July 11, 2013

How Boards Can Improve Quality and Reduce Harm: Questions are the Answer

Katherine J. Jones, PT, PhDUniversity of Nebraska Medical Center

e-mail: kjonesj@unmc.edu

Rural Nebraska Healthcare Network

• Agency for Healthcare Research and QualityCollaboration and Proactive Teamwork Used to Reduce Falls (CAPTURE Falls) Grant number R18HS021429 

• Nebraska Department of Health and Human Services Division of Public Health Medicare Rural Hospital Flexibility ProgramImplementing a Program of Patient Safety in Small Rural Hospitals Subgrant #17050‐Y3

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Funding Acknowledgement

http://unmc.edu/patient-safety/capture_falls.htm

Objectives1. Recognize the scope of the patient safety problem 

in US healthcare system

2. Use an established framework to guide your thinking about quality and safety issues

3. Describe the role of hospital boards of directors in improving quality and safety 

4. Identify a strategy to fulfill your responsibility to ensure the quality and safety of care (what questions should you ask and from whom you should hear the answers)

3

Obj. 1 Scope of the Problem

• From a 2010 analysis of a claims database– Medical errors cost the US at least $19.5 billion/year– 1.8% of hospital admissions experience a medical error (a preventable adverse outcome of medical care)

• From a random sample of 780 Medicare beneficiaries discharged Oct. 2008– 13.5% of hospitalized Medicare beneficiaries experience an adverse event (44% were preventable)

– 1.5% experienced an event that contributed to their deaths (projects to 15,000 total patients/month)

4http://www.soa.org/files/pdf/research-econ-measurement.pdfhttp://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf

• 50 of Nebraska’s 86 general community hospitals are members of Nebraska Coalition for Patient Safety (NCPS) http://www.nepatientsafety.org/ , a federally designated Patient Safety Organization (PSO)

• By state and federal statute, events reported to a PSO for purposes of quality improvement are legally protected

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Nebraska is not Different

40

19

7

11

25

0 10 20 30 40

Category E (temporary harm)

Category F (prolonged hospitalization)

Category G (permanent harm)

Category H (required intervention to…

Category I (contributed to death)

Harmful Events Reported to NCPS 2008 ‐ 6/2013

6

What do we know about causes?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Medication Use

Continuum of Care

Care Planning

Operative Care

Information Management

Physical Environment

Assessment

Communication

Leadership

Human Factors

Root Causes of Sentinel Events Reported to Joint Commission 2009 ‐ 2012

2012 (n=901) 2011 (n=1243) 2010 (n=802) 2009 (n=936)

http://www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_04_4Q2012.pdf

Human FactorsSide One of CardDescribe a human error that you have made. 

I ran a stop light. 

Why did it happen?I was preoccupied thinking about a work problem; there were no other cars stopped in front of me; light was hard to see at top of hill.

Side Two of CardDescribe a recent error made at a hospital.CNA had pt hang onto IV pole as she walked to bathroom; pt’s legs buckled and she fell. A walker and gait belt were in the room.

Why did it happen?CNA unaware of pt’s transfer limitations; had received no information from nurse; not empowered to ask for clarification; did not see walker & gait belt; did not ask pt how she usually walks.

7

8

Why Do Errors Occur—Some Obstacles

• Workload fluctuations

• Interruptions

• Fatigue

• Multi‐tasking

• Failure to follow up

• Poor handoffs

• Ineffective communication

• Not following protocol

• Excessive professional courtesy

• Halo effect

• Passenger syndrome

• Rigid Hierarchies

• Complacency

• High‐risk phase

• Strength of an idea

• Task fixation (lack of situational awareness)

How do we account for the fact that imperfect human beings are caring for others in complex systems?

9

To Err is Human

"The Korean culture has two features—respect for seniority and age, and quite an authoritarian style," said Thomas Kochan, a professor at the Sloan School of Management at the Massachusetts Institute of Technology. "You put those two together, and you may get more one-way communication—and not a lot of it upward.“ http://www.nbcnews.com/business/korean-culture-may-offer-clues-asiana-crash-6C10578732#

The use of theoretical frameworks advances our knowledge of 

organizational factors that are fundamental to successful 

implementation and sustainment of evidence‐based care.

Obj. 2: Framework

10

Eccles M, Grimshaw J, Walker A, et al. Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings. J Clin Epidemiol 2005;58:107–12.

