2020 Vizient PSO HRO and Safety Education Prioritization and Design of Reliable Outcomes
Tuesday, March 17, 2020
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©2020, Vizient Inc. and Vizient PSO. Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient. There may be information that does not apply to or may be inappropriate for the medical situation.
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Learning Objectives
• Identify the difference between highly reliable outcomes and highly reliable organizations
• Quote techniques for creating proactive design expectations related to patient safety
• State techniques for creating highly reliable outcomes, one class of outcome at a time
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Presenter
NameCredentialsTitleOrganization
©2020, Vizient Inc. and Vizient PSO. Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient. There may be information that does not apply to or may be inappropriate for the medical situation.
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David Marx, CEO, Outcome Engenuity
Disclosure
Our presenter, David Marx, is the owner of Outcome Engenuity, “The Just Culture Company” and “Trajectories
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©2020, Vizient Inc. and Vizient PSO. Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient. There may be information that does not apply to or may be inappropriate for the medical situation.
Agenda
• The Safety Paradox
• Prioritizing Risks - The Risk Register
• Quantitative v. Qualitative
• Risk Modeling
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The Safety Paradox
Vizient Presentation │ Date │ Confidential Information7
Highly Reliable Organizations?
A Look At Aviation
• Hull loss accident rate: 1 in 20 Million
• Mishandled/damaged baggage rate: 3 per 1000
• Lost baggage rate: 1 per 10,000
• Don’t arrive within 15 minutes of scheduled time: 16 of 100
Industry Average: 3.2 per 100 full time workers per year• Financial Portfolio Management: 0.1• Nuclear Power Generation: 0.3• Petroleum Refining: 0.7• Railroads: 2.0• Commercial Fishing: 2.0• Coal Mining: 3.8• Healthcare: 4.5• Logging: 5.1• Airlines: 8.2• Police: 10.6• Fire: 12.1
2014 Bureau of Labor Statistics
Non-Fatal Injuries and Illnesses in the US
The Real World…
11
Liberty
Cost
Time
Customer Safety
Employee Safety
Environmental Protection
ALARP (risk as low as reasonably practicable)
Vision Zero (zero preventable deaths)
Two Competing Philosophies
Highly Reliability Organizations• Do Not Exist• We get what we value, and invest the time and resources to work
Highly Reliable Outcomes• We can achieve good outcomes• We’ll never get to zero
It’s about a set of tools• To design better systems around employees• To steer human choices in the “right” direction
The Premise…
Prioritizing Risks -
Risk Registers
Vizient Presentation │ Date │ Confidential Information14
Global Burden of Disease
healthdata.org
Global Burden of Disease
healthdata.org
A Rail Risk Register
500+ rank-ordered items in their Safety Register
Requires the Board to “accept” what will happen in the next year
Gives the Board a hierarchy by which to prioritize efforts
Board decisions grounded by the Risk Register, rather than simply reacting to last month’s big event
Specific Hazardous Event TotalPercentage of
Total Collective Risk
Trespasser struck/crushed while inside the mainline railway/depots/yards/sidings 27.3 36.81%
MOP attempted suicide or suspected suicide 13.6 18.35%
Passenger train collision with road vehicle on level crossings 1.96 2.64%
Non-passenger train collision with road vehicle on level crossings 1.94 2.61%
Train crew assaults 1.70 2.29%
Passenger train fire 1.69 2.28%
Passenger train derailment 1.52 2.05%
Passenger or MOP slip/trip/fall while using escalators 1.42 1.91%
Train crew on-train incident (excludes train crew on-train assaults) 1.37 1.85%Miscellaneous (include muscular strain and stress injury, exposure of environmental heat/cold, prick by sharp object etc) 1.21 1.64%
Passenger falls between train and platform 1.10 1.48%
Staff manual handling incident .96 1.30%
Collision between two passenger trains (rear-end) .86 1.16%
Passenger or MOP slip/trip/fall while using stairs or ramps .79 1.07%
Staff slips, trips and falls (
• How do you prioritize your change efforts?• Severity Bias?• Recency Bias?• Political forces?• Regulatory forces?• Time?• Cost?• Constraints on
liberty?
• Disability-adjusted life years? (my choice!)
