first do no harm building a culture of patient safety at novant health physician education part 1:...
TRANSCRIPT
First
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Building a Culture of Patient Safety at Novant Health
Physician EducationPart 1: Safety Concepts and Theory
©2009 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVEDPrepared for Novant Health for their non-exclusive, internal use only.
First, Do No Harm:
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Objectives: 1. Describe what we mean by building and sustaining our
patient safety culture. 2. Explain why people make errors in complex systems and
how we can reduce errors from propagating through these systems.
3. Present an overview of the Safety Behaviors here at Novant in preparation for the second part of our CME program
Goal and Objectives
Goal: Understand the Novant Safety Behaviors and commit to making them personal work habits
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Why are we here?
Mary
Nicholas
Lizzy
Molly Carson
Kiko
Damon
Mary Beth Richard
Megan
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Safety Culture – “A 747 a Day”
• 2000 IOM report, To Err is Human: Building a Safer Health System– 44,000 to 98,000 Americans dying annually from medical errors
• 98,000 = 270 people / day (747 capacity)• 44,000 = 120 people / day (737 capacity)
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Published Cases
• Savannah, GA• 500 bed academic institution• 89% reduction in 2 years
• 50% reduction in 18 months• AHA Quest for Quality Award 2004• TJC Eisenberg Quality Award 2005
• HPI - a Reliability company• Comprehensive safety culture engagement• Over 140 hospitals nationwide
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Precursor Safety Event• Reaches the patient• Results in minimal to no detectable harmAnalysis: RCA or Apparent Cause Analysis (ACA)
Serious Safety Event• Reaches the patient• Results in moderate to severe harm or deathCause Analysis: Root Cause Analysis (RCA) Required
Near Miss Safety EventDoes not reach the patient – error iscaught by a last strong detectionbarrier designed to prevent eventCause Analysis: No formal
PrecursorSafetyEvents
SeriousSafetyEvents
Near Miss Safety Event
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
SafetyEventClassificationSEC
SM
A deviation from standard of care or practice expectations that…
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Rolling 12-month rate of Serious Safety Events per
10,000 adjusted patient days
Why a 12-month rolling average?• Smoothes the curve for infrequent events• Encourages sustainability in reliable safety performance (it
takes 12 months for an event to “drop out” of the average)
# SSE during past 12 months
# APD for past 12 monthsX 10,000SSER =
Serious SafetyEventRate
SSER
SM
SSER Calculation
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1000 Bed HospitalSSER JAN 2005: 1.21SSER JAN 2007: 0.34 71.9% reduction
Serious SafetyEventRateSSER
SM
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Novant Health (9 hospitals)Rolling 12-month rate of Serious Safety Events per 10,000 adjusted patient days
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Journey to Improving Reliability
OptimizedOutcomes
10-6
10-5
10-4
10-3
10-2
10-1
Process DesignEvidence-Based Best PracticesTechnology EnablersProcess optimization/simplificationTactical interventions
Behavior AccountabilityBehavior ExpectationsKnowledge & Skills – Error PreventionReinforce & Build Accountability
Integrated With
Time
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Why Do Events Happen?
Adapted from Dr. James Reason, Managing the Risks of Organizational Accidents, 1997
Active Errorsby individuals
result in initiating action(s)
EVENT ofHARM
Multiple Barriers - technology, processes, and people -
designed to stop active errors (our “defense in depth”)
Latent Weaknessesin barriers
#1 Prevent thehuman errors
#2 Find and fixsystem and process problems
Two Strategies to Eliminate Safety Events:
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Influencing Behaviors at the Sharp End
Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994)
Design ofCulture
Outcomes
Behaviorsof Individuals & Groups
Design ofStructure
Design ofTechnology & Environment
Design ofWork
Processes
Design ofPolicy &Protocol
“You have to manage a system. The system doesn't
manage itself.”
