5/16/2010. Opportunity for Disaster? Using HFMEA to ensure a safe environment for our patients and employees. Got Defects?

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1 Using HFMEA to ensure a safe environment for our patients and employees Opportunity for Disaster? OAHQ May 22, 2010 Got Defects? Facts about errors/defects Even well designed processes have holes Defects are not an option We needed a systematic method of studying failure Welcome! Jeff Christensen Perioperative Business Manager 8+ years reengineering processes and systems to improve performance and quality in healthcare Mike Fetzer Service Line QI Coordinator 10+ years of process and quality improvement in Manufacturing as an Industrial Engineer and Quality Manager Preview Why Intraoperative MRI? Our challenges HFMEA Our team Our project Lessons learned HFMEA at Nationwide Children s Questions Why implement an imri? A TWO for ONE special: for Neurosurgery Crucial for a leading edge Neurosurgery program Scan for remaining tumor during a procedure Reduces need for follow-up procedures for Radiology Increased MRI capacity to our facility by 20% Increases access to general anesthesia for MRI patients 1

2 NCH imri Facts 11 months of preparation $7 million investment Three room design Neurosurgical OR Non-operative diagnostic room Central magnet bay MRI magnet weighs 12,000 lbs imri Design imri Design Creating a Safe Day Every Day Imperative that Safety was the top priority when considering the imri Challenges facing safety Complexity: Location within OR Two workflows Integration of staff Financial Accountability: Ability to use the MRI diagnostically Ability to use the MRI intraoperatively Creating a Safe Day Every Day How do we deliver safety given the challenges facing this project? HFEMA: H Healthcare F Failure M Modes & E Effects A Analysis Joint Commission Standard (LD ) Introduction This standard describes a safety program that integrates safety priorities into all processes, functions, and services within the hospital, including patient care, support, and contract services. Proactive Risk Assessment By undertaking a proactive risk assessment, a hospital can correct process problems and reduce the likelihood of experiencing adverse events. A hospital can use a proactive risk assessment to evaluate processes to see how they could fail, to understand the consequences of such a failure, and to identify parts of the process that need improvement. The processes that have the most potential for affecting patient safety should be the primary focus for a risk assessment. Proactive risk assessments are also useful for analyzing new processes before they are implemented. These processes need to be designed with a focus on quality and reliability to achieve desired outcomes and protect patients. 2

3 Step 1: Select and Define the High-Risk Clinical Process Select high-risk clinical process. Assemble multidisciplinary team to include subject matter expert(s), leader and advisor. Define the scope of the process. Clearly define what is included in and excluded from the process. Gather and record current baseline data and metrics. Step 2: Graphically Describe the Current Process STEP 3: CONDUCT HAZARD ANALYSIS STEP 4: DEVELOP RISK REDUCTION METHODS Column 3.1 Failure Modes (What might happen) Column 3.2 Cause (Why it happens) Column 3.3 Effects (What could happen to the patient) 3-4 Severity 3.5 Probability Columns 3.4, 3.7 Scoring 3.6 Intercept Ability 3.7 Hazard Score Column 4.1 Potential intervention/risk reduction methods Col. 4.2 Selected Interventions Step 5: Validate the Redesigned Process Redraw the graphic representation of the redesigned high risk process to reflect the revised process and the selected interventions/risk reduction methods. Perform a final check on the entire redesigned process by challenging it against the following factors based on Norman s Principles of Human Factor Error. STEP 6: IMPLEMENT AND MONITOR Column 6.1 Column 6.2 Column 6.3 Column 6.4 Metric Definition Numerator (N) Denominator (D) Data Source Frequency of data collection aggregation & analysis Responsible person imri Team Composition Step 2: Describe the Process VP of Perioperative Services VP of Operations and Professional Services Director of Radiology Quality Improvement Services (QIS) Medical Director MRI Physicist Chief of Neurosurgery Anesthesia Physicians Clinical Leader Surgery Unit OR Program Manager MRI Manager Perioperative Nurse Education Specialist Perioperative Materials Manager Perioperative Business Manager Neurosurgery Specialty Leader Peri-anesthesia Manager Place Rad Order Schedule (s) Initial MRI Screen Pre-DOS History & Eval MRI Pat Arrives DOS in SU IntraOp Scan End Pat to Recovery 3

4 Step 3: Conduct a Hazard Analysis Place Rad Schedule Initial MRI Pre-DOS Pat Arrives Order (s) Screen History & Eval DOS in SU Pat MRI IntraOp Scan End to Recovery Step 3: Conduct a Hazard Analysis Hazard scores range from failure modes with hazard scores 24 Identified over 40 actions or solutions Used priority/payoff matrix to identify which solutions we should implement Several solutions required $$$ Step 4: Develop Risk Reduction Methods Identified over 40 risk reduction methods Custom MRI safe cribs and carts Aluminum O2 tanks Checklists Visual cues Used payoff matrix QIP Approval Step 5: Validate Redesigned Process Place Rad Schedule Initial MRI Pre-DOS Pat Arrives Order (s) Screen History & Eval DOS in SU Pat MRI IntraOp Scan End to Recovery Step 6: Implement and Monitor Utilized PDSA when implementing risk reduction methods Implementation committee met bi-weekly to review action plans and address risks Ten subcommittees each with designated lead Daily huddles Post-implementation HFMEA meetings Utilized HFMEA to solve new failure modes Lessons Learned New process Cross-functional team Two cultures Ups and downs in momentum Inconsistent physician involvement Managing the parking lot 4

5 Summary Why Intraoperative MRI? Our challenges HFMEA Our team Our project Lessons learned HFMEA at Nationwide Children s Questions HFMEA at Nationwide Children s Past projects: Intraoperative MRI Pregnant teens in ER Bedside specimen collection Offsite MRI IV patient-controlled analgesia Future projects: Bedside medication verification Questions? 5