Impact and Changeability
Impact
Low
Medium
High
Low Medium High
Cha
ngea
bilit
y
Qualitative v. Quantitative
Vizient Presentation │ Date │ Confidential Information19
FAR §25.1309 - Equipment, systems, and installations
Designed to one loss per one billion flight hours
(b) The airplane systems and associated components, considered separately and in relation to other systems, must be designed so that --(1) The occurrence of any failure condition which would prevent the continued safe flight and landing of the airplane is extremely improbable… [1x10-9]
Quantitative Requirements
Quantitative, Probabilistic Risk Modeling
From…
1 RFO per 15,000 surgeries“the AORN standard”
to…
1 RFO per 1,000,000 surgeries
Child hit by car
Child moves
into harms way
Driver does not see child in walk
around car
Back up camera does not warn
Quantitative – With how many dice do you play the game?
Qualitatively Mapping Failure Paths
0%
10%
20%
30%
40%
50%
60%
70%
2014 2015 2016 2017
Perc
ent o
f Pro
gres
sion
of S
epsi
s to
Se
ptic
Sho
ck
Year
Progression of Sepsis to Septic Shock
Data from Dr. Samrina Kahlon, Metropolitan Hospital, 2019
52% Reduction
from standard QI work
24% Reduction
from standard QI
work
90% Reduction
Attributed to Trajectories
Modeling
QualitativeRiskModeling
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A Qualitative Design Goal: Play the game with three dice
0
50
100
150
200
250
Under defended by 2 Under defended by 1 Adequately defended Overly defended by 1 Overly defended by 2
Chemotherapy Ordering, Dispensing, and Administration
Individual Trajectories
Active Failure
Negative Outcome
Step 3 - Analyze the Outcome
Step 1 - Scope the Model- Environment, Type of Active Failure(s), Type of Outcome(s)
Step 2 - Analyze the Active Failure
Active Failure
Negative Outcome
Step 4 - Identify Defenses- Design for two defenses
ActiveFailure
Negative Outcome
Step 5 - Analyze Defenses
- Barrier, Recovery, or Redundancy?- Physical or Procedural?- Dependencies?
Physical Barrier
Procedural Recovery
Physical Redundancy
Step 6 - Analyze Procedural Defenses for Compliance
- Is Compliance High Enough to Consider It a Reliable Defense?- If no, remove from total defense count
ActiveFailure
Negative Outcome
Physical Barrier
Procedural Recovery
Physical Redundancy
ActiveFailure
Negative Outcome
Step 7 - IF Less than 2 Effective Defenses, THEN Develop Precursors and Mitigation Strategies
Create preventative precursor strategies
Create mitigation strategies
Physical Barrier
Procedural Recovery
Physical Redundancy
Drug delivered to wrong patient
Nurse walks into
wrong room
Not caught in name verification
Not caught in date of birth
confirmation
Not caught by barcode scan
An Example Failure Path
Conclusion
• We will not be great at everything we do
• Employee safety, patient safety, and environmental protection will compete with cost, time, and liberty
• We can prioritize where we put our limited resources– Embrace risk registers– Articulate your values– Set design criteria (qualitative - 3 dice?)– Prioritize based upon impact and changeability
• Build qualitative trajectories to design against the criteria
2020 Vizient PSO HRO and Safety Education Prioritization and Design of Reliable Outcomes�����Guidelines for Receiving Continuing Education Learning ObjectivesPresenter��Name�Credentials�Title�Organization���DisclosureAgendaThe �Safety �ParadoxHighly Reliable Organizations?A Look At AviationNon-Fatal Injuries and Illnesses in the USThe Real World…Two Competing PhilosophiesThe Premise…Prioritizing Risks - ��Risk RegistersGlobal Burden of DiseaseGlobal Burden of DiseaseA Rail Risk RegisterImpact and ChangeabilityQualitative �v. �QuantitativeQuantitative RequirementsQuantitative, Probabilistic Risk ModelingQuantitative – With how many dice do you play the game?Qualitatively Mapping Failure PathsQualitative�Risk�ModelingA Qualitative Design Goal: Play the game with three diceSlide Number 26Slide Number 27Slide Number 28Slide Number 29Slide Number 30An Example Failure PathConclusion
