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High Reliability Bob Spillane MD
Interventional RadiologyDepartment of Radiology
Medical Director of Quality Hartford Hospital
High Reliability Organizations (HROs)
Bob Spillane MD Interventional RadiologyDepartment of Radiology
Medical Director of Quality Hartford Hospital
High Reliability
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High Reliability
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High Reliability
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HROs
High Reliability Bob Spillane MD
Interventional RadiologyDepartment of Radiology
Medical Director of Quality Hartford Hospital
High Reliability We’re all in this
together….Bob Spillane MD Interventional RadiologyDepartment of Radiology
Medical Director of Quality Hartford Hospital
High Reliability—We’re all in this together
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High Reliability—We’re all in this together
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High Reliability– Financial Disclosures
1. I have no financial disclosures.
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High Reliability—We’re all in this together
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High Reliability- Agenda
Hartford Hospital and Why Me?Medical Errors
The Swiss Cheese Model The Complex IR EnvironmentHigh Reliability Organizations
Characteristics of HROsHigh Reliability in IR
Crew Resource Management (CRM)Take Aways
Hartford Hospital implementation
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High Reliability—Hartford Hospital
Hartford, CT-800 beds
Established 1854Acute, tertiary care hospital
4500 transfers per year
Level 1 Trauma CenterLifeStar Helicopter program
TransplantCelebrated #3000 in 2014
1600 doctors 7000 employees
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
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High Reliability—Acknowledgements
CT High ReliabilityDr. Mary Cooper
Initiated 2012
25 of 28 hospitals
10, 000 staff trained
“CHAMP” Card
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High Reliability—We’re all in this together
Institute of Medicine1999
44, 000 – 98, 000 each year
“A 727 each day”
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High Reliability– Medical Disclosures
1. I have been involved with, or present for, medical errors.
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High Reliability– Medical Disclosures
1. I have been involved with, or present for, medical errors.
Allow me an exercise……
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High Reliability—We’re all in this together
If you have been the victim of a medical error,
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High Reliability—We’re all in this together
If a loved one, or someone you know, has been the victim of a medical error,
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High Reliability—We’re all in this together
If, through work, you’ve been party to, or present for, a medical error,
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High Reliability—We’re all in this together
Raise your hand, please
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
Swiss Cheese ModelLayered protections for failure prevention
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High Reliability—We’re all in this together
Swiss Cheese ModelLayered protections for failure prevention
J. Reason Human ErrorCambridge University Press1990
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High Reliability—We’re all in this together
Institute of Medicine
199944, 000 – 98, 000 each year
“A 727 each day”
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High Reliability—We’re all in this together
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High Reliability- Were all in this together
• James– J Patient Safety 2013;9:122-128
• Estimate based on data extrapolated from 4 data mining studies– Contemporary data – IOM To Err is Human ca. 1984
• Estimates error rate (Preventable Adverse Event, PAE)• Extrapolates a LETHAL error rate
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High Reliability—We’re all in this together
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High Reliability- Were all in this together
• James– J Patient Safety 2013;9:122-128
• Estimate based on data extrapolated from 4 data mining studies– Contemporary data – IOM To Err is Human ca. 1984
• Estimates error rate (Preventable Adverse Event, PAE)• Extrapolates a LETHAL error rate• 200 000 -400 000 per year
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High Reliability- Were all in this together
• Serious Harm is 10X-20X more common than LETHAL Harm
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High Reliability- Were all in this together
• Serious Harm is 10X-20X more common than LETHAL Harm
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
www.jointcommission.org
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
Why does this happen?
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High Reliability—We’re all in this together
We work in a COMPLEX environment
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High Reliability—We’re all in this together
We work in a COMPLEX environment
Various resourcesIR SuitesStaff needsPatient needsTransportEquipment needsIT issues “downtime”
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High Reliability—We’re all in this together
We work in a COMPLEX environment
Various resourcesIR SuitesStaff needs
Variable acuity
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High Reliability—We’re all in this together
We work in a COMPLEX environment
Various resourcesIR SuitesStaff needs
Variable acuity
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High Reliability—We’re all in this together
We work in a COMPLEX environment
Various resourcesIR SuitesStaff needs
Variable acuityEmergent add-ons
Equipment issues, phone calls
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High Reliability—We’re all in this together
We work in a COMPLEX environment
Various resourcesIR SuitesStaff needs
Variable acuityEmergent add-ons
Equipment issues, phone calls
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High Reliability—We’re all in this together
We work in a COMPLEX environment
Various resourcesIR SuitesStaff needs
Variable acuityEmergent add-ons
Equipment issues, phone calls
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High Reliability—We’re all in this together
Why does this happen?
