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Healthcare Performance Improvement, LLC

Phone: 757.226.7479 www.hpiresults.com

Triple Play A Healthcare Strategy for Break-throughs in Safety, Quality, and Reliability

© 2013 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. This material is a proprietary document of Healthcare Performance Improvement LLC. Reproducing, copying, publishing, distributing, presenting, or creating derivative work products based on this material without written permission from Healthcare Performance Improvement is prohibited

Eastern Carolina Regional Symposium

4 Sep 2013

Triple Play A Healthcare Strategy for Break-throughs

in Safety, Quality, and Reliability

© 2013 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. This material is a proprietary document of Healthcare Performance Improvement LLC. Reproducing, copying, publishing, distributing, presenting,

or creating derivative work products based on this material without written permission from Healthcare Performance Improvement is prohibited.





Slide 3

Objectives

1. Define reliability and high reliability. And describe how high reliability

enables healthcare delivery, a complex system, to be safe, effective

and patient-centered.

2. Describe the three steps for culture change using a behavior-based

model.

3. Explain the role of feedback to people within a complex system has in

building and sustaining a high reliability organization.

4. Describe how the Collegial Interactive Team (CIT), training in-situ using

evidence-based protocols with human factors, can accelerate change

in complex systems – and assure sustained improvement.

Slide 4

Reliability

re·li·a·bil·i·ty [ri-lahy-uh-bil-i-tee]

A probability that a system will yield a specified result





Slide 5

Slide 6

High reliability organizations (HROs) “operate under very trying conditions all the time and yet

manage to have fewer than their fair share of accidents.” Managing the Unexpected (Weick & Sutcliffe)

Risk is a function of probability and consequence.

By decreasing the probability of an accident,

HRO’s recast a high-risk enterprise as merely a

high-consequence enterprise.

HROs operate as to make systems ultra-safe.

http://www.hroconference.com/en/about-hro





Slide 7

Preoccupation with Failure Operating with a chronic wariness of the possibility of unexpected events that may jeopardize safety by engaging in proactive and preemptive analysis and discussion

Sensitivity to Operations Paying attention to what’s happening on the front-line – Ongoing

interaction and information-sharing about the human and organizational

factors that determine the safety of a system as a whole

Reluctance to Simplify interpretations Taking deliberate steps to question assumptions and received wisdom

to create a more complete and nuanced picture of ongoing operations

Commitment to Resilience Developing capabilities to detect, contain, and bounce back from errors that have already occurred, before they worsen and cause more serious harm

Deference to Expertise During high-tempo operations, decision-making authority migrates to the person or people with the most expertise with the problem at hand, regardless of rank

Five Principles of HROs

From Vogus & Sutcliffe, The Safety Organizing Scale, Medical Care, 45/1, Jan 2007, p. 46-54.

Slide 8

Health Affairs 2011;30:559-68





Slide 9

Slide 10

RELIABILITY

CULTURE “Failure Prevention”

Proven Tactical

Doctrine +

performed as intended

consistently over time =

Mission

Effectiveness

Evidence-Based

Process Bundles +


consistently over time = Clinical Excellence

Safety Focus + performed as intended

consistently over time = Zero Mishaps Safety Focus +


consistently over time = No Harm

Reliability Culture - Genius of the AND

Patient Centered + performed as intended

consistently over time = “Satisfaction”

????? + performed as intended

consistently over time = Intended outcome





Slide 11

Changing Behaviors

Set Expectations

Educate & Build Skill

Reinforce & Build

Accountability

© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Slide 12

Making It Happen & Making it Stick

20%

Eve

nt R

ate

Awareness

Skill Acquisition

Habit Formation

Performance

Time

100%

2 Years


Leadership Influence





Slide 13

Slide 14

Rapid Cycle Feedback Learning is “doing” with “feedback”


Do

Feedback

Traditional

Feedback Cycle

Optimal

Feedback Cycle

Time

Pe

rfo

rma

nce





Slide 15

Technical

Skills

Technical +

Non-Technical

Skills

Non-Technical

Skills (Individual & Team)

Simulation in the Lab

Pre-Job

Briefing

Real-Time Sim Teaching

on the Spot

Simulation at the Line

Is there any

technical skill that

does not also

require non-technical

skills? NO!

