1. Patient Safety: Disruptive Innovations & Liberating Structures
Northwest Chicagoland Chapter AACN June 10, 2107
Linda Ptack, RN, CCRN
Carolyn Ruud, DNP, RN, CCRN, CVRN, SCRN

2. Where Are We From? A
Privileged and Confidential under the Illinois Medical Studies Act and Federal Patient Safety Act

3. Objectives
Describe positive deviance and it’s relation to patient outcomes
Identify indicators for patients at risk of deterioration
Discuss behaviors of proactive vs. reactive response to patients at risk
Explain TRIZ and how it can be used to identify opportunities for improvement

4. Creativity

5. The Patient Safety Movement
A 2015 article in the British Medical Journal states if medical error was a disease, it would rank as the third leading cause of death in the country.
The Institute of Medicine published To Err is Human: Building a safer health system
Health Care is NOT as safe as it should be
98,000 deaths annually (Harvard Study 1999)
AHRQ Report (Medicare Patients)
195,000 deaths annually (2004)
The Journal of Patient Safety
400,000 deaths annually (2013)
No matter what the number…
we can all agree, it’s too many!!
1999 The Institute of Medicine published To Err is Human: Building a safer health system …
Health care in the United States is not as safe as it should be--and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle accidents, breast cancer, and AIDS.
The most commonly cited estimate of annual deaths from medical error in the US—a 1999 Institute of Medicine (IOM) report—is limited and outdated. The report describes an incidence of 44 000-98 000 deaths annually.7 This conclusion was not based on primary research conducted by the institute but on the 1984 Harvard Medical Practice Study and the 1992 Utah and Colorado Study.8 9 But as early as 1993, Leape, a chief investigator in the 1984 Harvard study, published an article arguing that the study’s estimate was too low, contending that 78% rather than 51% of the 180 000 iatrogenic deaths were preventable (some argue that all iatrogenic deaths are preventable).10 This higher incidence (about 140 400 deaths due to error) has been supported by subsequent studies which suggest that the 1999 IOM report underestimates the magnitude of the problem. A 2004 report of inpatient deaths associated with the Agency for Healthcare Quality and Research Patient Safety Indicators in the Medicare population estimated that 575 000 deaths were caused by medical error between 2000 and 2002, which is about 195 000 deaths a year (table 1⇓).11 Similarly, the US Department of Health and Human Services Office of the Inspector General examining the health records of hospital inpatients in 2008, reported 180 000 deaths due to medical error a year among Medicare beneficiaries alone.12 Using similar methods, Classen et al described a rate of 1.13%.13 If this rate is applied to all registered US hospital admissions in it translates to over 400 000 deaths a year, more than four times the IOM estimate.
Medical error—the third leading cause of death in the US
BMJ 2016; 353 doi: (Published 03 May 2016) Cite this as: BMJ 2016;353:i2139
BMJ 2016;353:i2139
The Institute of Medicine (IOM) report, Keeping Patients Safe:
Transforming the Work Environment of Nurses, was commissioned to address the
increased incidences of errors in the nurse environment (Page, 2004). The report
recommended that healthcare organizations (HCO) embrace strategies that are aimed at
comprehensive safety reform, such as improving the culture of how patient care is
provided (Page, 2004).
Keeping Patients Safe: Transforming the Work Environment of Nurses identifies solutions to problems in hospital, nursing home, and other health care organization work environments that threaten patient safety through their effect on nursing care.
A companion to the Institute of Medicine's earlier patient safety report, To Err is Human, the report puts forth a blueprint of actions that all health care organizations which rely on nurses should take.
The report's findings and recommendations address the related issues of management practices, workforce capability, work design, and organizational safety culture. Actions needed from the federal and state governments, as well as from coalitions of parties involved in shaping the work environments of nurses also are specified.
The report presents evidence from health services, behavioral and organizational research, and human factors and engineering to address pressing public policy questions, including nurse staffing levels, nurse work hours, and mandatory overtime
After 17 years since the IOM’s To Err is Human & we still have errors!
Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ, 353, i2139. doi: /bmj.i2139

6. Patient Safety Historical Perspective
Disruptive Innovations! Creative Thinking!

7. Negative Deviance
Negative deviance focuses on find and fix but tells us little about the presence of safety and replicating the positive outcomes
Solutions to problem can be identified thru identifying the Positive deviance and are best identified by the frontline clinical providers

8. Positive Deviance

9. Positive Deviance

10. Positive Deviance Absence vs Presence Thinking
Find and Fix vs Accentuate and Replicate
Reactive vs Proactive/Back vs Forward Look

11. Positive Deviance
Positive deviance identification recognizes behaviors, processes and outcomes that contribute to safer care and better outcomes.
Positive deviance also recognizes outstanding work and sends a positive message to our team for all the excellent care and effort provided.

12. Identification

13. Identification Focus on what went right?
Focus on unexpected positive outcome.
Empower teams to identify the “feeling” even if they don’t know why?
Standardize interview questionnaire in a timely manner (that’s the hard part!)
What process seemed to make the difference?