Complex Systems are intrinsically hazardous systems
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High Reliability—We’re all in this together
Why does this happen?
Complex Systems contain changing mixtures of latent failures within them
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High Reliability—We’re all in this together
Why does this happen?
Complex Systems run in degraded mode
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High Reliability—We’re all in this together
Why does this happen?
Catastrophe is always just around the corner
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High Reliability—We’re all in this together
Why don’t these things happen more often?
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High Reliability—We’re all in this together
Why don’t these things happen more often?
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High Reliability—We’re all in this together
Why don’t these things happen more often?Complex Systems are heavily and successfully defended against failure
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High Reliability—We’re all in this together
Human Operators have dual roles: as Producers of and Defenders against failure
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High Reliability—We’re all in this together
Catastrophe requires multiple failures – single point failure is not enough
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High Reliability—We’re all in this together
Human practitioners are the adaptable element of complex systems
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High Reliability—We’re all in this together High Reliability Organizations (HROs)Concept developed based on complex systems that successfully avoid accidents and catastrophic failures
Examples studied: Aircraft Carrier operationsNuclear Power generationCommercial aviation
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High Reliability—We’re all in this together
High Reliability Organizations (HROs)Concept developed based on complex systems that successfully avoid accidents and catastrophic failures
Examples studied: Aircraft Carrier operationsNuclear Power generationCommercial aviation
Recommendations put forth:1. Seek to know what you don’t know
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High Reliability—We’re all in this together
High Reliability Organizations (HROs)Concept developed based on complex systems that successfully avoid accidents and catastrophic failures
Examples studied: Aircraft Carrier operationsNuclear Power generationCommercial aviation
Recommendations put forth:1. Seek to know what you don’t know2. Recognize the cost of failure and the benefits of reliability
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High Reliability—We’re all in this together
High Reliability Organizations (HROs)Concept developed based on complex systems that successfully avoid accidents and catastrophic failures
Examples studied: Aircraft Carrier operationsNuclear Power generationCommercial aviation
Recommendations put forth:1. Seek to know what you don’t know2. Recognize the cost of failure and the benefits of reliability3. Keep everybody in the loop
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High Reliability—We’re all in this together
1.High Consequence Industries1. Healthcare2. Nuclear Power 3. Military Command and Control4. Commercial aviation5. Space Exploration6. Wildfire firefighting7. Chemical process control8. Deep Sea Oil/Gas exploration9. Deep ground mining10.Mass transit systems11.“Big Science” projects
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High Reliability—We’re all in this together
“The healthcare industry may be the largest and most expensive endeavor in the developed world, with the United States at the top of the list of per capita expenditure.”
“ A decentralized and massive undertaking”
4000-6000 hospitals (Same number of surgicenters)Owned by 1000-2000 firms200 000 physician offices20 million surgical procedures with Anesthesia1 billion prescriptions written per year
Risk and Reliability in HealthCare and Nuclear Power: Learning from Each Other. AAMI Monograph 2013. Eds: Weinger MB Halbert BD Logan MK
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High Reliability—We’re all in this together In contrast, Nuclear Power….
About 100 Nuclear power plants in the United StatesOwned by 30-40 firmsRegulated and scrutinized by the NRCHighly-trained individuals Extensive use of simulation and team work
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High Reliability—We’re all in this together
High Consequence events: Health Care v. Nuclear PowerScale of catastrophePublicityOperator riskFacility Risk
D Gaba MD. AAMI Monograph. Page 22
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High Reliability—We’re all in this together In contrast, Nuclear Power….
About 100 Nuclear power plants in the United StatesOwned by 30-40 firmsRegulated and scrutinized by the NRCHighly-trained individuals Extensive use of simulation and team
“If you’ve seen one hospital….you’ve seen one hospital”
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together Medical Errors—
OR Fires happen maybe 600 times per year
Wrong patient or wrong side surgery happen maybe 50 times per week in the U.S.
Chasen MR Loeb JB Milbank Quarterly 2013;91(3):459-490.
