Presentation on theme: "Leading Change and Improving Reliability--"— Presentation transcript:
1 Leading Change and Improving Reliability-- Steve Narang, MD MHCM Chief Executive Officer Banner Good Samaritan Medical CenterLeading Change and Improving Reliability--Delivering the Right Care to the Right Patient at the Right Time
3 The Iceberg…. …Now it is complex, effective and potentially dangerous” . “Medicine used to be simple, ineffective and relatively safe……Now it is complex, effective and potentially dangerous”Sir Cyril ChantlerUK Health Policy AdvisorFormer Dean, Guy’s, King’s and St. Thomas Medical and Dental SchoolsThe Iceberg….
6 Scientific understanding The Iceberg…Scientific understandingProgressTimeImplementation GapPatient careSo we start out by noticing an area of focus. This focus for quality improvement projects should develops from recognition of a gap between the level of care that is optimal and best supported by the evidence contrasted with the care that is actually being delivered to our patients.We are all here today because we know that management of hyperglycemia in the hospital is one of these areas. What is actually being done, is far from what is supported in the literature.How do we ultimately bridge that gap? It can be accomplished by using qi principles and following steps that have been determined to be essential by those who have gone before you.
7 The Iceberg… Most advanced healthcare system in the world High Cost, Low QualityFor the money the United States spends on healthcare, about $2.5 trillion a year – the quality of care is unacceptably lowEach year as many as 15 million patients harmed in some manner by America’s healthcare system
12 The Iceberg is Melting…. Doing the right thing,the right way,at the right time,in the right amount,for the right patientthat does not resultin harm to the patientThe Iceberg is Melting….
13 Those of us who work in the health-care chains will have to contend with new protocols and technology rollouts every six months, supervisors and project managers, and detailed metrics on our performance. Patients won’t just look for the best specialist anymore; they’ll look for the best system
18 Observation: The reliability of applying known or required processes commonly is 10-1 (80%) or worse(When dealing with non-catastrophic processes)18
19 Example of 3 Step Design in Implementing the Ventilator Bundle RT built into 1 hour scheduled vent checks as a)Integrate daily goals with MDR to identify defects as aFeedback on complianceEducationBaselineBaselineBaselineBaseline
20 Framework for Reliable Design Process is the action point of all improvement methodologiesReliability occurs by design not by accident
21 Starting Labels of Reliability Chaotic process: Failure in greater than 20% of opportunities10-1: 80 or 90 percent success. 1 or 2 failures out of 10 opportunities10-2: 5 failures or less out of 100 opportunities10-3: 5 failures or less out of 1000 opportunities10-4: 5 failures or less out of 10,000 opportunities(These are IHI definitions and are not meant to be the true mathematical equivalent)
22 Reasons for the Reliability Gap In Healthcare Current Improvement methods in healthcare are highly dependent on vigilance and hard workThe focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of securityPermissive clinical autonomy creates and allows wide performance marginsThe use of deliberate designs to achieve articulated reliability goals seldom occurs
24 Improvement Concepts Associated with 10-1 Performance (Primarily can be described as intent, vigilance, and hard work)Common equipment, standard order sheets, multiple choice protocols, and written policies/proceduresPersonal check listsFeedback of information on complianceSuggestions of working harder next timeAwareness and training
25 Improvement Concepts Associated with 10-2 Performance (Uses human factors and reliability science to design sophisticated failure prevention, failure identification, and mitigation)Decision aids and reminders built into the systemDesired action the default (based on scientific evidence)Redundant processes utilizedScheduling used in design developmentHabits and patterns know and taken advantage of in the designStandardization of process based on clear specification and articulation is the norm
28 Hard work and vigilance although commendable is not a good design principle If 10-2 change concepts do not make up at least 25% of the improvement effort on a given project require the team to rethink the designKey Learning Points
29 Reasons for the Reliability Gap In Healthcare Current Improvement methods in healthcare are highly dependent on vigilance and hard workThe focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of securityPermissive clinical autonomy creates and allows wide performance marginsThe use of deliberate designs to achieve articulated reliability goals seldom occurs
30 Biology Protects Us All defects in process do not lead to bad outcomes Healthcare tends to look at outcomes and not the reliability of the process leading to outcomes (handwashing is an example)Benchmark to best practice not aggregate averagesBiology Protects Us
31 If you accept benchmark level performance in your organization you compare yourself against mediocrity and foster 10-1 performance in non catastrophic processesBenchmark against the industry best, but also insist on reliable processesMeasure processes against a specific reliability goal (10-2)Measure linked processes using the “all or none” ruleKey Learning Points
32 Reasons for the Reliability Gap In Healthcare Current Improvement methods in healthcare are highly dependent on vigilance and hard workThe focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of securityPermissive clinical autonomy creates and allows wide performance marginsThe use of deliberate designs to achieve articulated reliability goals seldom occurs
33 Health Care Processes Current - Desired - variation Variable, lots of autonomynot owned,poor if anyfeedback for improvement, constantly altered by individual changes, performance stable at low levelsDesired - variationbased on clinical criteria, no individual autonomy to change the process,process owned from start to finish,can learn from defects before harm occurs, constantly improved by collective wisdom - variationHealth Care ProcessesTerry Borman, MD Mayo Health System
34 René Amalberti: Premises “Unconstrained” human performance (guided by personal discretion, only) is worse than 10-2Constrained human performance can reach 10-2
35 A single standardized process within the acceptable science is superior to allowing multiple processes while we decide which is the best because it allows testing and trainingKey Learning Point
36 Why not 10-2 or better for your patients Why not 10-2 or better for your patients? Why not YOU being a leader in the 10-2 model? Where to start?
