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©2015 ECRI INSTITUTE
Thomas W. Diller, MD, MMMVP System Chief Medical OfficerCHRISTUS Health
October 15, 2015
ECRI Patient Safety OrganizationHFACS and Healthcare
©2015 ECRI INSTITUTE
Learning Objectives
Understand the human factors errors for a large health system.
Understand lessons learned from the roll out of HFACS across two healthcare systems.
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Current Quality Approach Good Quality is Assumed to Equal Safe Patient Care Quality Improvement is Project Based
■ Examples … Core Measures, CLABSI, Hand Hygiene, etc.■ Too Many Things to Do!!! Not Sustainable!!!
PI Methods are Inadequate■ Copy what someone else did and replicate it.■ Use of simple PI methods (PDCA, Best Practice, etc.).■ Failure to identify specific causes for performance and fix
them. Reactive, rather than Proactive
■ We will be talking about the same errors with the next case.■ Punitive approach, rather than a system’s based approach.
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The pursuit of mediocrity is
always successful.
Karl Albrecht
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Event Opportunity Continuum Customer Complaints
■ Patient driven reporting■ Focus is on immediate mitigation and patient satisfaction■ Currently difficult to obtain systematic information
Occurrences■ Staff reported events and near misses■ Identifies areas for process improvement■ Captured in database, but <10% of events are reported
Adverse Events■ Intense investigation of adverse events■ Identifies both process and behavioral root causes
Malpractice Claims■ Limited data with several year lag time■ Generally it is about money, not about process or behavior
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Traditional Healthcare Root Cause Analysis
Heavily focused on TJC “Sentinel Events”■ Focused primarily on actual harm, rather than the risk of harm.
Facilitates a Culture of Blame■ Find out “Who” did “What”, rather than “Why” an event occurred.
Flawed Investigation Process■ Identification of risk events is not optimal.■ The RCA process is not standardized leading to inconsistent investigation processes and thus findings.
The Root Causes are Usually High Level and Not Actionable■ Events are managed individually without a systematic assessment of risk.■ We can’t improve “poor communication”.
Corrective Actions Do Not Solve the Problems, which then Recur■ Many corrective actions are relatively weak.
Find who is at fault and punish them. Change a policy or process with variable outcomes. More education and training. “Try Harder!!!”
©2015 ECRI INSTITUTE
©2015 ECRI INSTITUTE
Error Causation James Reason … University of Manchester
■ Organizations create redundant system defense barriers to prevent error.
■ Each defense barrier has its own inherent weakness.■ Failure or error occurs when the system defense barrier weaknesses
accumulate and align. ■ The failures can be due to “latent” or system failures, or can be due to
“active” or human failures.■ Thus, usually adverse events have more than one cause.
Used with Permission of HPI
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Greenville Health SystemP9
• 5 Medical Campuses with 1268 Beds• GMH = 750 Bed Tertiary Center• 2 Community Hospitals• Acute Surgical Hospital • LTACH
• > 10,000 Employees• > 1,250 Medical Staff• 731 Employed / Contracted Physicians
• $1.5B Net Revenue• > 42,000 Discharges• > 2.3 M Outpatient Visits• ~ 170,000 ETS Visits
• USC School of Medicine – Greenville• 7 Residencies / 7 Fellowships• > 5,000 Health Care Students
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Greenville Health System Process Centralized Risk Management Department
■ Fully trained in methodology (helped develop it)■ Monitored occurrence reports to identify potential and actual harm
events■ Led investigations and analytics
Academic Health System■ Vice Chairs of Quality all trained in HFACS■ 2 Vice Chairs of Quality assisted in the development of the
methodology■ Vice Chairs of Quality partnered with Risk Management in the
conduction of the investigation and review of findings■ They were typically accountable for fixes
©2015 ECRI INSTITUTE
©2015 ECRI INSTITUTE
Human Factors Analysis Classification System (HFACS) Framework
Organizational Influences
Resource Management
Organizational Climate
Organizational Process
Supervision
Inadequate Supervision
Inappropriate Planned
Operations
Failure to Address a Known
Problem
Supervisory Violation
Preconditions for Unsafe Acts
Environmental Factors
Physical Environment
Technological Environment
Personnel Factors
Communication / Coordination /
PlanningFitness for Duty
Conditions of the Operator
Adverse Mental State
Adverse Physiological
State
Chronic Performance
Limitation
Unsafe Act
Errors
Skill-Based Error
Decision Error
Perceptual Error
Violations
Routine Exceptional
©2015 ECRI INSTITUTE
©2015 ECRI INSTITUTE
HFACS
P14
434
372
183
97
62
