Reliability Principles

CQN Asthma ProjectJanuary 14, 2010

“I have no relevant financial relationships with the manufacturers(s) of any

commercial products(s) and/or provider of commercial services discussed in this CME

activity.”

Outline

• Definition and purpose of high reliability systems

• Measuring reliability - some simple math• Reliability principles and chronic illness

care changes– How much improvement can we expect from

each?

GLOBAL CQN AIMWe will build a sustainable quality improvement infrastructure within our practice to achieve measurable improvements in asthma outcomesSpecific Aim From fall 2009 to fall 2010, we will achieve measurable improvements in asthma outcomes by implementing the NHLBI guidelines and making CQN’s key practice changes

Measures/Goals

Outcome Measures: >90% of patients well controlled

Process Measures >90% of patients have “optimal” asthma care (all of the following) assessment of asthma control using a validated instrument stepwise approach to identify treatment options and adjust therapy written asthma action plan patients >6 mos. Of age with flu shot (or flu shot recommendation)

>90% of practice’s asthma patients have at least an annual assessment using a structured encounter form

Engaging Your QI Team and Your Practice*The QI team and practice is active and engaged in improving practice processes and patient outcomes

Using a Registry to Manage Your Asthma Population *Identify each asthma patient at every visit *Identify needed services for each patient *Recall patients for follow-up

Using a Planned Care Approach to Ensure Reliable Asthma Care in the Office * CQN Encounter Form * Care team is aware of patient needs and

work together to ensure all needed services are completed

Developing an Approach to Employing Protocols * Standardize Care Processes * Practice wide asthma guidelines

implemented

Providing Self management Support

* Realized patient and care team relationship

Key Drivers

Interventions

Form a 3-5 person interdisciplinary QI Team

Formally communicate to entire practice the importance and goal of this project

Meet regularly to work on improvement

All physicians and team members complete QI Basics on EQIPP

Collect and enter baseline data

Generate performance data monthly

Communicate with the state chapter and leaders within the organization

Turn in all necessary data and forms

Attend all necessary meetings and phone conferences

Select and install a registry tool

Determine staff workflow to support registry use

Populate registry with patient data

Routinely maintain registry data

Use registry to manage patient care & support population management

Select template tool from registry or create a flow sheet

Determine workflow to support use of encounter form at time of visit

Use encounter form with all asthma patients

Ensure registry updated each time encounter form used

Monitor use of encounter form

Select & customize evidence-based protocols for your office

Determine staff workflow to support protocol, including standing orders

Use protocols with all patients

Monitor use of protocols

Obtain patient education materials

Determine staff workflow to support SMS

Provide training to staff in SMS

Assess and set patient goals and degree of control collaboratively

Document & Monitor patient progress toward goals

Link with community resources

CQN Asthma Project Practice Key Driver Diagram Version 2.0

Associates in Process Improvement, 2009Slide 5

Health System Perspective: Quantifying “Reliability”

“Reliability” = Number of actions that achieve the intended result ÷ Total number of actions taken

“Unreliability” = 1 minus “Reliability”

It is convenient to use “Unreliability” as an index, expressed as an order of magnitude (e.g. 10-2 means that the action fails to achieve its intended result 1 time in 100)

White Paper, p. 3

Associates in Process Improvement, 2009Slide 6

Un-Reliability?

What changes in the process of care delivery will change the outcome?

Assessment of asthma control

AppropriateTreatment

ImprovedOutcomes

Associates in Process Improvement, 2009Slide 8

Definition Of “Reliability”

Reliability is failure free Reliability is failure free operation over time.operation over time.

Can reliability principles be applied effectively to improve the consistent delivery of high-quality health care?

White Paper, p. 2, 3

Reliability most connected to the IOM’s dimensions for the health care system of• effectiveness (where failure can result from not applying evidence), • timeliness (where failure results from not taking action in the required time)• patient-centeredness (where failure results from not complying with patients’ values and preferences).

