1. The Tolerated Defects in Healthcare Introducing a new approach to safety in small rural hospitals Aug 22, 2012 Roger Resar MD Senior IHI Fellow 1

2. The Small Hospital Challenge Large scale projects promoted for large hospitals frequently do not apply (either by volume or nature) Staff time for team meetings is much less available Improvement skills are less available Resources are frequently very limited (travel, consultants, etc) 2

3. A New Concept 1-Projects are small with the entire emphasis on frontline driven identification.(meaning not top down) 2-All work on the project is done by a dyad in a dyadic fashion (meaning no teams) 3-There are no team meetings (meaning work takes place on the project as work takes place on the unit) 4-Has no relationship to a large change package (meaning every unit will have unique projects with little chance of sharing ideas unless the finished project is spread to other units in the organization) 5-The cost in resources to design the improvement is essentially nothing (meaning even small hospitals, clinics etc can afford the methodology) 6-Measurement is local with pencil and paper and emphasis is based on bimodal simplicity (meaning data collection is simple without need for IT) 7-Emphasis on JIT teaching rather than more formal quality improvement modules (meaning less cost, less time lost and better application of what QI knowledge the organization currently has) 3

4. Frontline Structured Conversation Frontline Structured Conversation Frontline Defects Clinical Non-clinical Collect Data Collect Data Suggest Strategie s Suggest Strategie s Identify Defects Identify Defects Frontline Engagement Small Tests Leading To Project Success Frontline Defect Driven Project Model x

5. Surface Defects Surface Defects Scope Defects Validate Select specific work Design Strategy Finish Project Actions Design Benefits Timeline90 min2 Days1 day60 min 30 days Frontline Engagement Leadership Engagement Frontline Engagement Tester Engagement Frontline Engagement Design Basics of the Actions Conversation Specific Methodology Anchoring Questions Frontline Feedback Align work Gauge Capacity Articulate Implications Study the next defect Y/N Frontline Data Collection Determine frequency Define Boundaries Determine Simple measures Frontline Input Small Tests Frontline Defect Driven Project Framework R Resar x1

6. The Framework Multidisciplinary Team 90 Minute Visits Intro Identification of defects Normalization of Deviation Non-threatening & blame free environment 6

7. Check List for setting up the Conversation Pre-arrange for a 90 minute conversation (preferably the conversation occurs on the unit) Pre-arrange a time for the conversation (chose a time when a representative group of frontline staff can participate) Invite a leadership representative 7

8. Technique to Start the Conversation Make introductions Have one lead person (others can participate later) initiate the conversation by asking individual frontline staff to describe their daily routine (without questions or interruption) Spend about 15-20 minutes in the start of the conversation (to allay fears) 8

9. Technique to Surface Defects Use anchoring questions to start to surface defects Examples: 1-We all have good and bad days at work, describe the last difficult day you recall? 2-Things have to be adjusted in work flow to make the day smooth, describe how you make adjustments to accomplish getting the work done 3-What clinical diagnoses are most common on this unit, describe the most difficult cases you work with? 4-The unexpected is bound to occur from time to time, describe the last unexpected event that occurred in your work? 9

10. The Defects Each anchoring question usually surfaces at least one defect Most 90 minute conversations surface from 12-20 defects Avoid spending time on possible solutions (that will come later) Have a scribe write down each of the defects with as much detail as possible Finish the conversation by listing the defects surfaced, assure the frontline staff one or more of these will be solved and then thank the team 10

11. Some Observations Daily interruptions are commonly viewed as normal, so little or no attempt is currently made to change processes The units function primarily at an artisan level of work. Staff pride themselves in their unique ability to deal with defects (scrambling). Victimized by external factors. Most areas described problems with a system out thereunits, physicians, scheduling systems, a physicians preference and they are viewed as beyond their control 11

12. Cedars-Sinai Examples CVIC Patients arrive for a procedure still on anti- coagulation Daily search for equipment OR/PACU Cases delayed due to wrong equipment Radiation Oncology Add-ons Missing information 12

13. Cedars: Initial learnings It became clear that the seeds for the next event have already been sown in the day-to-day missteps described as normal by staff. Start small with the creation of small islands of stability. An island of stability represents an area of work that has been reviewed and changed to create a new standardized way to organize workflow. Build unit-based learning, reflection on work, measurement, and change leadership systems to support work at the local level. 13

14. Surface Defects Surface Defects Scope Defects Validate Select specific work Design Strategy Finish Project Actions Design Benefits Timeline90 min2 Days1 day60 min 30 days Frontline Engagement Leadership Engagement Frontline Engagement Tester Engagement Frontline Engagement Design Basics of the Actions Conversation Specific Methodology Anchoring Questions Frontline Feedback Align work Gauge Capacity Articulate Implications Study the next defect Y/N Frontline Data Collection Determine frequency Define Boundaries Determine Simple measures Frontline Input Small Tests Frontline Defect Driven Project Framework x2