37 Reasons for the Reliability Gap In Healthcare Current Improvement methods in healthcare are highly dependent on vigilance and hard workThe focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of securityPermissive clinical autonomy creates and allows wide performance marginsThe use of deliberate designs to achieve articulated reliability goals seldom occurs
38 The Three Step Design for Reliability Design TechniquesSteps1-Identify the process to standardize2-Segment the population to test thedesign for anomalies3-Use both 10-1 and 10-2 conceptsPrevent initial failure by standardizing the process to achieve 10-1 (step 1)1-Utilize a robust 10-2 concept to make visible failures from step 1 after step 1 has achieved 10-1 reliability2-Once the failure is identified, apply an action to mitigate the failureIdentify failures in step 1 and apply an action to achieve 10-1 for these failures (step 2)1-Identify common failures2-Develop a method to measure and study failures3-Utilize knowledge of common failures to redesign either step 1 or step 2In either step 1 and/or step 2 detect the failures, and use the knowledge from analysis of the failures to redesign (step 3)
39 The “Set Up” for Reliability Exercise #1 Select a topic whose outcome you want to improveDetermine a high volume segment for initial design testingBuild a high level flow chart for that segmentDetermine where the defects occur in the current systemDetermine where your design work will begin with by identifying where the commonest defects occurVerbalize the reliability
40 Topic: Ventilator Bundle Segment: Medical ICUPatient Placed on Ventilator4 Elements of the bundle ordered4 Elements of the bundle accomplishedPatient removed from ventilatorOf the 4 elements of the bundle, the head of the bed elevation is most commonly not accomplishedOur aim is to with a reliability of 95% or to achieve keeping the head of the bed elevated.
41 The Reliability Design Strategy Prevent initial failure using intent and standardizationIdentify defects (using redundancy) and mitigateMeasure and then communicate learning from defects back into the design processThe Reliability Design Strategy
42 New Standardization Concepts Standardize to provide the appropriate infrastructure (the how, what, where, who and when)The “what” we are standardizing is based on medical evidenceThe “how” does not need medical evidence but rather systems knowledgeInitial standardized protocols are developed with small time investment by experts tested at a very small scaleChanges to the protocol in the initial stages should be required and encouragedDefects are studied and used to redesign the process
43 Three Tier Design Strategy Prevent initial failure using intent and standardizationRedundancy/contingency function (identify failure and mitigate)Critical failure mode function (identify critical failures and then redesign)Three Tier Design Strategy
44 Allows less than perfect design in the standardization step (we do not have to plan for every possible contingency)Anticipates and allows failure in the prevent failure (standardization function) stepAllows a better balance of resource use (no need to spend months coming up with the perfect design)Fosters the atmosphere of mitigation and recoveryWhy the Step is Needed
45 Characteristics of “Redundancy Tools” Require careful consideration since they do represent a form of “waste”Needs to be connected to the process almost all the time (at least 10-1)Requires a good prevent failure step (standardization function) before implementing a redundancyNeed to be truly independentNeed to be used or will no longer function as a good filterMust follow with a mitigation strategyCharacteristics of “Redundancy Tools”
46 What we really mean by the redundancy/contingency step is the use of model 10-2 concepts
47 Model 10-2 Concepts Decision aids and reminders built into the system Human Factors and Reliability Science: 10-2 Performance(Designing sophisticated failure prevention, failure identificationand mitigation)Decision aids and reminders built into the systemDesired action the default (based on evidence)Redundant processesUse fixed current scheduling in designTake advantage of habits and patternsStandardization of process based on clear specification and articulation
48 Examples:Decision Aid Pop-ups: “Remember to give Flu Shot”, “Did you order a drug level?”Default to the appropriate option: Patients get smoking cessation education whether physician orders or not.Redundancy: Two people check narcotics, Order read back for verbal orders, second person verifies charge capture at the end of clinicChecklists: Direct Admit Checklist, Handoff Checklist.Scheduling: An area is scheduled to be cleaned every morning, does not need to be requested.Real-Time ID of Failures: Identify and Mitigate Recommendations
49 Three Tier Design Strategy Prevent initial failure using intent and standardizationRedundancy function (identify failure and mitigate)Critical failure mode function (identify critical failures and then redesign)Three Tier Design Strategy
