Annual NPSF High Reliability Patient Safety Congress … · 2 2008 NPSF Patient Safety Congress...

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Annual NPSF Patient Safety

Congress

May 14 - 16, 2008Gaylord Opryland

Nashville, TN

Maureen Ann Frye, MSN, CS, CRNPDirector, Center for Patient Safety and Health Care Quality

Abington Memorial HospitalAbington PA

High Reliability Demonstration

Project

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2008 NPSF Patient Safety Congress Connect, Communicate, Commit

Objectives- Outline our journey in applying High Reliability

principles to our organization

- Describe our method of developing, testing and implementing an HRO assessment tool within a microsystem (or two!)

- Share the lessons learned (and “hot off the press” results!)

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Abington Memorial Hospital

- 600 bed independent, nonprofit acute care facility- Northern suburbs of Philadelphia- Level II Trauma Center - 96+ K ETC visits annually- 2nd busiest Maternity Center in Pennsylvania - > 5000 births/year- 5500 employees, 900 physicians, 1200 volunteers

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-ANCC Magnet Hospital -John M. Eisenberg Award 2003 -AHA Quest for Quality Award 2003-ISMP Cheers Award 2004-Most Wired Hospital Award 2004

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5 Pillars of ExcellencePatient Safety / Quality - #1Patient SatisfactionEmployee SatisfactionDiversityFinancial/Operational

Defined Patient Safety GoalsReduction of MortalityReduction of HarmFoundational Aspects of Patient SafetyEvidence-Based Care at the Bedside

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Foundational Efforts for Patient Safety

TeamSTEPPS: team practice and communication>2000 physicians/residents/nurses trained FY08Required for medical staff recredentialling

Safety Briefings all units/all shifts

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Our Organizational “HRO” Readiness: Understanding Baldrige

LeadershipCMO is the Chief Patient Safety OfficerBoard is “on Board”11 Physician/Nurse Patient Safety OfficersStrong Physician / Nursing / Ancillary Collaboration

Strategy and StructureGoals defined by Pillar and cascaded down Center for Patient Safety and Health Care Quality

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•Employee Focus for Patient Safety/Quality

- Alignment to organizational goals

- “Engage Every Employee” (E 3) cards

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Measurement, Analysis and Knowledge Management

Hospital Scorecard with measures of success

Process Management and ImprovementLean Change Acceleration ProcessIHI’s Model for Improvement / PDSA

Patient FocusPatient Satisfaction goals Patient centered care efforts

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Is any of this making us safer or more reliable?

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Why bother developing an HRO tool?

We were intrigued by the idea of

Assessing, Improving & Aligning

a discreet clinical service/microsystem in HRO principles using a Baldrige framework

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Our Participation in the APSF/SCCM HRO Collaborative

November 2006

Utilized the “straw man” example for Cardiac Surgery which included Baldrige Categories

Leadership, Strategic Planning/Deployment, Staff Focus, Process Management, Measurement/Analysis and Knowledge Management; Patient Focus

Developed a tool to elicit high reliability evidence from the stakeholders in a microsystem

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Multidisciplinary Surgical Weight LossService Line: Focus Group

Chose the team to complete the excel tool Engaged Physician Champion & multidisciplinary teamSuccessful FMEA before first bariatric surgeryFirm belief in Drills/Simulations and Teamwork

Incorporated information on ONE ToolSRC Centers of Excellence CriteriaOur Organizational GoalsBaldrige framework

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Attitude / Opinion

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A = ApproachIs there a standard way (a process) that everyone does this?

D = Deployment Does everyone use/do this or just some of you?

L = LearningAre we learning from this process and using what we learn to improve the process?

I = IntegrationDoes this process work with other processes or feed into other processes? Or does it stand alone and no one else uses it?"

Built in an ‘audit’ component to elicit further Evidence using Baldrige concepts

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No Process exists- STOPAn informal process exists-NEXTA Process exists but needs improvement-NEXTAn established process exists that guides actionUnable to answer- STOP

Approach

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No one used/uses the processOnly some team members use the process The process is/was used by all members of the teaThe process is/was used throughout the organizatioUnable to answer

Deployment

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No learning occurred / occurs as part of the procesWe learn some things We learn from the process and make improvementWe continually learn from the processUnable to answer

Learning

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This process works independently of other processThis process helped inform/improve other processeThis process is integrated with other improvementUnable to answer

Integration

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It was “Ex- “hell”Pros

Educated them on the ‘big picture’Content was useful but our deployment was wrong

ConsToo long to explain the tool 2 hours, Q&A, practiceToo long to complete > 3 hours! Not engagingToo difficult to answer the A,D,L,I componentsToo cumbersome in format and data managementDid not capture “WIIFM” and essential elements that reflect the daily function in the service lineDid not reveal anything significant in the data

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Reflection

Asked too much Reached too farWhat were we thinking?What were we asking?

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HRO Survey Redesign: Labor and Delivery Unit

- Since 1996, 14 area hospitals closed maternity

services.