What is Quality?

“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

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Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Donabedian’s FrameworkQuality is inferred by measuring elements of care• Structure–conditions under which care is provided (human resources, equipment, environment)

• Process–what was done (diagnosis, treatment, rehabilitation, prevention, patient education)

• Outcome–changes in individuals and populations that are due to health care

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Structure Process Outcomes

Donabedian, A. (1980). The definition of quality and approaches to its assessment. Ann Arbor, Michigan: Health Administration Press.

Element Advantage LimitationsOutcome “Ultimate validator” of quality • Determined by multiple factors

• Time to develop (survival)• Difficult to measure; adverse 

events may be relatively rare• Must know  processes that 

produce outcomesStructure • Equivalent to system design, 

capacity for work• Major determinant of 

average quality of care • Readily observable, easily 

documented, stable

Variations must be large to validly judge quality

Process • Most closely associated with outcomes

• Small variations in process easily related to variations in outcomes

• Must establish causal relationship between process and outcome

• Must understand complexity of process inputs

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Donabedian’s Framework

Structure of Fall Risk Reduction in Nebraska Hospitals

14%

86%

Non‐CAHs (46 – 689 Beds, n=14)

NobodyAn IndividualA Team

14

27%

25%

48%

CAHs (12 ‐ 25 Beds, n=56)

NobodyAn IndividualA Team

Who is Accountable for Implementing and Evaluating Your Fall Risk Reduction Program?

Jones, Venema, Nailon, Skinner, Kennel; in progress.

Mean Fall Rates in Nebraska Hospitals by Team Structure

8.5

3.5

5.8

1.4

5.3

1.2

2.9

0.10

1

2

3

4

5

6

7

8

9

All Falls Injurious Falls

Even

t Rate/10

00 patient days

Nobody (n=13) Individual (n=13)Team (n=34) CALNOC*(n=196; 07‐08)

p=.01

15

p=.09

*(Brown, 2010)

Jones, Venema, Nailon, Skinner, Kennel; in progress.

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Structure Determines Process

0%10%20%30%40%50%60%70%80%90%100%

Nobody (n=13) Individual (n=13) Team (n=34)

Jones, Venema, Nailon, Skinner, Kennel; in progress.

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Process Determines Outcomes 

6.8

2.2

4.8

1.0

Total Falls per 1000 Patient Days Injurious Falls per 1000 Patient Days

Sometimes/Rarely/Never Integrate Multidisciplinary Evidence (n = 32)

Always/Frequently Integrate Multidisciplinary Evidence (n = 27)

Does your fall risk reduction team integrate evidence from multiple disciplines to continually

improve fall risk reduction efforts?p=.030*

p=.006*

*Negative binomial model Jones, Venema, Nailon, Skinner, Kennel; in progress.

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Process Determines Outcomes 

6.5

2.1

4.7

0.9

Total Falls per 1000 Patient Days Injurious Falls per 1000 Patient Days

No, Team Does Not Reflect (n = 37) Yes, Team Reflects (n = 23)

Does your fall risk reduction team…1. Collect and analyze data regarding fall risk reduction program

outcomes?2. Modify fall risk reduction policies and procedures based on outcome

data?3. Conduct root cause analyses of injurious falls?

*Negative binomial model

p=.056*

p=.002*

Jones, Venema, Nailon, Skinner, Kennel; in progress.

Six Components of Quality

Equitable

Efficient

Timely

Patient‐Centered

Effective

Safe19

IOM (2001). Crossing the Quality Chasm: A New Health System for the 21st Century.

What is Patient Safety?• An attribute of a health care system that minimizes the incidence and impact of adverse events 

• A discipline in the healthcare professions that applies safety science methods with the goal of maximizing the safety and reliability of the delivery of health care 

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*Emanuel L, Berwick D, Conway J, Combes J, Hatlie M, Leape L, Reason J, Schyve P, Vincent C, Walton M. What exactly is patient safety? In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): Agency for Healthcare Research and Quality; 2008 Aug.

Ensuring quality and safety of care is a fiduciary 

responsibility of hospital governing boards.

Obj. 3: Role of Hospital Boards

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Governance Responsibilities

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Quality and Safety

Financial Management

Leadership Performance

Mission

Goeschel CA, Wachter RM, Pronovost PJ. Responsibility for quality improvement and patient safety: Hospital board and medical staff leadership challenges. Chest;138:171-178.

