confidential building a strategy and structure for patient safety michael leonard md cpsoc
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Confidential
Building A Strategy and Structure for Patient Safety
Michael Leonard MDCPSOC
Confidential
The Profile of Safety & Quality Leaders Superior safety / quality and operational efficiency is
their non-negotiable core value Leadership engagement and accountability - senior
and clinical, safe & just culture Cultural work – actionable cultural metrics, teamwork
& communication, environment of respect Transparency of clinical data and process Actionable, integrated metrics Reliable processes of care Learning organization - systematic flow of information,
feedback, continuous process improvement
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3*Adapted from Safeskies 2001, “Aviation Safety Culture,” Patrick Hudson, Centre for Safety Science, Leiden University
PATHOLOGICALWho cares as long as we’re not
caughtChronically Complacent
REACTIVESafety is important. We do a lot every time we have an accident
CALCULATIVEWe have systems in place to
manage all hazards
PROACTIVEAnticipating and preventing problems before they occur
GENERATIVESafety is how we do business
GENERATIVESafety is how we do business
Incr
easing A
wareness
,
Intr
ospect
ion &
Sust
ained
Inte
rventio
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The Evolution of Organizational Safety & Reliability
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Psychological safety
• Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes.
• A shared sense of psychological safety is a critical input to an effective learning system
Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, Vol. 44, No. 2 (Jun., 1999), pp. 350-383 Amy Edmondson
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Psychological Safety Is Local
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Effective Leadership With regard to quality and safety work, the most
important factor in predicting success was the quality of leadership and the organizational culture (Krause)
Organizations highly successful in safety were also generally successful in operational performance (Krause)
Clear commitment of senior and clinical leaders to quality and safety efforts is essential
Effective leaders define very clear behaviors that create value for the patient, clinicians and the organization. They model these behaviors, and have “one set of rules”, i.e. they apply to everyone.
There is engagement at all levels of the organization
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Building a Culture Where it’s Safe to Learn Safety culture is a profound driver of behavior
How long does it take when your nurses walk in to know it will be a good day or a bad day? About 10 seconds
Far too many of our caregivers tell us they are hesitant to voice a concern regarding a patient, call a difficult physician, or talk about a mistake because they believe it will be held against them or they have too little faith that something will change
Building a culture of safety is essential so we can safely share the stories internally to help drive improvement and avoid harm
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RN rates Physician Physician rates RN
% o
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team
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k Teamwork in the eye of the beholder: ICU RNs and ICU MDs rate
each other
62 Michigan ICUs 2004Only ICUs with 5 or more physicians reported here (all had 5 or more RNs)
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Using Cultural Data to Raise the Bar The perceptions of individual caregivers at a clinical
unit level are essential, as there is 5-6 times more variation there than across the hospital
Issues of psychological safety, resolving disagreements in the best interest of the patient, fear of disclosing errors, problems with handoffs, and perceptions of leadership are all common areas of profound opportunity
Look at the broad themes organizationally
Use the data so front line caregivers can debrief their results, commit to action, and link it to leadership support in a measurable fashion – this is very powerful.
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Teamwork Climate Across Michigan ICUs
No BSI = 5 months or more w/ zero
The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient
care
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Only one verification injury in a hospital where RN perceptions of safety were less than 60%
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What cultural strengths can we leverage, where are we at risk?
Debriefer Plus – Closing the Loop
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Workforce Engagement – 7S Surgical Floor
2009 Percent Favorable 2010 Percent Favorable 2010 Hospital Partner
ConfidentialAttribution: Margaret Cornell, MS, RN
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Linking Culture and Outcomes:RI ICU Effort to Decrease Infection
• ICU’s that reflected on their SAQ scores and took action:
– Increased their SAQ scores in 5 of 6 domains
– Achieved a 10.2% decrease in BSI rates
– Achieved a 15.2% decrease in VAP rates
● ICU’s that did NOT reflect on their SAQ scores and take action:
– Increased their SAQ scores in 1 of 6 domains
– Achieved a 2.2% decrease in BSI rates
– Achieved a 4.8% increase in VAP rates
Attribution: Margaret Cornell, MS, RN
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Social Metrics – Attitudes / PerceptionsClinical Metrics – Process/ Outcome / Risk
Operational Metrics
Tracking / Measuring
Debriefing with Action
Analysis / Integration
Leadership Engagement / Support to Unit
Level Caregivers
Data AcquisitionFeedbackValidation
Improvement
Continuous Learning – the Cyclic Flow of Information
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Accountability – Fair and Just Culture Clear, simple rules - “one set” that apply to everyone
Four questions:
- Was there malice involved?
