Reliability Presentation Guidance Note

7/23/2019 Reliability Presentation Guidance Note

http://slidepdf.com/reader/full/reliability-presentation-guidance-note 1/39

Reliability Theory and its

Application to Healthcare



Aims of session

• Introduction to reliability theory – the frameworkand the three step model

• Highly reliable organisations – who are they?

Can we learn from them?• Healthcare as a highly reliable industry –

designing reliable systems of care

• Care bundles – a reliability approach





Reliability in healthcare

• Healthcare is a high hazard industryHealthcare is a high hazard industry• We are not able to reliably deliver healthcare toWe are not able to reliably deliver healthcare to

all of our patients all of the timeall of our patients all of the time

• !ppro" #$% &'$$($$$) of patients admitted tohospital e"perience an incident

• *+($$$ of these incidents,adverse eventscontribute to the death of patients

• -any go unrecognised



Patient safety – a global issue



Impact

.irect costs/• in 0ngland healthcare associated infections are

estimated to cost over 1# billion pounds per year

• on average( preventable drug events resulted inan additional 23 days in length of stay

• estimated cost of preventable adverse events in45! is 6#$# billion &7eape et al #''8)



9rust :oard !way .ay – ;ctober +$$<



Is medicine a high-reliability industry?• 9he practice of medicine involves comple" systems in

which humans play a key role• =rocedures are very technical and sometimes risky

• -edicine should be a high>reliability industry

• 4nfortunately literature shows that it is fraught with error(

can be unsafe( and at times is not effective• 9he potential for error and system failure is always there

• 9hings happen on a daily basis/ staff go off sick(euipment doesn@t work( people forget to do something >

we are all human no matter how diligent• 9his is a normal part of a comple" healthcare system



What is reliability science?

• Aeliability principles are used successfully inindustries such as manufacturing and air travelto help evaluate( calculate and improve theoverall reliability of comple" systems

• 9hese can be used to design systems thatcompensate for the limits of human ability( canimprove safety and the rate at which a system

consistently produces the desired outcomes



How is it measured?

• Aeliability is measured as the inverse ofthe systems failure rate

• ! system that has a defect rate of one inten or #$% performs at a level of #$ – #

• Aeliability is defined as failure>freeoperation over time

• Aeliability B number of actions that

achieve the intended result( divided bytotal number of actions taken



A reliability framewor

• !" – ! performance on process measures indicates noarticulated common process and an emphasis ontraining and reminders &international studies of adverseevents in hospitals shows an error rate of #$%suggesting a level at which most organisations currently

perform)• !" – # performance on process measures indicates

processes intentionally designed with tools and conceptsbased on the principles of human factors engineering

• !" – $ or better performance on process measuresindicates a well designed system with attention toprocesses structure and their relationship to outcomes



%&amples•

#$>#

B $ or '$% success( # or + failures out of #$opportunities & ! chaotic process) – :>blockers after acute -I

• #$>+ B < failures or less out of #$$ opportunities – -ortality in general surgery

• #$>8B < failures or less out of #$$$ opportunities > -ortality in routine anaesthesia

• #$>2 B < failures or less out of #$($$$ opportunities

! chaotic process is failure in greater than +$% of opportunities

!lmost all studies that investigate the reliability of the application of

clinical evidence conclude that it is #$>#



Impro'ing reliability

(e'el I Intent( vigilance D hard work

(e'el II .esign systems for reliability constraints( decision aids( reminders( checklists( bundles

(e'el III =revent design for reliability

Identify make failures visible -itigate prevent , treat harm due to failures



How to reduce 'ariability

• 5tandardisationCare bundles

IC=sEuidelines

• Checklists• Improve access to information• Aeduce reliance on memory

• Constraints• Aeduce handovers• 5implify processes



)tandardisation concepts

• 5tandardisation is done to provide theappropriate infrastructure

• 9he Fwhat@ we are standardising based on good

medical evidence• 9he Fhow@ does not need to be based on good

medical evidence but rather on systemsknowledge



In a broader conte&t

• !viation passenger safety is measured at #$>3

• Guclear power plants must demonstrate a

design capable of operating at #$>3 before theycan be built



IHI three-tiered strategy for designing

reliable care systems

# =revent failure

+ Identify and mitigate failure – identify failurewhen it occurs and intercede before harm is

caused( or mitigate the harm caused byfailures that are not detected

8 Aedesign the process based on the criticalfailures identified



*esigning effecti'e and reliable

systems

• Have simple rules – comple" systems best handled by this• eature redundancy – offers multiple layers of defence from error • Incorporate forcing functions – a mechanism that makes it easy to

do the right thing and hard to do the wrong thing &ie on a plane thetoilet light cannot be turned on without locking the door first)

• 0nsure people cannot work around the system first – understandwhy people develop workarounds• -inimise reliance on human memory• !llow the e"pertise of the people performing the work to be used –

standardised protocols provide a systematic approach• Incorporate technology where possible• Communicate the advantages of the system to clinicians – if staff do

not see this they will develop workarounds• Consider what happens if the system fails – be prepared



How Ha+ardous Is Healthcare?

