apply): � Create/revise protocols, policies and/or procedures � Change the management and/or treatment of my patients � Other change(s) � I will not make any changes to my practice

Please describe what you plan to do:

Clinical discipline: MD_____________ RN________________ Other______________________________________ [Please indicate] Name (Optional): _____________________________________ Institution:_________________________________

Please turn over for additional evaluation questions.

Creating Sustainability for High Reliability Organizations Evaluation Form Continued

Please circle the extent to which these objectives were met:

POOR BELOW EXPECT-ATIONS

SATIS- FACTORY

GOOD EXCELLENT

Explain the importance of safety metrics and how measurements must be maintained and made visible across the organization.

1 2 3 4 5

Define transparency in terms of making harm visible throughout the organization through various mechanisms, including story-telling and sharing of lessons-learned.

1 2 3 4 5

Describe the importance of hard-wiring structured leadership methods to find and fix system problems and to reinforce and build accountability.

1 2 3 4 5

Explain the importance of physician engagement and ownership of patient safety culture.

1 2 3 4 5

Describe how enhanced cause analysis programs are critical to learning organization improvements.

1 2 3 4 5

What one thing about this activity would you most like to see improved?

What one thing about this activity did you like most?

Please give an example of how the content was relevant or thorough on this issue:

On what other topics would you like to see general CHA education?

Other Comments:

DISCLOSURE: The speaker and members of the Planning Committee have made full disclosures and do not have any commercial or financial interest which would bias the presentation.

PLEASE RETURN THIS FORM TO CHA REGISTRATION TABLE AT THE END OF THE SESSION.

Notes From HRO Creating Sustainability forHigh Reliability Organization

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Healthcare Performance Improvement, LLC Phone: 757.226.7479 Fax: 757.226.7478 www.hpiresults.com

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Connecticut Hospital Association Leadership Workshop

© 2014 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.

Building a High Reliability Organization: Sustaining Reliability and Safety Culture

Slide 2

Safety First in Every Meeting Demonstrate Safety First by starting each meeting with a two-minute (or less) statement or story about patient or personal safety: 1. Share your convictions on patient or personal safety 2. Explain how safety contributes to our mission 3. Explain how our policy & practice contribute to safety 4. Tell a story about something good that we did 5. Tell a story about something bad that happened to us 6. Tell a story about harm in another healthcare system 7. Tell a story about another system preventing harm 8. Read a Safety Success Story from your people 9. Read a Safety Success Story from CHA 10. Review our safety behaviors 11. Teach applications of our safety behaviors to our jobs 12. Discuss the importance of reporting problems 13. Discuss the importance of speaking-up for safety 14. Ask staff to be safe, and explain how 15. Thank staff for practicing / working safely


Page 2

Slide 3

"Good ideas are not adopted automatically. They must be driven into practice with courageous impatience. Once implemented they can be easily overturned or subverted through apathy or lack of follow-up, so a continuous effort is required."

Admiral Hyman G. Rickover 1900-1986

Slide 4

The “ATM” of Safety Culture Leadership

A – Attention Attention is the currency of leadership.

T – Transparency and Trust Transparency = learning. Trust is the

enabler of transparency.

M – Measure, Measure, Measure from Lee Carter, Chairman of the Board – Cincinnati Children’s Hospital Medical Center


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Slide 5

Sustainment through Measurement

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

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

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

Precursor Safety Events

Serious Safety Events

Near Miss Safety Event

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

A deviation from generally accepted performance standards (GAPS) that…


Page 4

Typical Improvement Curve

Actual increase due to complacency or reverting to old habits

Achieved in 1 to 3 years, approximately

Time

Sign

ifica

nt E

vent

Rat

e

Start of Culture Change

Apparent increase due to healthier event/problem reporting culture

80% reduction in serious preventable harm as a result of prevention activities

Long-term improvement through sustained prevention

Hospital X

Slide 8

Best Practice Tips in Safety Event Classification

Identify a consistent group of people to serve as a “Safety Event Review Panel” to provide expertise, consistency, and integrity in event classification. The group should be a mix of clinicians and methodology experts and senior enough to gain organizational trust.

When classifying an event, use the SEC algorithm and always ask ALL the questions – e.g. Was there a deviation? Did the deviation reach the patient? What was the level of harm?

Charge one person with the responsibility for thinking/asking about precedent.


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Slide 9

Best Practice Tips in Safety Event Classification

Keep a record of challenging event classification cases and classification rationale. This record provides a useful reference when assessing similar future cases and enables the group to look at changes in their own perspectives in event classification.

What happens in the discussions, stays in the discussions. The group speaks with one voice outside the meetings.

Slide 10


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Slide 11

Use SSER to Make Harm Visible …and more importantly, our efforts to eliminate it!

Slide 12

Present SSER Data Monthly to… Overall Board of Directors (high level view) Quality Committee of the Board (deeper dive) Executive Leadership Team Overall Leadership Team Quality and safety committee Patient Safety Coaches MEC (and any other standing medical staff committees) Physician champions


Page 7

Beyond SSER – The SSE+PSER

with permission of Holy Redeemer Health System

The SSE+PSER… Prevents complacency during long event-free stretches Heightens awareness of the wealth of learning opportunities from “lesser events”

At Holy Redeemer: The SSER and SSE+PSER is monitored at the Board and Senior Leader levels. The SSE to PSE ratio at this Holy Redeemer division is 1:16. (In a state of optimal reporting health, the ratio likely is 1:100 or more.)

SSE PSE

What It Tells Us How many people did we injury?

How many people received an error in care with minimal or no harm?