Balance Interests

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Medical Staff Hospital

Teamwork

Population Focus

Financial Margin

Autonomy

Individual Patient Focus

Efficiency

Goeschel CA, Wachter RM, Pronovost PJ. Responsibility for quality improvement and patient safety: Hospital board and medical staff leadership challenges.Chest;138:171-178.

Community

Culture of Safety

Awareness Accountability  

Ability    Action

Structure Process Outcome

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Obj. 4 Strategy to Ensure Quality

What is a Culture of Safety?

• LEARNED,1 shared, enduring beliefs and behaviors that reflect an organization’s willingness to learn from errors2

• Four beliefs present in a safe, informed culture3

– Our processes are designed to prevent failure– We are committed to detect and learn from error– We have a just culture that disciplines based on risk‐taking; not outcomes

– People who work in teams make fewer errors

2. Wiegmann. A synthesis of safety culture and safety climate research; 2002. http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf3. Institute of Medicine. Patient safety: Achieving a new standard of care. Washington, DC: The National Academies Press; 2004.

1. Schein, E. Organizational Culture and Leadership. 4th ed. San Francisco, CA: John Wiley & Sons; 2010.

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Four Components of Safety Culture

SENSEMAKING

TRUST

A culture of safety is informed. It never forgets to be afraid…

Reason, J. (1997). Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited.

Battles et al. (2006). Sensemaking of patient safety risks and hazards. HSR, 41(4 Pt 2), 1555-1575.

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27

Why is Culture Important?

Negativecorrelationbetween safety culture and patient safety incidents

J Patient Saf 2010;6: 226-232

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Why is Culture Important?

Positive correlationbetween safety culture and patient satisfaction

J Patient Saf 2012;8: 131‐139

• Do we monitor our culture of safety using the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture?

• Reporting: Do staff report errors and near misses?• Just: Do staff feel free to report? Do we discipline based on risk taking or outcomes? Do we balance individual and system accountability? 

• Teamwork: Do staff use teamwork skills as a safety net? Do staff feel psychologically safe to speak up to those with more authority? 

• Learning: How do we learn from (make sense of) our errors and near misses? Are we in the learning zone…staff feel psychologically safe and accountable? 29

Do we measure and improve culture?

RecklessBehavior

Conscious Disregard of Substantial and

Unjustifiable Risk

Manage through:

• Remedial action• Punitive action

At-RiskBehavior

A Choice: Risk Believed Insignificant or Justified

Manage through:

• Removing incentives for at-risk behaviors

• Creating incentives for healthy behaviors

• Increasing situational awareness

HumanError

Product of Our Current System Design and Behavioral Choices

Manage through changes in:

• Choices• Processes• Procedures• Training• Design• Environment

Console Coach PunishSource: Outcome Engenuity

How do we discipline?

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Do staff use team skills?

Shared Mental Models

ADAPTABILITYLEARNING

MUTUAL TRUST

TEAM ORIENTATION

TeamSTEPPSTeam Strategies and Toolsto Enhance Performance and Patient Safety

• Evidence‐based team training program

• Based on 30 years of research in military, aviation, nuclear power, industry

Agency for Healthcare Research and Quality. TeamSTEPPS. http://www.teamstepps.ahrq.gov

Team StructureClear roles, responsibilitiesCommon purposePerformance goalsMutual accountability

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TeamSTEPPS Tools and Strategies Address BarriersTOOLS and

STRATEGIESBrief

Huddle Debrief

Situational MonitoringSituational Awareness

STEPCross Monitoring

FeedbackAdvocacy and Assertion

Two-Challenge RuleCUS

DESC ScriptCollaboration

SBARCall-Out

Check-BackHandoff

OUTCOMES

Shared Mental Model

Adaptability

Team Orientation

Mutual Trust

Team Performance

Patient Safety!!

BARRIERS to Team Performance

• Inconsistency in Team Membership

• Lack of Time• Lack of Information Sharing• Hierarchy• Defensiveness• Conventional Thinking• Complacency• Varying Communication Styles• Conflict• Lack of Coordination and 

Follow‐Up with Co‐Workers• Distractions• Fatigue• Workload• Misinterpretation of Cues• Lack of Role Clarity

• Teamwork is a core competency of all health professionals—Institute of Medicine“People who work in teams make fewer errors.”

