sms and healthcare - reducing medical errors

Aviation Technology Solutions

Reducing Healthcare ErrorsSafety Management Systems (SMS)

and Safety Risk Management


Topics

• Introductions

• About JDA

• Health Care and Aviation

• Comparative Data

• System Complexity Impact

• Heinrich Safety Triangle

• Building Safer Healthcare System

• SMS

• First Steps

• Safety Culture

• Benefits


Why Are We Here?

To engage in a dialogue and get feedback about the potential application

and benefit of Aviation‟s Safety Management System to

Healthcare Patient and System Safety Challenges.

Aviation Technology Solutions4


Similarities• Significant Infallibility Issues

• Personnel Hierarchy

• Interacting Components Working

Together

• Rapid Introduction of Complex New

Technologies

• Redundancies and Backups

• Several Links in Mishap Chains

• Response to Errors - Usually

Punishment

• Safety vs. Production and/or

Throughput

• Significant Litigation Potential

DifferencesAviation Has

• Greater Inherent Reporting

Incentive (Pilots)

• More Prescriptive, Less

Judgmental Operating

Environment

• More Media and Political Attention

– Fear of Flying

• More Robust Data Collection

Infrastructure

• Independent (Non-Adversarial)

Mishap Investigation

• Federal vs. State Law

HealthCare and Aviation


Part 121 Fatal Accident Rate

(Part 121 Onboard Fatal Accidents; 5 year moving average)

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Fa

talit

y A

ccid

en

ts p

er

10

Mill

ion

De

pa

rtu

res

83% Fatality Accident

Rate Reduction

• Regulations, Policies and Programs

• Aircraft and System Design

• Crew Resource Management

• Human Factors

• Data Collection, Analysis and Corrective Action

• Checklists

• Training

Aviation Drove Down Accident Rate

Safety Management System (SMS) Key to lowering accident rate


Human Error

PersonalFactors

600

30

10

1

Incidents

Accidents

Serious Accidents

Fatal Accident

Heinrich Safety Triangle

Mandatory Reporting

Voluntary Reporting

Culture OrganizationalProceduresTrainingEquipment

Design

Causal Factors


• Public Disclosure

• Job Sanctions and/or Enforcement

• Criminal Sanctions

• Civil Litigation

Areas That Discourage Voluntary Data Collection, Analysis, and Sharing

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• More System Interdependencies Large, complex, interactive system Tightly coupled Hi-tech components Continuous innovation

• Safety Issues More Likely to Involve Interactions Between System Parts

FACILITIES

PEOPLE

MATERIALS

TOOLS

PROCEDURES

SOFTWARE EQUIPMENT

Increasing Complexity


Effects of Increasing Complexity

More “Human Error”

• System More Likely to be Error Prone• More Unanticipated Situations• Scenarios Where Non Standard Procedures No

Longer Work


HealthcareMedical Error

“Errors made by Doctors and other medical caregivers cause 44,000 to 98,000 deaths a year”

“Hospital infections , many considered preventable, take another 100,000 lives”

Mistakes involving medications injure 1.3 million patients annually in the US according to the FDA

“Avoidable failures continue to plague us in healthcare – in almost every realm of organized activity”

“The volume and complexity of knowledge today has exceeded our ability

to properly deliver it to people – consistently, correctly and safely”

“What will it take to fix healthcare? Start by getting the facts”


“If you keep doing what

you‟re doing…you‟re going

to keep getting what you

got!”

Yogi Berra


“The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into

the system.”

Institute of Medicine, Committee on Quality of Health Care in America, 1999

To Err Is Human

Building Safer Healthcare System


Institute of MedicineCommittee on Quality of Health Care in America

Recommendations

• Leadership

• Mandatory and Voluntary Error Reporting Systems

• Implement Safety Systems

• Tools

• Data

• Accountability

• Transparency

• Protocols


Safety Management System (SMS)

1. Systematic and comprehensive process for the proactive management of safety risks.

2. Integrates operations, technical services with financial and human resource management.

3. Needs to be top priority.

4. Safety culture and management commitment key!


Implementing SMS

1. Provides :

• Deal with events so valuable lessons are applied to improve safety and efficiency.

• Capacity to anticipate and address safety issues before they are incidents or accidents.

2. Instills inter-dependent culture among employees and management.

3. Reduces losses and improves productivity.


SMS Pillars

1. Safety Policy & Objectives

2. Safety Risk Management

3. Safety Assurance

4. Safety Promotion


SMS Pillar 1 Safety Policy & Objectives

• Safety Policy Senior Management’s overall safety commitment and strategy

Framework to put organization and responsibility in place.