Message We Want To Send Reduce…and eliminate! Freely report and learn

Slide 14

Worker Safety Improvements (5 hospital system – Southern US)

$0

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

CY 07 CY 08 CY 09 CY 10

Workman's Compensation Costs

Over $1, 200,000 saved year to date!

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Month

Monthly Lost Time Claims July 06 - April 2011

802 Over 300 Serious Injuries prevented

90% reduction in OSHA IIR


Page 8

Measurement of Safety Culture

Sentara Safety Dashboard

Leading Indicator • Safety Culture Survey Scores Real Time Indicators • Safety Behavior Pulse Checks

• Leaders • Staff • Physicians

• Safety Success Stories Received & Communicated • Number of Events Reported Lagging Indicators • Serious Safety Event Rate (SSER) • # Serious Safety Events • # Precursor Safety Events • #/$ Professional Liability Claims & Suits • OSHA Employee IRR • #/$ Worker’s Comp Injuries


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Slide 17

Sustainment through Rigorous Reinforcement of

Safety Habits

Slide 18

Safety Success Stories Brief narrative about a person who

engaged in a safe practice and the outcome experienced as a result.

A challenge to leaders and staff to reflect and consider how their behaviors protect (or harm) their patients.

Not about measuring event totals, but the

ability of people to capture how actions (behaviors) affect patient outcomes.

Shared across the organization to recognize the individual and reinforce safe practices.


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What Makes a Great Story Great??? Everyday excellence – not just the great saves Language we can all understand Name names to recognize Link to a behavior expectation

More Clever: Use the number of published safety success stories as

a real-time metric.

Share Safety Success Stories

Nurse on 3 West Exercises a Questioning Attitude Jessica Tyler picked up a unit of blood from the Blood Bank for a sickle cell patient. Validating, she noticed that the unit of blood did not have a specific label that she was used to seeing on units of blood for sickle cell patients. Verifying, she asked the Blood Bank Technician about the missing label. The Technician looked at the patient profile, and realized that the patient indeed was a sickle cell patient and should receive irradiated blood. Great example of using a Questioning Attitude to catch an error that could have harmed one of our patients. Well done Jessica!

More Clever: All in it together – leaders take the quiz, too!

Quiz for Knowledge


Page 11

Safety Habit Audits

Safety Habit Survey – SBH

100 100 100 100 100100 100 100 100 100

0102030405060708090

100

Attention to Detail CommunicateClearly

QuestioningAttitude

Handoff Effectively Wingman

January 2010

February 2010

Percentage of Surveyed Staff Who Could Name the Safety Habits (BBEs)

2010 Goal = 60% surveyed will be able to name all 5 Safety Habits


Page 12


100 100 100 100 100100 100 100 100 100

0102030405060708090

100

Attention toDetail

CommunicateClearly

QuestioningAttitude

HandoffEffectively

Wingman

January 2010February 2010

Percentage of Surveyed Leadership Who Could Name the Safety Habits (BBEs)

2010 Goal = 60% surveyed will be able to name all 5 Safety Habits


70

55

20

10 10

60

0

7570

60

9086

7167 67

90

71

8681 81

0102030405060708090

100

STAR RB/RB CQ PhNC SBAR VV STOP 5Ps PCh Pco


STAR – Stop, Think, Act, Review SBAR – Situation, Background, Assessment, Recommendation/Request PCh – Peer Checking

RB/RB – Read Back, Repeat Back VV – Validate and Verify PCo – Peer Coaching

CQ – Clarifying Questions STOP - Stop

PhNC – Phonetic & Numeric Clarification 5Ps – Patient/Project, Plan, Purpose, Problems, Precautions

Percentage of Surveyed Staff Who Could Name the Error Prevention Tools

2010 Goal = 60% surveyed will be able to correctly tie 1 EPT to each Safety Habit


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70

50

30 30 30

70

0

90

70

60

70 70 70 70 70 70 70 70 70 70

0102030405060708090

100

STAR RB/RB CQ PhNC SBAR VV STOP 5Ps PCh Pco


Percentage of Surveyed Leadership Who Could Name the Error Prevention Tools

STAR – Stop, Think, Act, Review SBAR – Situation, Background, Assessment, Recommendation/Request PCh – Peer Checking

RB/RB – Read Back, Repeat Back VV – Validate and Verify PCo – Peer Coaching

CQ – Clarifying Questions STOP - Stop

PhNC – Phonetic & Numeric Clarification 5Ps – Patient/Project, Plan, Purpose, Problems, Precautions

2010 Goal = 60% surveyed will be able to correctly tie 1 EPT to each Safety Habit

Other Reinforcement Mechanisms Start unit-based Huddles with an Error Prevention Tool of the Week (the Sesame Street approach) Have a Safety Habit or Error Prevention Tool of the month - Highlight it in stories - Make it the focus on Rounding to Influence - Make it the focus of Safety Coaching

Integrate Safety Habits and Error Prevention Tools into simulation activities and skills fairs Ensure annual refresher training occurs - With commitment statements

Posters, screen savers, badges, pens, mousepads, etc. Leverage multi-media whenever possible (MedStar)


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Sustainment through Integration into HR

Performance Reviews and Hiring Criteria

Integration into Annual Performance Reviews


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Specific Expectations

HR Integration at Main Line

• Every employee has the goal to demonstrate mastery of EP tools by providing evidence of the use of 4 different tools as they apply to their scope of work. • The attached document was developed for staff to document their accomplishments to be submitted to their manager (some expect it quarterly). Or they can enter it directly into the electronic system for performance management.


