A Knowledge Management Solution for Red Rules at Presbyterian

Hospital

Prepared by Myra Herrmann

Kathleen Maxfield &Leslie Rettinger

IntroductionIntroductionEvery organization has a few rules

that are well understood by all should never be broken, under any circumstance, by anybody in the organization.

This Red Rules project will design a learning system for a healthcare organization to support their “Red Rules”.

Definition of Red RulesDefinition of Red RulesRed Rules cannot be broken.

◦ few in number, ◦ easy to remember, and ◦ associated only with processes that can cause

serious harm to employees, customers, or the product line.

◦ must be followed exactly as specified except in rare or urgent situations.

◦ possible and desirable for everyone to follow

Definition, cont.Every worker is expected to stop the

work if the red rule is violated. Empowers workers to speak up

regardless of rank or seniority.

Criteria for Red RulesCriteria for Red Rules

It must be possible and desirable for everyone to follow a red rule every time

Anyone who notices that the Red Rule violation has the authority and responsibility to stop further progress.

Criteria, cont.All violations of a Red Rule are

mediated through a Just Culture approach

Workers' actions are evaluated based on process in which it occurred.

Just Culture is used regardless of staff member's rank, popularity, and importance to the company.

Problem StatementProblem StatementCurrent:

◦ Both hand hygiene and the surgical “time-out” are protocols at Presbyterian Hospital. Not consistently observed. Potential harm to patients

Desired: ◦ 100% compliance hand hygiene and

the surgical “time-out” procedure.

Symptoms of the Problem Symptoms of the Problem Surgical Time-OutQuality Control Compliance Assessment

◦ Wrong site, Wrong side, Wrong patient wrong site 2000-2003 wrong patient 2000-2003

◦ Average of 10 operations per year perioperative infections 2007 medication reactions 2007

Hand HygieneQuality Control Compliance Assessment

◦ Average 70% compliance◦ Average 57% physician compliance◦ C. difficile in 6 patients

Root Causes of ViolationsRoot Causes of ViolationsRoot Causes

Knowledge 1. Lack of knowledge about implications of non-hand washing

2. Lack of awareness of the implications and/or of the frequency of non-patient verification before an invasive surgery

Skills 1. Lack of computer skills to successfully complete the online training

Attitude 1. Hierarchical/seniority issues in the hospital culture that inhibits or prevents compliance

2. Perception of lack of time

GoalsGoalsTo design a scalable learning system

with reusable learning objects (RLOs) These RLOs will be integrated into the

existing repository system.To create a RLO strategy to

accommodate Red Rules in the existing online employee training system.

This initial project will develop a framework into which historical RLOs will be adaptable.

Strategies to Address Root Strategies to Address Root CausesCauses

Root Causes

Knowledge 1. Training emphasizing consequences to patient

Skills 1. RLOs delivered in a variety of mediums

Attitude 1. Training via case studies/scenarios

2. Workplace mentoring

3. Just Culture initiative

TrainingInstructional Solutions

Workplace Learning(Knowledge and Support Solutions)

E-Learning

Learning and Performance Architecture

Classroom Training

All Employee

Online Training

Information Repositories

Networks & Communities

Perform-ance

Support

Experts

Mentoring & Coaching

Informal Workplace SettingsFormal Learning Settings

Traditional Blended Learning

KM System & Learning KM System & Learning EnvironmentEnvironment

The knowledge management system at PHS is designed for the creation, archiving and sharing of expectations and expertise across the entire organization.

Red Rules online training is required for all employees and is targeted to clinical, non-clinical, administrative and management audiences.

All employee training is mandatory and will be taken between January 1 and March 31, 2009.

Training will be repeated annually to ensure continued reinforcement of red rules

Target AudiencesTarget Audiences

Target audience includes ◦ Decision Makers◦ Managers◦ Healthcare Practitioners◦ Administrative Staff

Media will be designed to meet the needs of these groups.

The Work SettingThe Work SettingResources and constraints

◦ Funding◦ Personnel◦ Technology/tools, time

Prevalent philosophy and culture PHS values and vision Strategy to continuously improve

processes

The implementation of Red Rules is integral to the vision of National

Excellence.