Increased surge of patients

Increased complexity of patients

- Declining number of practicing obstetricians due to

the unfavorable malpractice climate in PA

Increased production pressures

Increased financial burden to the hospital

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HRO Survey Redesign: Labor and Delivery Service Line

Burning platform to achieve higher reliability

“Culture is the residue of your past successes…” Edgar Schein

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Engaged Chief Patient Safety Officer and Organizational Support

Patient Safety Officer as Medical Director, Labor and Delivery

Conducting drills, simulationsTeam Training, Safety BriefingsAWHONN trainingLearning from ‘events’ and making system improvements

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Other Microsystem challenges

Private and employed obstetricians

Non-dedicated Anesthesia service

Physical space limitations to manage the surge

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Face an excess of unexpected eventsHave complex technologiesMust coordinate OB, anesthesia, nursing, NICU and anesthesia care under demanding conditionsMultiple simultaneous demands Two patients for every one encounterPatient expectations

“Small moments of inattention and misperception can escalate into serious adverse events…”

Weick and Sutcliffe

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In Redesigning the Survey, we…Asked the questions that matter most to themFramed questions related to their ‘events’Stopped at Approach & DeploymentFound a better format that engages staff Built the tool for staff to “tell us” what’s really happening in their microsystem…. And they did!

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Internet-Based Tool

User FriendlyPoint & click

Likert questions + “tell me more” text featuresOpen ended / Fill-in Questions Baldrige “Process Questions” (Approach & Deployment)

Anonymous for participants Confidential for Unit Leaders

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Labor and Delivery Focus GroupInvited all who ‘touch’ the unit to participate.

Random selection of 20% from each role

Intro session 30 min Done “on the unit” with all staffDescribed an HRO: “All Unit” Assessment

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Focus Group

Voluntary participationCMEs/CEUs offeredToken of appreciationPromise of feedback

Deployed March 5 - April 15, 200862 interdisciplinary focus group members (97%)

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Brief Peek at the Tool

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Introduction to the Tool and Why

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Allowed us to Sort Responses by Profile

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Allowed us to assess current environmental conditions affecting the survey

What risks are occurring in the environment?

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Questions elicited their ‘Opinion”

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And told us how well they know our processes

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Baldrige questions drill down for A= Approach (Process) and

Do we have an approach/process?

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D = Deployment (extent that the process is used)

Is the Process being deployed/used?

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We can get culture questions….

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and “Pop Up” boxes clarify terms

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Allows the difficult conversations to be aired anonymously

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Running bars allow the respondent some sense of ‘where they are’ in the tool

Enjoyed

Seeing

Photos of

Their

Team

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Staff cannot progress without answering key questions

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Pros

Easier ‘on the eyes’Less time to complete

(~90 min)Running progress barCan come ‘in/out”;

paced completionDone Online “Pop Ups” for clarityStaff were informed while eliciting responses

Cons

160 questionsTakes ~90 min to completeSome questions were “fuzzy”Intranet tool requires significant data management on the “back end”Not statistically validated

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Managing the DataCategorized by

Question typeLikertOpen Ended (Text Responses)Process Questions

Role of respondent

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160 questions aligned with 14 Dimensions

Strategic Emphasis on Pt SafetyLeadership “Setting the Tone”Just CultureSocial Milieu of the UnitEducational Infrastructure for Safe PracticeAdaptive Factors / Learning OrganizationSystem Design and TechnologyRisk Perception

Human Factors Mindset & DesignStaff Alignment to Organizational and Unit GoalsTeamwork Skills and BehaviorsConflict ResolutionEvidence-Based Perinatal Care and Reliable Standards of PerformancePatient Centered Care

AND

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9 15 16 30 32 33 34 39 40 78 83 88 89 90 97

107 109 11

0111

114

117

118

120

134

136

158

Deference to Expertise Defer to those

with most experience, flattening of the hierarchy,

freely share information and concerns

12 16 25 26 38 41 78 119

120

132

21 23 44 57 63 88 101

105

106

110

114

117

120

122

124

125 128 12

9130

133

134

136

137

139

143

160

161

5 6 8 12 15 26 29 35 41 44 57 63 79 83 87

89 90 91 96 97 98 100

101

113

114

117

123

130

132

134

139 140 14

2145

146

147

148

149

150

151

12 15 16 19 25 30 32 33 34 35 36 37 38 40 41

44 52 63 88 89 90 97 101

110

117

118

124

125

131

139

134 135 14

0158

161

Reluctance to Simplify Search for true causes of error/near

misses; recognize the range of things that could go wrong.

Seek the meaning not the obvious. Diverse teams in

decision making

Sensitivity to Operations Quick

resolution of problems, situational awareness, error identification and addresses.

How long staff on duty, needed resources, potential

distractions to care.

Commitment to Resilience Quickly contain errors after they

happen, improvise, perform quick situational

assessments. Drill, huddle

Preoccupation with Failure Focused on

predicting and eliminating catastrophies before they happen. Near misses are opportunities to improve.

Mindfulness

HRO Characteristics Mindsets

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Early Findings

Variation exists between likert and text responses. What does this mean?

Respondents did “tell us more” in the text fields. They told scenarios and often changed their likertresponse in their narratives.

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Text Responses are identifying…

- Gaps in shared values between different groups related to flow/unit priorities.

- That residents need more safety education, situational awareness and to “speak up” for help

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Unit leaders struggle with managing the patient safety message and budget/finance issues.

There’s a need for shared mental modeland a better strategy for situational awareness embraced by everyone – how to get them all “in the same movie” Michael Leonard, MD

Learning from near misses/events occursJust culture/safe social milieu is improvingTeamSTEPPS strategies are being implemented

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Early lessons learned

Begin with the microsystem to build reliability

Are attitudinal surveys enough to understand the microsystem?

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Next Steps

Continue to analyze & understand the resultsFeedback to the MicrosystemObservational analysis to assess behaviorsReview of policies, job descriptions, etc for alignment with survey answersDevelop specific intervention strategiesNarrow the tool and resurvey

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Annual NPSF High Reliability Patient Safety Congress … · 2 2008 NPSF Patient Safety Congress...

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