Page 16

What is a behavioral interview? Behavioral-based interviewing involves discovering how the interviewee acted in specific employment-related situations. The logic stems from how you behaved in the past will predict how you will behave in the future (i.e. past performance predicts future performance.)

Critical to the sustainment of a safe and reliable culture is hiring new personnel who will fit into the culture we have created.

Managing Turnover

Peer

Person

r Leader Behavioral interviews have been found to be helpful in hiring personnel with the attitude and character we want.

During transformation, members select the culture To sustain culture, the culture must select its members

Individual Accountability - Hiring for Fit


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Sustainment through Transparency

Slide 34

The HRO Difference Harm is visible – Risk is visible


Page 18

Slide 35

Make Harm Visible

Slide 36

“Success teaches us nothing; only failure teaches...

Develop the capacity to learn from experience.”

Admiral Hyman G. Rickover, US Navy (27 January 1900 – 8 July 1986)

Known as the “Father of the Nuclear Navy”

"It is necessary for us to learn from others' mistakes. You will not live long

enough to make them all yourself.”


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Slide 37

Safety Event Communication A nurse received a telephone order from a physician for a medication. She was unfamiliar with the medication and called the pharmacy for assistance. The pharmacist gave instructions on how to calculate the dose. The nurse was concerned about preparing the medication herself but the patient needed the medication urgently so she calculated and administered the dose. The dose was incorrect and the patient required intervention from the rapid response team. Whenever you have concerns it is your responsibility to STOP, validate and verify. If you have attempted to verify, and still have questions or concerns, it is important that you seek out another expert to help you. DO NOT proceed until your concerns are resolved. Also, if you are doing an unfamiliar task or something you have not done in a long time, don’t be afraid to ask for a cross check. When doing complex tasks, two heads are better than one. Challenge Questions: Have you ever been asked to do an unfamiliar or new task? What did you do? Who are the experts you can consult if you need a cross check? If you need to verify?

• Written in simple language • Avoids naming or blaming

Reinforces organization’s error prevention tools and safety behaviors

Challenge questions enable staff to apply lessons learned to own environment

Share Lessons Learned

Slide 38

Held at each site – open to all “SBAR” presentation of Serious Safety Event RCA S – Brief description of event B – Sequence of events A – Inappropriate acts and root causes R – Corrective actions to prevent recurrence

Layman’s language Discussion about lessons learned - Link to Safety Behaviors - How could this happen in other places? - How can we apply lessons learned?

Clif Knight, MD – Chief Medical Officer Community Health Network

with permission of Community Health Network w

Lessons Learned Lunch Series


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Slide 39

BREAK

Slide 40

Sustainment through Physician Engagement


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Slide 41

HPI Lessons-Learned

“Physicians do not make safety transformation happen but they can prevent it from happening.”

More accurately stated:

“No hospital can achieve a state of high reliability without the full engagement of the

medical staff.

True physician leadership, optimally from the outset, is required to achieve and sustain a safe

environment for patients.”

Slide 42

Sharp End Provider to Blunt End Influencer

Proportion of time by: Residents? Attendings? Division chiefs? Department chairs? CMO?


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Slide 43

Vive la Difference

Sharp End Provider Know and comply with behavior expectations for error prevention – make them personal work habits Encourage the practice of behavior expectations for error prevention in others

Blunt End Leader Demonstrate in word and actions safety as a core value that cannot be compromised at any time Find and fix causes of system and process problems that challenge safe, high quality care Reinforce and build accountability for behavior expectations for error prevention

Slide 44

Critical Impact of Physicians on Safety Transformation

Significant contribution to errors associated with patient injury Unequaled impact on hospital morale through their considerable influence on hospital staff and leaders Strengths may become liabilities – intelligence, independence, analytical, sense of urgency Profound impact on long-term hospital culture – sustained improvements require physician ownership Ensure a strong Peer Review program is in place - To respond to both technical and behavioral issues - Integrate Safety Event Classification and Fair and Just criteria


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Slide 45

The Disruptive Path Attributes

Intelligence

Independence

Objectivity

Analytic Capability

Sense of Urgency

Influence

Liabilities

Elitest

Team averse

Impersonal

Critical

Impatient

Aggressive

Unreliability

Condescending

Abrasive

Belligerent

Blaming

Insensitivity

Sabotage

Derived from Overcoming Your Strengths, by Lois P. Frankel, PhD

Slide 46

The Success Path Attributes

Intelligence

Independence

Objectivity

Analytic Capability

Sense of Urgency

Influence

Strengths

Competence

Confidence

Thinking Critically

Problem Solving

Safety First

Team Building

Reliability

Preoccupation with failure Sensitivity to operations Reluctance to simplify Commitment to resilience Deference to expertise


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Slide 47

Medical Staff Stratification for Safety Culture Leadership

Where are our physicians and how can we engage them?

Characteristics Actions to Engage in Safety Culture Leadership

Level 3 Blunt End Leader for the Common Best

Influences changes in systems and processes to improve the sharp end condition in the interest of all providers and patients

Crystallize role of blunt end leaders Actively engage as leaders and as influencers of Level 1 and 2 physicians

Level 2 Blunt End Leader for My Own Good

Influences changes in systems and processes to improve the sharp end condition for their own benefit

Educate about blunt end role and expectations Develop strategies to:

-Move the willing and able to Level 3 -Moderate the unmovable -Manage disruptors

Level 1 Sharp End Provider

Functions primarily as a care provider, delivering care and service to patients or supports the delivery of care and service

Encourage accountability for individual and team behaviors for safe, productive practice


Slide 48

How Rigorously have you Engaged your Medical Staff?

