steve narang, md mhcm chief executive officer banner good samaritan medical center leading change...
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STEVE NARANG, MD MHCMCHIEF EXECUTIVE OFFICERBANNER GOOD SAMARITAN MEDICAL CENTER
Leading Change and Improving Reliability--Delivering the Right Care to the Right Patient at the Right Time
The Iceberg….
. “Medicine used to be simple, ineffective and relatively safe…
…Now it is complex, effective and potentially dangerous”
Sir Cyril Chantler
UK Health Policy Advisor
Former Dean, Guy’s, King’s and St. Thomas Medical and Dental Schools
The Iceberg…• Most advanced healthcare system in the world
• High Cost, Low Quality
• For the money the United States spends on healthcare, about $2.5 trillion a year – the quality of care is unacceptably low
• Each year as many as 15 million patients harmed in some manner by America’s healthcare system
7
Deaths Due to Surgical or Medical Mishaps per 100,000 Population
9
0.7
0.6
0.5 0.5 0.5
0.4 0.4
0.2 0.2
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
United States
Germany Canada France United K ingdom
Australia OECD Median
J apan Netherlands
a2003b2002
ab
b
bb
b
Source: The Commonwealth Fund, 2004 data calculated from OECD Health Data 2006.
Variation in Cardiac Care from State to State
10
Cardiac Surgery Report. Lebanon, NH: The Dartmouth Institute for Health Policy and Clinical Practice, 2005.
The Iceberg is Melting….
Doing the right thing,
the right way,
at the right time,
in the right amount,
for the right patient
that does not result
in harm to the patient
Those of us who work in the health-care chains will have to contend with new protocols and technology rollouts every six months, supervisors and project managers, and detailed metrics on our performance. Patients won’t just look for the best specialist anymore; they’ll look for the best system
Average Rate Per Exposure of Catastrophes and Associated Deaths Per Activity (“Reliability”)Amalberti, et al. Ann Intern Med.2005;142:756-764
Observation: The reliability of applying known or required processes commonly is 10-1 (80%) or worse(When dealing with non-catastrophic processes)
Example of 3 Step Design in Implementing the Ventilator Bundle
Integrate daily goals with MDR to identify defects as a
EducationBaseline
Feedback on compliance
RT built into 1 hour scheduled vent checks as a)
BaselineBaseline
Baseline
Framework for Reliable Design
• Process is the action point of all improvement methodologies
• Reliability occurs by design not by accident
Starting Labels of Reliability• Chaotic process: Failure in greater than 20% of opportunities
• 10-1: 80 or 90 percent success. 1 or 2 failures out of 10 opportunities
• 10-2: 5 failures or less out of 100 opportunities
• 10-3: 5 failures or less out of 1000 opportunities
• 10-4: 5 failures or less out of 10,000 opportunities
(These are IHI definitions and are not meant to be the true mathematical equivalent)
Reasons for the Reliability Gap In Healthcare
• Current Improvement methods in healthcare are highly dependent on vigilance and hard work
• The focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of security
• Permissive clinical autonomy creates and allows wide performance margins
• The use of deliberate designs to achieve articulated reliability goals seldom occurs
Improvement Concepts Associated with 10 -1 Performance (Primarily can be described as intent, vigilance, and hard work)
• Common equipment, standard order sheets, multiple choice protocols, and written policies/procedures
• Personal check lists
• Feedback of information on compliance
• Suggestions of working harder next time
• Awareness and training
Improvement Concepts Associated with 10-2 Performance (Uses human factors and reliability science to design sophisticated failure prevention, failure identification, and mitigation)
• Decision aids and reminders built into the system
• Desired action the default (based on scientific evidence)
• Redundant processes utilized
• Scheduling used in design development
• Habits and patterns know and taken advantage of in the design
• Standardization of process based on clear specification and articulation is the norm
Key Learning Points
• Hard work and vigilance although commendable is not a good design principle
• If 10-2 change concepts do not make up at least 25% of the improvement effort on a given project require the team to rethink the design
Reasons for the Reliability Gap In Healthcare
• Current Improvement methods in healthcare are highly dependent on vigilance and hard work
• The focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of security
• Permissive clinical autonomy creates and allows wide performance margins
• The use of deliberate designs to achieve articulated reliability goals seldom occurs
Biology Protects Us
• All defects in process do not lead to bad outcomes
• Healthcare tends to look at outcomes and not the reliability of the process leading to outcomes (handwashing is an example)
• Benchmark to best practice not aggregate averages
Key Learning Points
• If you accept benchmark level performance in your organization you compare yourself against mediocrity and foster 10-1 performance in non catastrophic processes
• Benchmark against the industry best, but also insist on reliable processes
• Measure processes against a specific reliability goal (10-2)
• Measure linked processes using the “all or none” rule
Reasons for the Reliability Gap In Healthcare
• Current Improvement methods in healthcare are highly dependent on vigilance and hard work
• The focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of security
• Permissive clinical autonomy creates and allows wide performance margins
• The use of deliberate designs to achieve articulated reliability goals seldom occurs
Health Care Processes
Desired - variationbased on clinical criteria, no individual autonomy to change the process,process owned from start to finish,can learn from defects before harm occurs, constantly improved by collective wisdom - variation
Current - Variable, lots of autonomynot owned,poor if any feedback for improvement, constantly altered by individual changes, performance stable at low levels
Terry Borman, MD Mayo Health System
René Amalberti: Premises
• “Unconstrained” human performance (guided by personal discretion, only) is worse than 10-2
• Constrained human performance can reach 10-2
Key Learning Point
A single standardized process within the acceptable science is superior to allowing multiple processes while we decide which is the best because it allows testing and training
Why not 10-2 or better for your patients?