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0
50
100
150
200
250
300
350
400
450
500
Personnel,Communication,
Coordination, Planning
Error, Decision Violation, Routine Operator, Adverse MentalState
Error, Skill-Based
Perc
ent o
f Cas
es
Num
ber o
f Cas
es
General Causal Category
Causal Categories Most Common in Adverse Events
105 coded cases
©2015 ECRI INSTITUTE
HFACS
P15
50
3633
30 2623
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0
10
20
30
40
50
60
Environment, Physical Organization,Organizational
Climate
Environment,Technical
Supervision,Inadequate
Organization,Organizational
Processes
Supervision,Inappropriate planned
operations
Perc
ent o
f Cas
es
Num
ber o
f Cas
es
General Causal Category
Causal Categories Most Common in Adverse Events
105 coded cases
©2015 ECRI INSTITUTE
Organizational Influences
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Supervision
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Preconditions for Unsafe Acts
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Unsafe Acts
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Findings ComparisonSource Pt. Safety Survey Occurrence Reports HFACS
Adverse Mental State
No No Yes
Communication Yes Yes Yes
Errors (Decision / Skill Based)
No No Yes
Handoffs and Transitions
Yes Yes Yes
OrganizationalLearning
Yes No No
Staffing (Resource Management)
Yes +/- +/-
Violations No No Yes
P20
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Findings Comparison• Prior to HFACS
– No preceding cause
– Lack of sufficient information
– May have failed to address root causes
– Non-actionable Root Causes
• With use of HFACS– Actionable Common Causes identified
– Avoid unintended consequences
– Identify commonalities across departments/services/units
– System solutions
P21
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Lessons Learned• HFACS required refining for the healthcare industry
– Resource intensive and took over two years of adjustments– Future refinements should be expedited
• Retrospective application of HFACS was ineffective– Traditional reviews failed to address multiple failure modes or
preceding causes
• Training for key staff (physician leaders and risk managers) is essential
• Excel database works well• Identification of causes is only the beginning; appropriate
solutions are essential
P22
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CHRISTUS Health
Catholic Health Care System Top 15 Health System by Size
■ ~25 Hospitals in the U.S. in TX, LA, NM■ ~11 Hospitals in Mexico / Chile
$4.5B in Net Revenues ~30,000 Employees Non-academic, community based
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Root Cause Analysis Transition Roll out HFACS as the system-wide standard for the conduction
of RCAs.■ Standardize the process for the conduction of an RCA.■ Requires substantial education and reinforcement.■ Focus RCAs on events with both harm and the potential risk of harm.
Develop an HFACS database to analyze adverse events / potential events and identify specific opportunities for system-wide and local mitigation of risk.
Link performance improvement activity, training including simulation and clinical policies to system-wide risk mitigation.
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CHRISTUS Health System Roll Out Process 4 – Two day training sessions with Dr. Shappell.
■ Focus on Regional CMOs / CNOs / Quality / Risk / Clinical Education■ System office key clinical leaders (CCO / CMO / CNO / CQO / CMIO)■ ~130 key individuals trained
Clinical Risk Management■ Developed a Go Team to assist regions in processes
Senior Clinical Leadership■ Introduced over time as part of a cultural transformation discussion■ Reinforced including in novel settings … capital equipment
acquisition
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CHRISTUS Health Adverse Event Workflow
Potential
Risk Event Occurs
Actual Risk Event
Occurs
Front Line Staff Enter Event into Event
System
Service Recovery / Mitigation
Identifies as High Risk Event
Mgr. Reviews Event (24 hrs.)
Service Recovery / Mitigation
Investigates, Clarifies &
Identifies as High Risk Event
CRM Reviews … Risk Based
Prioritization (48 – 72 hrs.)
Identifies as High Risk Event
Track and Trend
Patient Safety Officer Reviews
RCA2 Process Initiated
Assign a Team
Conduct Investigation
Review Findings
Implement Corrective Action Plan
Track and Trend
Low
High
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CHRISTUS Health Lessons Learned Roll Out
■ Training was spread out over 4 months, needed to be more compact
■ Have regional people come in teams, rather than as individuals■ Training of senior clinical leaders (CMOs, CNOs) was critical
~12 Adverse Event Investigations To Date■ All have numerous decision and skill based errors■ Resource management (staffing) is a concern■ Fitness for duty (primarily sleep deprivation from more than 1
job)
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Questions / Discussion
Tom Diller, MD, MMMThomas.Diller@christushealth.org