Dr. Stephen Muething - Can We Become High Reliability Healthcare Organisations?
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The Journey Towards Zero Harm A Report from One Journeyman Stephen E. Muething, MD Vice President for Patient Safety James M. Anderson Center October 23, 2012
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A presentation given by international keynote speaker Dr. Stephen Muething from Cincinnati Children's Hospital, USA at the CHA conference The Journey, in October 2012.
Transcript of Dr. Stephen Muething - Can We Become High Reliability Healthcare Organisations?
The Journey TowardsZero Harm
A Report from One Journeyman
Stephen E. Muething, MDVice President for Patient Safety
James M. Anderson Center
October 23, 2012
It Truly Is A Journey
Thank you to CHA, the CEO’s and the Children’s Hospital’sfor sharing and learning together.
523 Bed Medical Center32,000 Admissions/Year 1,000,000 outpatient visits$143 million externally funded research
12,000+ employees31,000 Surgical Procedures (20% Inpt)17% average annual growth over past decadeNational /International partnerships
Today’s Discussion Using Reliability as the Guidebook:
Process Reliability High Reliability Culture
Employee Safety HRO Techniques Learning Together to accelerate the journey Next Steps on the Journey
Reliability: more than Safety
No needless deaths No needless pain No helplessness No unwanted waiting No waste Don Berwick, Institute for Healthcare Improvement
Our Safety Strategy: Eliminate all serious harm for patients and employees by June 30th, 2015
SSE’s &Lost-timeInjuries
Serious Harm Index &OSHA Recordable Injuries
Events of Minimal to Moderate Harm & All Employee Injuries
Near-Miss EventsPatient and Employee
Pyramid of Harm(Patient and Employee)
Strategy:Focus on the topof the pyramid andprogressively move down
Reliable Key ProcessesDozens across organizationStandardizationSustainability built into the systemReal-time failure awarenessData feedback to the microsystemsMaking the right thing, the easy thing
Key Processes
VAP Bundle CLA-BSI Bundle Pressure Ulcer Bundle Safe Medication Practices CA-UTI Bundle Etc, etc, etc………..
Real Time Failure AwarenessPatient Safety Sept. 9- Sept. 15
Events of HarmCA-BSI9/10 A5N9/10 A5S9/11 B6HI
VAP9/2 B6HI (disease progressed to classify this week – effective date 9.2)
SSI9/1 (upon review – met criteria for SSI)
Employee Safety Sept 14 – Sept 20
ISSUE PAST WEEK
FY 13 YTD
FY12YTD
Total OSHA Recordable cases: 4 48 59
- Lost-Time 1 7 2
- Blood Borne Pathogen Exposures 1 15 18
- Slips, Trips, Falls 0 4 6
- Patient Interaction 1 4 8
Late Incident Reports(These are incidents called in to 803-OUCH beyond the day of injury)
2 28
N/AUntil
2/23/13
CONFIDENTIAL
Data Feedback To Microsystems
Data Feedback To Microsystems
Making The Right Thing, The Easy Thing
No aviation fatalities…
No crashes…
No nuclear leaks…
No Serious Harm
Characteristics of High Reliability Organizations
1. Preoccupation with failureRegarding small, inconsequential errors as a symptom that something is wrong; finding the half-event
2. Sensitivity to operationsPaying attention to what’s happening on the front-line
3. Reluctance to simplifyEncouraging diversity in experience, perspective, and opinion
4. Commitment to resilienceDeveloping capabilities to detect, contain, and bounce-back from events that do occur
5. Deference to expertisePushing decision making down and around to the person with the most related knowledge and expertise
Senior Leadership “Owns” Safety
Transparency
Development of a High Reliability Culture
Developing Mindfulness• Aware of all harm –
EVERYDAY• Aware of all risk –
CONTINUOUSLY• Harm reduction owned by
front line leaders• Learning to find the cause • Alignment of the strategic
plan with the front line
Leadership• High functioning
microsystems
• Executive reinforcement to front line.
• Daily and shift huddles; Organizational Daily Brief
• Multiple improvements going on simultaneously
• Just culture• Managing by Prediction rather
than Reaction
Development of a High Reliability Culture
Error Prevention• Behavior training• Reinforce via Safety Coaches• Reinforcement and accountability by supervisor
(5:1 feedback)• Situation Awareness
– Identify - Mitigate – Escalate
SSE’s &Lost-timeInjuries
Serious Harm Index &OSHA Recordable Injuries
Events of Minimal to Moderate Harm & All Employee Injuries
Near-Miss EventsPatient and Employee
Pyramid of Harm(Patient and Employee)
Employee Safety
Top 3:Blood Borne Pathogen ExposurePatient InteractionSlips/Trips/Falls
Structures & Techniques From HRO’S
• Pre-Briefs/Debriefs• Checklists• Flattening Hierarchy• Standardizing Communication• Huddle• Situation Awareness
James M. Anderson Center for Health Systems Excellence
Managing By Prediction
James M. Anderson Center for Health Systems Excellence
The Admirals’ Huddle on aCarrier Task Force• Look Back• Look Forward• Identify and Solve Issues
Every Morning @ 9AM
Organization HuddleAdopted from the US Navy
James M. Anderson Center for Health Systems Excellence
Daily Operations Brief8:35 AM
Department Huddles
8:00AM
Unit-Clinic-Team Huddles6:30-7:45AM
CincinnatiChildren’s
Version
James M. Anderson Center for Health Systems Excellence
• What Happened in the Previous 24 Hours?
• What’s Predicted for the Next 24 Hours?
• Issues Which Need Resolution.
Three Topics
James M. Anderson Center for Health Systems Excellence
Employee SafetyInpatient & ICUs Surgery (Liberty too)Emergency Department (Liberty too)OutpatientPsychiatry (A4C2 too)Home Health CarePharmacyRespiratory
Departments Reporting Out on Daily Operations Brief
RadiologyFamily RelationsLaboratoryInfection ControlSupply ChainInformation SystemsProtective ServicesFacilitiesOthers
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Inpatient Huddles
SITUATION AWARENESS
Bedside nurse
InternWatch Stander
Senior Resident
Watch StanderPCF/Manager
Safety Team(MPS and SOD)
at 800, 1600 & 100
Family concerns
High risk therapies
Watcher
PEWS>5
Communication concern
RapidResponse
Reliable escalation of riskRapid assessment and communication with primary team
Attending
Bedside Team
Microsystem Team
OrganizationTeam
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Situation Awareness Model
Situation Awareness project go-live
Learning Together
Start With One State
Develop Ohio NetworkInitial HAC improvement work
SSE reduction; efforts to address organizational culture
Creation of pediatric patient harm index
Create National Children’s NetworkExpand network to include 26 leading children’s hospitals outside Ohio (Phase I)
Active improvement work on 10 HACs
Efforts to address organizational culture
“All Teach, All Learn”
Develop mentor hospitals
Spread Share network best practices with all (2012)
Disseminate at national meetings (2012)
Develop strategies with national organizations
(2012)
Add 50 hospitals (Phase II) to data sharing and network learning opportunities (2013)
Establish other regional collaboratives (2013)
Expanding Scope to Eliminate Harm Across US Children’s Hospitals
(2008-2011)
(2012)
(2012)
8 33 83
National Children’s Network Phase I Hospitals: 33
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Adopting Common Behaviors
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Thank you
Questions?
[email protected]/andersoncenter
Human Factors
SEIPS Model
Pascale Carayon et al.
