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Healthcare Performance Improvement, LLCPhone: 757.226.7479 Fax: 757.226.7478www.hpiresults.com
Page 1
Gary R. Yates, MD
Sentara Healthcare
Healthcare Performance Improvement, LLC
How a Safety Culture Fosters High Reliability
2
Sentara Healthcare
� Formed through a series of mergers of community hospitals
� 11 hospitals; 2,580 beds; 3,825 physicians on staff
� 13 long term care/assisted living centers
� 4 Medical Groups (750+ Providers)
� 450,000-member health plan
� $4.7B total operating revenues
� 26,000+ employees
� AA/Aa2 bond ratings
� Sentara Quality Care Network (SQCN)
� Sentara eCare® HIMSS Analytics Stage 7 and HIMSS Davies Award
� SDI #1 Integrated Healthcare System 2001, 2010, 2011
� AHA Quest for Quality Award 2004, John M. Eisenberg Award 2005
Virginia
North Carolina
Healthcare Performance Improvement, LLCPhone: 757.226.7479 Fax: 757.226.7478www.hpiresults.com
Page 2
HPI – A Reliability Company
Methods based on science and facts
� Science of human error and event prevention
� Practical experience in high-reliability industries including
nuclear power and aviation
Experienced-based mentoring
� Over 500 hospitals
� Consulting team with HRO experience and healthcare experience (clinicians, non-clinicians, and physicians)
As of June 2013
Slide 4
4
A Change in Course
� Looked outside of healthcare(experience from other risk-averse, technology based industries such as nuclear power and aviation)
� Belief that to improve our outcomes we have to change our behaviors
Culture = Shared Values & Beliefs
�
Behaviors
�
Outcomes
Healthcare Performance Improvement, LLCPhone: 757.226.7479 Fax: 757.226.7478www.hpiresults.com
Page 3
Slide 5
Optimized
Outcomes10
-8
10-7
10-6
10-5
10-4
10-3
10-2
10-1
Relia
bili
ty
Journey to Reliability – Process + People
• Core values & vertical integration
• Behavior expectations for all
• Hire for fit
• Fair, just ,and 200% accountability
• Evidence-based best practice
• Focus & Simplify
• Tactical improvements (e.g. process bundles)
• Intuitive design
• Obvious to do the right thing
• Impossible to do the wrong thing
© 2010 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Process Design
Human Factors
Integration
Reliability
Culture
Slide 6
Shaping Behaviors at the Sharp EndDesign of
Culture
Outcomes
Behaviorsof Individuals & Groups
Design of
Structure
Design of
Technology & Environment
Design of
WorkProcesses
Design of
Policy &Protocol
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Healthcare Performance Improvement, LLCPhone: 757.226.7479 Fax: 757.226.7478www.hpiresults.com
Page 4
Technology
EOC
ProcessPolicy
JobDesign
Protocol
Culture
Culture is not just
one of the spaces
Culture is also the space
between the other spaces
High Reliability is
the right mix of
Blunt End behavior
shaping factors.
Culture makes
the other shaping
factors work as
intended.
Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994)
© 2012 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Slide 8
Safety Culture: An Overview
� Built on an understanding of the limits of human performance in complex, adaptive systems
� Key elements
- Psychological Safety
- Organizational Fairness/ Just Culture
� Encourage reporting and learning from errors
� Balance with accountability
- “Compliance culture”
� Widespread use of Non-Technical Skills
- Teamwork
- Communication
Healthcare Performance Improvement, LLCPhone: 757.226.7479 Fax: 757.226.7478www.hpiresults.com
Page 5
Slide 9
Just Culture creates an atmosphere of trust in
which people are encouraged to provide, and even rewarded for providing, essential safety-related information but in which they are clear about where the line must be drawn between acceptable and unacceptable behavior.