(Leape and Amalberti)



Highly reliable organisations?

• ! definition of a HA; is one that is known to becomple" and risky( yet safe and effective

• 9hese organisations acknowledge thecomple"ity of their systems create an

environment in which individuals cancommunicate openly about concerns and designsystems that make it difficult for failures to occur

• HA;s ask Fwhat happens when the systemfails?@( not FWhat if the system fails?@



%&amples of highly reliable

organisations

• !viation

• Guclear power plants

• !ir traffic control centre

• Guclear aircraft carriers



(earning from highly reliable

organisations

• ;ther highly technical industries bear a similarityto medicine

• !irline industry > thousands of flights take place

every day in varying weather conditions If asignificant error occurred the conseuenceswould be dire

• 5o why is the error rate in aviation not thesubect of public and media interest?



(essons learned the hard way,



The airline industry

• !viation industry recognised years ago thathuman error is an inevitable part of doingbusiness

• 9he industry chose to address error preventionand safety by improving communication(flattening team hierarchy and implementing failsafe systems

• 9hese actions have made aviation a highlyreliable industry



High reliability organisations

• 5trong organisational culture of reliability

• Continuous learning

• 0ffective and varied patterns of communication

• Human resource management practices thatsupport reliability

• !daptable decision>making dynamics

• -anaging technology• 5ystem and human redundancy



The need to apply a )ystems Approach

• ailure is predictable and can be detected

• ailure arises out of systematic andorganisational factors – not ust erratic behaviour

of individuals• High reliability departments create safety by

anticipating and planning for une"pected events

and future surprises



an reliability be applied to healthcare?

• !lthough healthcare is not currently highlyreliable( it has the potential to be

• IHI and others believe that applying reliability

principles to healthcare has the potential toreduce defects in care or care processes(increase the consistency with which appropriatecare is delivered( and improve patient outcomes

• 9o move in that direction we must overcome oneof the largest barriers – the culture of medicine



There is hope

• ;ne bright light in the field of healthcare with regard to

high reliability – anaesthetics• Go other medical discipline has come as close• Aealisation that the weak link in the process was the

people not the technology &#'2 Cooper published hisstudy – review of 8+' incidents involving anaesthesia in a

-assachusetts Hospital identified that nearly *$% of theseincidents related to human error • 9hey have learned lessons and implemented changes that

the rest of the healthcare field are ust beginning toacknowledge

• In #'<2( one out of every #(<$$ patients died as a result ofproblems with their anaesthetic• In +$$# that risk has dropped to one in every +<$($$$



.sing care bundles to impro'e reliability

• :undles demand Fall or none@ thinking andmeasurement

• :undles facilitate identifying failures

• ailures are actively used to redesign theprocess

• 9eam work and communication proven to

improve



What are they?

• ! series of interventions relating to a treatmentor intervention

> ventilator bundle

> central 7ine bundle> tracheostomy bundle etc

• When implemented together will achieve

significantly better outcomes than whenimplemented individually &IHI +$$<)



Why?

• ! way of reducing the gap between researchand practice in clinical areas

• =romotes evidence>based change

• 9he bundle of care will have a greater effect onthe positive outcome of the patient than if usedin isolation

• Aeduces variation from unit to unit or clinician toclinician



are bundles

:ased on reliability principles – all or nothing compliance/

• =lane takes off ok( one engine fails during flight(descends ok( lands ok B *<%

• =lane takes off ok( one engine fails during flight(descends badly( crashes on landingB +<%

• =lane takes off ok( engines ok during flight( descends ok(lands ok B #$$%

• ;verall flight compliance – 33%

Would you want to travel on this airline?



%'idence

• IHI estimates that it could be possible to achievean $% reduction in 5urgical 5ite Infections &ofwhich 8% could be fatal) and a <$% reduction indeaths from !cute -yocardial Infarction

• 9hey also estimate that an average bed sized45 hospital could save # lives from 55I and#$ lives from !-I each year as a result ofimplementing care bundles



An e&ample

7evel of reliabilityof all 2 elementsof ventilator bundle

J '<% compliance

K '< % compliance

Aeduction ofLentilator !cuired=neumonia

23 %

<' %



(/* 0 *aily compliance with -are 1undle

2uly 3 Aug 3)ept34ct35o'3*ec"$32an"63feb37ar3Apr"6

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4utcomes

• 0vidence that the unit is achieving uality careand doing the right thing for the right patient

• !verage length of stay is reducing

• 5edation costs reduced – financial savings



entral line bundle



entral line infection rate



7aing the mo'e

• Geed to move towards a culture focused on safety andreliability

• 7eadership driven with staff focused on safe and reliablecare

• !doption of standardised methods of communication andin the creation of an environment in which peopleinteract collaboratively and feel free to speak up if theysee something worrying

• 0ngineer systems with redundancy and safeguards thatmake doing the wrong thing difficult

• Create a learning environment in which little problemsare seen as indicators of deeper potential faults to beaddressed proactively

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Reliability Presentation Guidance Note

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