eliminate devastating medical errors with 10 high reliability safety tools

Eliminating Harm Using 10 Proven High Reliability Tools 10 PROVEN Tools You Can Use Today

John Byrnes MD & Sonja Beute

Learning Objec-ves Discover how to implement the 10 most important high reliability tools that will improve patient safety by reducing medical errors. Describe a strategy to convince senior leadership that these tactics are effective and efficient solutions for reducing medical errors

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Agenda •  The Number of American Deaths Caused by Errors

•  Review 10 + High Reliability/Safety Tools •  Case Studies •  Recommended Resources (Bibliography) •  Surprise Bonus if you stay for the en-re presenta-on -‐ $400 Value !

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Sonja Beute •  Sonja Beute, currently serves as a System

Director for Spectrum Health, headquartered in Grand Rapids, Michigan.

•  Ms. Beute has over 14 years of healthcare experience in the areas of clinical integration, quality improvement, patient safety, education, and communications. She is an education specialist with special expertise in adult learning principles.

•  She is a gifted communicator and public speaker and always achieves the highest ratings on speaker evaluations.

John Byrnes MD •  Dr. John Byrnes is na-onally recognized for his work in quality, safety, and physician leadership. He is Clinical Associate Professor, MSU, College of Human Medicine and Founder of the Byrnes Healthcare Group.

•  In this role, he designs award winning quality and safety programs for healthcare organiza-ons throughout the US and Europe. As the CQO, his last organiza-on received over 100 quality awards, was ranked as a Top 15 health system on three occasions, and received mul-ple Top 100 hospital designa-ons.

•  Dr. Byrnes is on the na-onal faculty of the American Associa-on for Physician Leadership (formerly ACPE) and serves on the Na-onal Board of Directors for the Healthcare Financial Management Associa-on.

•  He has authored over 35 ar-cles and eight book chapters. His first book, The Quality Playbook, will be released in May 2015.

•  He’s been a guest lecturer at the UC Berkeley Haas Business School, UM Ross Business School, Baylor College of Medicine, MIT, and Emory School of Medicine, among others.

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Eliminating Harm Using 10 Proven High Reliability Tools 10 PROVEN Tools You Can Use Today

John Byrnes MD & Sonja Beute

What’s Going On In Our Hospitals?

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220,000 to 440,000 Deaths per Year

“PAEs (preventable errors) account for “roughly one-sixth of all deaths

that occur in the U.S. each year.”

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–The Advisory Board Company, Sept. 24, 2013

“Medical Errors May Be the Country’s Third Leading Cause of Death”

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Answer: High Reliability Organizations

A Culture of SAFETY

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The CEOs (Leaders) 10 Step Checklist for Safety Success

•  CEO is THE Leading Role •  Makes Q&S the #1 Priority •  Makes Safety a Core Value •  Establishes a Board Quality Commidee •  Conducts Monthly Systema-c Review equal to scope of Monthly Financial Review

•  Establishes C-‐Suite Accountability •  Intolerant of Holdouts – Takes Decisive Ac-on •  Well versed in Q & S Science •  Dedicated adequate RESOURCES •  Chars or Co-‐chairs the organiza-on's Quality Commidee

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Can You Do These? But … Will You Do These?

C-Suite Leaders:

You Hold the Key “The culture of a company, is the

behavior of its leaders … You change the culture of a company by changing the

behavior of its leaders.”

Dick Brown

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Tool #2: Data

Serious Safety Event Rate

Data and information that rivals financial reporting

Incentivize no-fault reporting

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#3: Analyze the Data Cause Analysis

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Great Summary

Lewis, G. et al, Concepts from Aviation That Could Improve Patient Safety, The Milbank Quarterly, Vol. 89, No. 1, 2011 (pp. 4-38)

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Safety Tac-cs & Tools Used in Avia-on

•  Checklists

•  Crew Resource Management

•  Joint Safety Briefings

•  Minimum safety requirements

•  Sterile cockpit rule

•  Alterna-on of roles

•  Standard layout

•  Black box

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Has Antibiotic Been Given Within the Last

60 min?