14. Examples?? Door to balloon times Sepsis Initiatives Airway Others??
Stroke, time out, hourly rounding

15. Rewards Healthy Work Environment Meaningful work Promoting Recognition
Improving Outcomes
Achieve sustained performance over time
Improved workflow= improved efficiency

16. Reducing Harm and Improving Outcomes
Patient Safety Initiative: Making Hospitals Safer!
Deterioration outside the intensive care unit
Identification/early intervention on patient deterioration

17. Terminology RRT – Rapid Response Teams
Medical Emergency Teams (METs) or Medical
Emergency Response Teams (MERT), and other terms
Patient at Risk Team (PART) and Critical
Care Outreach Team (CCOT)

18. Rapid Response Teams Positive Deviance?
An individual or group of individuals trained in critical care to respond to and deliver critical care to deteriorating patients outside the critical care
Has evolved at some institutions to include proactive rounding and mentoring

19. Rapid Response Teams Positive Deviance?
Reducing length of stay
Increasing patient satisfaction
Team building
Mitigating medical errors
Decreasing ICU admissions and readmissions (bounce backs)
Continuity of care across the system
Decreasing mortality

20. Indicators for Identifying at Risk Patients
Identifying patients BEFORE they deteriorate has been a challenge
Rapid response “system” is a regulation
Early warning systems are one way
Risk stratification models

21. Identifying at Risk Patients
Nurses Intuition (Nurses develop this skill over time, and often anticipate a patient’s decline before any objective evidence of deterioration is present)
Nurses gut feeling something is wrong
Patients gut feeling something is wrong

22. Indicator Signs and/or Symptoms
Change in Breathing
Noisy breathing and/or short of breath and/or no full sentences and/or accessory muscles and/or increasing supplemental O2 to maintain SaO2 and/or increase in respiratory rate
Change in Circulation
Color and/or clammy and/or coldness and/or Impaired perfusion and/or color drainage changes and/or hypertension and/or arrhythmia
Temperature
Rigors and/or fever and/or hypothermia
Mental Status
Lethargic and/or confused and/or sensory change in level of consciousness
Agitation
Restless or Anxious
Pain
New pain and/or increasing pain
No Progress
No progress and/or abdominal distension and/or nausea and/or bleeding and/or dizzy and/or fall and/or hypoglycemia
Patient Subjective
Not feeling well and/or feeling of impending doom
Nurse Subjective
Change in behavior and/or does not look good and/or a look in the eyes, like a gaze
Gut Feeling/Knowing without Rationale
Gut feeling and/or knowing something is wrong

23. Proactive vs Reactive Behavior Studies
Confounding literature
Difficulty validating outcomes with RRT
Data extraction can be labor intensive
Seen as an additional cost
Proactive practice still needs to be defined
Continually need to define and redefine

24. Proactive Approaches
The ability to anticipate patient requirements and confidence to act on clinical presentation are essential
Role of proactive rounding using a variety of tools, MEWS,EWS, Electronic health record reports
Building confidence through mentoring
Just in time teaching moments for less experienced nurses

26. Liberating Structures
Keith McCandless – Henri Lipmanowicz
33 microstructures
Adaptive
Innovative
Simple
Cost effective
UNCONVENTIONAL

28. TRIZ Creative Destruction Russian Acronym
Teoriya Resheniya Izobretateskikh Zadatch “Theory of Inventive Problem Solving”
Developed between
Study of patterns

29. TRIZ What must we stop doing to make progress on our deepest purpose?
A seriously fun yet very courageous conversation unfolds.
Creative destruction enables renewal

30. TRIZ
What is the most reliable thing we can do to get the worst result?
Avenue to think outside the box
FUN!

32. AFTER THE FUN Make the lists
Compare that list to what we do now. BE HONEST!
What first steps will help us stop what we know creates terrible results?

33. TIMING 3 segments of 10 minutes each Worst result possible
How does this compare
Steps to stop the madness

34. PROCESS

35. TIPS & TRAPS Enter into TRIZ with a spirit of serious fun
Don’t accept innovation ideas: be sure suggestions are about stopping activities or behaviors, not starting new things. It is worth the wait.
Begin with a VERY unwanted result, quickly confirm your suggestion with the group
Check in with groups that are laughing hard or look confused

36. TIPS & TRAPS
Take time with similarities to what you are doing now and how this harms you
Include the people that will be involved in stopping the activities that come out
Make real decisions about what will be stopped (number your decisions 1,2,3…)

37. COMMIT CELEBRATE SUCCESS Involve Front Line Staff
Be clear on what will be stopped
List the decisions
Use other exercise to enforce the plan
CELEBRATE SUCCESS

38. Liberating Structure Summary

39. Go Forth and Conquer!

40. Thank You! Questions????

41. References
Douw, G., Schoonhoven, L., Holwerda, T., van Zanten, A. R., van Achterberg, T., & van der Hoeven, J. G. (2015). Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review. Critical Care, 19(1), 230.
Endacott, R., & Westley, M. (2006). Managing patients at risk of deterioration in rural hospitals: a qualitative study. Australian Journal Of Rural Health, 14(6),
Alshehri, B., Ljungberg, A. K., & Rüter, A. (2015). MEDICAL-SURGICAL NURSES' EXPERIENCES OF CALLING A RAPID RESPONSE TEAM IN A HOSPITAL SETTING: A LITERATURE REVIEW. Middle East Journal Of Nursing, 9(3), 3-23.