high reliability & healthcare...high reliability & healthcare 7/23/2018 ~ the j 1oint...

H1ealth and Humarn Serv1ices

Texas D1epartment of Stat1e Health1 Servims

High Reliability & Healthcare

7/23/2018

~ The J1oint Commiss.i1on

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p ~ tint Commis~ion Center for Tran . fo·1•m1ng .. ealthcare

~ int Commission Center for Transforming Healthcare

Four Entities – One Vision

All people always experience the SAFEST, HIGHEST QUALITY, BEST-VALUE

health care across all settings.

© 2018, Joint Commission Center for Transforming Healthcare

2

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and Health Care

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Unique Scope Of Operations Comprehensive Accreditation / Certification Services

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IE'I ACCREDITATION C'~ & REGULATORY

CONSULTING SERVICES

I -~ PERFORMANCE IC... IMPROVEMENT

CONSULTING SERVICES


Unique Scope Of Operations Comprehensive Support Services

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4


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Safety Culture

Robust Process

Improvement® ·

• • • • • • • • • • • • • • • • • • • •

: · · · · · · · · · · · · · · �> HIGH RELIABILITY <� · · · · · · · · · · · · · · :

Unique Approach To Zero A Healthcare Framework For High Reliability


5

High Reliability & Health Care

7/23/2018



Objectives

⎻ Discuss the principles of high reliability organizations and what makes health care different

⎻ Describe the High Reliability Health Care Maturity model and its specific application

⎻ Discuss the importance of performance improvement capacity in healthcare and identify the robust tool set that provides the most benefit.

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~ int Commission Center for Transforming Healthcare Evolution of Healthcare


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Current State of Quality

⎻Routine safety processes fail routinely • Hand hygiene • Medication administration • Patient identification • Communication in transitions of care

⎻Uncommon, preventable AEs • Wrong surgery, retained foreign objects • Fires in ORs • Infant abductions, inpatient suicides

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Current State - Improvement

⎻We have made some progress • Project to project work “project fatigue” • Satisfied with modest improvement

⎻Current approach is not good enough • Improvement difficult to sustain/spread • Getting to zero harm, staying there is very rare

High Reliability offers a different approach


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I I • I I l JI 'i

Five Principles of High Reliability Organizations

Anticipation – “Stay Out of Trouble” 1. Preoccupation with failure2. Reluctance to simplify3. Sensitivity to operations

Containment – “Get Out of Trouble” 4. Commitment to resilience5. Deference to expertise

Mindful Organizing © 2018, Joint Commission Center for Transforming Healthcare

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High Reliability Organizations’ Secret Sauce• Nearly error-free performance is a function of

mindful-organizing • Set of behavioral and cognitive processes • Workers discern latent and manifest threats • Actions are swiftly taken to resolve threats

• Mindful organizing results in: • Lower error rates • More reliable service performance • Lower turnover

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Milbank Q 2013;91(3):459-90 14



High reliability in healthcare is “maintaining consistently high levels of safety and quality over time and across all health care

services and settings” Chassin & Loeb (2013)

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HIGH RELIABILITY MODEL FOR HEALTHCARE

Leadership Safety Culture

Robust Process

Improvement®

Empowering Systematic, data-Commitment staff to driven approach to zero harm speak up to complex

problem solving

Chassin MR, Loeb JM. High-Reliability Health Care: Getting There from Here. Milb Q 2013;91(3):459-90


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AREAS OF PERFORMANCE

Robu

st P

roce

ss Im

prov

emen

t

Methods

Training

Spread

Board

Lead

ersh

ip Trust

Safe

ty C

ultu

reCEO Accountability

Physicians Identify Unsafe

Conditions Quality Strategy

Strengthening Systems Quality

Measures Assessment

Safe Adoption of I.T.

Stages of Maturity: Beginning Developing Advancing Approaching


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Leadership Elements Le

ader

ship

Board

CEO

Physicians

Quality Strategy

Quality Measures

Safe Adoption of I.T.