Why not YOU being a leader in the 10-2 model?
Where to start?
Reasons for the Reliability Gap In Healthcare
• Current Improvement methods in healthcare are highly dependent on vigilance and hard work
• The focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of security
• Permissive clinical autonomy creates and allows wide performance margins
• The use of deliberate designs to achieve articulated reliability goals seldom occurs
The Three Step Design for Reliability
Design Techniques Steps1-Identify the process to standardize2-Segment the population to test the design for anomalies3-Use both 10-1 and 10-2 concepts
Prevent initial failure by standardizing the
process to achieve 10-1 (step 1)
1-Utilize a robust 10-2 concept to make visible failures from step 1 after step 1 has achieved 10-1 reliability 2-Once the failure is identified, apply an action to mitigate the failure
Identify failures in step 1 and apply an action to achieve 10-1 for these failures (step 2)
1-Identify common failures2-Develop a method to measure and study failures3-Utilize knowledge of common failures to redesign either step 1 or step 2
In either step 1 and/or step 2 detect the failures, and use the knowledge from analysis of the failures to redesign (step 3)
The “Set Up” for ReliabilityExercise #1
• Select a topic whose outcome you want to improve
• Determine a high volume segment for initial design testing • Build a high level flow chart for that segment
• Determine where the defects occur in the current system
• Determine where your design work will begin with by identifying where the commonest defects occur
• Verbalize the reliability
Topic: Ventilator Bundle
Patient Placed on Ventilator
4 Elements of the bundle ordered
4 Elements of the bundle accomplished
Patient removed from ventilator
Segment: Medical ICU
Of the 4 elements of the bundle, the head of the bed elevation is most commonly not accomplished
Our aim is to with a reliability of 95% or 10-2 to achieve keeping the head of the bed elevated.
The Reliability Design Strategy
• Prevent initial failure using intent and standardization
• Identify defects (using redundancy) and mitigate
• Measure and then communicate learning from defects back into the design process
New Standardization Concepts
• Standardize to provide the appropriate infrastructure (the how, what, where, who and when)
• The “what” we are standardizing is based on medical evidence
• The “how” does not need medical evidence but rather systems knowledge
• Initial standardized protocols are developed with small time investment by experts tested at a very small scale
• Changes to the protocol in the initial stages should be required and encouraged
• Defects are studied and used to redesign the process
Three Tier Design Strategy
• Prevent initial failure using intent and standardization
• Redundancy/contingency function (identify failure and mitigate)
• Critical failure mode function (identify critical failures and then redesign)
Why the Step is Needed
• Allows less than perfect design in the standardization step (we do not have to plan for every possible contingency)
• Anticipates and allows failure in the prevent failure (standardization function) step
• Allows a better balance of resource use (no need to spend months coming up with the perfect design)
• Fosters the atmosphere of mitigation and recovery
Characteristics of “Redundancy Tools”
• Require careful consideration since they do represent a form of “waste”
• Needs to be connected to the process almost all the time (at least 10 -1)
• Requires a good prevent failure step (standardization function) before implementing a redundancy
• • Need to be truly independent
• Need to be used or will no longer function as a good filter
• Must follow with a mitigation strategy
Model 10-2 Concepts
• Decision aids and reminders built into the system• Desired action the default (based on evidence)• Redundant processes• Use fixed current scheduling in design• Take advantage of habits and patterns• Standardization of process based on clear
specification and articulation
Human Factors and Reliability Science: 10-2 Performance (Designing sophisticated failure prevention, failure identification and mitigation)
Examples:
• Decision Aid Pop-ups: “Remember to give Flu Shot”, “Did you order a drug level?”
• Default to the appropriate option: Patients get smoking cessation education whether physician orders or not.
