9/10/2014

1

Reducing VariationLearning Session 3September 2014

Prof Kevin RooneyMiss Catherine Jones

“Healthcare Improvement is

about 3 things, reductions in

waste, harm and unnecessary

variation.”Gerry Marr

CEO, NHS Tayside

9/10/2014

2

Framework for Reliable Design

Process is the action point of all improvement methodologies

Reliability occurs by design not by accident

Segmentation allows the perfection of the design

Starting Labels of Reliability

Chaotic process: Failure in greater than 20% of opportunities

80 or 90 % success. 1 or 2 failures out of 10 opportunities

95% success: 5 failures or less out of 100 opportunities

Success in parts per one thousand: 5 failures or less out of 1000 opportunities

9/10/2014

3

Non-Catastrophic Processes

Definition: Failure of the process does not lead to death

or severe injury within hours of the failure

80% or less reliability is most commonly seen in these

processes (hand-washing as an example)

Poor outcomes do not occur with each defect due to

either to biologic or system resilience.

High Reliability Organisations

Environment rich with potential for errors

Unforgiving social and political environment

Learning through experimentation difficult

Complex processes

Complex technology

Nuclear Power, Airlines, Forest Fire Fighting

Weick, KE and Sutcliffe, KM 1999

9/10/2014

4

“Society’s huge investment in technological

innovations that only modestly improve efficacy,

by consuming resources needed for improved delivery of

care, may cost more lives than it saves.”

“Health, economic, and moral arguments make the case

for spending less on technological advances and more

on improving systems for delivering care.”

The aspirin example

In patients who have had a stroke or TIA aspirin reduces

risk by 23%

100,000 patients – 23,000 fewer strokes

58% of eligible patients receive aspirin = 13,340 fewer

strokes

9/10/2014

5

Two options

Fidelity – increase to 100% of eligible patients = 9,660

fewer strokes

Efficacy – requires a proportional improvement over

aspirin of 74%

Clopidogrel = 10% more efficacy than aspirin

Institute of Medicine Report

“Quality

problems are

everywhere.”

9/10/2014

6

Reasons for the Reliability Gap In

Healthcare

• Training and education

• Vigilance and hard work

• Focus on benchmarked outcomes

• Excessive clinical autonomy

• Rarely use deliberate designs

Improvement Concepts Associated with Performance

Resulting in 80-90% Process Reliability

• Primarily can be described as intent, vigilance, and hard work

• Common equipment, standard order sheets, multiple choice protocols, and written policies/procedures

• Personal checklists

• Feedback of information on compliance

• Suggestions of working harder next time

• Awareness and training

9/10/2014

7

How do we become even more

reliable?

Use human factors and reliability

science to design failure prevention,

failure identification, and mitigation.

We need to predict rather than react!

Improvement Concepts Resulting

in 95% Process Reliability

Decision aids and reminders built into the system

Desired action the default (based on scientific evidence)

Redundant processes utilized

Habits and patterns known and taken advantage of in the design

– Escalation to experts

Standardisation of process

Mitigation / Communication

Resilience in the face of adversity

9/10/2014

8

The Reliability Design Strategy

Prevent initial failure using intent and standardisation

Back-up/contingency function (identify failure and mitigate)

Measure and then communicate learning from defects back into the design process

The “Set Up” for Reliability

Select a topic whose outcome you want to improve; articulate the outcome goal

Determine a high volume segment for initial design testing

Build a high level flow chart for that segment

Determine where the defects occur in the current system

Determine where your design work will begin with by identifying where the commonest defects occur

Verbalise the reliability (hint: it is always 95%)

9/10/2014

9

Finding your first segment

The segment must represent a reasonable volume

The segment should have clear cut defined boundaries

The segment should have willing participants so the barrier of agreeing is not a problem

Segment for the

Ventilator Care Bundle

Patients in the general ICU

Prof. Rooney’s patients

Patients on the South side of the ITU

18

9/10/2014

10

Example: Ventilator Care Bundle “Set Up”Segment: ITU With Prof Rooney’s Patients

Patient placed

on ventilator

Elements of

the bundle

ordered

Elements of

the bundle

accomplished

Patient

removed from

ventilator

Of the elements of the bundle, the

head of the bed elevation is most

commonly not accomplished

Our aim achieve a 95% or better reliability at

keeping the head of the bed elevated

The Reliability Design Strategy

Prevent initial failure using intent, simplification and standardisation

Identify defects (using redundancy) and mitigate

Measure and then communicate learning from defects back into the design process

22

9/10/2014

11

“If I had to reduce

my message for

management to just

a few words, I’d say

it all had to do with

reducing variation.”

