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MHA’s Quarterly Quality Webinar Safety Across the Board, Part II
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
safe.
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
Why Should We Achieve Safety Across the Board? (cont)
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
Why Should We Achieve Safety Across the Board? (cont)
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
10
Why Should We Achieve Safety Across the Board? (cont)
#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.
How Do You Count Total Harm?? (cont)
Utilize debriefs
How Do You Count Total Harm?? (cont)
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
Safety Across the Board
SAFETY & RELIABILITY CULTURE
MEASURE & UNDERSTAND THE TOTAL
HARM IN YOUR ORGANIZATION
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
15%
20%
55%
10%
Distribution of Events
CAUTI OB Trauma With Inst OB Trauma Without Inst SSI
6%
1% 4%
[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
Safety Across the Board
SAFETY & RELIABILITY CULTURE
MEASURE & UNDERSTAND THE TOTAL
HARM IN YOUR ORGANIZATION
TRANSPARENTLY REPORT
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
Safety Across the Board
SAFETY & RELIABILITY CULTURE
MEASURE & UNDERSTAND THE TOTAL
HARM IN YOUR ORGANIZATION
TRANSPARENTLY REPORT
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,
ACT
Often, left out…
X
Target Setting
PDCA is an acknowledgment of failure, but a victory in learning
STANDARDIZE THROUGHOUT ORGANIZATION
Organizational/MACRO PDCA
DRIFT
Situational Awareness
Safety Across the Board
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.
Gemba
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
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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)
MONL
Alison Williams, R.N., BSN, MBA-HCM
Vice President of Clinical Quality Improvement
Clinical quality SME
Oversight of Quality Improvement
Grant management
Collaboratives management
MONL
MOAHQ
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
MOAHQ
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
MOAHQ
MONL
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
[email protected] 573/893-3700x1305
[email protected] 573/893-3700x1326
[email protected] 573/893-3700x1314
[email protected] 573/893-3700x1391
[email protected] 573/893-3700x1382
http://web.mhanet.com/strategic-quality/
