“INTO THE WEEDS”
How to apply concepts of resilience and Safety II
to improve performance.
Lacey Colligan MD MSc FAAP Consultant, Dartmouth Hitchcock Medical Center
Sharp End Advisory LLC IHI Workshop 10 December 2014
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No Disclosures Grateful Acknowledgment:
the Center for Kvalitet Region Syddanmark Denmark
Regions of Denmark E. Hollnagel PhD
J. Hounsgaard HRD, IRCA
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Overview
• Models
• How a way of thinking (model) about of your system can be useful.
• Methods
• How a new method may augment your performance improvement efforts.
Retired Danes at lunch (65yo +)
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Start with a system Model
Why use a system model? • Traditional: in order to predict and control system
• Philosophical: in order to understand system
• Practical: gain shared vocabulary and methods so that we can communicate about our system
“Essentially all models are wrong,
but some are useful.” – Box GEP and Draper NR (1987)
Empirical Model Building and Response Surfaces.424.
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Model of STS
Underlying Philosophy Tracta-
ble?
COMPLICATED LINEAR
Descartes
17thC Rationalism
sum components analytic method “Reason is the chief test and source of Knowledge”
Y
COMPLEX NON-LINEAR
Serra and Zanarini, 1990
Cilliers, 1998
“complex” and “simple” can be our distance in system
components PLUS
theirinterdependent relationships in a non-linear manner
N
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Model Case 1: No Double Lumens
• Double lumen umbilical central lines are life-saving for sick newborns, especially prematures.
• No double lumens, on “back order”.
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Model Case 1: No Double Lumens
• AE1: surgical cut-down for CHD patient.
• AE2: exchange of single lumen for double lumen on day 3 after birth.
• NM1: “borrowed” double lumen from Transport team.
• “Moral Distress” meeting convened over inadequate supply availability. Rose to Level of Chief Nursing Officer.
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2x
“STORE FRONT” NICU STORE ROOM
Complicated Linear (WAI)
Supply Chain
DIRECT PATIENT CARE ©Sharp End Advisory, LLC
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Complicated Linear WAI/WAD:
Pull-Push
Transparency
Precision
Production Smoothing
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Complex Non-linear (WAI)
Neonatal Nursing
NICU STORE ROOM
1. POD 2.BEDSIDE CARTS
3.PROCEDURE CARTS
4.CUPBOARDS
Get your supplies…..
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Complex Non-linear(WAD)
1. POD 2.BEDSIDE CARTS
3.PROCEDURE CARTS
4.CUPBOARDS 5. SOMEWHERE ELSE
Get your supplies…..
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Complex Non-linear(WAD)
1. POD 2.BEDSIDE CARTS
3.PROCEDURE CARTS
4.CUPBOARDS 5. SOMEWHERE ELSE
Get your supplies…..
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Complex Non-linear WAD:
Searching Secret
Networks and Stashes
Hiding/Hoarding
Information Seeking ©Sharp End Advisory, LLC
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Inter-dependent Relationships
Complicated Linear Supply Chain
Complex Non-linear Neonatal Nursing
• Priority is patient care
• Pull-Push coupling (tight) • Transparency • Precise counting
• Priority is patient care
• Loose coupling • Little transparency • Worker adaptations erode
counting • Patient requirements erode
counting
Supply Availability is
CONTROLLED
Supply Availability is
EMERGENT
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2x
1. POD 2.
BEDSIDE
CART
“
Complicated Linear
Complex Non-linear
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2x
1. POD 2.
BEDSIDE
CART
“
Complicated Linear
Complex Non-linear
• Training? • Increased sanctions? • Patient Technicians? 30% understaffed.
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1. Reallocate stockists so that one is dedicated to Pediatrics. – Supply personnel are "embedded”.
– Enables two way communication thus improving FEEDBACK.
2. Supply chain extends reach. – Stockist stocks all satellite supply stations.
– Ensures precise counting.
Cost of PCA’s & wasted Nursing time justifies additional infrastructure (carts).
