1. Reliability Principles CQN Asthma Project January 14, 2010

2. “I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.”

3. Outline Definition and purpose of high reliability systems Measuring reliability - some simple math Reliability principles and chronic illness care changes –How much improvement can we expect from each?

5. Associates in Process Improvement, 2009Slide 5 Health System Perspective: Quantifying “Reliability”  “Reliability” = Number of actions that achieve the intended result ÷ Total number of actions taken  “Unreliability” = 1 minus “Reliability”  It is convenient to use “Unreliability” as an index, expressed as an order of magnitude (e.g. 10 -2 means that the action fails to achieve its intended result 1 time in 100) White Paper, p. 3

6. Associates in Process Improvement, 2009Slide 6 Un-Reliability?

7. What changes in the process of care delivery will change the outcome? Assessment of asthma control Appropriate Treatment Improved Outcomes

8. Associates in Process Improvement, 2009Slide 8 Definition Of “Reliability” Reliability is failure free operation over time. Can reliability principles be applied effectively to improve the consistent delivery of high-quality health care? White Paper, p. 2, 3 Reliability most connected to the IOM’s dimensions for the health care system of effectiveness (where failure can result from not applying evidence), timeliness (where failure results from not taking action in the required time) patient-centeredness (where failure results from not complying with patients’ values and preferences).

9. Associates in Process Improvement, 2009Slide 9 Levels of Reliability LevelReliability Success Rate Failures in 10,000 actions 1 10 -1 80%-95%1500-2000 2 10 -2 96%-99.5%50-1499 3 10 -3 99.6% - 99.95%5-49 4 10 -4 99.96%-99.9950.5-4 10 -5 99.996 – 99.99950.1-0.4 10 -6 >99.9996<.1 White Paper, p. 4

10. Human Factors Engineering René Amalberti: Premises “Unconstrained” human performance (guided by personal discretion, only) is worse than 10 -2 “Constrained” human performance can reach 10 -2 to 10 -3

11. Associates in Process Improvement, 2009Slide 11 No system beyond this point 10 -2 10 -3 10 -4 10 -5 10 -6 Civil Aviation Nucleur Industry Railways (France) Chartered Flight Himalaya mountaineering Road Safety Chemical Industry (total) Fatal risk Medical risk (total) Blood transfusion Anesthesiology ASA1 Cardiac Surgery Patient ASA 3-5 Fatal Iatrogenic adverse events No limit on discretion Microlight or helicopters spreading activity Excessive autonomy of actors Craftmanship attitude Ego-centered safety protections, vertical conflicts Loss of visibility of risk, freezing actions Increasing safety margins Becoming team player Agreeing to become « equivalent actors » Accepting the residual risk Accepting that changes can be destructive Very unsafe Ultra safe René Amalberti White Paper, p. 3-4 Amalberti’s Reliability Framework

12. Associates in Process Improvement, 2009Slide 12 Exercise 1.Review the goals on your improvement project. 2.What Level of reliability are you targeting on your project? 10 -1 10 -2 10 -3

13. How reliable is the collaborative?

14. Alabama Data

15. What can we learn from variation across states? AlabamaOregon Ohio

16. Level 2 Reliability at CCCH Asthma Action Plan

17. How are they doing it? Optimal Care at CCCH

18. Components of a Process Have Known Failure Rates

19. Level 1 ( 80-90%) Reliability Team focus on the outcome goal Working harder Feedback of information on performance Awareness and training Standardize decision-making (e.g., guidelines)

20. Level 1 Reliability Concepts in CQN Team focus on the outcome goal: –Team aim and goals. Working harder: –Collaborative participation Feedback of information on performance: –Monthly measurement and feedback of results Awareness and training: –Training of practice physicians and staff Standardize decision-making: –Algorithms for severity classification, control, medications

21. % of children screened Level 1 Reliability

22. Level 2 (95%) Reliability Real time identification of failures (“identify and mitigate”) Checklists and observation Redundancy Making the “right thing” the “easy thing” Standardization of process

23. Level 2 (95%) Reliability Embedded in CQN Key Drivers Real time identification of failures –Auditing and daily review of failures Checklists and observation –Templates (structured encounter form) Redundancy –Planned care (e.g., pre-clinic huddle involving nurses) –Monthly population review using registry for care management –Patients empowered to participate in pre-visit planning Making the “right thing” the “easy thing” –Protocols –Default to the appropriate option: Patients get asthma encounter form whether physician orders or not. –Standing “flu shot” orders Standardization of process –Protocols and defined roles for template use (e.g., front desk, nurse) –Defined staff roles (includes hiring, training, performance evaluation)

24. Desired Outcome Level 2 Reliability

26. Level 3 (99%) Reliability Preoccupation with failure: –Real time awareness of failures –“Process Owner” for patient education –Measure days between serious events (e.g., ED visits) Reluctance to simplify interpretations: –Learning from each failure and from those doing better. Sensitivity to operations: –Support the front line (e.g., practice coaches) Deference to expertise: –Avoid a strict “Top-Down” Culture

27. Desired Outcome: Level 3 Reliability

28. “Robust Design” Outcomes + Situational factors Process/control factors Optimal care QOL Admissions Level 1 Components Level 2 Components Level 3: Mindfulness Severity of problem Values/habits/lifestyle Preferences Support system Resource availability

29. THANK YOU QUESTIONS?