•  Checklists

•  Crew Resource Management

•  Joint Safety Briefings

•  Minimum safety requirements

•  Sterile cockpit rule

•  Alterna-on of roles

•  Standard layout

•  Black box

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•  Corporate responsibility for training

•  First names only rule

•  Incen-vized no-‐fault repor-ng

•  Bodle-‐To-‐Throdle rule

•  Mistake proofing

•  Forcing func-ons

•  Flight envelope protec-on

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Crew Resource Management

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#5 Crew Resource Management

•  Avoid the errors that you can by good system design

•  Trap the errors you cannot prevent through collegial interac-ve teams

•  Mitigate the consequences of the errors you cannot trap -‐ back up strategies

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#5 Crew Resource Management • Situa-onal Awareness

• Group Dynamics/ Team Decision Making

• Effec-ve Communica-on

• Leadership

• Asser-veness

• Shij Planning and Event Analysis

• Conflict Resolu-on

• Workload Management

• Risk Management/Mi-ga-on

• Stress Management

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Ideal Hospital Loca/ons …

Sterile Flight Deck AKA No Interrup-on Zones

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Sterile Flight Deck

Think of “No Interruption” Periods for Anesthesia Administration!

Induction!

Emergence!

Maintenance!

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Standardized Layouts

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Standardized Communica-on

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•  Standardized Phraseology

•  Read back of cri-cal communica-ons

•  Important communica-ons are structured

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Joint Safety Briefings

•  Daily Check-‐In •  Safety Huddles •  Time out before procedures

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First Names Only

•  Demonstrating rank!•  Asking permission!•  Subordinates take blame!•  Class divisions!•  Hierarchy!•  “Insubordination”!

Low Power Distance Culture

•  Flat organization!•  Teamwork!•  Independence!•  Common connection!•  Social network!•  Encouragement!

High Power Distance Culture

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FNO + ARCC

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Simula-on But not how you imagined it!

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Safety Coaches

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Avia-on Engineering Solu-ons

•  Mistake Proofing –  Error is prevented by design

•  Forcing Func-ons –  You don’t have a choice to do the wrong thing

•  Flight Envelope Protec-on –  The system will not let you go outside preset parameters

•  Black box –  Recordings are being made

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RED RULES

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Used with permission, HDVCH, Spectrum Health

Errors Resulting in Patient Harm

Safety Culture Transformation + HRD

76% reduc/on at 2 years

Over 90% reduc/on at

4 years

High

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Children’s National Hospital

54 Harm Events Avoided

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Children’s National Hospital

$66,809,000 Saved

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Safety Culture

Ignites Hospital Turnaround

Before:Mired in controversy and almost closed !

by the community

After:No harm events in over 835 days

Top 100 Hospital three years in a row

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The Tools We Reviewed •  CEO & C-‐Suite Leadership •  Safety Must Be a Core Value •  Data & Metrics -‐ The SSER •  Cause Analysis •  Checklists •  Crew Resource Management •  Joint Safety Briefings •  No Interrup-on Zones •  Standardized Layouts •  Standardized Communica-on •  First Names Only & ARCC •  Red Rules •  Safety Coaches •  Daily Check-‐in and Safety Huddles

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Secret Recipe for Safety Success

1 CEO 1 PSO 1 Secret Ingredient Pinch PT Trainers 2 cups Common ____ 4 cups KIS Powder Bake – 2hr Training

Together, We Can Fix This ! And, It Doesn’t Have to be Hard !

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A Surprise Bonus and

Thank You

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www.JohnByrnesMD.org

Sign up Today !

Will be published in May – FREE chapters at www.JohnByrnesMD.org

Bibliography & Resources on the following slides

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Great Summary

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High Reliability Organiza-on

•  Preoccupa-on with Failure

•  Sensi-vity to Opera-ons

•  Reluctance to Simplify •  Commitment to Resilience

•  Deference to Exper-se

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2009 ACHE James A. Hamilton Book of the Year

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Dekker and Marx

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Sydney Dekker

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Reason and Dekker

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