pursuing zero harm - solutions for patient safety

Pursuing Zero Harm:Moving A Strategic Priority- Safety

Jeffrey M. Simmons, MD, MScSafety Officer, CCHMC

Associate Division Director, Hospital Medicine

Associate Professor of Pediatrics

Setting a Strategic Goal

Measurement

Theory

Case Study--CLABSI

Serving as a Catalyst

Today’s Discussion

DISCLAIMER: This document is part of the quality assessment activities of Ohio Children’s Hospitals’ Solutions for Patient Safety Learning Network and, as such, it is a confidential document not subject to discovery pursuant to Ohio Revised Code Section 2305.25, 2305.251, 2305.252, and 2305.253. Any committees involved in the review of this document, as well as those individuals preparing and submitting information to such committees, claim all privileges and protection afforded by ORC Sections 2305.25, 2305.251, 2305.252, 2305.253 and 2305.28 and any subsequent legislation. The information contained is solely for the use of the individuals or entity intended. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this information are prohibited.

High Reliability System For

Safety

Strategic Goal:Eliminate Serious

Harm For All Patients

Pyramid of Harm(Patient and Employee)

SSE’s &Lost-timeInjuries

Serious Harm Index &OSHA Recordable Injuries

Events of Minimal to Moderate Harm &All Employee Injuries

Near-Miss EventsPatient and Employee

Strategy:Focus on the topof the pyramid andprogressively move down


Measurement

Theory

Case Study--CLABSI



CCHMC OSHA Rate

30

32

1

1

20

22

92

29

18

35

1

7

21

67

19

0 20 40 60 80 100

Slip, Trip or Fall

Overexertion

Other

Motor Vehicle Accident

Exposure

Caught / Struck

BBP Exposure

Aggressive Patient

OSHA Fiscal Year Comparison

FY2017 (168) FY2016 (227)

Children's Hospitals' Solutions for Patient Safety (SPS) National Network

Cincinnati Children's Hospital Medical Center

Central Line Associated Blood Stream Infections (CLABSI)


Measurement

Theory

Case Study--CLABSI



Key Processes

VAP Bundle

CLA-BSI Bundle

Pressure Ulcer Bundle

Discharge Bundle

CA-UTI Bundle

Etc, etc, etc………..

High Reliability Organizations

Environment rich with potential for errors

Unforgiving social and political environment

Learning through experimentation difficult

Complex processes

Complex technology

Karl E. Weick, PhD

Kathleen M. Sutcliffe, MSN, PhD

DEVELOPING MINDFULNESSAware of All Harm – Immediately

Aware of All Risk – Continuously

Harm Reduction Owned – By All Leaders

Front Line Teams Feel Supported – Every Shift

We Learn From Errors – Every Day

Organizational Mindfulness

1. Preoccupation with failure

2. Sensitivity to operations

3. Reluctance to simplify

4. Commitment to resilience

5. Deference to expertise

Preoccupation With FailureRegarding small, inconsequential errors as a symptom

that something is wrong; finding the half event

We treat near misses and errors as information about the

health of our system and try to learn from them

Managers seek out and encourage bad news

People are rewarded if they spot problems, mistakes,

errors or failures

Sensitivity To OperationsPaying attention to what’s happening on the front line

Should problems occur, someone with the authority to act

is always accessible and available, especially to people on

the front lines

People are familiar with operations beyond one’s own job

Managers constantly monitor workloads and are able to

obtain additional resources if the workload starts to

become excessive

Reluctance

To Simplify InterpretationsEncouraging diversity in experience, perspective and

opinion

Questioning is encouraged

People are not attacked when they report information that

could interrupt operations

People show considerable respect for one another

Commitment To ResilienceDeveloping capabilities to detect, contain, and bounce-

back from events that do occur

Resources are continually devoted to training and

retraining people to operate the technical system

People want to learn and do learn from mistakes

Asking “What If…?” is a normal part of work

Deference To ExpertisePushing decision making down and around to the

person with the most related knowledge and expertise

People respect the nature of one another’s job activities

People in this organization value expertise and experience

over hierarchical rank

People typically “own” a problem until it is resolved


Measurement

Theory

Case Study--CLABSI



High Reliability Case Study

Lessons learned from CCHMC CLABSI experience 2015-2017

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

Apr 16

May 16

Jun 16

Jul 16

Aug 16

Oct 16

Nov 16

3 8 12 13 13 14 7 9 10 5 9 13 9 13 11 8 8 4 7 9

4968 5195 5411 4592 4533 4698 4663 4755 4479 4578 4723 4651 5128 4788 5287 4533 5474 4331 4879 4494

0.60 1.54 2.22 2.83 2.87 2.98 1.50 1.89 2.23 1.09 1.91 2.80 1.76 2.72 2.08 1.76 1.46 0.92 1.43 2.00