Eliminate

technical simulation

in isolation!

Off-Line Education & Training Real-Time Simulation

Best Use Initial education on new concepts; intensive skill

development

Reinforcement and application of known concepts;

development of critical thinking and analytical problem

solving

Location Classroom, training lab, meeting On-the-job

Nature Objective-bound Time-bound

Prep Time Longer Short to none

Touch Time Longer (>30 minutes, typically hours) Short (30/60/90 seconds; typically <5 minutes)

Frequency Episodic; longer time between sessions Often; shorter time between touches

Facilitator Trained instructors or manager Manager or coworker

Costs Salary of instructors/learners; supplies None

To build and reinforce

technical skills and

critical thinking skills

Build real-time simulation as a leadership competency!


Simulation Continuum

Slide 16

Types of Simulation

Frequency

(repetitions)

Logistical Complexity

Learning Value

60 Second Sim

Real-time Sim

Protocol Sim

Protocol In-situ Sim

Resiliency Sim

Size of data point indicates relative numbers of

people through the program in a unit time

Lower Fidelity Sim

http://www.youtube.com/watch?v=bqca9oK_bUM&feature=player_embedded

http://www.google.com/url?sa=i&rct=j&q=red+sphere&source=images&cd=&cad=rja&docid=4_s3AU8HVHHOjM&tbnid=QGpT-4_R57R69M:&ved=0CAUQjRw&url=http://marvelunlimited.forumotion.com/t566-red-sphere-of-mars-plot-mission&ei=tbX-UZCNIZLy8AS4p4DQBw&bvm=bv.50165853,d.eWU&psig=AFQjCNGowv0N2gXPiW7Hfp_m5Ie1Uc1PcA&ust=1375733548065575










Slide 17

“Doing” with Feedback

Slide 18

The Gossman Center for Advanced Healthcare Simulation

Sim Center Sim Center In-Situ Sim

Technical skills

Team skills

Environment Protocol EBM + human factors

Technical

+ CIT skills

A fool’s choice: o technical skills in isolation, or o team skills in isolation

Perfect practice makes perfect.

Practice only makes permanent.

“What you do every day is what you do in an emergency.” Joe Martin, Battalion Chief - LAFD

A Triple Play





Slide 19

Non-Technical Skills

Non-technical skills describe how people interact with technology, environment,

and other people. These skills are similar across a wide range of job functions.

These skills include attention, information processing, and cognition.

Flin, O’Connor, and Crichton

Safety at the Sharp End

Generic non-technical skills:

Situational awareness

Attention

Communication

repeat backs

call outs

phonetic & numeric clarification

clarifying questions

inquiry, advocacy, assertion

Critical thinking

Protocol use

Decision-making

Slide 20

Collegial Interactive Teams (CIT)

The most advanced approach to human reliability in

complex systems. The standard tools for CIT’s promote:

• Thinking – preventing misjudgment and decision-

making error

• Thinking together – anticipating and managing the

unexpected, preventing group-think

• Resiliency – recognizing the team is off the success

path and getting back on a path

• and intended for training of natural work teams in

simulation.





Slide 21

Collegial Interactive Teams (CIT) =

Tone + Tools Context • Patient focused – like we’re

caring for a loved one

Collegiality • Greetings & introductions • Eye contact & open body language • Relationships • Team goals – use “we” and “us” vs. “I” and “you”

Coordination • Who’s in charge • Roles & responsibilities • Brief>Execute>Debrief

– pocket card in-hand

Communication • Information – ready & in hand • 3-way repeat backs • Clarifying questions • Phonetic/numeric

clarifications • SBAR for requests Confidence in Speaking Up

• Cross Monitoring – peer checking & peer coaching • “If anyone – regardless of role or experience – senses a

problem that would compromise safe, quality care, I expect you to speak up.”

