![Page 1: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/1.jpg)
Everyday HeRO
Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk
AHS Provincial Patient Safety
![Page 2: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/2.jpg)
What the heck is a High Reliability Organization?
![Page 3: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/3.jpg)
Why wouldn’t we want this for healthcare?
![Page 4: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/4.jpg)
Is high reliability currently being practiced in AHS?
How do you keep patient’s
safe?
![Page 5: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/5.jpg)
Is high reliability currently being practiced in AHS?
What do you feel, hear, see
that makes you feel safe?
![Page 6: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/6.jpg)
Five principles of high reliability
The World Health Organization defines 5 characteristics that support high reliability
![Page 7: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/7.jpg)
Is high reliability currently being practiced in AHS?
![Page 8: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/8.jpg)
Commitment to
resilience
![Page 9: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/9.jpg)
Deference to
Expertise
![Page 10: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/10.jpg)
Pre-occupation
with
Failure
![Page 11: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/11.jpg)
Reluctance to
accept
simplification
![Page 12: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/12.jpg)
Sensitivity to
operations
![Page 13: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/13.jpg)
How can
patients be
proactive in their
own care?
![Page 14: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/14.jpg)
1 – 2 – 4 ALL STORYTELLING ACTIVITY
1 - Think of a high reliability behavior story (1 min)
2 – Share with someone at your table (2 min)
4 – Share the stories at your table (5 min)
ALL – Share one story with the larger group (8 min)
![Page 15: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/15.jpg)
Ever heard of a BLACK BOX being used in the OR?
![Page 16: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/16.jpg)
SafeOr Program
Alberta Health Services Quality and Patient Safety summit
October 17th
Dr Tom Lloyd, Director Saegis Safety Institute
![Page 17: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/17.jpg)
Objectives
To introduce you to a
transformative new
program in OR safety
Show how technology
and different thinking
could lead to OR and
patient safety
![Page 18: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/18.jpg)
Most incidents occur during the intra-operative phase
Phase of care when surgical incident occurred
0
100
200
300
400
500
600
700
800
900
Pre-operative Intra-operative Post-operative
HIROC CMPA
Data from Surgical Safety in Canada: A 10-year review of CMPA and HIROC medico-legal data
![Page 19: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/19.jpg)
![Page 20: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/20.jpg)
© SST
![Page 21: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/21.jpg)
The operating room is a critical area of opportunity.
To advance
patient
safety
To
improve
team culture
![Page 22: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/22.jpg)
22
The Saegis SafeOR Program
Leading
edge
technology
Data and
insights
Customized
coaching &
education
![Page 23: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/23.jpg)
23
Surgical Safety Technologies
Leading
edge
technology
Data insightsCustomized
coaching &
education
BRINGING EXPERTS FROM HEALTH SCIENCES, ENGINEERING, DATA SCIENCE, MATHEMATICS,
DESIGN, AND TECH INDUSTRY
DESIGN ENGINEERING DATA SCIENCE HEALTHCARE INDUSTRY
• Human
Factors
• Arts and
Design
• Industrial
Design
• Signal
Analysis
• Comp Science
• Biomedical
Engineering
• Math &
Statistics
• Deep
Learning
• A.I.
• Education
• Quality &
Safety
• ClinEpi
• Nursing
• Medical
Device
• Insurance
• Technology
![Page 24: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/24.jpg)
OR Black Box: The OR Quantified™
Room cameras
and surgical
cameras
OR Black Box®
Audio
recordingRoom audio
recorder
Device
sensors
Patient
physiologyWearable
techEnvironmental
factors
![Page 25: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/25.jpg)
Secure Data Transmission
• Minimal intrusion in the surgical space
• Encrypted files are transmitted over a secure socket connection to
Surgical Safety Technologies Servers, co-located at the St. Michael's
Hospital Data Center in Toronto.
Surgical Space (Hospital)St. Michael’s
Hospital Data Centre (SST)
![Page 26: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/26.jpg)
OR BlackBox
safety threats
resilience supports
error mechanisms
event patterns
performance
Data Analysis Mitigation
educational themes
![Page 27: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/27.jpg)
Early insights from research sites
Patient Safety
8+ individuals in
OR = double the
adverse events
OR doors opened
every 2 minutes
Pilot study: of 66
adverse events,
75% were
unnoticed
Team Culture
Unnecessary
conversation is a
prevalent threat
Surgical
coaching results
in significant
reduction in
errors
Efficiencies
30% of cases
have technology
malfunctions
Team member
late (13%) or
absent (7%)
Multidiscipline
team can
improve
inefficiencies
Source: SST CONFIDENTIAL
![Page 28: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/28.jpg)
Prevalent Safety Threats
CONFIDENTIAL
0 5 10 15 20 25 30 35 40
Suboptimal mental state
Active attention failure
Insufficient task experience/knowledge
Distracting human sounds
Substandard skill/technique error
Inefficient configuration/positioning
Other case interruption
Diversion, tool/tech issue
Item missing
Challenging anatomy
Unnecessary conversation
Distracting electronic sounds
Distracting workflow sounds
Tool malfunction
![Page 29: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/29.jpg)
Prevalent Resilience Supports
CONFIDENTIAL
0 5 10 15 20 25 30 35 40
Options available
Paying attention
Efficient positioning
In situ training
Communicating progress
Timeout
Safety check
Positive feedback
Good situation awareness
Verbalize/narrate action
Proactive task completion
Surgical quality control
Proactive team management
Skills coaching
![Page 30: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/30.jpg)
Data reports
• Problem
identification/
clarification
• Problem
prioritization
SafeOR supports problem identification & prioritization; facilitates QI.
Quality
Improvement
Interventions
• Coaching
• Education
![Page 31: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/31.jpg)
Lets find trouble before it finds us
Black Box does not equal disaster
Need to learn from what we did, not by whom
Aggregated data not individual cases
Confidential and non punitive
OR Black Box
![Page 32: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/32.jpg)
![Page 33: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/33.jpg)
Transparency and accountability
Perfection is not the goal
Assessment and reflection
Recognize, tolerate and learn from error
Improving safety is impossible without improving team culture
OR Black Box
![Page 35: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/35.jpg)
How do we continue to grow high reliability behaviors?
![Page 36: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/36.jpg)
CREATE
NEW CARD
CAPTIONS
NEW CARD
IDEAS
OTHER
RESOURCES TITLE 4
Cards with
pictures,
you create
the captions
to support
high
reliability
behaviors!
Do you see
the need for
a new card
concept/
design?
What resources
have you found
helpful in your
areas?
What else can
we create to
support HR
activities in your
area?
How else can
we celebrate
HR behaviors?
Insert body
text here…
Modified
Open
Space
Exercise 3 areas for discussion
![Page 37: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/37.jpg)
A shift in mindset to get ahead of harm…
![Page 38: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/38.jpg)
Oct.29-Nov.2
Join us in
celebrating
our Everyday
HeROs by
sending an
AHS Spirit
card!
![Page 39: Everyday HeRO Getting ahead of harm · Everyday HeRO Getting ahead of harm Jodi Ploquin, Roxanne Stelmaschuk AHS Provincial Patient Safety](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fd12a2a2289013a8e43c043/html5/thumbnails/39.jpg)
Thank youJodi Ploquin, [email protected]
Roxanne Stelmaschuk, [email protected]
Provincial Patient Safety, AHS