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

Apr 16

May 16

Jun 16

Jul 16

Aug 16

Oct 16

Nov 16

1180 1430 1382 74 787 602 729 752 682 640 9 37 44 36 166 227 271 226

1248 1539 1448 74 806 631 753 779 708 676 10 46 58 37 208 292 337 274

94.6% 92.9% 95.4% 100.% 97.6% 95.4% 96.8% 96.5% 96.3% 94.7% 90.% 80.4% 75.9% 97.3% 79.8% 77.7% 80.4% 82.5%

44.9% 41.4% 50.7% 39.4% 38.2% 50.% 46.5% 47.1% 50.% 50.% 38.5% 36.8% 39.2% 42.5% 44.9% 37.% 43.% 36.3% 41.8% 41.4%




Feb 15

Sep 16

Monthly Hospital Rate 2.23 2.96

# of CLABSI Ev ents 10 13

Central Line Days 4477 4391

Maintenance Bundle

Feb 15

Sep 16

Bundles Completed 1377 227

% of Hospital At 90% Reliability 48.6% 38.5%

Bundles Rev iewed 1453 292

% Reliability to Bundle 94.8% 77.7%

Theory:If improve process reliability will improve outcomes

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

Apr 16

May 16

Jun 16

Jul 16

Aug 16

Oct 16

Nov 16

3 8 12 13 13 14 7 9 10 5 9 13 9 13 11 8 8 4 7 9

4968 5195 5411 4592 4533 4698 4663 4755 4479 4578 4723 4651 5128 4788 5287 4533 5474 4331 4879 4494

0.60 1.54 2.22 2.83 2.87 2.98 1.50 1.89 2.23 1.09 1.91 2.80 1.76 2.72 2.08 1.76 1.46 0.92 1.43 2.00

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

Apr 16

May 16

Jun 16

Jul 16

Aug 16

Oct 16

Nov 16

1180 1430 1382 74 787 602 729 752 682 640 9 37 44 36 166 227 271 226

1248 1539 1448 74 806 631 753 779 708 676 10 46 58 37 208 292 337 274

94.6% 92.9% 95.4% 100.% 97.6% 95.4% 96.8% 96.5% 96.3% 94.7% 90.% 80.4% 75.9% 97.3% 79.8% 77.7% 80.4% 82.5%

44.9% 41.4% 50.7% 39.4% 38.2% 50.% 46.5% 47.1% 50.% 50.% 38.5% 36.8% 39.2% 42.5% 44.9% 37.% 43.% 36.3% 41.8% 41.4%% of Hospital At 90% Reliability 48.6% 38.5%

Bundles Reviewed 1453 292


Maintenance Bundle

Feb 15

Sep 16



# of CLABSI Events 10 13





Feb 15

Sep 16

But, in 2015:The rules changed

Results in 2014: As process reliability increased to >90%, outcomes improved

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

Apr 16

May 16

Jun 16

Jul 16

Aug 16

Oct 16

Nov 16

3 8 12 13 13 14 7 9 10 5 9 13 9 13 11 8 8 4 7 9

4968 5195 5411 4592 4533 4698 4663 4755 4479 4578 4723 4651 5128 4788 5287 4533 5474 4331 4879 4494

0.60 1.54 2.22 2.83 2.87 2.98 1.50 1.89 2.23 1.09 1.91 2.80 1.76 2.72 2.08 1.76 1.46 0.92 1.43 2.00

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

Apr 16

May 16

Jun 16

Jul 16

Aug 16

Oct 16

Nov 16

1180 1430 1382 74 787 602 729 752 682 640 9 37 44 36 166 227 271 226

1248 1539 1448 74 806 631 753 779 708 676 10 46 58 37 208 292 337 274

94.6% 92.9% 95.4% 100.% 97.6% 95.4% 96.8% 96.5% 96.3% 94.7% 90.% 80.4% 75.9% 97.3% 79.8% 77.7% 80.4% 82.5%




Maintenance Bundle

Feb 15

Sep 16








Feb 15

Sep 16

CDC/NHSN expanded CLABSI definition

• 2015: Outcomes worsened• But our process remained

reliable

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

Apr 16

May 16

Jun 16

Jul 16

Aug 16

Oct 16

Nov 16

3 8 12 13 13 14 7 9 10 5 9 13 9 13 11 8 8 4 7 9

4968 5195 5411 4592 4533 4698 4663 4755 4479 4578 4723 4651 5128 4788 5287 4533 5474 4331 4879 4494

0.60 1.54 2.22 2.83 2.87 2.98 1.50 1.89 2.23 1.09 1.91 2.80 1.76 2.72 2.08 1.76 1.46 0.92 1.43 2.00

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

Apr 16

May 16

Jun 16

Jul 16

Aug 16

Oct 16

Nov 16

1180 1430 1382 74 787 602 729 752 682 640 9 37 44 36 166 227 271 226

1248 1539 1448 74 806 631 753 779 708 676 10 46 58 37 208 292 337 274

94.6% 92.9% 95.4% 100.% 97.6% 95.4% 96.8% 96.5% 96.3% 94.7% 90.% 80.4% 75.9% 97.3% 79.8% 77.7% 80.4% 82.5%