• Redundancy: Two people check narcotics, Order read back for verbal orders, second person verifies charge capture at the end of clinic
• Checklists: Direct Admit Checklist, Handoff Checklist.• Scheduling: An area is scheduled to be cleaned every
morning, does not need to be requested.• Real-Time ID of Failures: Identify and Mitigate
Recommendations
Three Tier Design Strategy
• Prevent initial failure using intent and standardization
• Redundancy function (identify failure and mitigate)
• Critical failure mode function (identify critical failures and then redesign)
Critical Failure Mode Essentials
• A measurement of critical failure modes needs to be part of the initial design strategy
• Assesses the defects that occur from the current design• Should be prioritized in terms of overall affect on the
reliability of the process change• Should be used to redesign the process
Example of 3 Step Design in Implementing the Ventilator Bundle
Integrate daily goals with MDR to identify defects as a 10-2 change concept (step 1)
Education as a 10-1 concept
Baseline
Feedback on compliance as a 10-1 concept
Redundancy in the form of a check by RT built into 1 hour scheduled vent checks as a 10-2 change concept (step 2)
Example of using 10-1 and 10-2 change concepts to initially reach a reliability of 10-1
then additionally using a robust 10-2 change concept (redundancy) to reach 10-2 reliability in the 4 elements of the ventilator bundle (Baptist Memorial, Memphis)
Level 3 Concepts:(Sophisticated Behavioral Designs)
• Take advantage of habits and patterns• Make the system visible• Clear and unambiguous communication• Mindfulness – Weick and Sutcliffe: “High Reliability Organizations”
Attributes of High Reliability Organizations: Weick
1. Preoccupation with failure
2. Reluctance to simplify interpretations
3. Sensitivity to operations
4. Commitment to resilience
5. Deference to expertise
Weick, et al. Research in Organizational Behavior. 1999;21:81-123Weick, Managing the Unexpected: Assuring High Performance in an Age of Complexity, Jossey Bass 2001
Attributes of High Reliability Organizations: Weick
• 1. Preoccupation with failure Small failures are as important as large failures Avoid complacency:
Success breeds confidence in a single way of doing things and generates complacency Ex. “My patient has never had a Potassium
overdose, so why should I change?” Success narrows perceptions
Worry about normalization of unexpected events
Attributes of High Reliability Organizations: Weick
• 2. Reluctance to simplify interpretations Closer attention to context leads to more
differentiation of worldviews and mindsets Look for the root cause, not the obvious cause Ex. Dumb resident wrote a 10-fold overdose
Root Cause: “dumb” resident was up all night, in ED with seizing kid, called for verbal order, …
Attributes of High Reliability Organizations: Weick
• 2. Reluctance to simplify interpretations Differentiation (diverse viewpoints) brings a varied
picture of potential consequences better precautions and responses to early warning signs.
Over dependency on insiders leads to simplification Ex. This is how we do it at Good Sam….
Attributes of High Reliability Organizations: Weick
• 3. Sensitivity to operations Attentive to the front line where the real work gets done Authority moves toward expertise:
Role of RNs Role of Clinical MDs, PNPs Role of Parents
Make continuous adjustments that prevent errors from accumulating and enlarging based upon reporting from operations, not the “master plan”
Attributes of High Reliability Organizations: Weick
• 4. Commitment to resilience Develop capabilities to detect, contain, and
bounce back from those inevitable errors that are part of an indeterminate world Ex. Trigger tools (and automation)
A focus on intelligent reaction, improvisation Correct errors before they worsen and cause
more serious harm Ex. “stop the line”
Attributes of High Reliability Organizations: Weick
• 5. Deference to expertise Decisions are made on the front line, and
authority migrates to the people with the most expertise, regardless of their rank
Avoidance of the structure of deference to the powerful, coercive, or senior
Mindfulness: Weick
“Together these five processes produce a collective state of mindfulness. To be mindful is to have an enhanced ability to discover and correct errors that could escalate into a crisis.”
consider what a resident in a busy pediatric emergency department might do when he is unable to determine whether an ear examination is normal or abnormal and the attending physician is not immediately available…(s/he) weighs the consequences of misdiagnosis for the patient, the humiliation of having to call the otolaryngology resident…loss of self-esteem by having to admit incompetence…
…A mindful conscious approach would be to cultivate awareness not only of the correct course of action but also of the factors that cloud the decision-making process. The mindful practitioner is mentally and technically better prepared for the next situation
Rene Amalberti, MD, PhDCognitive Science Department, Bretigny-sur-Orge, FranceAmelberti et al. Ann Intern Med 2005;142:756-764
…the most important difference among industries…lies in their willingness to abandon historical and cultural precedent and beliefs that are linked to performance and autonomy, in a constant drive toward a culture of safety…