Associates in Process Improvement, 2009Slide 9

Levels of Reliability

Level Reliability Success Rate Failures in 10,000 actions

1 10-1 80%-95% 1500-2000

2 10-2 96%-99.5% 50-1499

3 10-3 99.6% - 99.95% 5-49

4 10-4 99.96%-99.995 0.5-4

10-5 99.996 – 99.9995 0.1-0.4

10-6 >99.9996 <.1

White Paper, p. 4

Human Factors EngineeringRené Amalberti: Premises

• “Unconstrained” human performance (guided by personal discretion, only) is worse than 10-

2

• “Constrained” human performance can reach 10-2 to 10-3

Associates in Process Improvement, 2009Slide 11

No

system

bey

on

d

this

po

int

10-2 10-3 10-4 10-5 10-6

Civil Aviation

Nucleur Industry

Railways (France)

Chartered FlightHimalayamountaineering

Road Safety

Chemical Industry (total)

Fatal risk

Medical risk (total)

Blood transfusion

Anesthesiology ASA1

Cardiac Surgery Patient ASA 3-5

Fatal Iatrogenic adverse events

No limit on discretion

Microlight or helicopters spreading activity

Excessive autonomy of actors

Craftmanship attitude

Ego-centered safety protections, vertical conflicts

Loss of visibility of risk, freezing actions

Increasing safety margins

Becoming team player

Agreeing to become « equivalent actors »

Accepting the residual risk

Accepting that changes can be destructive

Very unsafe Ultra safe

René Amalberti

White Paper, p. 3-4

Amalberti’s Reliability Framework

Associates in Process Improvement, 2009Slide 12

Exercise

1. Review the goals on your improvement project.

2. What Level of reliability are you targeting on your project?

10-1

10-2

10-3

How reliable is the collaborative?

Alabama Data

What can we learn from variation across states?

Alabama Oregon

Ohio

Level 2 Reliability at CCCHAsthma Action Plan

How are they doing it? Optimal Care at CCCH

Components of a ProcessHave Known Failure Rates

Level 1 (80-90%) Reliability

• Team focus on the outcome goal

• Working harder

• Feedback of information on performance

• Awareness and training

• Standardize decision-making (e.g., guidelines)

Level 1 Reliability Concepts in CQN

• Team focus on the outcome goal: – Team aim and goals.

• Working harder: – Collaborative participation

• Feedback of information on performance: – Monthly measurement and feedback of results

• Awareness and training: – Training of practice physicians and staff

• Standardize decision-making: – Algorithms for severity classification, control,

medications

% of children screenedLevel 1 Reliability

Level 2 (95%) Reliability

• Real time identification of failures (“identify and mitigate”)

• Checklists and observation

• Redundancy

• Making the “right thing” the “easy thing”

• Standardization of process

Level 2 (95%) Reliability Embedded in CQN Key Drivers

• Real time identification of failures– Auditing and daily review of failures

• Checklists and observation– Templates (structured encounter form)

• Redundancy– Planned care (e.g., pre-clinic huddle involving nurses)– Monthly population review using registry for care management– Patients empowered to participate in pre-visit planning

• Making the “right thing” the “easy thing”– Protocols– Default to the appropriate option: Patients get asthma encounter form

whether physician orders or not. – Standing “flu shot” orders

• Standardization of process– Protocols and defined roles for template use (e.g., front desk, nurse)– Defined staff roles (includes hiring, training, performance evaluation)

Desired OutcomeLevel 2 Reliability

Pct asthma pts w ith current f lu vaccine

0

2040

6080

100

Pct of asthma patients w ith 3 care components

0

2040

6080

100

Pct of asthma patients w ith action plan

0

2040

6080

100

Level 3 (99%) Reliability• Preoccupation with failure:

– Real time awareness of failures– “Process Owner” for patient education– Measure days between serious events (e.g., ED visits)

• Reluctance to simplify interpretations: – Learning from each failure and from those doing

better.

• Sensitivity to operations:– Support the front line (e.g., practice coaches)

• Deference to expertise: – Avoid a strict “Top-Down” Culture

Desired Outcome:Level 3 Reliability

“Robust Design”

Outcomes+Situational factors

Process/control factors

•Optimal care•QOL•Admissions

• Level 1 Components• Level 2 Components• Level 3: Mindfulness

• Severity of problem• Values/habits/lifestyle• Preferences• Support system• Resource availability

THANK YOU

QUESTIONS?