Developing a Culture of Safety in Health Care: The Benefits of Becoming a High Reliability Organization

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1 Developing a Culture of Safety in Health Care: The Benefits of Becoming a High Reliability Organization June 24, 2015 George Mason University, Fairfax, Virginia Bahadir Baha INOZU, PhD - NOVACES Dr. Inozu has worked with more than 40 organizations to improve performance and reliability in healthcare, government, maritime, and maintenance, repair, and overhaul (MRO) industries. He is an internationally renowned expert in system reliability analysis and improvement as well as in the integration best-of-breed methodologies for superior performance. He conducted extensive research about the best practices in high-risk industries for safety and reliability improvements such as the Nuclear Power Industry, Offshore Industry as well as the U.S. Navy. He developed a Reliability, Availability and Maintainability data collection and analysis system and led its implementation at Liquefied Natural Gas Carriers operated by ETG. He also developed a Failure Reporting and Corrective Action System (FRACAS) for San Antonio class amphibious transport dock (LPD) warships. He has provided process improvement support for Kent Hospital, Anadolu Medical Center affiliated with Johns Hopkins, Jackson North Medical Center, Northrop Grumman, Coloredge Inc., Government of Utah, Texas Workforce Commission, Naval Aviation Enterprise, Defense Logistics Agency, Crowley, and Turkish Airlines Technic. Some of the improvements he facilitated includes: Microspheres Therapy for Advanced Liver Cancer Patients, Preparation of Patient for Surgery, Pre-operative Patient Arrival Time, MRI Repair and Maintenance, Management of Physicians' Calendar, Outpatient Appointment and Scheduling, Discharge Process, Billing and Collection. He is also the author of Healthcare: Leading Change with Lean, Six Sigma, and Constraints Management (McGraw Hill, 2011). He has worked closely with the Navy throughout his career and his hospital experience includes working with leaders of healthcare providers to customize and facilitate sustainable process improvements with system level impact, specifically with Navy Medicine, where he has served in an executive and advisory role with leadership while also directly involved in the substantial training rollout. He is a NOVACES principal and co-founder. Baha received a PhD in Naval Architecture & Marine Engineering (University of Michigan, 1990), an MSE in Naval Architecture & Marine Engineering (University of Michigan (1986), and a BS in Mechanical Engineering (Technical University of Istanbul, 1982). His doctoral dissertation was on Reliability and Replacement Analysis of Great Lakes Marine Diesels. His certifications include: Master Black Belt, Theory of Constraints Jonah, Enterprise AIRSpeed TOC Supply Chain Technical Expert (SCTE) [Avraham Y. Goldratt Institute, LLP], and Enterprise AIRSpeed TOC Supply Chain Deployment Expert (SCDE) [Avraham Y. Goldratt Institute, LLP].

2 Daved van STRALEN, MD, FAAP NOVACES Dr. van Stralen is the Medical Director for the Riverside County (CA) Emergency Medical Services Agency, responsible for bringing the methods of High Reliability Organizing to the EMS system of prehospital care, Trauma Centers, and other specialty EMS centers. Collaborating with Ronald M. Perkin, MD, FAAP, FCCM, they created a Pediatric Intensive Care Unit at Loma Linda University Children s Hospital. To create the PICU they used principles from pre-ems ambulance, fire service, and US Navy Aviation, later described by Karlene Roberts as High Reliability Organizing. He used his fire EMS background to improve the pediatric critical care transport service which had quality, safety, moral, and service problems and served a geographic area four times the size of Vermont. He also developed the nation s first clinical academic Emergency Medical Care nonadministrative bachelor s degree for paramedics. He then moved to a troubled pediatric nursing home where he used a fire service/ems model with critical care principles to change it into the state s model for subacute care. He collaborates with safety, risk, and reliability experts from wildland firefighting, business, and health care in the US and Europe to identify common approaches the individual uses to ensure safety and reliability. He has traveled extensively in Europe studying HRO in multiple industries and developed a relationship with the Bouches du Rhone Fire Service (SDIS 13), which became the source for the US Forest Service-SDIS 13 HRO collaboration. He is an Assistant Professor of Pediatrics and a pediatric critical care physician on staff at Loma Linda University Children s Hospital and Children s Subacute Center at Community Hospital of San Bernardino (California); Adjunct Professor of Emergency Medical Service at Crafton Hills College, Yucaipa, California; and President, Strategic Reliability, LLC. He served as Medical Director for San Bernardino County Fire Department (covering 20,000 square miles) for ten years. He worked in South Los Angeles as an ambulance man and fire department rescue ambulance driver for the Los Angeles City Fire Department in the 1970s. By one review, he is the first career paramedic to attend medical school. He has a Bachelor of Arts in Social Ecology and a Bachelor of Science in Biological Science from the University of California, Irvine; an MD degree from University of California at Irvine College of Medicine where he completed his Pediatric Residency. He completed a Pediatric Critical Care Fellowship at Children s Medical Center and Parkland Memorial Hospital, Dallas, Texas.

