MHA’s Quarterly Quality Webinarweb.mhanet.com/SafetyAcrossTheBoardPartII_v1-01-23-2014.pdf ·...

transcript

MHA’s Quarterly Quality Webinar Safety Across the Board, Part II

Objectives

Review Safety Across the Board

Discuss Total Harm as a metric

Counting all harms

How to collect all harms data

Defining causality

Using High Reliability Organization principles to reduce total harm

Back to basics, PDCA, how health care falls off-course…and how to get back on track

Safety Across the Board happens when the hospital has a culture of safety and a

sensitivity to operations that makes it “difficult to the do the wrong thing”

and easy “to do the right thing” to prevent harm and keep care providers

Why Should We Achieve Safety Across the Board?

Increasing financial linkages

Private payer-leverage during contract negotiations

Increasing pressure from risk/liability insurers

“…is committed to its Policyholders by encouraging

patient safety, only insuring providers

who meet its high standards and holding down overhead, such a

recipe for success has produced consistent profits which are then shared with

qualifying providers." - Joseph B. Moody President & CEO

Healthcare Services Group

Why Should We Achieve Safety Across the Board? (cont)

Increasing federal quality—financial link

HHS.gov: January 2015 release

CMS set BOLD AIMS

– 30% of Medicare provider payments to be in alternative payment models tied to value—by 2016; 50% by 2018

• Examples: ACO, PCMH, “bundled payment” model

– By 2016, at least 85% of Medicare fee-for-service payments will be tied to quality and value; 90% in 2018

– Created a Health Care Payment Learning & Action Network

• Facilitation of public-private sector partnerships

• Streamline costs, business models, improve coordination and safety

Pressing internal organization financial needs-

Squeezing operating costs out of the organization remains a priority

Information technology will continue to gobble up a greater portion of the capital expenditures

Consolidation will continue at a strong pace and spread

Hospital and physician alignment will continue to be a top priority for hospitals

Increasing transparency of health care quality and patient harm stories

Cast Light Health

Transparency-it’s here…

and it’s

viral…

Hospitals Telling Their Story

Transparency-hospital/provider

directed

#1 It’s the right thing

to do! Right for patients,

right for providers!

Organization Goal:

BE SAFE

BE RELIABLE

Create Safety Across the Board

“An organization’s cultural commitment to applying the

scientific method to designing, performing, and

continuously improving the work delivered by teams of

people leading to measurably better value for patients

and other stakeholders.”

Mayo Clinic Proceedings

January 2013; 88(1):74-82

Safety Across the Board

SAFETY & RELIABILITY CULTURE

MEASURE & UNDERSTAND THE TOTAL

HARM IN YOUR ORGANIZATION

How Do You Count Total Harm??

Start with event reporting system

Who, What, Why, When, Where?

Caveats to event reporting systems:

Only 10-20% of errors are ever reported

Of those, some 90 to 95 percent cause no harm to patients

The inadequacy of the error-reporting system stems from limitations in the process itself

– it is voluntary and highly subjective

– often a cumbersome process, based on time-consuming paperwork required of over-burdened providers

– there is a punitive element that hinders reporting, despite organizational best intentions, reassurances

How Do You Count Total Harm?? (cont)

How do you start to capture the true picture of total harm?

Go to the GEMBA

Utilize safety huddles

Ask staff: • Did anything happen on your shift that you should have filled an event report out

for, but didn’t?

• Do we have any equipment not working correctly/missing equipment?

• Are we low on supplies?

• Did we provide unnecessary testing, medical care or additional tests/care because of mistakes today?

• What could have happened to make your shift more efficient?

• If you don’t feel comfortable speaking in a group, I am available to speak with you in private about any concerns.

Utilize debriefs

If additional errors, near-misses, or good catches are reported…

Make time to debrief or do a mini-RCA with staff in the moment

Consider need to forward to PI team for further review

Consider communication plan

Consider who will enter this information into the event reporting system (at a minimum, recommend actual patient harm errors be tracked through the system)

Praise and encourage staff!!

Report out findings to organization-wide safety huddle

TRANSPARENTLY REPORT

Put a “Face” on the Data

• Total harm is compelling data with an emotional impact

• Creates urgency to do what is right

• Has applicability to every person

• No rates, No denominators…ONLY numerators

“When organizations stop looking at harm rates and denominators, and begin to focus on only the numerators or numbers of patients harmed, this changes the focus of the staff from data to people and it becomes a personal crusade to keep those numbers to a minimum.”

