3 Known to be highly risky but also highly safe and effective. High ReliabilityKnown to be highly risky but also highly safe and effective.
4 The most important goal of Risk Management IS High Reliability
5 High ReliabilityKnown to be highly risky but also highly safe and effective.Highly reliable industries/organizations:Aviation industryKorean WarNuclear power plants3 Mile IslandChemical industriesUnion Carbide in Bhopal?Catholic ChurchBoston Sexual Abuse
7 HypothesesThe conceptual frameworks for Patient Safety, High Reliability and Risk Management are one and the same.The current legal processes impacting the healthcare industry undermine high reliability and subvert risk management.Change for the better is possible, and will occur through cultural remodeling by leadership and risk management.
8 Components of this talk The Nature of Systems (Healthcare)The Nature of Human BeingsAn Explanation of Individual InterestThe Nature of AccountabilityThe Nature of Risk ManagementProof of HypothesesActionsProfessionallyPersonally
12 Probability of success, each element: Complex systemsProbability of Performing Perfectly:Probability of success, each element:0.950.990.9990.9999100401250.0060.120.950.280.370.660.990.780.900.960.9990.9750.990.9950.99990.997# of steps14
13 High Reliability Organizations Manage Complexity and the Unexpected with Five Characteristics:1. Preoccupation with failure (safety)2. Deference to expertise3. Sensitivity to operations4. Commitment to resilience5. Reluctance to simplify interpretationWeick and Sutcliffe
15 HRO characteristics 1. Preoccupation with Failure (Safety) 2. Deference to expertise3. Sensitivity to operations3. Commitment to resilience5. Reluctant to simplify interpretationWeick and Sutcliffe
16 Fixing HealthCare: Application of Human Factors Human Factors – the study of the interface between humans, their environment, and technologyStandardizationSimplificationForcing Functions/ConstraintsMinimizing reliance on memorySalvendy
17 Nature of fixing complex systems Probability of success, each step:0.9950.9970.999504020300.780.820.900.860.860.880.940.910.950.960.980.97# of step
19 Human Beings Cognitive Psychology - The study of how we think Automatic thinkingRule based thinkingKnowledge based thinkingWe think on 3 levels, we err on 3 levelsSlips and LapsesRule based errorsKnowledge based errorsRasmussen and Reason
20 Human Beings How frequently do we make errors? Omission Errors 1 in 100 timesForgetting to turn on a pumpCommission Errors3 in 1000 timesMisreading a labelRisk of judgment errors under high stress90%Salvendy
21 Intrinsic Human Error and Complex Systems Probability of Performing Perfectly:Probability of success, each element:0.950.990.9990.9999100401250.0060.120.950.280.370.660.990.780.900.960.9990.9750.990.9950.99990.997# of elements14
22 The Nature of Human Beings: WHAT DRIVES MOTIVATION Systemic Migration of BoundariesVERY UNSAFE SPACE100%AgreementNon-acceptable‘Illegal normal’Real Life standardsBTCU-6095%Safety Reg’s &good practicesCertificationaccreditationstandards100%Expected safespace of actionas defined byprofessionalLOW Individual Benefits HIGHUsual SpaceOf ActionACCIDENTHIGH Production Performance LOWRene Amalberti, MD, PhD
23 Individual Interest (A brief detour into philosophy)
24 The Nature of Human Beings HappinessWe seek pleasures and satisfactionImmediate Pleasure – ice creamLong term satisfactionsFLOW“achieving optimal experience”“ego-less concentration”Seligman and Csikszentmihalyi
25 The Nature of Human Beings DeMello – Buddhist traditionAttachmentWe seek to acquirePassion drives the processWe identify with our acquisitionsWe become attached to our acquistionsAttachment is the source of our unhappinessHappiness is available to us through detachmentV. Frankl “In Search of Meaning”“What do I expect of life?”“What does life expect of me?”
26 Human Beings Cognitive Psychology - The study of how we think Automatic thinkingRule based thinkingKnowledge based thinkingWe think on 3 levels, we err on 3 levelsSlips and LapsesRule based errorsKnowledge based errorsRasmussen and Reason
27 The Nature of Human Beings: Systemic Migration of Boundaries VERY UNSAFE SPACE100%AgreementNon-acceptable‘Illegal normal’Real Life standardsBTCU-6095%Safety Reg’s &good practicesCertificationaccreditationstandards100%Expected safespace of actionas defined byprofessionalLOW Individual Benefits HIGHUsual SpaceOf ActionACCIDENTHIGH Production Performance LOWRene Amalberti, MD, PhD
29 Responses to Harm Law Regulation Culture Criminal Action Individual interest versus protectionProduction versus protectionRegulationCompetency – “I don’t know what I don’t know”Judgment – “I know what I don’t know, but I don’t ask”CultureError – Cognitive Limitations
30 Criminal Action Legal Process Apportions Blame. Complex process RulesBased on fairness and efficiency.Advocacy – with or without ethics.Dampens primal response into civilized process.‘Ferries’ victim from beginning to end.
