Perinatal High Reliability :

Transcription

1 Perinatal High Reliability : How HRO Methods Can Be Applied in OB Tom Peterson, MD VP, Chief Safety Officer Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 1

2 No Conflicts of Interest 2

3 The Journey to High Reliability in Healthcare High Reliability Process improvement - Mandated measures - NPSG s,hac s, Never events, VBP, MU Generative Safety is how we do business around here Proactive Safety leadership and values drive continuous improvement Evidence Based Guidelines Clinical Protocols Core Measures IOM Report Calculative We have safety systems in place to manage all harm events Regulations Compliance Malpractice - Captive insurance boom Reactive Safety is important, we do a lot every time we have an accident <1980 s Few lawsuits, No risk management Pathological Who cares as long as we re not caught 3

4 Class A Mishaps/100,000 Flight Hours Naval Aviation Mishap Rate aircraft destroyed in 1954 Angled Carrier Decks Naval Aviation Safety Center NAMP est RAG concept initiated NATOPS initiated 1961 Squadron Safety program System Safety Designated Aircraft ACT HFC s 15 aircraft destroyed in Fiscal Year Source: ORM Flight Mishap Rate 4 4

5 Significant Events at US Nuclear Plants Annual Industry Average, Fiscal Year Significant Events are those events that the NRC staff identifies for the Performance Indicator Program as meeting one or more of the following criteria: A Yellow or Red Reactor Oversight Process (ROP) finding or performance indicator An event with a Conditional Core Damage Probability (CCDP) or increase in core damage probability (ΔCDP) of 1x10-5 or higher An Abnormal Occurrence as defined by Management Directive 8.1, Abnormal Occurrence Reporting Procedure An event rated two or higher on the International Nuclear Event Scale Other HRO s Source: Nuclear Regulatory Commission Information Digest (1988 is earliest year data is available) Updated: November 2007 American Construction Company Worker Injury Rates American Hospitals

6 In Healthcare The Numbers Today Are Daunting. In ,000 deaths caused each year to patients in American Hospitals¹ 3 rd leading cause of preventable death in the US 670,000 injuries every year to healthcare workers² Healthcare leads all industries in workers injuries times higher than such industries as high rise construction and aluminum plants 1- Jour Patient Saf, 2013;9: Janocha JA, Smith RT. Workplace Safety and Health in the Health Care and Washington, DC: US Bureau of Labor Statistics; 2012 Social Assistance Industry, 6

7 Healthcare? We lead in both preventable deaths to our customers (patients) as well as injuries to our employees. Our time is far overdue.. Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 7

8 Frankly, there is little guidance in the high reliability science and in the case studies. There s very little guidance on how you get from our pretty mediocre state with quality, with respect to quality and safety. How do you get from low reliability to high reliability? So we have considered that problem and asked the question, how do we create blueprints, roadmaps, assistive devices that allow health care organizations to build toward high reliability? What would it take? Mark Chassin, M.D., President, The Joint Commission

9 What is an HRO? 9

10 HRO Descriptions Can Be Confusing Sutcliffe and Weicke The 5 Principles Mindfulness TJC Chassin and Loeb Leadership Culture Process improvement Amalberti Accepting limits Abandon autonomy Craftsman to equivalent actors Sharing risk vertically Managing visible risk Health and Safety Executive The 5 Principles Anticipation and Containment Leadership Safety culture Continuous learning Admiral Hyman Rickover Rising standards over time (more than the minimum) Highly capable people trained over a wide range Leaders face bad news (mobilize effort, report up) Healthy respect for dangers Training is constant and rigorous All functions fit together Learning from the past 10

11 High Reliability Organizing is an ongoing process that is never perfect, complete, or total. They are committed to safety at the highest level.and adopt a special approach to its pursuit. Schulman,

12 It is more accurate to think about high reliability as a dynamic process of organizing rather than being an HRO. Pursuing and achieving reliability is a continuous, ongoing accomplishment. Sutcliffe,

13 Journey to Improving Safety & Reliability Design to Optimize Human Performance at the point of people interface: Easy to do the right thing impossible to do the wrong thing Mistake proofing/human factors Industry standards The occurrence is viewed as a failure Reliability Culture Mindfulness The Mindset of Failures, Accountability Safety as the core value, Leadership commitment A 1000 safety champions Behavior expectations for error prevention Collaborative Interactive Teams Building resiliency 10-2 Process, Protocol 10-1 &Technology Resource allocation Evidence-based practice (e.g. bundles) Technology enablers Focus and simplify (protocols, guidelines) The blunt end barriers Reference: HPI, Inc, Sutcliffe and Weick 13

14 An HRO High reliability is a mindset Prevention is everything Strong responses to all weak signals The occurrence is viewed as a failure High reliability is being resilient, responding to the needed changes The responses and shared learnings are immediate, and do not alter operations Committed to resilience High reliability is always learning new ways, new skills continuous learning Learning new skills, learning from events, and sharing learning Refuses to follow simplified processes High reliability exists only when leadership owns the process, fully commitment. The CEO (unit supervisor) knows all of his/her events. The Zero Mindset High reliability requires a robust safety culture. There is not one safety officer, there are 2000 of them High reliability is a journey.. 14

15 High Reliability Examples High Reliability is Not Clinical 15

16 High Reliability at Alcoa Anytime someone was injured, the top executive had to report it within 24 hrs to O Neill, and have a plan or action so it would not happen again. The presidents had to hear from their VP s as soon as an injury happened So the VP s needed to be in constant communication with their floor managers...and the floor managers had to get workers to raise warnings as soon as they saw a problem, and keep a list of suggestions nearby So each unit had to build new communication systems that made it easy for the lowliest of worker to immediately get an idea to the loftiest of executives. The safety habits developed spilled into other areas of the organization, and the workers lives.. 16

