The Pursuit of Zero Harm – The
Goal of Highly Reliable Health
Care Organizations
A Webinar for NACBH
January 15, 2019
David Grazman, PhD
Center for Transforming Healthcare
2© 2019 Center for Transforming Healthcare All Rights Reserved.
Speaker Information
▪ Dr. David Grazman joined the Center for Transforming Healthcare leadership team in
2016 to oversee broad adoption of the Center’s High Reliability offerings including the
OroTM 2.0 assessment, as well as Robust Process Improvement® (RPI ®) program
building and training.
▪ 20+ years focused on healthcare systems strategy, provider management and clinical
operations across a variety of care settings (hospitals, behavioral health, home care,
primary care medical homes) as an administrator, a consultant, and an academic
researcher.
3© 2019 Center for Transforming Healthcare All Rights Reserved.
Today’s Objectives
1. Introduce you to Joint Commission Center for Transforming Healthcare and how it can support NACBH members as they think about Zero Harm
2. Explain the basic concepts of high reliability and high reliability healthcare – leadership commitment, safety culture and robust process improvement (RPI®).
3. Explore the components of RPI and how they start to drive an improvement culture within an organization
4. Quick glimpse into how one children-focused BHC has used RPI
5. An Overview of Two Change Management Tools
4© 2019 Center for Transforming Healthcare All Rights Reserved.
All people always
experience the safest,
highest quality, best-
value health care
across all settings
One Shared Vision
5
© 2018, Joint Commission Center for Transforming Healthcare
• Zero patient falls
• Zero complications of care
• Zero hospital-associated infections
• Zero patient safety events of any kind
• Zero harm to employees and visitors
• Zero lost opportunities to provide exemplary care
What does it look like?
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NACBH Mission Statement
To advance the field of children’s behavioral
health by engaging talented and promising leaders
to identify emerging practices of excellence and
transform them into effective public policy, while
promoting their broad implementation.
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Typical Healthcare Improvement
▪ Usual approach: best practices, toolkits, protocols, checklists, “bundles”
− Typical best practice is “one-size-fits-all”
− Can produce modest improvement
− Difficult to sustain, harder to spread
▪ The “one-size-fits-all” approach works well only for simple problems that do not vary
▪ Toughest problems are not simple
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Current State of Improvement▪ We have made some progress
− Project by project: leads to “project fatigue”
− Satisfied with modest improvement
▪ Current approach is not good enough
− Gains hard to achieve, difficult to sustain
− They are even harder to duplicate (spread)
▪ High reliability offers a different approach
− The goal is much more ambitious
− High reliability is not a project
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Why embark on a high reliability journey?
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© 2018, Joint Commission Center for Transforming Healthcare
What is High Reliability?
How Does This Impact Behavioral Health or the Children and Families We Care For?
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Transform health care
into a high-reliability
industry
© C
op
yrig
ht, T
he
Jo
int C
om
mis
sio
n
High Reliability Industries
12© 2019 Center for Transforming Healthcare All Rights Reserved.
5 Principles of High Reliability Organizations
Anticipation – “Stay Out of Trouble”
1. Preoccupation with failure
2. Reluctance to simplify
3. Sensitivity to operations
Containment – “Get Out of Trouble”
4. Commitment to resilience
5. Deference to expertise
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▪ “High reliability organizations” manage very serious hazards extremely well
− Excellent at process improvement
− Have created and maintained fully functional, self-regulating safety cultures
− Discover and fix unsafe conditions early
▪ In health care, we most commonly react after patients are harmed. We find it hard to commit to a process improvement methodology that isn’t quick and easy. We still feel that making a mistake warrants discipline.
How Have Others Done It?