—Cathleen Krsek, MSN, MBA, RN, FAAN Senior Director, UHC

Total Harm-Metric Use

Total harm as a metric is relevant for the entire organization

Particular relevance to staff and board members

Also, well understood by consumers for use in telling your health care quality story

0.0000

5.0000

10.0000

15.0000

20.0000

25.0000

Oct-2013 Nov-2013 Dec-2013 Jan-2014 Feb-2014 Mar-2014 Apr-2014 May-2014 Jun-2014 Jul-2014 Aug-2014 Sep-2014

Total Harm-General Hospital

193 Patients

Distribution of Harms-General Hospital

Distribution of Events

CAUTI OB Trauma With Inst OB Trauma Without Inst SSI

[VALUE]

Distribution of Cost per Event

CAUTI OB Trauma With Inst OB Trauma Without Inst SSI

Be Transparent

In a HIPAA protected area (unit break room), post unit

harms at the patient level

Harms this Month:

Harms this Year:

Zero Harm Strategies 1. 2.

Be Strategically Transparent

3 Patients w/ C. Diff

1 Patients w/ MRSA

1 Patients w/ CAUTI

5 Patients w/ sepsis

Visuals

Post-its/easel pads to track progress

Stand-ups/huddles-STAFF LED

Medical Staff meetings/Board meetings

Non-traditional methods

Storytelling

Patient and family advocate involvement

Start each meeting

Tell the good stories, too!!

350 patients harmed!! How do we fix this??

Daily identification of potential safety risks, opportunities for system failures, at-risk behaviors, raised awareness

Through huddles, leadership presence on units—you have to ask the questions…and keep asking…and ask again!

Staff have to see solutions in action

Do you know what is happening on nights and weekends?

In the moment solutions and implementation

Accountability

Who is designing the fix?

When is it due?

What is expected?

Who’s tracking it/reporting it?

Total Harms =

350 Patients

Near-Misses total 1,500

FOCUS ON INCREASING RELIABILITY OF

SYSTEM PROCESSES

Categorize Harm by Causality

Errors of commission

Errors of omission

Errors of communication

Errors of context

Diagnostic errors

Errors in failing to care across the continuum

James, JT. “A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care.” J Patient Saf. 9:3, Sep, 2013.

High Reliability Organizations

HRO is not a process improvement program…it is an organizational culture designed to reduce the

frequency and severity of catastrophic events

Historically, most HROs are machine-based…

Nuclear powered submarines

5,500 years of cumulative nuclear reactor operations

127 million miles submerged

Zero reactor accidents

Operated by 20 year olds

Highly complex

Myriad of communication

pathways

Human lives vs. machines

Applying

standardization to individual situations

Ego-centric

Are you focused on repair or reliability?

Repair Focused Reliability Focused

Fix it Improve it

Firefight Predict, Plan, Schedule

Tradesman Business Team Member

Manage defects Eliminate Defects

Reduce Maintenance Cost Increase Uptime

Program of the month Continuous Improvement

Believe failures are inevitable Believe failures are exceptional

Give priority to breakdowns Give priority to eliminating failures

Many failures Few failures

Low level of planned work High level of planned work

High level of rework Low levels of rework

Poor reliability High reliability

High maintenance costs Low maintenance cost

Short term plans Long term plans

Become non-profitable Attract new investments

Lessons from Human Factors Research

Reliance on memory

Distractions / interruptions

Fatigue

Sleep deprivation

Shift work

Lack of training and experience

Overload

Psychosocial factors

Human error is the not the cause of failure, but a

symptom of failure. It is the starting point for

investigations, not the conclusion.

Levels of Designing System Reliability

Level I: Intent, Vigilance and Hard Work

• Common equipment (and other structural standardization)

• Standard orders sheets

• Personal check lists

• Feedback of information on compliance

• Awareness and training

Levels of Designing System Reliability

Level II: Design informed by reliability science and research in human factors

• Standardization of processes • Building decision aids and reminders into the system • Taking advantage of existing habits and patterns • Making the desired action the default (based on

evidence) • Creating redundancy • Scheduling using proper operations theory

Level II Example

Levels of Designing System Reliability Level III: High Reliability Organizations (HROs)—Sophisticated design of human interactions and working relationships

Weick’s Attributes 1. Preoccupation with failure (Prevent)

2. Sensitivity to operations (Prevent)

3. Reluctance to simplify interpretations (Identify)

4. Deference to expertise (Identify/Mitigate)

5. Commitment to resilience (Mitigate)

Source: Weick, KE and Sutcliffe, Managing the Unexpected 2001.