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High Reliability—We’re all in this together Managing the Unexpected
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High Reliability—We’re all in this together Managing the Unexpected
Characteristics of HROs1. Preoccupation with failure.2. Reluctance to simplify.3. Sensitivity to Operations4. Commitment to Resilience5. Deference to Expertise
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High Reliability—We’re all in this together Managing the Unexpected
Characteristics of HROs1. Preoccupation with failure.2. Reluctance to simplify.3. Sensitivity to Operations4. Commitment to Resilience5. Deference to Expertise
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High Reliability—We’re all in this together
Mindfulness
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High Reliability—We’re all in this together
Mindfulness
History: L elbow pain
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High Reliability—We’re all in this together
Mindfulness
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High Reliability—We’re all in this together
Highly Reliable Organizations (HROs)
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High Reliability—We’re all in this together
Highly Reliable Organizations (HROs)—Teamwork is Innovation
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High Reliability—We’re all in this together
Highly Reliable Organizations (HROs)—Teamwork is Innovation
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High Reliability—We’re all in this together 1.Crew Resource Management (CRM)
1.Cockpit Resource Management1.IR SUITE RESOURCE MANAGEMENT
2. Coined by John Lauber1. NASA
3. NTSB analysis of United Airlines flight 173 in 19791. Crew was focused on a landing gear problem and the plane ran out of fuel
Wikipedia, “Crew Resource Management”
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High Reliability—We’re all in this together
1.IR SUITE RESOURCE MANAGEMENT
“…a set of training procedures for use in environments where human error can have devastating effect.”
“focuses on interpersonal communication, leadership, and decision making in the cockpit.”
“communication barriers are reduced and problems can be solved more efficiently, leading to increased safety.”
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High Reliability—We’re all in this together
Assertiveness
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High Reliability—We’re all in this together
Crew Resource Management
The need to speak up: HIERARCHY and the POWER DISTANCE INDEX (PDI)
IBM HR researcher Geert Hofstede, 1960s-1970s-Cross cultural psychology and its workplace impact-Questions about how people worked together,
how they solved problems, how they felt about authority
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High Reliability—We’re all in this together
Crew Resource Management
The need to speak up: HIERARCHY and the POWER DISTANCE INDEX (PDI)
Cultures have different POWER DISTANCE INDICES or POWER GRADIENTS
Moderate to Low in the United States
Industries and Teams have different POWER GRADIENTS
Anesthesiologists and Surgeons view it as LOWNurses tend to view it as HIGH
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High Reliability—We’re all in this together
Crew Resource Management
The need to speak up: HIERARCHY and the POWER DISTANCE INDEX (PDI)
Cultures have different POWER DISTANCE INDICES or POWER GRADIENTS
Moderate to Low in the United States
Industries and Teams have different POWER GRADIENTS
Anesthesiologists and Surgeons view it as LOWNurses tend to view it as HIGH
PERCEIVED POWER GRADIENTS LEAD TO AUTHORITY GRADIENTS
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High Reliability—We’re all in this together
Crew Resource Management is aboutCommunication !
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High Reliability—We’re all in this together
Crew Resource Management is about Communication !
Qual Saf Hlth Care 2002;11:355-357
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High Reliability—We’re all in this together
Intimidating behavior
Often ascribed to MDs, but it’s not just the MDs
Occurs with MDs, RNs, Techs, Pharmacists
Includes loud or profane language, but also things like,
-condescending language-not returning phone calls or pages-intimidating or belittling body language-impatient behaviors or language
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High Reliability—We’re all in this together
Intimidating behavior
Not tolerated by HROs
Why?
Because they suppress reporting of safety concerns
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High Reliability—We’re all in this together
What are we doing with this at Hartford Hospital?
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High Reliability—We’re all in this together
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High Reliability—We’re all in this together Crew Resource Management
Improved Communication
Structured interaction
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High Reliability—We’re all in this together Crew Resource Management
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High Reliability—We’re all in this together
Crew Resource Management
Expectations for interactions
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High Reliability—We’re all in this together
Multi-tasking is bad
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High Reliability—We’re all in this together
Multi-tasking is bad
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High Reliability—We’re all in this together
Focusing on the human interaction and the transfer of information
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High Reliability—We’re all in this together
Focusing on the human interaction and the transfer of information
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High Reliability—We’re all in this together Crew Resource Management
The expectation to speak up
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High Reliability—We’re all in this together
Staff training at Hartford HealthCare
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High Reliability—We’re all in this together
POLITE PERSISTENCE GRACIOUSNESS
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High Reliability We’re all in this
together….Human practitioners are the adaptable element of Complex Systems– Richard I Cook MD
Human practitioners are the adaptable element of Complex Systems– Richard I Cook MD
Thank you for having me.
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