resilience in healthcare - tas · safety - ii definition of safety that as many things as possible...
TRANSCRIPT
The Other Side of “Human Error”
Dr Carl Horsley, Critical Care Complex, Middlemore Hospital
Resilience in Healthcare
Patient
Safety
Staff
Safety
Outline
The current model of safety
The problems with the current model
A new view of safety
How it changes the way we work
The Aim of Safety
That as few things as possible go wrong
The Current View of Safety – Safety I
Normal functioning(compliance)
Acceptable outcomes(successes)
Unwanted transition (sudden or gradual)
Malfunctioning(non-compliance)
Unacceptable outcomes(failures)
Hollnagel E. Safety-I and Safety-II; the past and future of safety management 2014
The Swiss Cheese Model
Find and Fix
Compliance
More
Defenses
Safety: A non expert viewpointPeople
are a
liability
to follow the rules
Your Hospital
Work-As-Imagined
Safety - IDefinition of safety That as few things as possible go wrong
Safety management principle Reactive; responds when something happens orsomething is deemed an unacceptable risk
View of the human factor in safety Humans are predominantly seen as a liability or hazard
Accident investigations Accidents are caused by failures and malfunctions. The purpose of investigations is to identify the causes.
Risk Assessment Accidents are caused by failures and malfunctions.The purpose of investigations is to identify the causes and contributory factors
Reactive
Retrospective
Biased
Limits Learning About Our Systems
What We Focus On Matters…
“Things that never happened before happen all the time”
Scott D. Sagan “The Limits of Safety”
CreatesBrittleness
Hides the sources of Adaptability andInnovation
Safety vs Productivity
Healthcare Worker Patient and family
Starlings by Elbow 2008
Work-As-Done
Hollnagel The ETTO Priciple: Efficiency Thoroughness Tradeoff 2009
The New View – Safety II
Performanceadjustments
Acceptable outcomes(successes)
Unacceptable outcomes(failures)
Hollnagel E. Safety-I and Safety-II; the past and future of safety management 2014
The system only succeeds because people/teams
are able to adjust to meet the conditions of work
Ghaferi 2009
Complexity is the problem…
People are the solution
The New Aim of Safety
That as many things as possible go right
Safety - IIDefinition of safety That as many things as possible go right
Safety management principle Proactive, continuously trying to anticipate developments and events
View of the human factor in safety
Humans are seen as a resource necessary for system flexibility and resilience
Accident investigations The purpose of an investigation is to understand how things usually go right as a basis for explaining how things occasionally go wrong
Risk Assessment To understand the conditions where performance variability can become difficult or impossible to monitor and control
What Does This Mean For How We Work?
Are you making failureless likely?
Or usual success
more likely?
1. Understand Success and Failure
Come From the Same Source
Work as
Done
Work as Imagined
2. Learn from all events
Build in time for
reflection
3. Build Resilient Teams and Systems
Not this…
Resilience
is the ability of the team/system to
monitor and adjust performance to achieve its goals,
under expected and unexpected conditions.
“The system must be both prepared and prepared to be unprepared”
J. Paries Resilience Engineering in Practice 2011
Anticipate How Things Might Fail
The Law of Requisite Variety
“The greater the variety of responses,
the greater the variety of conditions the system can cope with”
First Law of Cybernetics: Ashby, 1956
Requisite VarietyRequisite Variety
Middlemore Hospital,Counties Manukau District Health Board
A Common Framework
Build a Shared Understanding
Leadership and Active Followership
Speaking Up
Resilience
Focus on Learning
Why did that seem the right thing
to do at the time?
Dekker A Field Guide to Understanding Human Error 2014
Demonstrate
“Interwoven into the daily”
Reinforce and Model
What Changes Have You Seen?
Improved Team Organising
“We are less dependent on individual experience now that people work together better, and have a bit more of an expectation about how things will go, that we will talk about what we are expecting.”
(Nurse, CCC)
Structured Variability
Knowing the normal, so you can tell when it’s not
Some Surprises
Followers help leaders lead
Enrt
Proactive Safety Behaviours
“So, for me the difference is sharing that worst case scenario saying “I don’t think that is going to happen”, “this would be the worst thing”, “what I think is going to happen here is”, “it would be terrific if this happened”.
I think that has allowed people to relax a little bit and focus on good care rather than everything being a surprise.”
(Doctor CCC)
Psychological Safety
“The whole culture has changed and I think it has become a really focused group effort department with everyone looking out for each other and working for each other and with each other.”
(Nurse, CCC)
Psychological safety
Google “Project Aristotle”
A shared belief held by the team
that the team is safe for
interpersonal risk taking
Improved Psychological Safety
More effective
More engaged
Safer
(Edmondson 1999, Nembhard and Edmondson 2006)
What Else Have We Seen?
Contributing Factors
•Lack of valve/cap on the access device
•Student nurse supervision
•Patient's condition
•Patient position
What helped get a fast response ?
•Personal: Reading and talking to people helped to gain insight into identifying the signs/symptoms; always think and prepare for the worst possible outcome/scenario
• Environment: Bedspace was tidy; emergency bell and equipment were within reach (only one pendant has emergency buttons - extra time to reach for the bell on the other side of the patient's bed would have cost valuable time).
What helped during and after the event?
• Team came promptly
• Self-introduction during rounds helped to identify team leader
• Plan of care was clearly stated
• Patient progress and staff followed up by team
• Reassurance and support offered by team
• "no blame" culture helped to debrief and hold open discussions to allow others to learn from this
• Debriefing with different members of staff
• Family meeting with team leader and staff
Other Ideas?
•Multiple voices and questions asked by different team members while primary nurse was attempting to bag patient. Suggest for other team members to take over ventilation to free primary nurse for a clear, concise SBAR to the team leader
•Potential scenario for focus day/students on orientation/graduate RNs
Family response ?
A Change of Perspective
How Does This Fit With CCDM?
Right staff, right place, right care
“The mind, once stretched by a new idea, never regains its original dimensions”
Oliver Wendell Holmes
Team Resilience
Helmer Zijdel
Pam Culverwell
Sunetra Chan
Susan Archibald
Steve Kirby
Andrew Gilhooly
Sue Takarei
Sheeja Joseph
Eve Christophers
Reena Patel
Catherine Hocking
Kylie Julian
Carl Horsley
Resilient Healthcare Network
From Safety-I to Safety-II: A White Paper
Hollnagel, Wears, Braithwaite 2015
Websitehttp://www.resilienthealthcare.net