- Was the individual knowingly impaired?
- Was there a conscious unsafe act?
- Did the person(s) make a mistake that someone of similar skill and training could make under those circumstances?
What is the elevator speech?
How are you going to drive it to the front line caregivers?
How are you going to reinforce the message so it becomes “the way we do business?”
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Systemic Migration of Boundaries:
Deviation is Normal
Usual Space Of Action
Safety Reg’s & good practices,
accreditation standards
100%
Expected safe space of action as defined by professional standards
‘Illegal normal’Real Life standards
60-90%
100%AgreementNon-acceptable
Rene Amalberti, MD, PhD
HIGH Production Performance LOWLO
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Ind
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HIG
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A System Error Gets Personal
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Little Blue Vials
• Heparin flush for the NICU
• We know this is a dangerous drug
• Desired concentration 10U / ml
• That’s what it says on the outer box
• Somehow it’s 1000 U / ml on the little blue vials
• Who could make that mistake in a busy Level 3
NICU?
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• Nine people – 3 neonatologists, 6 NICU nurses
• How did they figure it out? When they started bleeding – a lot.
• System error or nine incompetent people?
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Other ‘holes’due to latentconditions
DANGER
The Swiss Cheese Model of Organizational Accidents
© 2011 Pascal Metrics27From Reason, J. Human Error. Cambridge Univ. Press. 1990
Dangerous drug
Outer box says the right thing – 10 U /
ml
Fragile, sick newborns – high risk population
Very experienced, 20 year veteran, competent pharmacy tech
No verbal readback or confirmation of contents
Familiarity – experienced team – assumption of safety
Vials are small and hard to read –
they’re all blue
Multiple children get 100 times too much heparin – 3 fatalities
Lack of organizational learning – has
happened before
Some ‘holes”due to active failures
Defencesin depth
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Drawing the Bright LineMalicious
Substance Use
Conscious unsafe act
Substitution Test could 2-3 others make the same mistake in similar circumstances?
Repeat EventsRemediate / replace
Safe Harbor – Safe Harbor – Systems Systems ApproachApproach
Reason, James
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Why Do So Few Organizations Do This Well?
It is not real to front line caregivers –they don’t see it every day
Senior and middle managers are crucial to support the message
Consistency and reinforcement of the message is key
Alignment with HR is essential
Coupling with effective disclosure programs can be an important driver – COPIC, Michigan, Duke
Leaders taking real cases to front line caregivers is an important success factor
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Effective Communication and Teamwork Requires:
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Structured Communication
SBAR
Assertion/Critical Language
Key words, the ability to speak up and stop the show
Psychological Safety An environment of respect
Effective Leadership Flat hierarchy, sharing the plan, continuously inviting other team members into the conversation, explicitly asking people to share questions or concerns, using people’s names
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18% reduction in mortality Significant improvement in safety culture scores Significant improvement in surgical process measures – DVT, antibiotic administration On time OR starts – went from 38% to 60% 25% reduction nursing turnover Circulating nurses left the room less 144 serious events prevented, 11 million dollars