50 Critical Failure Mode Essentials A measurement of critical failure modes needs to be part of the initial design strategyAssesses the defects that occur from the current designShould be prioritized in terms of overall affect on the reliability of the process changeShould be used to redesign the process
51 Example of 3 Step Design in Implementing the Ventilator Bundle Redundancy in the form of a check by RT built into 1 hour scheduled vent checks as a 10-2 change concept (step 2)Integrate daily goals with MDR to identify defects as a 10-2 change concept (step 1)Feedback on compliance as a 10-1 conceptEducation as a 10-1 conceptBaselineExample of using 10-1 and change concepts to initially reach a reliability of 10-1 then additionally using a robust 10-2 change concept (redundancy) to reach 10-2 reliability in the 4 elements of the ventilator bundle (Baptist Memorial, Memphis)
54 Level 3 Concepts: (Sophisticated Behavioral Designs) Take advantage of habits and patternsMake the system visibleClear and unambiguous communicationMindfulness – Weick and Sutcliffe:“High Reliability Organizations”Level 3 Concepts: (Sophisticated Behavioral Designs)
55 Attributes of High Reliability Organizations: Weick 1. Preoccupation with failure2. Reluctance to simplify interpretations3. Sensitivity to operations4. Commitment to resilience5. Deference to expertiseWeick, et al. Research in Organizational Behavior. 1999;21: Weick, Managing the Unexpected: Assuring High Performance in an Age of Complexity, Jossey Bass 2001
56 Attributes of High Reliability Organizations: Weick 1. Preoccupation with failureSmall failures are as important as large failuresAvoid complacency:Success breeds confidence in a single way of doing things and generates complacencyEx. “My patient has never had a Potassium overdose, so why should I change?”Success narrows perceptionsWorry about normalization of unexpected events
57 Attributes of High Reliability Organizations: Weick 2. Reluctance to simplify interpretationsCloser attention to context leads to more differentiation of worldviews and mindsetsLook for the root cause, not the obvious causeEx. Dumb resident wrote a 10-fold overdoseRoot Cause: “dumb” resident was up all night, in ED with seizing kid, called for verbal order, …
58 Attributes of High Reliability Organizations: Weick 2. Reluctance to simplify interpretationsDifferentiation (diverse viewpoints) brings a varied picture of potential consequences better precautions and responses to early warning signs.Over dependency on insiders leads to simplificationEx. This is how we do it at Good Sam….Attributes of High Reliability Organizations: Weick
59 Attributes of High Reliability Organizations: Weick 3. Sensitivity to operationsAttentive to the front line where the real work gets doneAuthority moves toward expertise:Role of RNsRole of Clinical MDs, PNPsRole of ParentsMake continuous adjustments that prevent errors from accumulating and enlarging based upon reporting from operations, not the “master plan”
60 Attributes of High Reliability Organizations: Weick 4. Commitment to resilienceDevelop capabilities to detect, contain, and bounce back from those inevitable errors that are part of an indeterminate worldEx. Trigger tools (and automation)A focus on intelligent reaction, improvisationCorrect errors before they worsen and cause more serious harmEx. “stop the line”
61 Attributes of High Reliability Organizations: Weick 5. Deference to expertiseDecisions are made on the front line, and authority migrates to the people with the most expertise, regardless of their rankAvoidance of the structure of deference to the powerful, coercive, or senior
62 “Together these five processes produce a collective state of mindfulness. To be mindful is to have an enhanced ability to discover and correct errors that could escalate into a crisis.”Mindfulness: Weick
63 consider what a resident in a busy pediatric emergency department might do when he is unable to determine whether an ear examination is normal or abnormal and the attending physician is not immediately available…(s/he) weighs the consequences of misdiagnosis for the patient, the humiliation of having to call the otolaryngology resident…loss of self-esteem by having to admit incompetence……A mindful conscious approach would be to cultivate awareness not only of the correct course of action but also of the factors that cloud the decision-making process. The mindful practitioner is mentally and technically better prepared for the next situation
64 …the most important difference among industries…lies in their willingness to abandon historical and cultural precedent and beliefs that are linked to performance and autonomy, in a constant drive toward a culture of safety…Rene Amalberti, MD, PhD Cognitive Science Department, Bretigny-sur-Orge, France Amelberti et al. Ann Intern Med 2005;142:
66 Don’t let yourself be. Find something new to try, something to change Don’t let yourself be. Find something new to try, something to change. Count how often it succeeds and how often it doesn’t. Write about it. Ask a patient or a colleague what they think about it. See if you can keep the conversation going (Atul Gawande,MD)So how do you start???
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