Were physicians required to take the patient safety error prevention training as part of being credentialed? - Is it part of credentialing criteria for new members? - Are physicians required to take refresher training?

Did they attend patient safety training with staff? - If not, how did they get the training? - Did any physicians step up to become trainers?

Is patient safety, including SSER, discussed in medical staff meetings? - Do physicians start their meetings with safety first?

Are disruptive physicians dealt with fairly and consistently (or do we ride the fence?) Have you identified physician safety champions?


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Slide 49

Physician Safety Champions

Concept—select a respected, influential group of physician leaders to mold a high-reliability medical staff culture, beginning with patient safety

Not necessary to influence everyone to tilt the culture, only a segment equivalent to the square root of the number of participants—

Edwards Deming, Ph D

Slide 50

Physician Champions Additional initial education on concepts/ theory Potential roles: - Periodically attend daily huddle - Periodically round with operations colleague - Assist with education of other physicians - Meet periodically as a group of physician champions for additional skill

building and feedback - Serve as a resource to other committees and members of their own group - Participate in strategic safety/ reliability planning

Have high standards and promote professional atmospheres - Provide a safety and reliability perspective in medical staff meetings, medical

group meetings or informal gathering of colleagues - Share stories to reinforce importance of patient safety while also providing

relevant information


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Slide 51

Sustainment through Structured High Reliability

Leadership

Slide 52

Leadership Method (not micro-management)

“A well-led institution has predictable leadership…

you can conjecture what its managers are doing and what they

are likely to do next.”

Scott Snair West Point Leadership Lessons


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Slide 53

Define & Demonstrate Safety First at the “blunt end”

Reinforce & Build Accountability for behaviors at the “sharp end”

Find Problems & Fix Causes in systems and processes

Three Roles of HRO Leaders

Set the set point

Manage to prevent, detect, and manage drift


Slide 54 Slide 54

CHA High Reliability Leadership Methods

Build and Reinforce Accountability Leaders make reliability a reality by building a culture of collegial teamwork where sound practice habits are adopted by all to reduce human error. Leaders reinforce good habits, correct poor ones, never punish honest mistakes, yet are not afraid to hand out fair consequences to those who choose to adopt reckless behaviors. - Rounding to Influence with 5:1 Feedback - Fair and Just Accountability using the Performance Management Decision Guide - Safety Absolutes - Safety Coaches

Find and Fix System Causes Leaders remove barriers that impede team members from performing effectively and take active steps to find and fix the holes in the Swiss Cheese before they lead to patient or employee harm. - Daily Safety Check-in - Pre-Task and After-Action Huddles - Start the Clock on Safety Critical Issues - Leadership workgroups - Top 10 Lists with Action Plans - Unit Top 2 & Patient Communication Boards

Set the Tone of Safety as a Core Value Leaders show the way by setting expectations and setting good examples. Leaders model, inspire, train and encourage team members to keep themselves and others safe each and every day. - Safety First in Every Meeting - Thank those who Voice Safety Concerns - Safety First in Decisions – What’s best for the Patient? - Communicate Lessons from Safety Events - Encourage Error, Problem and Event Reporting - Educate for Safety Every Day


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Slide 55

Are you Starting Meetings with Safety? Demonstrate Safety First by starting each meeting with a two-minute (or less) statement or story about patient or personal safety: 1. Share your convictions on patient or personal safety 2. Explain how safety contributes to our mission 3. Explain how our policy & practice contribute to safety 4. Tell a story about something good that we did 5. Tell a story about something bad that happened to us 6. Tell a story about harm in another healthcare system 7. Tell a story about another system preventing harm 8. Read a Safety Success Story from your people 9. Read a Safety Success Story from CHA 10. Review our safety behaviors 11. Teach applications of our safety behaviors to our jobs 12. Discuss the importance of reporting problems 13. Discuss the importance of speaking-up for safety 14. Ask staff to be safe, and explain how 15. Thank staff for practicing / working safely

Slide 56


Do your Leaders Prepare to Participate?

Do Senior Leaders lead, or at least attend and engage, in the huddle?

Do you follow a set agenda?

Are leaders comfortable bringing up

their event reports?

Do you track items for follow-up?


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Slide 57

Do you Start the Clock on Safety-Critical Issues?

Start the Clock sense of urgency These are the clock ticker issues – issues that pose a significant threat. They may be local or global in nature.

Mobilize those with the expertise to solve the problem and authority to empower action using Condition-Problem-Cause solving

Priority for resolution should be stated (e.g. solved today, solved within 24 hrs); a single-point owner should be identified; the owner should have an action plan; and the issues should be tracked at Daily Check In.

Start the Clock Response to Safety Critical Issues at Community Health North

For these types of issues, Barb Summers at Community was known to request, “Page me by 3:00 pm today with a status report.” Her rationale was twofold – to demonstrate the sense of urgency and to be made aware of any barriers to resolution that may need to be addressed before close of business.

Slide 58

Do you have Unit-Based Safety Huddles?

Do they follow structured agendas?


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Slide 59

Do you have a Top 10 List?

A leadership tool for focusing efforts… • Shared awareness of issues • Prioritized by safety-critical and urgency • Focus attention and effort on solving problems and

problem causes to prevent recurrence • When a problem is resolved, a new problem is added –

always 10 on the Top 10

Problem Resolution Rate (PRR) = Problems Solved/Problems Identified

Slide 60

Do you have Standardized Action Planning?

