When ParallelWorlds Collide…Beautiful Things
Happen
A Story About High Reliability
Principles of a High ReliabilityCollective Mindfulness
Sensitivity to Operations
Commitment to Resilience
Deference to Expertise
Preoccupation with Failure
Reluctance to Simplify
The TSICU Story
Challenges
CollaborationAccomplishments
Great Outcome
The Ethical Dilemma292 Nurse Interactions
The OB Story
Challenges
CollaborationAccomplishments
Great Outcome
The NICU Story
Challenges
CollaborationAccomplishments
Great Outcome
Lessons Learned
Birth Plan
Post Delivery Care
Communication
Debriefing
Our Ultimate Goal
TSICU
NICUOB
Great Outcome
Great Outcomes
Quality Statistics
• Zero Hospital Acquired Infections
Life Gift Statistics
• Double Lung Transplant - 53yo F - waiting 78 days
• Right Kidney - 43yo M - waiting 1,501 days
• Left Kidney - 39yo M - waiting 2,173 days
• Liver - 43yo M - waiting 7 days
• Heart – recovered for research
NinfaMarch 7, 2016
Weight: 4 lbs. 3 oz.
Mother: Pamela
Father: Isaiah
Happy & Healthy
Principles of a High ReliabilityCollective Mindfulness
Sensitivity to Operations
Commitment to Resilience
Deference to Expertise
Preoccupation with Failure
Reluctance to Simplify
Questions?
References
• Weick, K. & Sutcliffe, K. (2007). Managing the unexpected: Resilient performance in the age of uncertainty, (2nd ed.) John Wiley & Sons: San Francisco.