Slide 22

The Gossman Center for Advanced Healthcare Simulation

Sim Center Sim Center In-Situ Sim

Technical skills

Team skills

Environment Protocol EBM + human factors

Technical

+ CIT skills

A fool’s choice: o technical skills in isolation, or o team skills in isolation

Perfect practice makes perfect.

Practice only makes permanent.

“What you do every day is what you do in an emergency.” Joe Martin, Battalion Chief - LAFD

A Triple Play





Slide 23

Protocol Selection Criteria

1. Uplifting for participants – so they want more

2. Targeted reduction in patient harm

3. Targeted reduction in risk

4. Targeted increase in reliability (safety/quality)

5. New facility or equipment or services or personnel

6. Infrequently performed or complex

7. Spread to new unit or new professional group

Slide 24

More Ideas

ED OR OB

Adult trauma Adult resuscitation Fetal monitoring

Pediatric trauma Pediatric resuscitation Emergent C-section

Adult resuscitation Malignant hyperthermia Shoulder dystocia

Pediatric resuscitation Airway management Neonate resuscitation

Sepsis Post-partum hemorrhage

Adult resuscitation

More for resiliency: 1. Sponge counts wrong in procedural areas

2. Time-out not done or done incorrectly in procedural areas

3. Sepsis in ED or Med-Surg (nursing-medical staff conflict resolution)

4. Code Blue response with infrequent/complex complication(s)

5. Contra-indicated procedure / therapy under time pressure





Slide 25

From Concept to Construct:

Focus & Simplify to

Improve Human Performance

“Everything should be as simple as possible,

but not simpler.” Albert Einstein

Slide 26

Human Factors Integration in

Guidance Document Design

People Guidance

Documents

Human Factors

Integration





Slide 27

Policies, Procedures & Job Aids

Define required high-level expectations

Fewer in number

Informational and reference use

Typically no more than one (1) page

Procedures

& Job Aids

Policies

Define action steps and provide tools to achieve policy expectations

Continuous and reference use

Slide 28

Focus & Simplify – Two Components

Work Process Simplification (Steps 1-7)

Before writing or revising a procedure…

Mapping the current work process

Assessing the process for risk and ineffectiveness

Changing the process to reduce risk and improve effectiveness

Procedure Simplification (Steps 8-12)

A procedure structure that…

Clearly articulates action steps

Highlights points of risk

Provides appropriate detail for experienced and new employees

Use of job aids to pull out of procedures the tools and references needed to accomplish a complex or infrequently-performed task





Slide 29

Slide 30

Debrief Structure

Review the objective. What were we trying to do e.g. smooth patient transfer, successful resuscitation, IT system upgrade, etc.

Reconstruct the event. Have the team review the evolution, walking through just the objective facts of what happened in enough detail for a common understanding of what occurred.

Review the reconstruction for differences between what was supposed to happen and what actually did. Why there were differences?

Capture the things we want to sustain and possibly spread to others:

Capture what we can improve and have others learn from?

Wrap up: Give each participant a last chance to comment on their own actions, team behavior, or system design.

Recap for the group 3 things we want to sustain and 3 things we want to improve

Document and hand-off to process owners for appropriate follow up action.

Checklist approach for leading an AAR





Slide 31

Debrief Technique

Source: Rudolph & Simon, “There is No Such Thing as a ‘Non-Judgmental’ Debrief, ” Simulation in Healthcare, Spring 2006.

Frames

Actions

Results

Debrief leads

to new frames

or reframing

Debrief leads

to new actions

Slide 32





Slide 33

Reliability in Quality and Safety

Slide 34

Elissa Orcutt

Benefis Hospital, Director Surgical Services

“Today we have changed our OR forever.”





Slide 35

QUESTIONS?

Slide 36

Scott Knapp

Tel: (757) 462-6955

Email: [email protected]

Contact Information

Healthcare Performance Improvement

5041 Corporate Woods Drive, Suite 180 • Virginia Beach, VA 23462

Tel: (757) 226-7479 • www.hpiresults.com