Dr. Stephen Muething - Can We Become High Reliability Healthcare Organisations?

download Dr. Stephen Muething - Can We Become High Reliability Healthcare Organisations?

of 54

Embed Size (px)

description

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?

  • 1. 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
  • 2. It Truly Is A JourneyThank you to CHA, the CEOs andthe Childrens Hospitalsfor sharing and learning together.
  • 3. 523 Bed Medical Center32,000 Admissions/Year1,000,000 outpatient visits$143 million externally funded research12,000+ employees31,000 Surgical Procedures (20% Inpt)17% average annual growth over past decadeNational /International partnerships
  • 4. Todays 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
  • 5. Reliability: more than Safety No needless deaths No needless pain No helplessness No unwanted waiting No waste Don Berwick, Institute for Healthcare ImprovementOur Safety Strategy: Eliminate all serious harm for patientsand employees by June 30th, 2015
  • 6. Pyramid of Harm (Patient and Employee)Strategy: SSEs &Focus on the top Lost-timeof the pyramid and Injuriesprogressively move down Serious Harm Index & OSHA Recordable Injuries Events of Minimal to Moderate Harm & All Employee Injuries Near-Miss Events Patient and Employee
  • 7. Reliable Key Processes Dozens across organization Standardization Sustainability built into the system Real-time failure awareness Data feedback to the microsystems Making the right thing, the easy thing
  • 8. Key Processes VAP Bundle CLA-BSI Bundle Pressure Ulcer Bundle Safe Medication Practices CA-UTI Bundle Etc, etc, etc..
  • 9. CONFIDENTIAL Real Time Failure AwarenessPatient Safety Sept. 9- Sept. 15 Employee Safety Sept 14 Sept 20Events of Harm ISSUE PAST FY 13 FY12CA-BSI WEEK YTD YTD9/10 A5N9/10 A5S Total OSHA Recordable cases: 4 48 599/11 B6HI - Lost-Time 1 7 2VAP - Blood Borne Pathogen Exposures 1 15 189/2 B6HI (disease progressedto classify this week effective - Slips, Trips, Falls 0 4 6date 9.2) - Patient Interaction 1 4 8SSI9/1 (upon review met criteria Late Incident Reports 2 28 N/Afor SSI) (These are incidents called in to 803- Until OUCH beyond the day of injury) 2/23/13
  • 10. Data Feedback To Microsystems
  • 11. Data Feedback To Microsystems
  • 12. Making The Right Thing, The Easy Thing
  • 13. No aviation fatalities No crashes No nuclear leaks No Serious Harm
  • 14. Characteristics of High Reliability Organizations1. Preoccupation with failure Regarding small, inconsequential errors as a symptom that something is wrong; finding the half-event2. Sensitivity to operations Paying attention to whats happening on the front-line3. Reluctance to simplify Encouraging diversity in experience, perspective, and opinion4. Commitment to resilience Developing capabilities to detect, contain, and bounce-back from events that do occur5. Deference to expertise Pushing decision making down and around to the person with the most related knowledge and expertise
  • 15. Senior Leadership Owns Safety
  • 16. Transparency
  • 17. Development of a High Reliability CultureLeadership Developing Mindfulness High functioning Aware of all harm microsystems EVERYDAY Executive reinforcement to Aware of all risk front line. CONTINUOUSLY Daily and shift huddles; Harm reduction owned by Organizational Daily Brief front line leaders Multiple improvements going Learning to find the cause on simultaneously Alignment of the strategic Just culture plan with the front line Managing by Prediction rather than Reaction
  • 18. Development of a High Reliability CultureError Prevention Behavior training Reinforce via Safety Coaches Reinforcement and accountability by supervisor (5:1 feedback) Situation Awareness Identify - Mitigate Escalate
  • 19. Pyramid of Harm(Patient and Employee) SSEs & Lost-time Injuries Serious Harm Index & OSHA Recordable Injuries Events of Minimal to Moderate Harm & All Employee Injuries Near-Miss Events Patient and Employee
  • 20. Employee Safety
  • 21. Top 3:Blood Borne Pathogen ExposurePatient InteractionSlips/Trips/Falls
  • 22. Structures & Techniques From HROS
  • 23. Pre-Briefs/Debriefs Checklists Flattening Hierarchy Standardizing Communication Huddle Situation Awareness
  • 24. James M. Anderson Center for Health Systems ExcellenceManaging By Prediction
  • 25. James M. Anderson Center for Health Systems Excellence Organization HuddleAdopted from the US Navy The Admirals Huddle on a Carrier Task Force Look Back Look Forward Identify and Solve Issues Every Morning @ 9AM
  • 26. James M. Anderson Center for Health Systems ExcellenceCincinnati Daily OperationsChildrens Brief Version 8:35 AM Department Huddles 8:00AM Unit-Clinic-Team Huddles 6:30-7:45AM
  • 27. James M. Anderson Center for Health Systems Excellence Three Topics What Happened in the Previous 24 Hours? Whats Predicted for the Next 24 Hours? Issues Which Need Resolution.
  • 28. James M. Anderson Center for Health Systems ExcellenceDepartments Reporting Out on Daily Operations BriefEmployee Safety RadiologyInpatient & ICUs Family RelationsSurgery (Liberty too) LaboratoryEmergency Department Infection Control(Liberty too) Supply ChainOutpatient Information SystemsPsychiatry (A4C2 too) Protective ServicesHome Health Care FacilitiesPharmacy OthersRespiratory
  • 29. James M. Anderson Center for Health Systems ExcellenceInpatient Huddles
  • 30. SITUATION AWARENESS
  • 31. Situation Awareness Model Family Bedside Microsystem Organization concerns Team Team TeamHigh risktherapies Intern