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Translating High Reliability Into a Health Care Setting
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High reliability in healthcare is “maintaining consistently high levels of safety and quality over time and across all health care
services and settings”
Chassin & Loeb (2013)
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Chassin MR, Loeb JM. High-Reliability Health Care:
Getting There from Here. Milb Q 2013;91(3):459-90
LeadershipSafety
CultureRobust Process
Improvement®
Commitment to
zero harm
Empowering
staff to speak
up
Systematic, data-
driven approach to
complex problem
solving
High Reliability Health Care Model
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Leadership
− Board commitment to goal of high reliability for all clinical services, with management aligned
− Management aims for zero patient harm for all clinical processes over long periods of time
− Quality (and therefore safety) is the highest priority strategic goal in the organization
− Clinicians routinely lead process improvement activities in and participate in incident reporting
− Key quality indicators understood widely and shared internally and displayed publicly
Characteristics of “Leadership”
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Characteristics of “Safety Culture”
Safety Culture
− High levels of (measured) trust exist in all clinical areas and self-policing of codes of behavior are in place
− All staff recognize and act on their personal accountabilityfor maintaining a culture of safety.
− Full adoption of equitable and transparent disciplinary procedures – “just culture”
− Close calls and unsafe conditions are routinely reported, leading to early problem resolutions
− System defenses are proactively assessed and weaknesses are proactively repaired
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© 2018, Joint Commission Center for Transforming Healthcare
Robust Process Improvement® or RPI ®
Growing Your Capacity for Improvement
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Why RPI®?
Causes Differ by Site
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Change
Management
Six SigmaLean
RPI® is a blended set of strategies, tools, methods, and training programs—including Lean, Six Sigma, and Change
Management—that is used to improve business processes and
clinical outcomes.
What is Robust Process Improvement®?
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▪ Looks at value streams from a
customer’s point of view
▪ Empower employees to fix
processes in which they’re
involved
▪ Eliminate waste because it
increases cost, produces no
value
▪ Unexamined processes are
thought to have as much as
50% of time and effort wasted
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▪ Structured, data-driven framework to address complex causes of quality problems
▪ Six sigma = accuracy and reducing variation
▪ Defines “defects per million opportunities”
▪ 1% rate of bad outcomes = 10,000 defects per million
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But, then, why do improvement efforts fail so often?
Failures occur when people don’t easily
accept, or even resist, good solutions -
regardless of their intentions.
RPI® addresses this challenge directly using
Change Management
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Changing Behavior is Hard
“Process improvement in healthcare isn’t rocket
science. It’s actually much more difficult than that
because rocket science involves getting machines to
behave as you want them to. With process
improvement, you have to change the behavior of
people.”
Dr. ChassinPresident, The Joint Commission
27© 2019 Center for Transforming Healthcare All Rights Reserved.
Change Management: Facilitating ChangeTM
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▪ An increasing number of health care organizations and systems use one or more of the RPI toolsets
▪ RPI is used differently by different organizations:
− Most use only some of the parts; change management is most often left out
− Most limit training to small group
− Most do not use it to transform
▪ Compelling business case for RPI (though it’s often missed)
RPI® in Health Care Today
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Best Practice: Building an RPI®
Program
• Commitment to widespread use of the full Robust Process Improvement methodology and tools – common language and methods for improvement
• Training a significant proportion (if not all) of employees
• Experts “seeded” throughout the organization
• Leadership fully engaged
• Building Improvement Capacity/Culture
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What Does Improvement Capacity Mean?
What Tools are Used
How EVERYONE
gets Trained
How Expertise Spreads
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© 2018, Joint Commission Center for Transforming Healthcare
A Quick Glimpse at a BHC focused on Children and Their FamiliesHow They’re Deploying RPI
https://vimeo.com/297144426
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Why RPI?
• Change Management
• Culture
• Voice of the Customer
• Infrastructure
• Systematic AND Accessible Tools
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Change Leader Projects
• Residential Census
• Timely Completion of Staff Evaluations
• Contract Management
• Staff awards and recognition
• Green Programming
• Mealtime etiquette
• Agency vehicle use etiquette
• Training Documentation
• Parking management and user violations
• Web purchasing/invoicing implementation
• Facilities Painting
• Office 365
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Green Belt Projects
• Diversity and Inclusion
• Medication Management
• Continuum of Care
• Staff Safety
• Authorizations and Benefits
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© 2018, Joint Commission Center for Transforming Healthcare
Change Management Tools
Effectively Used in Behavioral Health
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Assess the Culture
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Assess the Culture Cultural Landscape Map
Aspect of Culture What’s It Like Here?What Is the Impact on Your
Change Initiative?Are Any Immediate Actions
Needed?
