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Mary Baum President & CEO BA&T September 18, 2015
Mary Baum
President & CEO
BA&T
September 18, 2015
Objective
Why patient safety is so difficult to solve?
The problem remains
Advances in clinical workflow
A collaborative approach
Metrics matter
Just start…….
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Complex vs. Complicated A rocket to the moon and raising a child?
Extracting a brain tumor and a judge
deciding guilt or innocence?
Complicated procedures (Rocket and
Brain Surgery)– require an expert, are
based on a repeatable plan, step-by-step
– need to be well trained. It assumes a
rational and top-down planning, smooth
implementation, policy, work delegation.
They fail occasionally – 3 Mile Island and
the Challenger
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Complex Systems – like
Healthcare Complex Systems - Filled with moving
parts, varied expertise,
interdependence –constant adaptation.
The environment is constantly
changing and unpredictable. It is
turbulent.
Even with facades of command and
control and policy manuals – the
outcome can be unpredictable.
They are spider webs of
interconnecting strands.
The answer is complex
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Healthcare - Pressures
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Neonatal Care 2018
93,955 ICU Beds all types
10-20% of all hospital beds
20-30% of costs
Average cost per year in US $81.7B
Average costs for preterm births in US $26B
Changing dynamics – Regulations
Reimbursement
Outcome
Penalties and metrics
Patient and Family satisfaction
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Implication of an Error The Context
Mortality rates for VLBW 240.4 per 1,000 live births
77.3% of infants with VLBW admitted to a NICU
Preterm births have increased more than 35% 500,000 babies born before 37 weeks annually US
Average bill of $280,000 (56X as much as a healthy baby)
Not intentional or due to reckless behavior
Adverse Events – 74 per 100 patients
Infiltrates
Nosocomial infections
Accidental extubation
Intraventricular hemorrhage
Skin breakdown
Misidentification – 9% of errors ( wrong diagnosis)
Medication error
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Etiology of an Error
Complex Interactions between - Human factors causal or latent:
Low staffing – Multiple caregivers ( Interns, residents, fellows – weekends), insufficient staffing and high census – influences LOS and outcome
Inadequate staff training
Staff fatigue
Poor team coordination
Equipment malfunction
Poor communication
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Specific and Clear Measures for
Safety?
Not Really…
Several identified and consistent objectives
that are clustered around aspects of care
Central catheter infection rate
Ventilator associated pneumonia
Nurse patient ratio team performance
LOS (30-35% 4 days or fewer, 55-70% 20 days)
Patient/family satisfaction
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High Level Safety Metrics
Survival rates
Staffing and structure
Benchmark case mix – adjusted LOS and create meaningful goals
Clinical guidelines
Case management
Integrated home health team
Communication with family
Readmission rate
Satisfaction levels
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Solutions - Many Views
Point of Care
System level
Care provider level
Patient level
Team level
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Parallel Play
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How Do We Start To Make Change?
Process Culture
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Goals Understanding that workflow
is the framework for how you
get there.
A set of processes
Set of people and
resources
Set of interactions among
the processes, people and
resources
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Why Workflow?
Clinical
Workflow
“The inter-
relationship
between
humans, the
tools and the
environment”
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Sausage Making – Its Messy
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New building/unit - old process
Latent Conditions:
1. Inevitable failures – “between the couch cushions”
2. Location of equipment
3. New technology
4. Confusing procedures – change with the new physical design
5. Training gaps – new equipment/new work
6. Staff shortages
7. Staffing patterns
8. Poor design with team working patterns
9. Supply placement/inventory management
10. Cross team and interdisciplinary team work patterns – L&D, transport etc.
11. Patient care path – flow
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Patient Safety and Teamwork
Equipment design
Use of technology
Reliable and predictable work process – scheduling and staffing – matching employees knowledge and expertise to job requirements
Team training – vulnerabilities
Management practice
Rewards and incentives
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Patient Safety and Teamwork
Context - High level cognitive work and fast-paced team decision making in a rapidly changing technical environment – overload and breakdown in communication and in team performance
Physical setting re-design where most of the work has focused
Missing - The people side of workflow – the team collaboration determines how healthcare professionals behave – interact and influence and relate to one another
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What gets lost? Information is omitted, lost or
misinterpreted
The latent consequences – between the couch cushions
Solution - honest (no-blame), transparent and open communication preventing, reporting, analyzing,
tracking and monitoring
ensures workers are thinking about safety and implementing safety measures successfully
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Bottlenecks = Poor Outcomes
Nurse shortages
Nurse patient ratios
Long distance between rooms
Multidisciplinary work- harder to collaborate
New builds/units and towers Not all change is an improvement
Managing extreme complexity Managing 178 actions per day per patient
Errors in just 1% translates to 2 errors per day per patient
NICU/ICU care succeeds only when the odds of doing harm are low enough for the odds of doing good to prevail (Atul Gawande Dec. 2007 The New Yorker)
50% of ICU patients experience serious complications
Line infections 5M lines a year/10 days and 4% are infected/prolonged LOS
VAP: 10 days on a vent, 6% develop bacterial pneumonia ○ 40-55% mortality
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Current State Mini observation summary:
• Process variability
• Communication
• Documentation
• Utilization of space
• Transport conundrum/process
• Admit process
• Discharge process
• Mixed acuity
• Work done in silos
• Supplies
• Staff assignment
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Metrics - Working?
Results –
Wasted time, increased risk, Press
Ganey Scores, redundancy, silos of
activity, dollars, inefficiency and
outcomes suffer
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A beginning
Compliance monitored for 1 month –
Doctors skipped at least one step in more than 1/3 of patients ( wash hands, clean skin, cover with sterile drape, mask, sterile dressing etc.)
Empower nursing to ask if line is still needed/or stop a doctor if they missed a step
Results – amazing 0% line infections – prevented 43 infections and 8 deaths, saved $2M in costs
(Keystone initiative Dec. 2006)
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Fundamental problem?
We don’t view delivery of care as a science
We see science as disease and biology
Finding effective therapies
But ensuring that we work in efficient ways and
delivering therapies effectively is ignored most
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Workflow - Quality Improvement? Current State – how is your staff spending their time
Systematically define how in your hospital/your unit you can
improve
Analyze the data- What are your numbers /data– current
state analysis
Best practice - Do you know what others have established as
evidence based improvement strategies?
Focus on key vulnerabilities - Develop strategies to
overcome barriers /reluctance to invest time and resources
in expertise to support quality improvement
Culture change – BIG topic
Curiosity, creativity and transparency
Identify opportunities to improve
Develop and understand your data ( before and after
change)
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Workflow - Quality Improvement?
Blame free culture – identify risk/mistakes and work
together to prevent reoccurrence of the problem
Leadership needs to be involved and foster
interdisciplinary efforts
Adopt methodologies that can assess outcomes for
improvement efforts
Routinely measure, analyze and study
Benchmark for best and worst
Take time to examine outcomes and process
Create a vison for the future – aspirational goals
Create a plan – test and revise
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Get involved –
performance improvement works
Albert Einstein
“Insanity is doing the same thing over and
over again and expecting different results”
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Thank You!! 3/8/2016 29