Characteristics of HROs

Manage highly complex tasks

Interdependent departments

Hierarchical decision making

Interconnected professionals

Highly accountable

Inflexible standards and deadlines

Continuous feedback systems

HRO Principles

Anticipation-3 Elements—”Stay Out of Trouble”

Preoccupation with failure

– All near-misses and errors are proof of system errors

– Causality is pursued, no matter how small (avoidance of the Swiss cheese effect)

Avoid simplifying interpretations

– Details matter in error prevention

– Encourage diversity in experience, perspective, and opinion

Situational awareness

– Continual mindfulness by all staff of risks and failure opportunities

– Continual review with staff of the risks involved with their professional functions

– Paying attention to what’s happening on the front lines

HRO Principles (cont)

Containment: 2 elements—”Get Out of Trouble”

Deference to expertise

– Sr. managers and leaders of organizations generally have no idea (or no current idea) of how to perform the detailed elements of subordinates’ jobs

– Because of this, performance and expertise are critical in shaping performance and preventing harm

– Push decision-making down and around to the person with the most directly related knowledge and expertise

– Design for minimal process variation

HRO Principles (cont)

Resilience

– Develop capabilities to detect, contain, and bounce-back from events that do occur

– In the real world…failures still happen

– All errors in health care are catastrophic

– Maintain functions during high demand

FOCUS ON INCREASING RELIABILITY OF

SYSTEM PROCESSES

DESIGN RELIABLE, STANDARDIZED

SYSTEMS

Management by Improving Process

Pick you’re a process/focus area

Compare baseline rates to current rates

Flowchart process as designed vs. reality

CONSIDER

Are there steps where….

people must rely on memory to complete any portion of the step (no reference, tool, etc.)?

a distraction or interruption during the step would likely lead to failure of the step?

are there >10 things a person must do at this step?

a new or untrained person is much more likely to encounter error or failure with the step?

Make work and systems automatic…

Address Human Factors:

Avoid Reliance on Memory

Make Processes Visible

Review and Simplify Processes – Remove Waste

Decrease Reliance on Vigilance

Assign new processes to a role or function, not a person

Systems are supported by people…

Engage staff at all levels

Leadership support is crucial

Middle management support is the most crucial

Map out how the process improves efficiency, safety, benefits to patients and/or staff

Emily Jerry died of a medication error when a pharmacy tech used 23.4% sodium chloride

vs. 1% sodium chloride to compound her chemo treatment

“Our Emily was killed by an overdose of sodium chloride in her chemotherapy IV bag.” -Chris Jerry

Debrief

The technician stated she did not know why she had made this error.

The technician claimed she knew that something was not right but she was not sure what.

The pharmacy technician was asked if she knew that an overdose of sodium chloride could result in death. She claimed that she was not aware of that fact.

At the time of Emily’s death, Ohio didn’t register pharmacy technicians. There weren’t even any training or licensing requirements (2006).

What professional requirements could be instituted?

What is the labeling process?

In hanging the medication, were the 5 Rights reviewed by staff?

Is there a mix algorithm that could be printed to follow prior to mixing?

How could the technician and other involved staff be involved in designing a strong med mix/admin process?

Is there a standard mix solution for all chemo?

How can you maintain situational awareness so no one lags in safety assurance?

Applying HRO principles

Could a double-check process with a licensed pharmacist be put in place?

Could barcode scanning be utilized against an EHR record to verify medications?

Should pharmacy techs be allowed to mix medications, and if so, which ones? Should this be a pharmacist’s task?

What kind of initial education was provided to the tech?

What kind of signage/resources could be utilized to defer reliance on memory?

If relying on computer system, how will your downtime processes avoid error?

Could this happen today in Missouri? Could this happen in your hospital?

Missouri = F

http://emilyjerryfoundation.org/

• What is the current condition?

• What is the target condition?

• Then, apply PDCA to identify the root cause, counter-measures, and then adjust accordingly based on the results.

We say we PDCA is our

improvement model…but do we really do it? Do staff do it? How do they

know??

PLAN DO, CHECK,

Often, left out…

Target Setting

PDCA is an acknowledgment of failure, but a victory in learning

STANDARDIZE THROUGHOUT ORGANIZATION

Organizational/MACRO PDCA

Situational Awareness

Gemba-based leadership: Not just laissez-faire – step out of the way, “it’s up to

you”

Not just MBWA – slapping backs and offering praise

Not just MBO – okay, you’re empowered, get the numbers – I don’t care how you do it.

Gemba-based leadership: Rather, leaders who say:

My job is to develop you, so I need to hear your thinking, and develop you through coaching you on the job to design a reliable, safe work

environment. (Staff are valued)

I will give you expectations that are clear and challenging. (Outcomes)

I will give you a deadline. (Accountability)

I will expect you to report out on everything, all the time.

(Accountability)

I will ask you what you need; I’ll see what you need and provide on-going

support and coaching as required. (Staff are valued, mgmt. accountability)

And I will be back to check on how things are going. (Mgmt. accountability)

PI Team

By working together to systematically solve a problem, we feel more like a team and we create an environment that

fosters learning and effective problem solving.