Maintenance Bundle

Feb 15

Sep 16








Feb 15

Sep 16

Upon further review:• New definitions didn’t explain the whole story• Through interviews/observation we learned about practice

variability as a result of…• Unit-specific improvement work• Rapid implementation of new equipment

December 2015:• Cease and desist all testing• Develop ONE standard of CLABSI care

Key Aspects of ONE standard

• Direct observation to see variation and understand barriers

• Commit to consensus

• Human Factors lens to simplify practice where possible, and better articulate rationale

• Staged roll-out to sustain fidelity of training

• Gather ongoing “chatter” to reveal barriers• “TRIP Tank”

• Process measurement paradigm shift• Observing to coach instead of checking boxes

CLABSI Prevention Standard Rate

• Partnership 4 SPS hospitals & Toyota (June 2016)

• 1 Pilot unit @ CCHMC

• Spread other HACs and Units

PICU VisualDisplay Board

Human Factors (HF) Support for CLABSI ONE Standard

• Two primary objectives of human factors support:

1. Enhance the effectiveness and efficiency with which work is carried out • For this task, specifically looking at optimizing workflow for CVC

maintenance bundles

2. Enhance desirable human values, such as improved safety, reduced stress, greater user acceptance, etc

HF Involved at throughout

Design Phase

• Active member of the CLABSI Team to support the design and implementation

• Conducted observations of frontline staff while performing key CVC maintenance to get to know their work environment

• Partnered to facilitate focus group sessions to redesign/optimize the current workflows and engage staff to help solve the problem from their perspective

Implementation Phase

• Collaborated to develop a training model for educating the frontline staff

• Participated in interactive training sessions

• Small trainer to learner ratio (1:2).

• Fostered staff engagement to encourage them to troubleshoot barriers and challenges

How? HF Involved at All Level (con’t)

• Implementation Phase (continued)

• Partnered to redesign and optimize the dressing change, hub entry, and needless connector entry kits

• Ensure staff have the tools they need to do their jobs

• Execution (“Go Live”)

• Provided continued support during the training and Go Live

• Support staff during the transition to increase confidence and reinforce issues before they become a habit

• Active participant in the CLABSI TRIP TANK

• Monitor and influence the adoption of the new changes from the frontline staff

Outcomes

• The CLABSI One Standard reduced the number of hand hygiene moments by 20% in the Dressing Change workflow

• The CLABSI One Standard optimized the workflow by reordering steps to support the natural sequence performed by the RNs

• The CLABSI One Standard reduced the number of instructional steps by 50%, supporting the reduction of human error


Measurement

Theory

Case Study--CLABSI



On A Journey Toward Zero Harm

Solutions for Patient Safety

OUR MISSION:

Working together

to eliminate serious harm across

all children’s hospitals

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.gettyimages.com/detail/photo/mixed-race-girl-sleeping-in-hospital-bed-with-teddy-royalty-free-image/95580491&ei=uyPAVM72EZHGsQTihYG4BA&bvm=bv.83829542,d.cWc&psig=AFQjCNE95EpoV3MG7NshfoVIOx1qhEw7cg&ust=1421964564096904

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.gettyimages.com/detail/photo/mixed-race-girl-sleeping-in-hospital-bed-with-teddy-royalty-free-image/95580491&ei=uyPAVM72EZHGsQTihYG4BA&bvm=bv.83829542,d.cWc&psig=AFQjCNE95EpoV3MG7NshfoVIOx1qhEw7cg&ust=1421964564096904

500 Per MonthZERO

Working Together

46

130+ Children’s Hospitals

Greater than 50% of

Admissions

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Our ApproachLeadership MattersExecutive leadership is a critical aspect of successful improvement in pediatric patient safety. The network has designed efforts to inspire and continuously develop the safety leadership skills of the executives who lead our network hospitals.

Our mission motivates all that we do We must act with urgency and discipline, focusing on outcomes through a combination of high reliability concepts and quality improvement science methods. We learn through testing and partnering with families and front-line staff.

Network hospitals will NOT compete on safetyInstead, the SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone.

Our Approach (continued)

“All Teach, All Learn”SPS network hospitals must humbly share and gratefully learn from others. Accomplishing our goals requires focus on the detailed processes and cultural elements that lead to safer hospitals; guidance and support for hospital teams as they build the capacity for change; and facilitating relationships within the network to broaden and accelerate learning.

Network hospitals must commit to building a “culture of safety”Hospitals within the network are employing the cultural transformation strategies of other high reliability industries to significantly reduce harm in their institutions. This emphasis on creating a culture of safety within pediatric institutions is a unique aspect of SPS’s approach.

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PATIENT AND FAMILY ENGAGEMENT (PFE)

LEADERSHIP METHODS (LM)

ERROR PREVENTION (EP)

DISCLOSURE

40% reduction in pediatric HACs and 20% reduction in the readmit rate across SPS by 12/31/18

50% reduction in SSEs by 12/31/18

25% reduction in DART by 6/30/19

EMPLOYEE/STAFF SAFETY

Our Approach

Thank [email protected]

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pursuing zero harm - solutions for patient safety

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