1. Assign Executive Sponsor 2. Assign Problem Owner 3. Are goals as described on target? 4. Identify high-level actions (Level 1)

– Assign ONE Problem Owner for each Level 1 Action

5. Identify sub-level action steps (Level 2) – Assign ownership: Who might be best qualified to solve the problem(s)

identified? – What resources might this individual need?

6. Designate Due Dates for each action


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Slide 61

NOT about punishing the person

Building intrinsic motivation of the individual to meet performance

expectations

How do you Build Accountability?

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

Slide 62

Three Sources of Accountability

Leaders Vertical

Accountability

Peers Horizontal

Accountability

Individual Intrinsic

Accountability

Optimal Accountability

Accountab

I di id lid l



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Slide 63

Fr

Accountability: Where Are We Today?


L

I P

Free for All

L

I P

Leader Centric

L

I P

Team Survival Characteristics:

Significant blunt-end/sharp-end disconnect. Leader not aware of status of operations at the front line. Individual standards thrive. Workers work around each other, not with each other.

Characteristics: At worst, accountability is top-down driven and punitive; breeds fear. At best, L/I relationship reflects balanced feedback and trust. Yet condition is leader-dependent and, over time, exhausting for the Leader.

Characteristics: Leader is disconnected, yet high degree of teamwork and cross monitoring to get the work done. At best, good results can mask lack of leadership involvement. At worst, practice may differ sharply from – or, over time, deviate from – best-practice expectations.

Characteristics: Individuals “hired for fit” – high degree of motivation to do the right thing. High degree of teamwork and cross-monitoring, focused on best-practice standards. Leader provides real-time, 5:1 feedback; finds and fixes system problems. Strength in I and P accountability results in lesser relative L effort.

Optimal

P I

L

Slide 64

Fr

The Path to Optimal Accountability


L

I P

Free for All

L

I P

Leader Centric

L

I P

Team Survival

Optimal

P I

L

Team Building

P I

L

Standard Setting

P I

L


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Slide 65

Rounding to Influence

Connect to a core value

Assess knowledge and reinforce the specific behavior expectations

Identify problems impacting ability to follow the behavior expectations

Ask about commitment actions

♥

Slide 66

Have you Developed RTI Scripts? Rounding Focus: Attention to Detail 1. Core Value:

Have you been to our CHAMP safety training? When did you go? We’re rounding today to talk about those Safety Habits and tools because we want to ensure we are doing everything we can to keep our patients safe. (share some data or a story to get buy-in)

2. Can-do:

Can you tell me about the A in CHAMP? 1. Attention to Detail 2. Self check using STAR – Stop, Think, Act, Review 3. Helps to avoid skill-based errors when we are rushing, distracted,

interrupted, multi-tasking, fatigued 4. Like being at the candy machine, it helps us focus when in that auto-

pilot mode

3. Concerns: Is there anything that makes doing or thinking STAR difficult?

4. Commitment: Can I count on you to think STAR during your day? Use it when you’re getting a medication, tracing a line, doing the Timeout, loading a medication dispenser, doing 2-patient ID. There are so many times during the day when STAR can help avoid an error.


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Slide 67

Have you Set RTI Leader Expectations?

Senior Leaders – 2-4 times a month Directors – twice a week Managers – daily

How do you hold leaders accountable for these expectations? - Go from Huddle - Round in pairs - Log-in forms - One-on-one’s - Report out at leadership meetings

Slide 68

Do you Provide 5:1 Feedback?

Positive Feedback Encouraging someone to continue practicing an observed behavior Top Positive Reinforcements 1. Head nod 2. “Yes” 3. “Thank you”

Negative Feedback Discouraging someone from continuing to practice an observed behavior Top Negative Reinforcements 1. Furrowed brow 2. “No” 3. Offering a practice tip

Adapted from Bringing Out the Best in People, by Dr. Aubrey Daniels (1994)

5 positive bits of feedback for every 1 bit of negative feedback


Page 35

Slide 69

How Effectively Have you Implemented Fair and Just?

Train all your leaders on the effective use of the PMDG Ask managers if they applied the PMDG when responding to specific events

Assign HR as the process owner for PMDG implementation However, ensure all leaders understand Fair and Just is owned by Operations Ensure the PMDG is officially referenced in HR policies

Round-To-Influence on the importance of reporting and learning from errors and events

Emphasize the approach you are taking to Fair and Just “We don’t punish unintended human error, but there has to be fair consequences when people choose not to comply”

Do managers review the PMDG with staff whenever a performance deviation occurs, or only when they are seeking to show why they need

to “write up” the employee?

Slide 70

Performance Management Decision Guide Adapted from James Reason’s Decision Tree for Determining the Culpability of Unsafe Acts and

the Incident Decision Tree of the National Patient Safety Agency (United Kingdom National Health Service)

Did the individual intend the act?

Would individuals in the same profession and with comparable knowledge, skills, and experience act the same under similar circumstances?

Did the individual depart from policies,

procedures, protocols, or generally accepted

performance expectations?

Is there evidence of ill health or substance abuse?

Did the individual act with malicious intent

(i.e. to cause individual harm or other damage)?

Were there deficiencies in related training, experience,

or supervision?

Were the policies, procedures, protocols, or performance expectations available, understandable,

workable, and in routine use?

Did the individual have a known medical condition?

Were there significant mitigating circumstances?

Is there evidence that the individual chose to take an

unacceptable risk OR has a trend in poor performance or

decision making?