31 Individual Interest versus Protection Individual ResponsibilityEthical behavior“What do I want to acquire?”“What am I attached to?”
32 Production versus Protection Organizational responsibilityCriteria basedBest evidence, then….Local consensus
33 Competency Organizational expectation Criteria based Internal or external regulationCriteria basedBest evidence seeking most effective educationLocal consensus to promote simplicity
34 Judgment Individual Relationship with peers and organization Environmental expectationsCultureSense of AccountabilityPersonal make-up (parenting)Environmentally fostered
35 Error Cognitive Psychology The 3 ways we think and err: Thinking about how we thinkRasmussen and ReasonThe 3 ways we think and err:AutomaticallyRuled-basedKnowledge-based
38 Risk Management Reducing exposure Fiduciary responsibility (through patient safety)Fiduciary responsibilityProtectLitigation and Malpractice insuranceOut of control
39 Actions What do we want to accomplish? “Identify areas of actual/potential risk. Prevent injuries to patients, visitors and employees…”
40 Actions What changes do we need to make? Promote Feedback Promote TransparencyPromote Open CommunicationDemand Ethical negotiationFor harmed individuals: “What would be ethically and morally sensible for us to do for this person who has been harmed.”Think Systems: “What can we do to make harm to the next patient less likely?”Innovative compensationIatrogenic overnight stay in ICU – negative pressure pulmonary edemaLeadership involvement in safety –Leadership Patient Safety WalkRounds
41 Partners HealthCare Commitments to Patient Safety
42 EthicsDRAFTPatient Safety principles promoting transparency, accountability, and responsibility.
43 WE WILL SUPPORT THE EFFORTS OF EVERY INDIVIDUAL to deliver the best care possible and will view accountability for harm or potential harm in the context of individual and system influences.Ø We commit to supporting simplification, standardization, effective teamwork and open communication in order to foster an environment that is least likely to cause or support error.Ø We believe that individuals are accountable for their own performance but should not carry the burden for system flaws.
44 WE PROMOTE OPEN REPORTING of adverse events and potential harm by health care workers, patients, and patients’ families.Ø We commit to developing and maintaining easily available and simple ways for healthcare workers and patients to report adverse events and to discuss concerns about the safety of care delivery.Ø We commit to supporting and protecting individuals who report adverse events. Their information helps lead us to actions that will improve the healthcare environment.
45 WE WILL ACT TO IMPROVE SAFETY by implementing changes based on our analysis of adverse events and potential harms.Ø We know that actions designed to address the causes of adverse events will improve the safety of care. We commit to identifying and assigning responsibility for implementing those actions to specific individuals or groups.
46 WE WILL INFORM PATIENTS AND FAMILY MEMBERS, HEALTHCARE PROVIDERS, LEADERSHIP AND TRUSTEES about actions that have been developed from open communication about adverse events and potential harms.Ø We believe that patient input is indispensable to the delivery of safe care and we commit to promoting patient participation on our care delivery teams.Ø We commit to fostering a culture that is concerned with safety through continuous education, reminders and safety-based leadership.Ø We commit to ensuring that our leaders and all healthcare workers are cognizant of the risks in delivering care, the efforts generated to make care delivery safe, and the importance of supporting those efforts.
47 WE WILL ASSESS OUR SUCCESS IN PROMOTING A CULTURE OF SAFETY by evaluating willingness to communicate openly, and by improvements we achieve in patient safety.Ø We commit to monitoring actions and attitudes for their effectiveness in supporting a culture of safety and modifying actions as needed.
48 WE PROMOTE INTERDISCIPLINARY DISCUSSION and analysis of adverse events and potential harms. Ø We commit to eliciting different points-of-view to identify sources of harm and to use the information to improve safe delivery of care.Ø We commit to analyzing episodes of harm or potential harm in an unbiased fashion to best determine the contribution of system and individual factors.Ø We commit to fostering a teamwork approach to the analysis of adverse events and potential harms and the actions taken to address them.
49 Actions How will we know a change is an improvement? Outcome Data Decreased harmProcess DataSurvey of Attitudes toward Safety and TeamworkUnderstanding of human factors and systems/complexity/accountabiity theoryLawsuits and Complaints
50 HypothesesThe conceptual frameworks for high reliability and risk management are one and the same.Ever safer and more effective careProtection of system from miscreantsThe current legal processes impacting the healthcare industry undermine the industry’s ability to develop high reliability and subvert risk management efforts.Legal process diminishes feedback, transparency and communicationPromotes the qualities of acquisition and attachmentsCulture trumps all. Appropriate attitudes will confer safety, enhanced by technology.
51 Personal Happiness What does life expect of each of us? “Follow ones bliss”Joseph CampbellFlowMihaly CsikszentmihalyiHappinessMartin Seligman