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Annotations
1: Marked beds at 30 degree angle2: Fact Sheet for staff education3: Poster with weekly data feedback4: Vent bundle posted in all vent patient rooms5: Began initial trials of Daily goal sheet and pre-extubation sheet6: Initiated Powerpoint education for RT/RN7: Initiated Clinical Pharm rounds8: 1st test of multidisciplinary rounds9: Expanded use of Pre-extubation sheet
ICU Percent of Patients Receiving all Four Aspects Of Ventilator Bundle
10: Staff education on Goal sheet; mini inservices on unit on SBT and Pre-extubation sheet11: Incorporated Goal Sheet into Multidisciplinary Rounds12: Impact Extravaganza (staff/MD education)13: Expanded multidisciplinary rounds to include additional disciplines14: Check compliance on night shift past 2 weeks15: New sign at HOB,16: One on one follow up by Nursing & RT managers on collaboratiion in weaning process
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GRI VAP Prevention Bundle Reliability and VAP rate per 1000 ventilator days
Aim: > 95% reliability by March 2009
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Ventilator AssociatedPneumonia rate per1000 ventilator days
Median over first 6months
Ventilator AssociatedPneumonia carebundle reliability (%)
AIM
DG sheet
Script of questions to ask Drs
Retesting at DG sheet; handling sript; change DG sheet
DG sheet change; prompts added
Last VAP 02/01/2009
Malcolm DanielMalcolm Daniel
Department of Department of AnaesthesiaAnaesthesia
Glasgow Royal Glasgow Royal InfirmaryInfirmary
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Evolution of Risk Mitigation
No Preventable mortality – HSMR, sepsis, rapid response, etc.
No preventable harm – triggers, AE
– Baylor 30% patients with positive trigger / 6% patients adversely affected or increased LOS
- North Carolina study – 10 hospitals, 25% patients experienced harm – 60% “avoidable”
- More studies – KP, Florida Hospital, OIG all over it
No preventable risk
© 2011 Pascal Metrics
©2009 Baylor Health Care System
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Approaching preventability: Limit blame to increase learning
For 1,107 adverse events at Baylor identified by a random review of ~5,000 charts, RNs evaluated preventability:
Not preventable: 28%
Possibly preventable: 60%
Probably preventable: 10%
Definitely preventable: 1%
Key point: Patient safety should focus on making our systems more reliable i.e. less likely to fail
Primarily due to systems
Systems and people
©2009 Baylor Health Care System
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E F G H I TotalInfection 6.7 4.2 0.0 0.2 0.0 11.1Medication AE 18.8 3.7 0.0 1.2 0.3 24.0Thrombosis/Emboli 0.7 1.5 0.0 0.0 0.0 2.2Fall with Injury 0.3 0.2 0.2 0.0 0.0 0.7Pressure Ulcer 1.0 0.2 0.0 0.0 0.0 1.2Sepsis 0.5 0.7 0.0 0.0 0.3 1.5Stroke 0.0 0.3 0.2 0.0 0.0 0.5Pneumothorax 0.0 0.5 0.0 0.0 0.0 0.5Surgical/Procedural AE 31.3 12.6 0.2 1.7 0.3 46.1Perinatal AE 3.4 0.5 0.0 0.2 0.0 4.0Other AE 3.0 0.5 0.2 0.2 0.0 3.9Fluid Overload/Pulm. Edema 1.0 0.7 0.0 0.2 0.0 1.8Blood Transfusion Reaction 0.5 0.0 0.0 0.0 0.0 0.5IV Infiltrate 2.2 0.0 0.0 0.0 0.0 2.2
Total 69.4 25.5 0.7 3.5 1.0 100.0
Hospital Acquired Adverse Event Type vs. Severity
Adverse Event TypeNCC-MERP Injury Score (%)
GTT Data Guides PS Goal Setting
Courtesy Dr. Don Kennerly, BHCS
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Implementation – Making it Real
What are the broad themes that we want to drive throughout the organization?
At a unit or service line level, what are the: 2-3 areas of safety culture we want to focus on?
2-3 team behaviors we can embed – brief/ checklist/ critical language/ debrief?
2-3 process / operational / outcome measures we can focus on, test and improve?
Drive continual improvement through debriefing, capture, analysis and systematic feedback?
© 2011 Pascal Metrics