(Consult Human Resources) Disciplinary action Report to professional group or regulatory body Law enforcement referral

Identify Contributing System Factors

(Consult Human Resources) Disciplinary action Job-fit consideration


(Consult Human Resources) Console Coaching Mentor assignment Increased supervision Performance improvement plan Adjustment of duties


(Consult Human Resources) Occupational health referral Adjustment of duties Leave of absence

If substance abuse: Substance abuse testing Disciplinary action


Yes

Yes

Yes Yes

No No

Deliberate Act Test Incapacity Test Compliance Test Substitution Test

Yes

No

No

No

No No No

No

Console and/or Coach the

Individual AND Find & Fix Process

Problems

Start

Yes

Revision 3, April 2009 © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Yes

Yes

No

Yes

Medical Condition and/or Substance Abuse

Possible Reckless or Negligent Behavior

Possible Unintended Human Error

Possible System Induced Error

Malevolent or Willful Misconduct

Yes

D1

D2

I1

I2

C1

C3

C2

C4

S1

S2


Page 36

Slide 71

Safety Absolutes are NOT a discipline program

- Instead, they are a communication program for leaders

- “SO IMPORTANT, we do it each and every time”

- Should reduce “unintended” non-compliance

Should be used to encourage peers to speak up

- “That’s a Safety Absolute – we need to do it – I’ll help you”

Absolute: the highest priority for exact compliance

- Compliance must come before any other consideration, including revenue, speed or personal desire

There can still be unintended Safety Absolute violations or Safety Absolute errors driven by system problems

How Effectively have you Implemented Safety Absolutes?

Slide 72

Keys to Safety Coach Program Success

Executive Sponsorship (and expectations)

Engaged lead coach = engaged coaches

Effective Communication and agendas

Manager support - Get them to the monthly meetings! - Explain to your entire staff what they are all about - Reward and recognize them whenever possible - Meet with coaches monthly to discuss goods and

others

Recruit individuals who are well respected by their peers, good communicators and passionate about safety


Page 37

Slide 73

Do you Measure the Safety Coach Program?

Qualified Safety Coaches by unit Attendance at monthly meetings Number of observations made monthly Linked to senior leader incentives

Do senior leaders and physicians at your institution truly understand and support the Safety Coach program?

Do they come to the Safety Coach meetings periodically and talk to

the Coaches as part of the monthly agenda?

Do they thank them in public venues for what they are doing?

Slide 74

Sustainment through Best Practice Cause Analysis


Page 38

Slide 75

Best-Practice Cause Analysis Cause analysts trained in enhanced techniques Executive Sponsor & Operational Leader ownership Charter for event investigation 1:1 fact finding interviews Use of appropriate analytical cause tool - RCA, ECFC, ACA, CCA

Knowledge of failure mode taxonomies Transportability review Corrective Actions to Prevent Recurrence with single person accountability & operational ownership

Slide 76

Five Focus Areas for Cause Analysis Program Improvement

Enhance cause analysis methods and

capabilities

Refine cause analysis oversight

Implement robust lessons learned

program

Enhance safety event detection and

screening process

Integrate cause analysis concepts into

peer review

3

2

4

5 Enhance safety event detection and

screening process

1


Page 39

Slide 77

Do you have an RCA Advisory Group?

Purpose Provide oversight and operational ownership

of the cause analysis program and organizational learning from events

Typical Members

- Chief Operating Officer - Chief Nursing Officer - Vice President of Medical Affairs - Patient Safety Officer - Director of Quality - Director of Risk Management

Slide 78

Role & Responsibilities

Know what “good root cause” looks like Establish a sense of urgency for root cause identification and root cause correction Ask questions to drive effective cause analysis and to determine if effective cause analysis has been conducted Keep board and senior leadership informed Promote organizational learning – we are hostages of each other Measure and communicate performance Monitor for fair and just response


Page 40

Slide 79

RCA Advisory Group Metrics Report Safety Event Metrics 1. Event Counts

- # of safety events – SSE, PSE, NME

- # of JC sentinel events

- # of state reportable events

2. SSER

3. Days Since Last SSE - Point in time days since last

- Record run (longest days since last stretch)

4. Ratio of SSE to SSE+PSE (indicator of degree of harm)

5. # of SSE Discovered Through External Means

Cause Analysis Metrics 1. Total Events Reported 2. Cause Analysis Counts

- # RCA - # ACA

3. RCA Cycle Time (average days to complete an RCA)

4. CATPR Status & Effectiveness - # CATPR past due - % of actions still in place (of those

audited) 5. Organizational Learning

- Lessons Learned communicated - % Required Responses received

Slide 80

Do you Assign RCA Executive Sponsors? A senior leader who “owns” the quality of the overall RCA outcomes - to assure correct root

cause and corrective actions to prevent recurrence.

Responsibilities

Acts to stabilize the situation Charters the RCA Team Meets with RCA Team to discuss and agree on investigation scope and objectives Establishes priority and allocates resources Communicates investigation status Ultimately responsible for the root solution and implementation of corrective actions Addresses any issues team has with finalizing project Provides reports to hospital committees and other reporting groups

People Involved in the Event

RCA Team Sponsor

RCA Analyst Leader/Coordinator

Stakeholders & Subject Matter

Experts

RCA Analysts


Page 41

Slide 81

Do you Write Team Charters?

A clear, careful, and specific problem statement created by team sponsor for RCA Project Team members

Charter should indicate: - Members of the team - Subject experts to be involved - Leadership to be involved - Timeframe for project to be

completed - Expectations regarding updates

on project status - Other related issues from

previous events to incorporate into analysis

Root Cause Analysis Investigation

RCA Team Charter Date: [Insert date] To: [Insert name]

Root Cause Analysis Team Leader From: [Insert name]

Root Cause Analysis Executive Sponsor Subject: Root Cause Analysis Team Charter for

[insert title] Thank you for agreeing to lead an interdisciplinary team to investigate the event [insert description] on [insert date] on [insert location]. I am asking that you conduct a formal root cause analysis of the described incident. You and the Root Cause Analysis Team Members [insert names of Analyst Team] are:

expected to make this investigation one of the top three priority actions of the day relieved of all other duties until the investigation is complete.