Organization Goal:

BE SAFE

BE RELIABLE

Next quality webinar!!

To-Do List for Next Tuesday…

Pick a process

Apply HRO principles

Walk through the PDCA cycle, use other PI tools as needed

Define the gap between current condition and target condition

What will you measure?

How will you report back?

How will you engage staff?

How will standardized?

Who’s accountable?

Education Summary 2015 Quality Transparency Education Plan

Who What When

CEOs, CNOs, Quality Directors, Patient Safety Officers

Introduction to Quality Transparency Webinar January 26, 2015

Mid-year quality transparency webinar June/July 2015

Preparation for hospital-specific data release webinar Mid-November 2015

Coding Staff Coding of the claims-based measures Early Summer 2015

CEOs and Senior Leadership District Council Meetings Spring and Fall 2015

Site Visits with Mike Dunaway and Nick Nichols Ongoing

Lunch Bunch Ongoing

Quality Directors Measure definitions and trending on using data for improvement webinar May 2015

Monthly conference calls (What’s Up Wednesdays) Ongoing

Clinical Quality Regional Meetings April and September 2015

Site Visits with SQI staff Ongoing

Educational Summary 2015 Clinical Quality Education Plan

Who What When

Quality leads, Compliance, Frontline management, etc.

What’s Up Wednesday? Lunch & Learn 1st Wednesday monthly

Quality Topic Interactive Webinars Quarterly

Regional Workshops: 5 Sites April & September 2015

Strategic Quality 101 Conference May 2015

On-Demand Webinars On-going

MHA Quality Newsletter Monthly

Toolkits/Resources: Falls, Readmissions/Care Coordination, Harms/Infection, other priority areas

On-going

MHA Website-Strategic Quality tab On-going

Immersion Projects, Collaborative Development On-going

Upcoming Education

Missouri Quality Transparency Update

Tuesday, April 7. Noon-1 p.m.

Register here

Missouri Quality Measure Coding

Tuesday, April 21. 10-11 a.m.

Register here

Upcoming Events

April 1, from Noon to 1 p.m. - Lunch & Learn: What's Up Wednesday (register, then dial 855/427-9512)

May 27, from Noon to 1 p.m. – MHA Clinical Quality Webinar – Registration pending

Upcoming Events, April & May

MHA Spring Regional Quality Workshop – Readmissions and Care Coordination: Aim Towards Outcomes

April 14 - Marriott West, 660 Maryville Centre Dr, St. Louis (Register)

April 15 - Drury Lodge, 104 Vantage Dr, Cape Girardeau (Register)

April 17 - Comfort Inn, 1821 N. Missouri, Macon (Register)

April 22 - Hilton Garden Inn, 19677 East Jackson Dr, Independence (Register)

April 24 - Hilton Garden Inn, 4155 South Nature Center Way, Springfield (Register)

Interested in presenting your initiatives? We’re looking for speakers!

May 20, 21 – Strategic Quality 101 Conference, Hilton Garden Inn, Columbia

Visit our website for additional events and links

MHA Quality Staff

Leslie Porth, PhD-C, MPH, R.N.

Division Vice President for Strategic Quality Improvement

Triple Aim

Population Health

Oversight of division (Quality Improvement, Quality Works,

Emergency Preparedness)

Alison Williams, R.N., BSN, MBA-HCM

Vice President of Clinical Quality Improvement

Clinical quality SME

Oversight of Quality Improvement

Grant management

Collaboratives management

Dana Downing, B.S., MBA-H, CPHQ

Vice President of Quality Program Development

Patient and family engagement

National quality measures

Quality outcome transparency

Electronic clinical quality measures

MBQIP grant lead

Jessica Rowden, R.N., BSN, MHA

Clinical Quality Improvement Manager

Clinical quality SME

Data management and analytics

HEN/AHRQ grant projects

TeamSTEPPS

Host of WUW|LNL

Cheryl Eads

Executive Assistant of Quality Improvement

Provides support to the SQI team

Coordinates webinars, conference calls and meetings

Distributes correspondence and communication

Assists in maintaining reports

Lporth@mhanet.com 573/893-3700x1305

Awilliams@mhanet.com 573/893-3700x1326

Ddowning@mhanet.com 573/893-3700x1314

Jrowden@mhanet.com 573/893-3700x1391

Ceads@mhanet.com 573/893-3700x1382

http://web.mhanet.com/strategic-quality/

MHA’s Quarterly Quality Webinarweb.mhanet.com/SafetyAcrossTheBoardPartII_v1-01-23-2014.pdf ·...

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