W. Edwards Deming

Standardisation

9/10/2014

12

How to get things right ?

Cause & Effect Diagram

26

CVC

Infectio

n

CVC

maintenanceCVC use

Education CVC Insertion Surveillance

Nursing

Assessment

Documentation

Daily need

review

Dressing

Flushing

Hand

Hygiene Inappropriate

access

Hubs

Lack of CVC RN

Lack of timely lab results

Lack of database

Insertion site

Aseptic technique

Skin prep

Type of CVC

Maintenance

guidelines

Insertion technique

I

n

s

e

r

t

i

o

n

G

u

i

d

e

l

i

n

e

s

Competency

Nursing

Education

9/10/2014

13

Daily Assessment of need for CVC

Real Time Assessment / Redundant Check

CVC Insertion

9/10/2014

14

Why Standardise?

Contributes to building an infrastructure (who does what, when, where, how and with what)

Support training and competency testing to sustain the process

Achieve front line articulation of key processes by staff

Allows the appropriate application of Evidence Based Medicine consistently

Feedback about defects and application of learning to design is possible

New Standardisation Concepts

We are standardising an approach to get evidence into practice -The “what and not the “how”Initial standardised protocols are developed with small time investment by experts tested at a very small scale

Changes to the protocol in the initial stages should be required and encouraged

Defects are studied and used to redesign the process

30

9/10/2014

15

Standardisation

• Determine

– Who

– What

– When

– Where

– With What/How

• 3 person

procedure

Example: Ventilator Care Bundle – Head

of Bed Elevation

• Who: Nurse caring for the patient

• What: Measure the head of the bed

elevation

• With What: Tool at side of bed

• When: Every hour when checking vent.

• Where: At the bedside

• How: Read degree elevation at bedside

monitor and adjust if needed

32

9/10/2014

16

Three Tier Design Strategy

Prevent initial failure using intent and standardisation

Identify and mitigate (Redundancy/contingency function)

Critical failure mode function (identify critical failures and then redesign)

36

Why the Step Is Needed

Allows less than perfect design in the standardisationstep (we do not have to plan for every possible contingency)

Anticipates and allows failure in the standardisationfunction step

Allows a better balance of resource use (no need to spend months coming up with the perfect design)

Fosters the atmosphere of mitigation and recovery

37

9/10/2014

17

Characteristics of

“Redundancy Tools”

• Redundancy: back-up plan, failsafe etc

• Require careful consideration since they do represent a

form of “waste”

• Requires a good prevent failure step (standardisation

function) before implementing a redundancy

• Need to be truly independent

• Need to be used or will no longer function as a good filter

• Must follow with a mitigation strategy

Human Factor Concepts

Decision aids and reminders built into the system

Desired action the default (based on evidence)

Redundant processes

Use fixed current scheduling in design

Take advantage of habits and patterns

Standardisation of process based on clear specification

and articulation

Human Factors and Reliability Science:(Designing sophisticated failure prevention, failure identification and mitigation)

9/10/2014

18

Example:– Head of Bed Elevation:

Redundancy

Elevation is checked by ICU sister every two hours. If not

elevated contact nurse.

Elevation is checked by trainee at each visit to patient. If

not elevated contact nurse.

Measure: how many times does this task find that the

HOB is not elevated?

Who should be informed?

Three Tier Design Strategy

Prevent initial failure using intent and standardisation

Redundancy function (identify failure and mitigate)

Critical failure mode function (identify critical failures and then redesign) (Measure and then communicate learning from defects back into the design process)

9/10/2014

19

Critical Failure Mode Essentials

A measurement of critical failure modes needs to be part of the initial design strategy

Assesses the defects that occur from the current design

Should be prioritised in terms of overall affect on the reliability of the process change

Should be used to redesign the process

Measurement

Small samples over time should be use to determine if the

process is improving

Data should be collected by the team with strict attention to

the agreed upon tempo

Data should be collected for segments

Process measurements should be the primary team

measures

Outcome measures are needed but do not need to be

collected by the team

Outcome aims can be set at 0 or 100%, but your

process aims should be 95% or better

44

9/10/2014

20

Example of 3 Step Design in

Implementing the Ventilator Bundle

45

Key Message

Seek Usefulness

Not Perfection

9/10/2014

21

Any Questions?