Commitment to High Reliability

Aims for the goal of zero harm

Routinely champion PI initiatives

Elevated to highest strategic goal

Data transparency

Coordinated and integrated adoption


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Engaging Leadership

• High Reliability efforts unlikely to makeheadway without board engagement andaligned and supportive senior leadership

• Make the case for high reliability•Not “another project”

• Enlist support from key leaders• Illustrate the business case


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~ int Commission Center for Transforming Healthcare Physician Engagement

⎻Crucial to project and program success

⎻Sponsor & Champion Roles

⎻Provide training


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Quality Strategy & Measurement

⎻What is the organization’s approach to measuring quality and safety? • Measurement goes beyond regulatory

requirements

−Transparency of Information• Who can access & how?

−Align incentive systems based on results


21

~ int Commission Center for Transforming Healthcare Safe Adoption of IT

−Support from IT for quality/safety improvementprograms

−IT solutions are integral to sustained improvement−Commitment to safety


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Business Case for Quality

⎻ Opportunity – system failures to drive quality strategy ⎻ Reducing defects in care benefits all ⎻ Organizational Interests • Patient – trusting relationships • Caregiver – engagement • Reputation • Margin for mission

−Variation/Waste/Defect ROI −Diffusion ROI

Swensen, S et al. The Business Case for Health-Care Quality Improvement. J Patient Saf 2013; 9(1): 44-52. © 2018, Joint Commission Center for Transforming Healthcare

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Safety Culture Elements Sa

fety

Cul

ture

Trust

Accountability

Assessment

Identify Unsafe Conditions

Eliminate Hierarchy & Intimidation issues

Balance learning with accountability

Further upstream from harm

I.D. and repair weaknesses proactively

Formal and routine measurement

Strengthening Systems


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High Reliability Organizations’ Secret Sauce

• Nearly error-free performance is a function of mindful-organizing • Set of behavioral and cognitive process • Workers discern latent and manifest threats • Actions are swiftly taken to resolve threats

• Mindful organizing results in: • Lower error rates • More reliable service performance • Lower turnover


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26© 2018, Joint Commission Center for Transforming Healthcare

Drive out fear and create trust

- W. Edward Deming



Evolution of Safety Culture

• Today, we mostly react to adverse events • Unsafe conditions are further upstream from

harm than close calls • Close calls are “free lessons” that can lead to

risk reduction—if they are recognized, reported and acted upon • Ultimately, proactive, routine assessment of

safety systems to identify and repair weaknesses gets closer to high reliability

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Safety Culture Challenges

• Aim is not a “blame-free” culture • A true safety culture balances learning

with accountability • Must separate blameless errors (for

learning) from blameworthy ones (for discipline, equitably applied) • Assess errors and patterns uniformly • Eliminate intimidating behaviors


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Culture of Low Expectations −Expectation of failure instead of

preoccupation • Coding is inaccurate • Equipment can’t be found or is broken • Work arounds are necessary

−Simplification results from time pressures −High tolerance for hazard −Variation makes resilience difficult, as does

lack of transparency −Hierarchy issues persist

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PHONE IS

TEMPORARILY OUT

OF SERVICE

Identifying Unsafe Conditions ⎻Unsafe Condition: a

situation that could lead to an adverse event ⎻Unsafe conditions are

frequently not noticed or considered “annoyances”: • Nuisance alarms, missing

equipment, broken equipment


30

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Identifying Unsafe Conditions

Reason J. Human error: models and management. BMJ. 2000;320:768–70.. © 2018, Joint Commission Center for Transforming Healthcare

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Strengthening Systems

−What efforts are in place to recognize patterns of causal factors across the organization?

−Efforts to catalog and prioritize system weaknesses--proactively

• Responding to events that have already happened

Reactive

• Active identification of unsafe conditions through analysis of processes

Proactive • Ability to accurately

foresee potential problems based on system analysis

Predictive


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~int Commission Center for Transforming Healthcare


The most detrimental error is failure to learn from an error.

~James Reason

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Tactics for Assessing Culture

Assessment: • Frequency and distribution important

• Results used to plan efforts to improve

• Metrics around improvement efforts reported to senior leadership; systematic improvement initiatives are in place

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BUILDING POSITIVE RELATIONSHIPS ANO BETTER ORGANIZATIONS

EDGAR H. SCHEIN

HUMBLE INQUIRY

Using Assessment Results

⎻ Leadership mistake: • Asking what staff think (i.e. via

survey) and then deciding what they said.

⎻ Appreciative inquiry to understand by asking ‘why they said what they said’.

