Measuring Whole System and Whole Person Harm

CarolHaraden,PhDVicePresident,IHI

Safety is system

property

2015: NPSF Expert Panel 15 Years Post To Err Is Human

“…the expectation at the time was that expanded data sharing and implementing interventions to solve specific concerns would result in substantial, permanent improvement. In the intervening decade and a half, it has become increasingly clear that safety issues are far more complex—and pervasive—than initially appreciated.”

A “Project”…

Source: J. Reinertsen, 2005

Improving Surgical Safety!June 6, 1944

Source: J. Reinertsen, 2005

What’s the Difference?

A Project Improving Surgical Outcomes!

Source: J. Reinertsen, 2005

The Differences Are…

Level of ambitionCommitment: hearts poundingCore strategy: staying aliveClear measure of daily success: stay alive and territoryClear overarching goal: win the war

This is still ONE battle only- not the

war!

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The Theatres of World War IIEuropean TheatreMediterranean, African and Middle Eastern Theatres Pacific Asian Theatres

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European Theatre Alone 10

WesternFront•InvasionofDenmarkandNorway (April–June1940)•BattleofFrance (withBenelux countries/FallGelb)(May–June1940)•BattleofBritain (+OperationSeaLion )(July–October1940)•WesternFront(1944–1945)

• BattleofNormandy (June–August1944)• NorthernFranceCampaign (July–September1944)• SouthernFranceCampaign(OperationDragoon)(August–September1944)• BattleoftheSiegfriedLine (RhinelandCampaign,Ardennes-AlsaceCampaign)(August–December1944)

•PhonyWar• CentralEuropeCampaign (March–May1945)

EasternFront•BattleofPoland (OperationFallWeiss)(1939)•EasternFront (initiallyOperationBarbarossa)(June1941toMay1945)•Finland (June1941-September1944)

Leading the Whole System to Highly Safe, Reliable and Effective Results is even BIGGER than this!

The Big Picture View (Management)

The Ground Level View (Staff)

James Reason

Safety as a battle we can fight and winOR

Safety as guerilla warfare

What’s the difference?

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Some differences:

Conventional-Larger, more unwieldy force with much central control-Prepared for certain amount of time-Often seen as invaders-Often in unfamiliar terrain-Clear cut victory is aim-Fight, win, negotiate

Non-Conventional-Small, highly mobile and motivated bands of people, decentralized -Prepared for the long struggle-Depends on support of locals-Know the terrain well-Clear cut victory is rare-Exhaust, force invader to withdraw

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How Will You Know If….

You are winning the battle and losing the war?

All of your projects to improve quality and safety are adding up to system safety?

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Start to Think About Moving Beyond Project Measures

Process MeasuresAMI Care

Time to stintBeta Blockers on arrival

Pneumonia CareAntibiotic timing

Immunization RatesInfluenza vaccination

Medication reconciliationCAUTI rates

Whole System Outcome Measures– Mortality rate– Adverse event rate– Days lost to work

Let’s Start With a Couple System Level Aims…

Reduce MortalityReduce Harm

What would the measures of these be for an office practice, the ED, ICU, Pediatrics? What would the projects need to be?

An Example: Reduce Mortality

Mortality Reduction Tier 1: Big Dot

Tier 2:Portfolio

Tier 3:Projects

Reducing Patient Mortality

What besides great projects needs to be in place to achieve this large system aim?

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NHSScotlandSurgicalMortality

Safety is a System PropertyIt can not be understood using a number of disparate metricsEven good individual reliabilities do not equal reliability of the whole

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Framework for Safe, Reliable and Effective Care

Transparency

Leadership

PsychologicalSafety

Negotiation

Teamwork&Communication

Accountability

ReliabilityImprovement

&

Measurement

ContinuousLearning

EngagementofPatients&Family

LearningSystem

Culture

©IHIandSafeandReliableHealthcare

© 2010 Pascal Metrics Inc.© 2010 Pascal Metrics Inc.

A Familiar Framework

1. Risk Factors2. Exercise3. Nutrition4. Health Literacy5. Etc

1. Cardiovascular2. Pulmonary3. Gastrointestinal4. Musculoskeletal5. Etc

Personal Habits Physical Exam

Transparency

Leadership

PsychologicalSafety

Negotiation

Teamwork&Communication

Accountability

ReliabilityImprovement

&

Measurement

ContinuousLearning

EngagementofPatients&Family

Framework for Safe, Reliable and Effective Care

Facilitatingandmentoringteamwork,improvement,

respectandpsychologicalsafety.

Creatinganenvironmentwherepeoplefeelcomfortableandhave

opportunitiestoraiseconcernsoraskquestions.

Beingheldtoactinasafeandrespectfulmannergiventhetrainingandsupporttodoso.

Developingasharedunderstanding,anticipationofneedsandproblems,agreedmethodstomanagetheseas

wellasconflictsituations

Gaininggenuineagreementonmattersofimportancetoteammembers,patientsandfamilies.

Regularlycollectingandlearningfromdefectsandsuccesses.

Improvingworkprocessesandpatientoutcomesusingstandardimprovementtools

includingmeasurementsovertime.

Applyingbestevidenceandminimizingnon-patientspecificvariationwiththegoaloffailure

freeoperationovertime.

Openlysharingdataandotherinformationconcerningsafe,respectfulandreliablecarewithstaffandpartners

andfamilies.

©IHIandSafeandReliableHealthcare

Framework for Safe, Reliable and Effective Care

LearningSystem

Culture

Psycho

logical

Safety

Accoun

tability

Team

workand

Commun

ication

Negotiatio

n

Leadership

ContinuousLearning

ImprovementandMeasurement

Reliability

Transparency

©IHIandSafeandReliableHealthcare

Enduring Issues That Can Not Be Managed by Project Thinking• Best outcomes and safe care for off-service patients• Collaboration between professions, care units, office practices, home care

and care homes• Professionalism

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Insert Don video clipP27

In Summary• We need to think about drivers of safety as a system • Think in metaphors, if it helps • A framework can help us on the journey - white paper• Think about large system aims and drive projects to reach them

AND enduring issues that can not be solved by singular projects • And don’t forget spread….that’s another talk!• All the very best and we are here to help.

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