• Interpersonal skills and communication are core competencies of graduate medical education—Accreditation Council for Graduate Medical Education

• Improve the effectiveness of communication among caregivers— Joint Commission 2013 National Patient Safety Goal #2

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Team Training: Evidence‐based National Standard

http://www.jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_HAP.pdf

TeamSTEPPS in Nebraska

Annual training 2008 – 2013 Supported by Nebraska Department of Health and Human Services Rural Hospital Flexibility Program

Trained 2008 – 2012 • 8 nonCAHs…46 Master Trainers• 52 CAHs…266 Master TrainersNext training…Advancing TeamSTEPPS through Simulation Sept. 12 – 13, 2013

34http://www.unmc.edu/patient-safety/teamstepps_training.htm

EVERY 5% Increase in adoption of team behaviors…. • 11%     in communication openness• 15%      in teamwork within departments• 22%      in exchange of important patient information during shift change

• 24%      in perception that hospital mgt is interested in patient safety before adverse events occur

• 25%      in perception that serious mistakes don’t happen by chance

Evidence Supporting Team Training

Jones KJ, Skinner A. High R, Reiter-Palmon. A theory-driven longitudinal evaluation ofthe impact of team training on safety culture in 24 hospitals. BMJ Quality & Safety. 2013;22:394–404.

How do we learn from (make sense of) our errors?

Sensemaking:  active process of assigning meaning to ambiguousdata; only occurs through human reflection

Sensemaking Tools• Individual Root Causes 

Analysis• Aggregate Root Cause 

Analysis• Failure Mode and Effect 

Analysis• Safety Briefings• Leadership WalkRounds• Close the loop with 

reporters by providing feedback about actions taken based on events

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Battles et al. Sensemaking of patient safety risks and hazards. HSR. 2006; 41(4 Pt 2):1555-1575.

Sensemaking is a Conversation“The most fundamental level of data about patient safety is the lived experience of staff…”–Battles et al. HSR. 2006; 41(4 Pt2):1555‐1575.

• Sensemaking in RCAs must – Use data– Focus on the process of inquiry and the lived experience of staff (democratic and bottom up)

• Sensemaking in RCAs must NOT – Focus on consensus, closure, and re‐establishing organizational control

– Be bureaucratized and turned into a routine management chore

37Nicolini et al. Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the Gap. Soc Sci Med. 2011;73:217-225.

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Change in Culture is Measureable

Briefs, Huddles, DebriefsLeadership WalkRoundsSafety BriefingsRCA

Just Culture PracticesNOT Implemented

• Awareness—How often do we harm patients?– Benchmarking2

• Continuous internal and external comparison of performance• Used to prioritize quality improvement and delegate resources

– Know relevant benchmarks and your facility rates• Harmful medication errors/1000 doses dispensed• Injurious falls/1000 patient days • Pressure ulcers/1000 patient days• Healthcare acquired infections/1000 patient days

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The Four As of Leadership1

1. National Quality Forum (NQF). Safe practices for better healthcare--2010 update: A consensus report. Washington, DC: NQF; 2010.2. Brown DS, Donaldson N, Burnes Bolton L, Aydin CE. Nursing-sensitive benchmarks for hospitals to gauge high-reliability performance. J Healthc Qual. 2010;32:9-17.

• Awareness—How often do we harm patients?– Benchmarking Example 2011 Survey of Fall Risk Reduction Practices in Nebraska Hospitals 

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The Four As of Leadership

Hospital Type Total Falls/1000 pt days Injurious Falls/1000 pt days

Non‐CAH (n=13) 4.2 0.9 (inc. minor injury)

CAH (n=47) 6.3 1.8 (inc. minor injury)NDNQI med/surgunits (n=636)1 3.9

(72% no injury, 23% minor injury, 5% mod – major injury)

CALNOC (n=196)2 2.9 0.1 (exc. minor injury)

1. Lake ET, Shang J, Klaus S, Dunton NE. Patient falls: Association with hospital magnet status and nursing unit staffing. Res Nurs Health. 2010;33:413-425.

2. Brown DS, Donaldson N, Burnes Bolton L, Aydin CE. Nursing-sensitive benchmarks for hospitals to gauge high-reliability performance. J Healthc Qual. 2010;32:9-17.