• Safety Objectives

Leadership

Training

Measurable Safety Targets

Lessons Learned

Non-Punitive Reporting System


SMS Pillar 2Safety Risk Management (SRM)

Risk Matrix Model

• Comprehensive approach for managing risk throughout organization

• Five Phases

1. Describe the System

2. Identify Hazards

3. Determine Risk

4. Assess & Analyze Risk

5. Treat Risk


SMS Pillar 3Safety Assurance

• Continual Program Assessment• Data, management and utilization• Non-Punitive Safety Reporting System• Program audits

Internal External

• Lessons learned


SMS Pillar 4Safety Promotion

• Training & education

• Safety competency & continuous improvement

• Safety communication

• Safety culture development

Aviation Technology Solutions22

sms-demo2.com

Ability to Collect and Manage Data

All employees contribute

http://sms-demo2.com/




Safer Healthcare: Three Stage Process

Implement Safety Enhancements –

System wide

DataAnalysis

Set SafetyPriorities

Achieve consensus on

prioritiesIntegrate into

existing work and distribute

Agree onproblems and interventions


SMS First Steps

• Determine Safety Culture

Top Management Commitment

Communicate purpose/objective

Survey staff/employees

Interview representative set of employees

Collect, analyze and report results

• Conduct Safety Gap Analysis

Already in place vs. SMS

Identify strengths and shortfalls

• Compile and Report Results

• Develop SMS Plan

Good gauge of safety culture is"How we do things around here.”


Safety Culture AssessmentNeed

• Problem:

Management focuses on solving operational safety issues by

implementing process and procedural changes.

Effectiveness can be negatively affected by culture-related factors.

• Solution:

Safety Culture Assessment (SCA) conducted by Organizational

Development Specialists.

Provides both quantitative and qualitative data re: prevailing beliefs,

attitudes and behaviors within company toward safety.


Safety Culture AssessmentPurpose

• SCA identifies:

Existing safety concerns within organization.

Perceptions that may exist toward current safety

posture.

Likely amount of resistance, if any, to planned

operational change(s).

How best to build the “human” into organization‟s

mission, vision, values & objectives.


Safety Cultural Assessment Methodology

• Qualitative Data

Group and one-on-one interviews with employees at all levels of organization.

• Quantitative Data Survey Example

Online safety survey accessible to all employees.

• Reports

Written and oral presentation.

• Strategic planning

Session with management to craft action plan for addressing identified issues.

../Safety Culture/JDA_Culture_Survey_MASTER_July_2009_20090921.doc


„Choose all that apply” Questions –How Staff/Employees Describe Culture

• Perceptions of safety

culture varied across

employee groups.

• Physicians saw

culture in

unfavorable terms

while other groups

were more mixed

Top 4 Safety Descriptors %

Total Excl. Physicians:

Safety conscious 41%

Under resourced 40%

Reactive 39%

Lot of analysis, little action 38%

Physicians:

Blaming 71%

Disorganized 70%

Reactive 67%

Inconsistent accountability 65%


Data Breakdown by Functional Group How Staff/ Employees Report Safety Concerns

• Employees reported

that they generally felt

comfortable reporting

safety issues.

• Of those who had

taken online survey,

60% indicated they

had reported safety

issue

Reporting

VehicleDoctors Nurses Med Techs Pharm

%

Reported83% 36% 64% 31%

„Voluntary‟ 73% 5% 94% 13%

Supervisor 21% 91% 44% 87%

Other 12% 0% 6% 6%

TOC 9% 2% 6% 3%

Hotline 2% 2% 0% 3%

Admin 20% 5% 6% 6%


How Staff/Employees Felt Mgmt Dealt

With Reported Safety Concerns

• In reporting

safety

issues,

experience

across

employee

groups

varied

Employee‟s

ExperienceDoctors Nurses Med Tech Pharm

# Respondents 448 42 16 31

Acknowledged,

but no action30% 36% 25% 32%

Felt heard 22% 48% 19% 35%

Glad I did 17% 31% 13% 35%

Indifference 22% 5% 31% 10%

Issue addressed 9% 24% 9% 19%

Blamed 9% 2% 19% 6%

Punished 5% 2% 8% 3%


Conflicting Views of

Mgmt vs. Functional Groups

31


SMS Will…

• Establish meaningful safety policies, goals and objectives• Create individual accountability for safety• Demonstrate leadership regarding safety principles• Launch processes for risk measurement, hazard

identification and mitigation• Develop collegial interactive teams & improved

communications process • Implement non-punitive reporting; encourage “lessons

learned”• Lower accidental patient deaths and incidents• Reduce injury and damage claims costs; better productivity• Lower Operating Costs


4720 Montgomery LaneSuite 950

Bethesda, MD 20814www.jdasolutions.aero

301-941-1460

http://www.jdasolutions.aero/

sms and healthcare - reducing medical errors

Health & Medicine