identifying and mitigating barriers and hazards
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Identifying and Mitigating Barriers and Hazards. Armstrong Institute for Patient Safety and Quality Presented by: Ayse P. Gurses, PhD Assistant Professor, Human Factors Engineer. Learning Objectives. To learn how to identify hazards/ barriers in a healthcare work system - PowerPoint PPT PresentationTRANSCRIPT
© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011
Identifying and Mitigating Barriers and Hazards
Armstrong Institute for Patient Safety and Quality
Presented by: Ayse P. Gurses, PhD Assistant Professor, Human Factors Engineer
Learning Objectives
• To learn how to identify hazards/ barriers in a healthcare work system
• To understand how to develop a systematic approach to eliminate or reduce the effects of these barriers/ hazards
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Terminology
• Harm (adverse) events• No harm events• Near misses• Hazard: Source of danger but does not contain any
likelihood of an undesired impact• Risk analysis: Detailed examination of
– what hazards can happen– how likely a hazard will happen– what are the consequences, if such a hazard happens in
the system
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Terminology
• Barriers: Work factors that affect the overall performance of the system.- May affect safety of care, compliance with
evidence based practice, efficiency, effectiveness, profitability, quality of work life (e.g., stress, fatigue)
- Hazards: a subset of barriers that affect “safety”
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Safety Engineering
• Build safety into design of health care systems
• Proactively identify hazards in the system before errors and accidents occur
• Develop risk management strategies
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Hazard and Barrier Identification/ Analysis Tools: Reactive
• Archival records
• Event reporting
• Root cause analysis
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Identifying Hazards and Barriers: Proactive
• Work system analysis or process mapping (variations, workarounds, steps skipped, etc.)
• Observations• Interviews or focus groups• Brainstorming• Heuristic analysis• What-if checklists
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What to Observe?
• Physical layout• Disconnects and
surprises (e.g., automation surprises)
• Distractions• Ambiguities• Workarounds• Team behaviors (e.g. situation awareness,
shared mental model)
• Information tool characteristics
• Extreme, unexpected, unfamiliar cases
• Feedback mechanisms• Variations in conducting
tasks• Fit to the job (e.g., task-
technology fit)
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Systems Engineering Initiative for Patient Safety (SEIPS) Model
Carayon, P., Hundt, A.S., Karsh, B.-T., Gurses, A.P., Alvarado, C.J., Smith, M. and Brennan, P.F. “Work System Design for Patient Safety: The SEIPS Model”, Quality & Safety in Health Care, 15 (Suppl. 1): i50-i58, 2006.
Observation Tool for Identifying Hazards
Task People Tools Environment Organizational structure
Ambiguities Workarounds Consequences Risk management strategies currently used
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Interviews/ Focus Groups
• What could go wrong? How badly will it go wrong?
• How do you think that patients can be harmed in this unit while taken care of?
• If you could change a few things in your unit to improve patient safety, what would they be?
• What safeguards are in place to prevent errors?
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Workarounds as potential barriers/hazards
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Barriers/ Hazards by Pictures
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© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011
How to Use This Methodology to Improve Processes of Care?
Compliance with Evidence-Based Guidelines
• Consistent compliance with evidence-based guidelines is challenging yet critical to patient safety.
• Need for interdisciplinary approach to improve compliance
• From human factors point of view: Compliance as “systems property.”
• GOAL: To identify and eliminate/mitigate the effects of barriers to compliance with guidelines
• Remove unnecessary lines
• Wash hands prior to procedure
• Use maximal barrier precautions
• Clean skin with chlorhexidine
• Avoid femoral lines
Evidence-based Behaviors to Prevent CLABSI
Steps of Barrier Identification and Mitigation Tool (BIM)*
• Step 1: Assemble the interdisciplinary team• Step 2: Identify barriers
– Observe the process– Ask about the process– Walk (simulate) the process
• Step 3: Summarize barriers in a Table• Step 4: Prioritize barriers• Step 5: Develop an action plan for each prioritized
barrier
.* Gurses et al. (2009) A practical tool to identify and eliminate barriers to evidence-based guideline compliance. Joint Commission Journal on Quality and Patient Safety 35(10):526-532
Step 2: Identify Barriers
• Observe the Process– Include different lenses – nurse, infection control,
human factors/ QI expert conducting observations
– Why is it difficult to comply?
– Steps skipped, work-arounds
Step 2: Identify Barriers
• Ask about the process: Ask staff– whether they are aware of/ agree with the guideline– what some of the leading problems and barriers
encountered in their unit that may hinder compliance with this guideline?