17 High Reliability Thinking in Sports The team was 12-2 the year before, finished 5 th in the nation. Their defense was second best in the nation. A Defensive Back says this year: I'm part of a team, something bigger than myself, "We've got to get better at tackling. We all make tackles, but we want to make every tackle. One isn't just OK, every tackle needs to be made. We've got to tackle in space and teams are gonna try to test our safeties, our secondary as a whole. They did last year and had some success with that. This year I feel like we have to better ourselves in every aspect. Perfection is not attainable, but if we chase perfection, we can catch excellence. Vince Lombardi 17

18 The Bar Coding HRO Mindset One hospital set 90% as their goal for bar coding all medications with every patient before administering a medication Another hospital set 95% as a goal to reach but claimed there was too much push back and excuses explained by staff of how they could not reach a higher goal. The next hospital set 98% as a new goal, and received significant pushback, until the CEO stepped in and said 100% is all we will accept. Find a way to achieve it. That hospital is now focused 98% bar coding and continuously looking for new ways to achieve 100%. 18

19 Number of Events Per Year High Reliability in a Dietary Department Victory Over Injury Staff made commitment to become a safety culture Reminders daily at every meeting about safety Rewards set up for lengths of time without incidents Made days without incidents longer for rewards for two years One year without incident reward set HRO methods Daily huddles led by supervisor Every day with a safety brief read to staff, posted on bulletin board Each person in the huddle every day has to give a safety tip Everyone shows they have their cutting gloved on Points toward a reward are given daily when they show they have their gloves Days until next reward is verbalized daily and posted in the break room Outcomes: 0 OSHA recordable injuries in 2 years Food Services Annual OSHA and Non-OSHA Events Return To Work Program Initiated Food Services Made Associate Safety and Daily Huddles a Priority 1 OSHA Events Food Services has not had an OSHA recordable event since February, 2013!! 19

20 What High Reliability is not: ie, a quality improvement method focused on efficiency and productivity like Six Sigma, Total Quality Management, or LEAN. Rather, high reliability is a creation of a culture and processes that radically reduce system failures and effectively respond when failures do occur Knox, Simpson; Perinatal High Reliability,

21 Can a Perinatal Unit be Like a Commercial Airline? What the Airlines have done since 2001: 34,000 flights per day 0 deaths in past 15 years in large domestic carriers How? 80% of accidents due to human error All crew members have a say in safety issues Improved communication/interactions (CRM) Standardized procedures, checklists are valued Restriction on amount of time flying without sleep Simulators and required trainings Learn from near misses with increased reporting nationally Human error behaviors as industry standards 21

22 Characteristics of an HRO What Allows for the Continuous Dynamic Organizing? Leadership all levels Culture Transparency/reporting Systems thinking Accountabilities Continuous learning Infrastructures that allow Prevention (anticipation) and Containment (resiliency detection and correction) The zero mindset 22

23 Common Causes in Perinatal Harm Events System complexity Normalization of Deviance Production Pressures Hierarchy Hero worship Sleep Deprivation Harmful/abusive behavior Failure of trust, teamwork and effective communication 23

24 OB Safety Initiatives Safety Culture and Reliability Roadmap Problem Anticipation Reduce Serious Safety Events by 80% Key Drivers (based on HRO Principles) Mindful Leadership Containment of Unexpected Events Specific Interventions and Tactics Continuous learning Culture Safety Champions (coaches) identified on each unit Near Misses reviewed in safety huddles or at staff meetings Board rounds (Daily huddles) in MBU and L&D Day/Night (review each patient and concerns and collaborate on plan of care) Handoffs in room Daily leadership rounds with patients Ability of Labor and Delivery to go on OB divert Safety staffing huddles OB peer review program OB metrics (Elective Induction, exclusive breastfeeding) System Perinatal safety collaborative Reporting events (Pearls) Debriefs Critical events training for all of W&C services NERT Training Skills Fairs Cause analysis Active Debrief Program throughout Women s services. Debriefs happen with trained team within the shift of occurrence-anyone can call a debrief RCA s Prevention Anticipation Detection Containment Correction 24

25 Creating A Perinatal High Reliability Unit Trainings Training in cause solving Regular simulations (CETT, low fidelity) Training in human error prevention CRM or Team trainings Tools and Structures Efficient, easy reporting system Daily huddles (board rounds) De-briefs (Swarms) Standardized language, protocols, policies, medications Safety committee/coaches Purposeful rounding Safety Behaviors Peer checking and coaching, supporting the team Clear communications Stopping in the face of uncertainty Focus Always a questioning attitude Culture to Achieve Transparency, high near miss reporting rates, zero is the expectation Shared learnings Lowered power distance Multiple safety champions Unit leadership 25

26 It Doesn t Matter What the Occurrence or the Department Is Preventable infections Medication error Delay in care Admission to hospital Fire in the OR Back injury to associate Serious preventable safety event Checklist use Power outage in IT Patient fall Hand washing Bar coding A needle stick injury it s how much value you put on keeping it from happening. 26

27 One problem with most safety initiatives in American Hospitals is that they are projects. They are not efforts to create an organizational culture. Most projects will create incredible results for a short period of time, but there is a wasting back toward normal because the changes don t belong to the culture, they belong to a project. Paul O Neill,

28 Questions? 28