Patient/ Family

Core Team

Coordinating Team

Administration

Board of Directors41

Multi‐Team System (MTS) Chain of Accountability

The board needs to hear about quality and safety from coordinating teams…Interprofessional teams that have direct knowledge of front line structure, process, and outcome.

Provides direct patient careProvides direct patient care

Manages the environment, resources, p/p used by Core Team; holds Core Team 

Accountable

Manages the environment, resources, p/p used by Core Team; holds Core Team 

Accountable

42

MTS Chain of Accountability: Fall Risk Reduction

AdministrationHolds Fall Risk Reduction Team accountable for implementation and evaluation of fall risk reduction program; provides resources (time, money, equipment, personnel)

Ancillary & SupportRadiology is informed of fall risk during handoffHousekeeping turns on alarmsLaundry ensures clean gait beltEnv. Services fixes equipment

Core TeamPhysician

Nursing performs fall risk assessment, implements interventionsPT consults re mobility

Pharmacist reviews medicationsAll educate patient & family

Patient & Family

Teach‐back if cognitively able  

Coordinating Team = Fall Risk Reduction Team

Accountable for implementation and evaluation of fall risk reduction program; holds core team accountable 

Contingency Team = Post Fall Huddle about 1 patient

Ask-Me-317

Fall Risk Reduction1. Why might I fall?2. What do I need to do?3. Why is it important for me

to do this?

Board 

• Ability—do staff have the knowledge, skills, and resources needed to improve quality and safety? – How do we invest in our most important resource—our staff? 

– Which skills are assessed for competency annually?

• Action—do we make small tests of change before large scale change? Can we sustain change?– Are job descriptions changed to reflect changes?– Are new skills integrated into performance appraisals?

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The Four As of Leadership

Psychological Safety & Accountability Support Learning

Psycho

logical Safety

High  Comfort Zone Learning Zone

Low

Apathy Zone Anxiety Zone

Low High

AccountabilityEdmondson, AC. Making it safe to team. In teaming: How organizations learn, innovate and compete in the knowledge economy. San Francisco: Jossey-Bass; 2012. p. 130

Teamwork Supports Psychological Safety & Accountability

Safety Culture Item (Component) CAH in Learning Zone

CAH in AnxietyZone

Psychological Safety (Communication Openness): Staff feel free to question decisions, actions of those with more authority

53% 27%

Psychological Safety (Nonpunitive Response to Error):  Staff may worry mistakes are kept in personnel file

53% 69%

Accountability: Existing history of team approach to fall risk reduction

Yes No (nobodyaccountable

Learning: Staff agree that after we make changes to improve patient safety we evaluate their effectiveness

70% 57%

Outcome: Injurious falls/1000 patient days 0.5 (1/4 avg)

13 (2x avg)

How do we account for the fact that imperfect human beings are caring for others in complex systems?

46

To Err is Human

Culture of Safety

Awareness Accountability  

Ability    Action

Structure Process Outcome

• Ask about the structures and processes that produce outcomes – Are structures and processes evidence‐based? – Is the process reliable?– Does the structure support the process? Does the process make full use of the structure? (CPOE Yikes!)

• Measure and understand your culture of safety• Use the Four As to guide questioning about patient safety topics

• Are you in the learning zone? (Staff feel psychologically safe to speak up and accountable)47

Summary

48

AHRQ Patient Safety and Medical Errorshttp://www.ahrq.gov/legacy/qual/patientsafetyix.htm

AHRQ Hospital Survey on Patient Safety Culturehttp://www.ahrq.gov/legacy/qual/patientsafetyculture/hospsurvindex.htm

AHRQ Patient Safety Network Patient Safety Primers http://psnet.ahrq.gov/primerHome.aspx

Institute for Healthcare Improvement http://www.ihi.org/Pages/default.aspx

UNMC Patient Safety Teamhttp://www.unmc.edu/patient‐safety/index.htm

Nebraska Coalition for Patient Safetyhttp://www.nepatientsafety.org/ 49

Resources

University of Nebraska Medical Center

University of Nebraska Medical Center

CAPTURECollaboration and Proactive Teamwork Used to Reduce

Fallshttp://unmc.edu/patient-safety/capture_falls.htm