Proposal: identify assumptions and design targeted intervention
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METHODS are based on Models
Model Method Accident Investigation
Goal
Sum of components Decomposition works COMPLICATED LINEAR
Find holes in system
Construct barriers / defenses
COMPLEX NON-LINEAR
Sum of components
+ Relationships between components Decomposition does not work
Find couplings/ complex interactions
Monitor / manage performance variability
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Method Safety Principles Goal of work
Complicated Linear:
RCA/HFMEA
Direct causality Latent conditions Sequence matters Retrospective
matters
• Construct barriers / defenses
Complex Non-linear
FRAM/STAMP
Success=failure Variability Emergence Resonance Conflicting Demands
Monitor/ manage performance variability
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Method Safety Principles Goal of work
Complicated Linear:
RCA/HFMEA
Direct causality Latent conditions Sequence matters Retrospective
matters
• Construct barriers / defenses
Complex Non-linear
FRAM
Success=failure Variability Emergence Resonance Conflicting Demands
Monitor/ manage performance variability
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Efficiency-Thoroughness Trade-Off (ETTO) Thoroughness=
Time to think • Recognising situation • Choosing and planning • Consider outcome
RISK?
• Miss new event • Neglect pending
actions
Efficiency= Time to do
• Implementing plans • Executing actions
RISK? • Miss preconditions • Erode controls
• Confirmation bias Negotiating Conflicting Goals © Erik Hollnagel, 2012
1. The Equivalence of Successes and Failures
2. The Principle of Approximate Adjustments
FRAM Principles
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Performance variability is why
things go right
Performance variability is why things go wrong
Workers adjust their work to the situation.
Resources are always limited.
Because of these limitations, adjustments are always approximate.
Success = Failure and Adjustments
23 ©Erik Hollnagel
1. The Equivalence of Successes and Failures
2. The Principle of Approximate Adjustments
3. The Principle of Emergence
FRAM Principles
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Emergence
Safety in Healthcare is an Emergent Property
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1. The Equivalence of Successes and Failures
2. The Principle of Approximate Adjustments
3. The Principle of Emergence
4. The Principle of Functional Resonance
FRAM Principles
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Classical Resonance
• Ancient Greece
• Oscillations include
– frequency
– amplitude
• Forcing function
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Stochastic Resonance
• Early 1980’s
• No forcing function
• Random noise
• Outcome is non-linear
From http://www.joannaleng.com/
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Functional Resonance
• Hollnagel (2004, 2012,2014)
• Variability that results
from multiple approx. adj.
• Detectable outcome (signal)
that emerges from the unintended interaction of the everyday variability of multiple signals
• Considers outcomes that are non-causal (emergent) and non-linear (disproportionate)
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©Erik Hollnagel
FRAM: a Method to Tackle CAS Includes Values/Culture
30 ©Erik Hollnagel
n.b. Safety Culture reflected in Control
FRAM Applications
1. Retrospective: how something did happen (an event), build an instantiation;
2. Prospective: how anything can happen;
3. Assess the impact of variabilities in a re-design (ex. LEAN)
4. Facilitate work across cross-disciplines.
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Case: CLABSI prevention bundle • Extensive training in use
of checklist
• Checklist compliance excellent
• Work as Imagined looks good…… BUT minimal improvement (Work as Done)
http://www.jointcommission.org/CLABSIToolkit
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Executive Leadership
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Implementation of Bundle
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Line Placement WAD
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Controls of safety culture, and resources from education and stocked cart removed for clarity of diagram.
Operator/ Doc
Nurse
Instantiation 1: ETTO
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Controls of safety culture, and resources from education and stocked cart removed for clarity of diagram.
Time pressure disrupts ability to do both functions.
Instantiation 2: Disruptive Physician
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Controls of safety culture, and resources from education and stocked cart removed for clarity of diagram.
Instantiation 3: Fractured team rotations: discuss
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Controls of safety culture, and resources from education and stocked cart removed for clarity of diagram.
1893-1912
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