James ReasonManaging the Risks of Organizational Accidents (1997)
Slide 10
Culpability Assessment Tools
James Reason“Decision Tree for Determining the Culpability of Unsafe Acts”
from Managing the Risks of Organizational Accidents (1997)
United Kingdom’s National Health Service“Incident Decision Tree,” adapted from James Reason’s decision tree (2003)
P. HudsonRefined Just Culture Model from the
Shell Hearts & Minds Project (2004)
David Marx“Just Culture Algorithm” (2005)
Healthcare Performance Improvement, LLCPhone: 757.226.7479 Fax: 757.226.7478www.hpiresults.com
Page 6
Slide 11
"At the sharp end, there is almost always a discretionary
space into which no system improvement can completely reach. Systems cannot substitute the responsibility borne by individuals within that space."
Sidney DekkerJust Culture: Balancing Safety & Accountability (2007)
Slide 12
Non-Technical Skills
Non-technical skills describe how people interact with technology, environment, and other people. These skills are similar across a wide range of job functions. These skills include attention, information processing, and cognition.
Flin, O’Connor, and Crichton
Safety at the Sharp End
Generic non-technical skills:
� Situational awareness� Teamwork
� Communication� repeat backs
�phonetic & numeric clarification� clarifying questions� inquiry, advocacy, assertion
� Coping with Fatigue� Managing Stress
� Decision-making� Leadership
Healthcare Performance Improvement, LLCPhone: 757.226.7479 Fax: 757.226.7478www.hpiresults.com
Page 7
Slide 13
High Risk Situation
High Risk Behavior+ =
How Do Serious Safety Events Occur?
Safety Event
Slide 14
Collegial Interactive Teams
Tools: to facilitate effective assertion and clear communication
Tone: to help manage power distance
Examples:
� “You had me from Hello”– include first names
� Cordiality, openness
� Eye contact and body language
� Team goals Use “we” and “us” vs. “I” and “you”
� What’s best for the patient…
� Invite a Questioning Attitude Leaders set the tone for the flow of information
Improves Resiliency:
- Anticipatory thinking
- Cross-monitoring
- Thinking as a team The team senses they are off track and
works together to back on track
Healthcare Performance Improvement, LLCPhone: 757.226.7479 Fax: 757.226.7478www.hpiresults.com
Page 8
Actions to Create a Safety Culture
Organization’s
Values & Beliefs
Individual & Team
Behaviors
Our Outcomesin SAFETY as well as in
quality, satisfaction, and financial performance
Leader
Behaviors
Adopt behaviors for error preventiona “people bundle” for all (leaders, staff, and medical staff) and
engrain the behaviors as individual and team work habits.
Adopt behaviors for error preventiona “people bundle” for all (leaders, staff, and medical staff) and
engrain the behaviors as individual and team work habits.
Elevate safety – NO HARM – as the core valuethat is reflected in the words and actions of leaders,
medical staff, and employees.
Elevate safety – NO HARM – as the core valuethat is reflected in the words and actions of leaders,
medical staff, and employees.
Adopt a Daily Operating System for Leaders
for (1) reinforcing and building accountability for
performance expectations and
(2) detecting system problems and correcting causes.
Adopt a Daily Operating System for Leaders
for (1) reinforcing and building accountability for
performance expectations and
(2) detecting system problems and correcting causes.
�
�
�
© 2009 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Slide 16
A Rubric for Decision Making
with permission of Cincinnati Children’s Hospital Medical Center
“There is no priority higher than patient safety. If there is a conflict between safe practice
and speed, efficiency or volume, then
safety wins – hands down.”