⎻ Culture is local—actions need to be as well


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TRUST

REPORT IMPROVE

Adapted from Reason J and Hobbs A. Managing Maintenance Error: A Practical Guide. Ashgate. 2003.


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Sentinel Event

Plllllbl ished for Joint

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11 Tenets of a Safety Culture Definition of Safety Culture '----------------.. Safety culture is the sum of what an organization is and does in the pursuit of safety. The Patient Safety Systems (PS) chapter of The Joint Commission accreditation manuals defines safety culture as the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization's commitment to quality and patient safety.


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Robust Process Improvement® Elements Ro

bust

Pro

cess

Impr

ovem

ent

Methods

Training

Spread

Lean, Six Sigma, Change Management

Training for all employees

Widespread adoption


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INew Generation ,of Best Pr ctiices

Comple,x processe•s re qui re IRPI to pro uce s:ol uti ons that a r,e custom i.ze d to an o ,g:anizatio11Jrs most import61nt

c:ause.s ..

M . ny causesaf

thesa1me· pr,oblem

Key ,causes are diffel'lent f1rom p1lace

t:01 pla,ce

Each cause r,eq1u ''l'\es, a

el iffer,en1t

strategy

And: Performance

Improvement Capacity

• Two major factors are holding healthcare back:

Between 50% & 75% of improvement efforts fail due to a lack of focus on the people side

of change

39 © 2018, Joint Commission Center for Transforming Healthcare

Robust Process Improvement®

Change Management

Six Sigma Lean

RPI® is a blended set of strategies, tools, methods, and training programs— including Lean, Six Sigma, and Change Management—that is used to improve business processes and clinical outcomes.



Lean and Six Sigma

Lean empowers employees to identify and act on opportunities to improve processes Lean tools increase value by eliminating steps in processes that represent pure waste Six sigma improves outcomes of processes by identifying and targeting causes of failure Together they are a systematic, highly effective toolkit for process improvement

Lean and six sigma routinely produce 50%+ improvement 41




More than tools…

⎻Strategic project selection

⎻Common language

⎻Competency-based deployment

⎻Project management

⎻Data driven analysis is critical for complex problems

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Lean six sigma provide technical solutions that can markedly im Wh

R Change management = a systematic way to implement and


,proved processes y does improvement fail so often?Not for lack of a good technical solutionFailures occur when organization fails to accept and implement a good solution it had

PI addresses this challenge directly by including:

Technical Solution is Not Enough

Change management − − is the rocket science of

improvement − sustain good solutions



--

Change Management: GE’s Formula for Results

Q A A E QUALITY ACCEPTANCE ACCOUNTABILITY EFFECTIVENESS

Studies show that between 50% and 75% of improvement efforts fail due to a lack

of focus on facilitating change.

Adapted from General Electric Co.’s Change Acceleration Process © 2008. 44


People


Launch the

Initiative

Support the

Change

Facilitating ChangeTM

Plan Your Project − Assess the Culture − Define the Change − Assemble a Strategy − Engage the Right People − Brainstorm Barriers to Success − Build the Need for Change − Paint a Picture of the Future State

Inspire People − Make It Personal − Solicit Support and Involvement − Look for Resistance − Lead Change

Launch the Initiative − Align Operations and Infrastructure − Get the Word Out

Support the Change − Permeate the Culture − Monitor Progress − Sustain the Gains



Zero Patient Harm Is Achievable

https://vimeo.com/211533916 © 2018, Joint Commission Center for Transforming Healthcare

46

https://vimeo.com/211533916



Some organizations are achieving zero

⎻Small steps and specific goals: • CLABSI or CAUTI or HAPI

−Get beyond compliance—it is about behaviors and individual human factors

−Collaboration is the key—focus on safety culture change rather than injury reduction (OUCH Program!)

−Determine your cornerstones: Trust? Transparency? Accountability?

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Be Patiently Impatient…

The quest for high reliability takes time—so start now Culture change can be difficult High Reliability Organizations value information Everyone

…feels free to speak up with concerns …has a low tolerance for hazards …has conversations about risk and safety

The alternative doesn’t bear consideration

high reliability & healthcare...high reliability & healthcare 7/23/2018 ~ the j 1oint...

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