Environment Resources Constraints CultureDevelopmental Included in the project

plan and budget for the Subject Matter Experts for time, money and personnel

Limited time for development

3 months to have components designed and accessible for print media and online training

The Learning Center is open to considering RLO’s in their learning environment/ architecture

Benefits of RLO’s may not be apparent

PHS philosophy and culture are supportive of continuing education and training for personal and professional improvement

Delivery Included in the project plan and budget for the Subject Matter Experts for time, money and personnel

Availability of technological tools to incorporate RLO’s into the existing online training

Personnel’s familiarity with variety of delivery mediums (i.e. PDA downloadable, searchable database/ repository)

Red rules are consistent with the Just Culture environment at PHS where mutual accountability, respect and value are emphasized

Management schedules and commits time for their employees’ training

Application Perception of lack of time to comply with red rules

Peer cohesion, supervisory support and perception of autonomy by the employees will affect the transfer of knowledge/ training to their job

Each manager is responsible for his/her employees to complete the mandatory training

Employee training is tracked and charged back to the department

Task AnalysisTask Analysis - Hand Hygiene - Hand Hygiene

How is hand hygiene How is hand hygiene performed?performed?

◦ Alcohol hand disinfection (AHD) technique: Cover both hands thoroughly Rub until hands are dry Use a CHW every 5-6 AHDs to get rid of

emollient residue◦ Conventional handwash (CHW) technique:

Wet hands, apply 5cc of antimicrobial soap Rub hand surfaces under warm running water

for 15-30 seconds. ◦ Other aspects of hand hygiene:

Avoid skin dryness or irritation Use hospital-supplied lotions

Task analysisTask analysis – Surgical – Surgical “Time-Out”“Time-Out”How is Time out performed?How is Time out performed?

◦ Where the procedure will be done ◦ Before starting the procedure. ◦ Entire operative team involved.◦ Use active communication ◦ Checklist documented:

Correct patient identity. Correct side and site. Agreement on the procedure to be done. Patient Allergies If perioperative antibiotics are to be

given. Correct patient position

Topics Identified From Content Topics Identified From Content AnalysisAnalysis

Topic #1. Why Red Rules?1. Definition2. Criteria3. “Just Culture” approach

  

Topics Identified From Content Topics Identified From Content AnalysisAnalysis

Topic #2. Why hand hygiene?1. facts about hand washing2. procedure for hand- washing

i. Steps involvedii. when to perform “time-out”

Topics Identified From Content Topics Identified From Content AnalysisAnalysis

Topic #3. Why surgical “time-out”? 1. Facts about “time-out” 2. Procedure for “time-out”

i. steps involvedii. when to perform “time-out”

Topics Identified From Content Topics Identified From Content AnalysisAnalysis Topic #4. Identifying

noncompliance1. Principle about speaking out!2. Team members

3. Enforce Process Agreements i. Accept / Legitimize

Learner AnalysisLearner AnalysisTraining should take into consideration

◦ Background & experience of learners◦ Learning styles◦ Goals of learners◦ Group characteristics◦ Level of comfort entering the system

Build upon what is known Make it engaging & motivating

◦ Diversity (culture, language, etc.)

Learner Analysis, cont.Learner Analysis, cont.Online training is primary forumSpanish and English versions

providedPaper versions available upon

requestSome classroom training is

available

EvaluationQuarterly Reviews by the Quality

Control Department include the following measurements:◦# that passed online training◦Incidents of peri-operative infections◦Incidents of wrong site, wrong side,

or wrong patient surgery◦Incidents of medication reactions◦Self Evaluation surveys◦# of lawsuits

Reusable Learning Objects Reusable Learning Objects StrategyStrategy

Mission StatementMission Statement  

Create an architecture/framework to support RLO's, as well as legacy content, that are searchable and accessible in multiple formats to meet the needs of a demographically diverse and changing workforce.

RLO Strategy GoalsRLO Strategy Goals◦Set the framework for new patient

initiatives◦Establish components in RLOs◦Create a scalable approach to allow

for growth of RLOs◦Create format-free RLOs to support

multiple methods of delivery (i.e. print, on-line, searchable/exploratory, PDA, etc)

◦Reduce redundant information and efforts

The PHS Red Rules The PHS Red Rules Learning Object Learning Object

ProcessProcessAuthor Learning Object

DevelopmentStorage Delivery Learner

•Elements•Content•Metadata

ObjectivesSearch

•Learning ApproachInteractivityArchitectureContext

•Online training•Print•Instructor led

Patient Safety Council

Clinical Education and Quality Staff

PEL Learning CenterStaff

All Staff

Restrictions on useChanges to business processesShowing return on investment

(ROI)