James M. AndersonPast President & CEO
Cincinnati Children’s Hospital Medical Center
Healthcare Performance Improvement, LLCPhone: 757.226.7479 Fax: 757.226.7478www.hpiresults.com
Page 9
Slide 17
Culture Embedding MechanismsFrom Organizational Culture & Leadership, by Edgar Schein
Primary Embedding MechanismsSecondary Articulation &
Reinforcement Mechanisms
• What leaders pay attention to, measure, and control on a regular basis
• How leaders react to critical incidents and organizational crises
• Observed criteria by which leaders allocate scarce resources
• Deliberate role modeling, teaching, and coaching
• Observed criteria by which leaders allocate rewards and status
• Observed criteria by which leaders recruit, select, promote, retire, and excommunicate organizational members
• Organizational design and structure
• Organizational systems and procedures
• Organizational rites and rituals
• Design of physical space, facades, and buildings
• Stories, legends, and myths about people and events
• Formal statements of organizational philosophy, values, and creed
Slide 18
“Talking about safety should not be an event.”Barbara Summers, President Community Hospital North
� 9:00-9:15 AM, Monday-Friday
� All departments directors
� 100% attendance expectation –
“step out of meeting to attend”
� Facilitated by senior leader
Daily Check-In Agenda
1. LOOK BACK – Significant safety or quality
issues from the last 24 hours/last shift
2. LOOK AHEAD – Anticipated safety or quality
issues in next 24 hours/next shift
3. Follow up on Start-the-Clock Safety Critical
IssuesPalo Verde Nuclear Generating StationPressurized water reactor
Healthcare Performance Improvement, LLCPhone: 757.226.7479 Fax: 757.226.7478www.hpiresults.com
Page 10
Slide 19
Benefits of Daily Check-Ina house-wide safety huddle
Leadership Awareness- For the senior leader: awareness of what’s happening at
the front line by staying in touch with your people
- For operational leaders: awareness of “what’s going on” in other areas and cross-department impact
- Mental organization – a chance to “plan your day”
Problem Identification & Resolution
- Early notification of issues
- Breaking down silos – all directors to pool ideas and resources in solving problems and potential problems
Accountability for Safety
- “Talking about perfect care has become easier” – more aggressive in leadership for Zero events
- Dialogue about how we are at risk, how we can reduce our risk, and how we can support each other
- Transparency – “A patient fell on my unit last night and broke an ankle”
Slide 20
Error Prevention Toolbox
1. Pay Attention to Detail
� STAR (Stop/Think/Act/Review)
2. Communicate Clearly
� Repeat Backs & Read Backs
� Clarifying Questions
� Phonetic & Numeric Clarifications
� SBAR
3. Have a Questioning Attitude
� Validate & Verification
4. Handoff Effectively
� 5P’s (Patient/Project, Plan,
Purpose, Problems, Precautions)
5. Never Leave Your Wingman
� Peer Checking
� Peer Coaching
Healthcare Performance Improvement, LLCPhone: 757.226.7479 Fax: 757.226.7478www.hpiresults.com
Page 11
Slide 21
Process Bundle + People Bundle
Central LineInfections
HandHygiene
Surgical SiteInfections
Codes Outsidethe ICU
Culture
����������������
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Slide 22
Sentara Serious Safety Event Rate
0.00
0.25
0.50
0.75
J-0
3
M-0
3
M-0
3
J-0
3
S-0
3
N-0
3
J-0
4
M-0
4
M-0
4
J-0
4
S-0
4
N-0
4
J-0
5
M-0
5
M-0
5
J-0
5
S-0
5
N-0
5
J-0
6
M-0
6
M-0
6
J-0
6
S-0
6
N-0
6
J-0
7
M-0
7
M-0
7
J-0
7
S-0
7
N-0
7
J-0
8
M-0
8
M-0
8
J-0
8
S-0
8
N-0
8
J-0
9
M-0
9
M-0
9
J-0
9
S-0
9
N-0
9
J-1
0
M-1
0
M-1
0
J-1
0
S-1
0
N-1
0
J-1
1
M-1
1
M-1
1
J-1
1
S-1
1
Event R
ate
Sentara Hampton Roads Hospitals
80% SSER Reduction
74% Reduction in Claims Frequency
Healthcare Performance Improvement, LLCPhone: 757.226.7479 Fax: 757.226.7478www.hpiresults.com
Page 12
RELIABILITY CULTURE
Evidence-BasedProcess Bundles
+performed as intended
consistently over time= Clinical Excellence
Reliability Culture as a Chassis
Patient Centered +performed as intended
consistently over time= “Satisfaction”
Financial Focus +performed as intended
consistently over time= Margin
Safety Focus +performed as intended
consistently over time= No Harm
© 2011 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
*Also Impacts Morale, Employee
Engagement, Physician Satisfaction
Slide 24
Thank you
Gary R. Yates, MD
President, Sentara Quality Care Network
President, Healthcare Performance Improvement, LLC