– Have any suggestions to improve compliance with the guideline
– Specific questions (e.g., How do you find out the date that a central venous catheter was inserted to a patient?)
Step 2: Identify Barriers
• Walk the process– Try to comply with the guideline using
simulation or, if appropriate, under real circumstances.
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Types of Barriers
• Provider– Knowledge, attitude
– Current practice habits
• Guideline-related– Applicability to patient population
– Evidence supporting guideline
– Ease of compliance
• System– Inadequate or poorly designed tools and technologies
– Poor organizational structure (e.g., staffing, policies)
– Inadequate leadership support
– Unit/hospital culture
– Inadequate feedback mechanisms
– System ambiguities
• Other
Barrier Identification Form
CONTRIBUTING FACTORS BARRIER(S) POTENTIAL ACTIONS
ProviderCurrent practice habits : What do you currently do (or not do)?
Lines rarely discussed on daily interdisciplinary rounds
Add lines section to rounding form.
GuidelineEase of complying with guidelineHow does this guideline impact the workload?SystemTools & technologies Are necessary supplies and equipment available and used appropriately?
Materials (full drapes) were missing from the line cart for an afternoon procedure(cart restocked at night).
Physical environmentHow does the unit’s layout affect compliance?
MD walked through busy hallway to wash hands at closest sink before procedure.
Make sinks more convenient?
Performance monitoring and feedback mechanismHow does the unit know it is consistently (and appropriately) applying the guideline?
No mechanism to monitor central line use and provide feedback
Review central line use at monthly unit meetings.
Other
Barrier Summary and Prioritization
Barrier Relation to Guideline
Source Likelihood Score*
SeverityScore†
Barrier Priority Score‡
Target for this QI cycle?
Difficult for providers to cleanse their hands prior to performing central line insertion
Hand washing ObserveAsk
4 3 12 Yes
Central line cart missing items (especially late in the afternoon)
Full barrier precautions and clean skin with chlorhexidine
ObserveWalk
3 3 9 Yes
*Likelihood score: How likely will a clinician experience this barrier?1.Remote 2. Occasional 3. Probable 4. Frequent
†Severity score: How likely will experiencing a particular barrier lead to non-compliance with guideline?1.Remote 2. Occasional 3. Probable 4. Frequent
‡Barrier priority score = Likelihood score X Severity score
Development of Action Plan
*Potential impact score: What is the potential impact of the intervention on improving guideline compliance?
0. No impact 1. Low 2. Moderate 3. High 4. Very high
†Feasibility score: How feasible is it to take the suggested action?
0. Not feasible 1. Low 2. Moderate 3. High 4. Very high
‡Action priority core = Potential impact score X Feasibility score
Prioritized barriers
Potential Actions
Source Potential Impact Score*
Feasibility Score†
Action Priority
Score‡
This QI cycle?
Action Leader
Performance Measure(Method)
Follow-up Date
Difficult for providers to cleanse their hands prior to performing central line insertion
Install sinks in rooms
Observe 3 0 0 No
Place alcohol-based hand sanitizer in rooms
ObserveAskWalk
4 4 16 Yes KM
Compliance with hand cleaning
(observation)
2 months
Hazard/Barrier Reduction Strategies: Summary
• Simplify and standardize when you can– Make it easier for people to do the right thing (e.g.,
central line insertion cart)
• Create independent checkpoints
• Learn from mistakes and successes
• Think about “sustainability” of interventions
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References
• Carayon et al. (2006) Works system design for patient safety: the SEIPS model. Quality and Safety in Health Care 15: i50 - i58.
• Gurses et al. (2009) A practical tool to identify and eliminate barriers to evidence-based guideline compliance. Joint Commission Journal on Quality and Patient Safety 35(10):526-532
• Gurses et al. (2008) Systems ambiguity and guideline compliance, Quality and Safety in Health Care 17:351-359
• Gurses et al. (2010) Using an interdisciplinary approach to identify factors that affect clinicians’ compliance with evidence-based guidelines. Critical Care Medicine Forthcoming.
• Pronovost et al. (2008). Translating evidence into practice: a model for large scale knowledge translation. British Medical Journal 337:a1714
• Thompson et al. (2008) View the world through a different lens: shadowing another Joint Commission Journal on Quality and Patient Safety 34, 614-618(5).
References
• Battles and Lilford (2003). Organizing patient safety research to identify risks and hazards. QSHC 12:ii2-ii7.
• DeRosier et al. (2002). Using health care failure mode and effect analysisTM. Joint Commission Journal on Quality Improvement. 28: 248-267.
• Marx and Slonim (2003). Assessing patient safety risk before the injury occurs. QSHC. 12:ii33-ii38.
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© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011
Questions?