In addition to your RCA team members, the members of the Root Cause Analysis Project Group should also include:

[Name, Title] (department representative) [Name, Title] (subject matter expert) [Name, Title] [Name, Title]

Please add other expertise to the project team if you find it necessary. In your root cause analysis investigation, I am requesting a complete assessment of what happened, how it happened, and why it happened. Your report should include root causes and contributing factors, especially any failed system barriers and/or management barriers. Your report should address any generic implications of this occurrence to all other high-risk areas. Let me know as soon as possible if you identify any issues that need to be quickly communicated outside the department, even if you have not yet completed your analysis. Please provide me with regular progress briefings. I would like a detailed examination of internal and external operating experience. (For example: What opportunities did we fail to make use of to prevent this event? What lessons-learned did we overlook?) In particular, since this case addresses the broader issue of [insert details as appropriate], I would like you to address any recommendations that are relevant from a system perspective. When your analysis is completed, I request that you provide a briefing to senior leadership. Please notify me of any emergent issues associated with the investigation. I would like a final report including an action plan within 30 days. I will be responsible for communicating with the leadership team and to all external agencies. You and the Root Cause Analysis Project Team will be responsible for updating the department(s) involved. This charter may be revised by our mutual agreement. [Insert names of analysts], thank you for agreeing to participate in this activity and helping us to identify processes that will result in improved patient outcomes.

Slide 82

Do you use the Three Meeting Model? Operations Owns – Quality Supports

SOE = Sequence of Events CATPR = Corrective Actions to Prevent Recurrence

Investigate occurrence to

determine SOE & proximate causes

Determine failure scenario including

individual and system causal factors for each inappropriate act

Establish root causes and

conceptualize CATPR

Meeting #1 (Facts)

• Review Charter • Confirm scope of event • Identify & coordinate

interviews & data gathering

Meeting #2 (Causes)

• Agree on facts & proximate causes

• Build consensus for possible root causes

RCA Sponsor, Stakeholders & Subject Matter Experts

RCA Analyst Team

• Stabilize situation

• Control evidence

Meeting #3 (Corrections)

• Consensus on root causes

• Finalize Corrective Action plan

RCA Team


Page 42

Slide 83

Do you use Events and Causal Factor Charting to get from Proximate to Root Cause?

A high fall risk patient was undergoing bedside physical therapy. The physical therapist was assisting the patient back to bed when a nurse stopped by to talk to the therapist about another patient. The PT and RN walked out of the room without turning

bed alarm back on. Ten minutes later, patient found on floor by tech with a fractured wrist.

Therapist walks out of

room with RN and does not

re-engage bed alarm

Was distracted by conversation

with RN

No visual reminder in room about bed alarm

No prompt on therapy record

to check for bed alarm

Organization did not create situational awareness

regarding fall precautions for ALL care team members

Individual Failure (her individual reason

for doing what she did)

System Failures (how the system

influenced her actions)

Root Cause

WHY?

WHY?

WHY?

PROXIMATE CAUSE (inappropriate action)

Slide 84

Do you Monitor for Action Plan Completion?

Close the

Loop

Create control loop through Executive Owner • Action item owners must report to the executive owner when the

action items are completed

Create database of required actions and issue periodic reports • Action item owners enter completion information directly into report

or action plan on shared drive; executive owner reviews for completion.

Review action plan completion at senior leadership, RCA Advisory Group or other safety oversight meetings Ensure periodic audits are conducted to monitor for effectiveness and sustainment of corrective actions


Page 43

Slide 85

Summary and Wrap Up

Slide 86

1. Safety is a core value and fundamental to our mission.

2. Harm happens on our watch, in our hospital.

3. Serious harm events are preventable and a continuous journey towards ZERO is the only acceptable goal.

4. We improve reliability and safety by the right mix of process, people and system design.

5. It will take everyone: Board, senior leaders, operational leaders, staff and physicians.

What Does It Take?


Page 44

Slide 87

What Do I Need to Do? Review SSER data quarterly and put a face on safety Propose Safety and Quality Aims “Aim High, Aim Wide, take Dead Aim”, for example:

“We will reduce Serious Safety Events by 80% across the entire institution in the next three years”

Develop and Approve Safety and Quality Improvement Plan to achieve Aim

Hospital Boards

Set the bar Challenge leaders Safety first in decisions

Slide 88

Deliver a safety message through electronic or other means (newsletter) to all associates Measure, teach, reinforce, role model and inspire staff to make safety a core value

- Start meetings with Safety Moments - Thank those who voice safety concerns - Put Safety First in decision making

Conduct a Daily Safety Huddle with Directors and/or Managers Conduct weekly Rounds to Influence

Ask about errors and great catches Ask about conditions that make staff most concerned they will make an error or mistake that could result in harm to a patient or employee? Ask staff to report errors and make a commitment to them to establish a fair and just culture

Conduct monthly RCA oversight meetings Receive update on latest SSER and days since last event Review outstanding RCAs (including action plans and status) Review progress on process indicators and action plan that support safety and quality transformation

Hospital Leaders

Set the tone Relentless Drumbeat Personal Involvement Put a Face on Safety

What Do I Need to Do?