The PHS Red Rules Learning The PHS Red Rules Learning Object ProcessObject Process

PHS Existing Learning Object Diagram

PHS RLO Strategy Diagram

PHS RLO Hierarchical PHS RLO Hierarchical StructureStructure

RLO DeliveryTypes of Media Supported

◦PowerPoint presentations◦video clips◦supporting documents◦job aids

Static Delivery of Content

PHS System for Collecting PHS System for Collecting MetadataMetadata

 Learning Object Title

Content Type

Content Subtype

Functional Category

Keywords Facility

 

Hand Hygiene

Training Procedure 1.definition2.demonstration

Hand-washing, Red Rules, infection prevention, protocols

PHS hospital, PHSClinics,Administrative Center

 

Surgical “Time-Out”

Training Procedure 1. definition2. demonstration3. scenario

Surgical “time-out,” Red Rules, Wrong side surgery

PHS hospital, PHSClinics,Administrative Center

 

PHS RLO Knowledge PHS RLO Knowledge ProductProduct

Environment for Learning and Performance Improvement

Non-Learning Approaches to Performance

Posters on every floorAlcohol-based hand wash and lotion at

every patient roomPop-up reminders on electronic recordTargeted role modelsChecklists

Change Management and CommunicationsPatient Safety is one of two initiatives

◦ Red Rules is the vehicle to communicate the Patient Safety expectations

“Just Culture” sets the cultural expectations

Standards are set for 90% compliance◦ Compliance is measured

RLOs will be used as needed Workforce commitment will be sustained

through management oversightCommunication and training will be tied

Learning & Performance LeadershipLeadership supports Red RulesCommon vision & value will be developed

through:◦ All employee training◦ Refresher training for managers◦ Communication of benefits & best practices

Strategy is to demonstrate use of RLOs and Sharepoint as a Proof of Concept

Wins will be shared on the Sharepoint site Governance is managed by Patient Safety

Council

Environment for Learning and Performance Improvement Hand Hygiene - Barriers To Learning

Barrier Solution  

Environmental factors

1. Insufficent time

2. Understaffing

3. Lack of access to hand hygiene supplies

1. Alcohol based instant wash 2. Management to reduce understaffing3. Access at every patient room

Self Reported

1 Not thinking about

2 Skin irritation

3 Lack of role model

1. Posters and other media reminders2. Less irritating product and lotion 3. Experienced staff role models

Individual Characteristics

1. Male Physicians 1. Pop-up with electronic records  

Environment for Learning and Performance ImprovementEvaluation of Performance

◦Incidents of peri-operative infections◦Incidents of wrong site, wrong side,

or wrong patient surgery◦Incidents of medication reactions◦Self Evaluation surveys◦# of lawsuits◦Monitor volume of alcohol based rub

per 1,000 patient-days

Reuse and Repurpose Reuse and Repurpose KnowledgeKnowledge

(Process Diagram)(Process Diagram)

Reuse and Repurpose Reuse and Repurpose KnowledgeKnowledge(Metadata)(Metadata)

Levels of Metadata◦RIOs, RLOs, legacy

content ConsistencyTagsStandards

Reuse and Repurpose Reuse and Repurpose KnowledgeKnowledge

(Metadata Standards)(Metadata Standards)TitleContent Type

Values (Audit, Bylaws, Clinical Procedure, etc)

Content Subtype Values (Member, Patient, Staff, etc)

Functional Category Values (Environmental, Marketing,

Clinical/Amb Svc, etc) Release DateFacility

Values (Dr Office, Hospital, ER, etc)

• Full-Text Search Words

Red Rules Knowledge Red Rules Knowledge CenterCenter

Objective

The objective of the SharePoint portal is to provide a single-

source, collaborative, interactive resource for the development of reusable objects (Red Rules) and

their implementation at Presbyterian.

Red Rules Knowledge Red Rules Knowledge CenterCenterFeatures/Resources

• Blog/threaded discussion• Third party resources/links• Identification of experts• Announcements• RLO objects/documents (in progress

and published)• Survey for feedback/assessment• Calendar (and work/meeting

spaces)

Red Rules Knowledge Red Rules Knowledge CenterCenter

Red RulesKnowledge Center

Questions?