W. Edwards Deming
"A bad system will DEFEAT a good person
every time.“
W. Edwards Deming
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As Humans, We Work in 3 Modes
Knowledge-Based Performance “Figuring It Out Mode”
Rule-Based Performance “If-Then Response Mode”
Skill-Based Performance“Auto-Pilot Mode”
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Skill-Based PerformanceWhat You’re Doing At The Time:
Very routine, frequent tasks that you can do without even thinking about it – like you’re on auto-pilot
3 in 1,000 acts performed in error(pretty reliable!)
Slip – Errors of commission – the act is performed wrong
Lapse – Errors of omission – you fail to do what we meant to do
Fumble – Motor skill errors
Errors We Experience
Stop and think before acting
Error Prevention Strategy
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Rule-Based PerformanceWhat You’re Doing At The Time:
Responding to a situation by recalling and using a rule that you learned either through education or experience
Used the wrong rule – You were taught or learned the wrong response for the situation
Errors You Experience
Educate about the right rule
Error Prevention Strategy
Misapplied a rule – You knew the right response but picked another response instead
Think a second time
Non-compliance – Chose not to follow the rule (usually, thinking that not following the rule was the better option at the time)
Reduce burden, increase risk awareness, improve coaching
1 in 100 choices made in error (not too bad!)
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Knowledge Based Performance
What You’re Doing At The Time:Problem solving in a new, unfamiliar situation. You come up with the answer by:
• Using what we do know• Taking a guess• Figuring it out by trial-and-error
30-60 of 100 decisions made in error(yikes!)
You came up with the wrong answer (a mistake)
Errors You Experience
STOP and find an expert who knows the right answer
Error Prevention Strategy
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Power Distance
Geert Hofstede’s Power Distance• Extent to which the less powerful expect and accept that power is distributed unequally• Measure of interpersonal power or influence superior-to-subordinate as perceived by the subordinate• Leads to strong Authority Gradients, which is the perception of authority as perceived by the subordinate
USA• Moderate to low PD (38th of 50 countries)• Surgeons & anesthesiologists view low• Nurses view as significantly higher
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Korean Airlines Flight 801
Bad Weather
Minor Technical
FailureFatigue
High Power
Distance
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Authority Gradient
Dr. MD
Perception of authority as perceived by the subordinate
Culturally imbedded & handed down
Requires active measures to overcome in order to communicate clearly & share vital information
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Crew Resource Management
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Assertiveness
• The willingness to state and maintain a position until convinced otherwise by facts– Requires initiative and courage to act
Behavior Continuum
PASSIVE ASSERTIVE OVER-AGGRESSIVE
‘Too nice’ Actively involved Dominating
Procrastinates Ready for action Intimidating
Avoids conflict Useful contributor Abusive
‘Along for the ride’ Speaks up Hostile
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Three Principles of AnticipationPreoccupation with FailureRegarding small, inconsequential errors as a symptom thatsomething’s wrong
Sensitivity to OperationsPaying attention to what’s happening on the front-line
Reluctance to SimplifyEncouraging diversity in experience, perspective, and opinion
Two Principles of ContainmentCommitment to ResilienceDeveloping capabilities to detect, contain, and bounce-back fromevents that do occur
Deference to ExpertisePushing decision making down and around to the person with the mostrelated knowledge and expertise
Five Principles of High ReliabilityOrganizations (HROs)
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Novant Safety Behaviors & Error Prevention Tools
1. Practice with a Questioning AttitudeA. Stop, Reflect & Resolve in the face of uncertainty
2. Communicate ClearlyA. Use SBAR-Q to share informationB. Communicate using three-way repeat backs and read backsC. Use phonetic and numeric clarifications
3. Know & Comply with Red RulesA. Practice 100% compliance with Red Rules B. Expect Red Rule compliance from all team members C. If compliance with a Red Rule is not possible, STOP action until any uncertainty can be resolved
4. Self-check: Focus on TaskA. Use the STAR technique
5. Support Each OtherA. Cross-check and AssistB. Use 5:1 Feedback to encourage safe behaviorC. Speak up using ARCC – “I have a concern”
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Novant Contact Information
• Sue DeCamp-Freeze• Senior Director Clinical Improvement• (704) 210-5767• [email protected]
• Catherine Fenyves• Patient Safety Manager• (704) 384-9329• Email: [email protected]