3 Mark A. Crafton, MPA, MT(ASCP) The Joint Commission, Executive Director of Communications and External Relations Mark Crafton is the executive director of communications and external relations for The Joint Commission. In this role, Mr. Crafton oversees all Joint Commission activities related to communications, corporate marketing, market research, and state relations. Mr. Crafton is a frequent speaker at national conferences on topics related to quality, safety and accreditation. He also serves on the board of the Organ Donation and Transplantation Alliance. Before joining The Joint Commission, Mr. Crafton was the senior director of advocacy for the Michigan Health & Hospital Association. As senior director, he was responsible for monitoring all legislative and regulatory activity that affected member hospitals and health systems. Mr. Crafton began his career as a Medical Technologist at Edward W. Sparrow Hospital in Lansing, Michigan, where he worked in a variety of laboratory positions. He has held several other clinical positions, including Virology Technician and Infection Control Coordinator in acute care hospitals. Mr. Crafton also worked as a Risk Management Consultant for the Michigan Hospital Association Insurance Company where he provided guidance to over 100 client hospitals on loss avoidance and loss control issues. Mr. Crafton graduated with honors from Michigan State University where he majored in Natural Science. He completed a one- year internship in Medical Technology and became registered as a Medical Technologist by the American Society of Clinical Pathologists. Mr. Crafton received his Masters Degree in Public Administration from Western Michigan University, and is also a certified Six Sigma Green Belt.

4 W. Earl Carnes - U.S. Department of Energy (retired) Senior Advisor for High Reliability & Liaison with Institute of Nuclear Power Operations For over 40 years W. Earl Carnes served private sector and government organizations in evaluating and improving operations of complex organizations that perform societally critical missions. His principal focus has been working with senior management on leadership, culture, governance and organizational systems needed to promote excellence in safety and performance. In recognition, Earl was presented with the U.S. Department of Energy (DOE) Award for Distinguished Career Service for his contributions to the United States and the Department, also a Proclamation of Distinguished Career Service by the Institute of Nuclear Power Operations for his contributions to the nuclear industry and the Institute. As the DOE Senior Advisor for High Reliability & Liaison with the Institute of Nuclear Power Operations (INPO) Earl served in oversight, policy and advisory positions for the DOE research, nuclear defense and environmental missions. His advisory portfolio included safety management systems, human and organizational factors, safety culture, accident investigation, and performance analysis. Earl developed the DOE Human Performance initiative for DOE laboratory and operational missions; this improvement model was subsequently adopted as a foundation for performance analysis and improvement for the U.S. electrical transmission industry. Representing DOE Earl engaged with other federal agencies, the International Atomic Energy Agency, the academic community and the private sector in high reliability collaborations for the nuclear industry, the U.S. electrical transmission grid, health care, petro-chemical operations, energy pipelines, and transportation. Earl s primary DOE focus prior to retirement was as senior advisor on safety culture for the DOE Office of Independent Assessment conducting safety culture assessments of high profile nuclear defense operations. Before joining DOE Earl worked in the commercial nuclear industry with the Institute of Nuclear Power Operations, with a Southern Company nuclear operating utility and as a nuclear management advisor. Prior to joining the energy industry he was a university faculty member teaching and conducting research principally on interpersonal and organizational communication. Earl earned degrees in Chemistry and Communication; completed graduate work in Engineering Management & Systems Engineering emphasizing knowledge management; obtained professional certification in nuclear, chemical & biological emergency management, Lead ISO quality auditor, Human Performance Improvement from the American Society for Training & Development and as a DOE Accident Investigation Chair. Earl is an associate with the U.C. Berkeley Center for Catastrophic Risk Management and recently authored Lessons from Efforts to Apply Reliability Principles as a chapter for From High Reliability to Reliable Organizing: A Handbook written with other Center colleagues to be published by Stanford University Press.

5 Spence Byrum - CEO, HRS Consulting, Inc. Spencer L. Byrum is the Chief Executive Officer of HRS Consulting, Inc., a premier human performance improvement company that was specifically created and designed to enhance individual and team decision making in high risk industries. Mr. Byrum s specialty is taking lessons learned in aviation and other high risk occupations and developing innovative process improvements and training for professions in which people need to make critical decisions in a stressful, demanding environment. Mr. Byrum is former Coast Guard rescue pilot, Head of Standardization and Training, and an internationally-know expert on the subject of human performance in demanding, time-critical environments. He has developed and delivered training to all US Combat Air Forces, Air National Guard, Air Force Reserve; multiple NATO Forces; domestic and international commercial airlines; commercial heavy construction crews; undergraduate and graduate university programs; FAA; NASA Dryden Test Pilots, Project Engineers and Project Managers. Since becoming integrally involved in healthcare almost 20 years ago, Mr. Byrum has worked with over 600 healthcare facilities ranging from major tertiary care centers to Ambulatory Surgery Centers to Critical Access Hospitals. He has developed tools for the quantitative and qualitative assessment of the processes associated with the HAIs, SSIs, H&Ps, Informed Consent, Surgical Time Out, Surgical Site Marking, Surgical Counts, Medication Errors, and other processes that have been implemented by some of the largest healthcare institutions and companies in the country. Mr. Byrum has developed and delivered medical training for over 100,000 participants on the Introduction of High Reliability Organization (HRO) Processes for staff and physicians, the Time Out, OR Burns, Elimination of Retained Surgical Items, Elimination of Look-Alike, Sound-Alike Medications, Patient Scheduling Optimization, and the Role of the Surgeon in Surgical Counts that have been utilized by hundreds of facilities across the US, Canada and Europe. He has developed a web-based safety culture survey tool that has assessed over 750,000 responses to questions about organizational safety and culture. HRS Intro to HROs and the Role of the Surgeon in the Surgical Count process are currently being used as requirements for credentialing surgeons in Texas. HRS has experience in assessing over 1,000,000 near miss and sentinel events and is an expert in evaluation of the causal factors and remediation of their impact. Finally, HRS tools have been recognized by major insurers to reduce losses, leading to medical malpractice premium reductions for physicians and facility premium reductions for individual hospitals and related healthcare entities.