Page 45

Slide 89

Step 1: Set Expectations Define concrete and prescriptive Safety

Behaviors & Error Prevention Tools proven to help reduce human error

Step 2: Educate & Train Educate and build skills in the use of the

Safety Behaviors and Error Prevention Tools Step 3: Reinforce & Build

Accountability Practice the Safety Behaviors and Tools

while making them personal work habits

Clinical and Non-clinical Staff

What Do I Need to Do?

Slide 90

1. Serve as good role models

Exhibit safe behaviors in everyday work 2. Provide 5:1 Feedback

Positively reinforce safe and reliable practices on the part of staff and colleagues Coach staff and colleagues real-time when you see the opportunity

3. Have high standards and promote professional atmospheres

Provide a safety and reliability perspective in medical staff meetings, medical group meetings or informal gathering of colleagues Share stories to reinforce importance of patient safety while also providing relevant information

4. Work with nurse leaders, administrative leaders and front line staff toward a common purpose

What Do I Need to Do? Physicians and Providers


Page 46

Slide 91

Healthcare Performance Improvement 5041 Corporate Woods Drive, Suite 180 | Virginia Beach, VA 23462

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

The HPI Team

Steve Kreiser Senior Consultant Cell: (757) 353-7833 • [email protected]

• Every employee has the goal to demonstrate mastery of EP tools by providing evidence of the use of 4 different tools as they apply to their scope of work.

• The attached document was developed for staff to document their accomplishments to be submitted to their manager (some expect it quarterly, others just want 4/yr). Or they can enter it directly into the electronic system for performance management.

• All of the Recruiters ask at least one Patient Safety question of all applicants: “Tell me about a time when you observed a situation where a patient could have been harmed. What did you do? What was the result?”

Error Prevention Tool Quarterly Report

Name Date Select the quarter of submission:

First Quarter Second Quarter Third Quarter Fourth Quarter 2013

A different example must be used for each quarter

Select the Error Prevention Tool and explain how you specifically used the tool:

Attention to detail – We focus our attention to always think before we act, especially in high risk situations. Self checking using STAR.

StopThink Act Review

Communicate Clearly – We’re responsible for professional, clear, and complete verbal and written communication.

3 way Repeat Back & Read Back Phonetic and Numeric Clarifications Clarifying Questions

Handoff Effectively – We provide effective handoffs of patient, tasks, and materials by taking the time to give appropriate information and ensuring understanding and ownership.

SituationBackground Assessment Recommendation

Speak up for Safety – We use good judgment at all times to ensure our actions are the best. We use an assertion and escalation technique to act on a responsibility to protect patients & co-workers in a manner of mutual respect.

Question & Confirm Use ARCC to escalate safety concerns

Ask a Question Make a Request Voice a Concern Use Chain of Command

Stop the Line

Got your Back! – We make reliability by building our own sound practice habits and in our co-workers. We’re accountable not just for our own actions by for our teammates’ as well.

Peer Checking Peer Coaching

Utilize the space below to explain how you utilized the error prevention tool….

Tips for Leaders• Redirect unrelated reports and conversation• Give clear direction about prioritization• For issues, identify a single Problem Owner and time

for resolution (“page me by 3:00 this afternoon if the equipment has not been fixed”)

Lines for Leadersto encourage high-reliability thinking• How do you know you had no problems?• What immediate actions did you take?• Is this happening in other places? Could this happen

in other places?• What other areas does this impact?• How are you preparing your team for that task?• What Safety Behavior error prevention technique

should be used?If any deficiencies that impact safe care:• That’s a Safety Critical Issue that requires Rapid

Response…

We huddle at the start of the day to maintain situational awareness of immediate problems impacting SAFETY & QUALITY of patient care at the front line.

We give direction about priority and responsibility for problem resolution.

Daily Check-InAn HPI Leadership Method for Performance Excellence

Daily Check-In Agenda1. LOOK BACK – Significant safety or quality

issues from the last 24 hours/last shift

2. LOOK AHEAD – Anticipated safety or quality issues in next 24 hours/next shift

3. Follow up on Start-the-Clock Safety Critical Issues

How We Do It• Include direct reports and others who know the status of operations in your areas of responsibility.• Establish a standing time. Schedule the time on your calendar and stick to it.• Keep it short – 10 to 15 minutes at the most – and hold it as a “stand-up” meeting.• Keep it focused. Follow a routine, 3-point agenda:

Prepare to ParticipateConsider yourself and ask others:• Do we have any high-risk patients or

procedures?• Do we anticipate any non-routine procedures or

tasks?• Are we dealing with any situations or conditions

that distract our ability to focus or think critically about our patients?

• Are there any safety issues that I know about that may impact other departments?

• Do we have what we need to deliver safe, quality care? Are there any deficiencies in information, equipment, supplies, or staff that will make it hard to deliver safe, high quality care?

• What conditions outside our unit or outside our hospital could impact our ability to deliver safe, quality care today?

If any of the above…What actions am I taking to have a safe day?If no issues…

We have what it takes toCreate a Safe Day

Mobilize to solve safety-critical issues or deficiencies:1. Identify the Problem Owner and experts2. State time to resolve with a “start-the-clock” sense

of urgency – how quickly can we close this hole in the Swiss cheese

3. Add issue to a “start-the-clock” follow-up list

Start-the-Clock Safety Critical Issues

Revision 0, December 2008© 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

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Connecticut Hospital Association HRO Creating …...Creating Sustainability for High Reliability...

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Transcript of Connecticut Hospital Association HRO Creating …...Creating Sustainability for High Reliability...