Values and Beliefs
Norms and Assumptions
Attitudes
Behaviors
Decision-making
History and Artifacts
Symbols
Ceremonies and Celebrations
Heroes
Stories, Legends, and Jokes
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Assess the CultureCultural Landscape Map: A Resource Sheet
▪ About the Tool− Change initiatives don’t live on their own. They live within a culture. The
culture in which your change initiative lives has a lot to do with its potential success or failure.
− The Cultural Landscape Map is a tool that assesses your readiness to change by looking at the current state of an organization’s culture. It helps answer the question, “What’s it like here?” for each aspect of culture, as well as the potential impact the culture could have on the change initiative and the potential impact the change initiative could have on the culture.
▪ How to Use the Tool− Ask key stakeholders to answer, “What’s it like here?” for each aspect of
culture.− Then have them brainstorm the impact on your change initiative.− Note: This tool is designed to capture the current state and potential impact
as a change initiative begins. Later, revisit the cultural question with the Cultural Roadblocks tool, which can help identify barriers and make a plan to address them.
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Solicit Support and InvolvementStakeholder Analysis
Stakeholder
Name
Re
sis
tan
t
Skep
tica
l
Neu
tral
Sup
po
rtiv
e
Enth
usi
asti
c
Issues or
Concerns“Wins”
Action Items/
Strategy to
Influence
41© 2019 Center for Transforming Healthcare All Rights Reserved.
Solicit Support and InvolvementStakeholder Analysis
Stakeholder
Name
Re
sis
tan
t
Skep
tica
l
Neu
tral
Sup
po
rtiv
e
Enth
usi
asti
c
Issues or
Concerns“Wins”
Action Items/
Strategy to
Influence
Steve X O Time constraints Doesn’t take his
team’s time
TBD
Jane X O Resource
Concerns
Demonstrate
ROI on project A
TBD
42© 2019 Center for Transforming Healthcare All Rights Reserved.
Solicit Support and InvolvementStakeholder Analysis: A Resource Sheet
▪ About the Tool
− A Stakeholder Analysis allows teams to see a complete picture of who the key stakeholders are, how they currently feel about the project, and the minimum level of support they need to have for the initiative to be successful.
− This tool is not designed to label any stakeholder as good/bad or friend/enemy. It is about understanding each stakeholder’s perspective. No matter how supportive or unsupportive a stakeholder may be, each one will have something they are concerned about and something important to them that could be a “win” from the project.
▪ How to Use the Tool
− Have the team identify key stakeholders and indicate their current level of support for the project (mark with an “X” on the chart). Then identify the minimum level of support that is needed from each for the project to be successful (mark with an “O” on the chart).
− Next, note any issues or concerns that a stakeholder may have. Then identify what is important to each stakeholder or what would be a “win” for them.
− Finally, develop an influence strategy for each stakeholder.
− Note: It is important to reach out to key stakeholders to understand their perspectives, rather than guessing about their levels of support. Also, this tool should be kept confidential.
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© 2018, Joint Commission Center for Transforming Healthcare
Concluding Thoughts
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Concluding Thoughts
▪ Health care organizations of all types are adopting a more ambitious goals for improvement – pursuing zero harm.
▪ Growing recognition that good people are operating in bad systems.
▪ Culture change is difficult and takes time.
▪ High reliability is a journey that transcends years.
▪ The Center for Transforming Healthcare is proud to be at the forefront by offering inspiration, tools, thought leadership and support.
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Questions?
David Grazman, [email protected]
(630) 792-5471
www.centerfortransforminghealthcare.org