a positive patient safety culture final -...
TRANSCRIPT
10/30/2016
1
A Positive Patient Safety Culture as a
Path to High Reliability Bruce McIntosh, Pharm.D.
VA National Center for Patient Safety
CPE Information and Disclosures
The American Pharmacist Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
Bruce McIntosh declares no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.
CPE Information
• Target Audience: [FOR APHA USE ONLY]
• ACPE#: [FOR APHA USE ONLY]
• Activity Type: [FOR APHA USE ONLY]
Learning Objectives
• State several barriers to transforming our health care system into a high reliability system
• List the fundamental elements of a positive patient safety culture and their application across the health care system
• Identify several tools that promote effective practice initiatives and expansion across the health care system to foster a positive patient safety culture
Self-Assessment Questions
• Medical errors may be the third leading cause of death in the U.S. (T/F)
• A fault tolerant system is not capable of functioning successfully when an error occurs. (T/F)
• Checklists are effective in developing a shared mental model for a team. (T/F)
…and a Shared Responsibility
Patient Safety is a Journey….
10/30/2016
2
How is our Safety Journey Going?
NEJM (2010)NEJM (2010)
Health Affairs (2011)Health Affairs (2011)
OIG Report on Medicare (2010)OIG Report on Medicare (2010)
BMJ (2016)BMJ (2016)
Leading Causes of Death in U.S.
614,348
591,699
251,454
147,101
136,053
Heart Disease
Cancer
Medical Error
Resp. Disease
Accidents
Makary Martin A, Daniel Michael. Medical error—the third leading cause of death in the US BMJ 2016; 353 :i2139
1.Misdiagnosis
2.Unnecessary treatment
3.Unnecessary tests and deadly procedures
4.Medication errors5.Never events
6.Uncoordinated care
7.Iatrogenic infections
8.“Accidents”
9.Missed warning signs
10.Going home
Things that can Kill you in a Hospital
Wen L. 10 Things that can kill you in the hospital. The Huffington Post; April 2013.
Preventable medication errors
– at least 1.5 Million in the U.S. each
year
– One error per hospital patient per day
Incidence and Costs
Aspden P, Wolcott J, Bootman JL, et. al. Preventing medication errors- Quality chasm series. Institute of Medicine; 2007.
Incidence and Costs
100,000
or
> 400,000
DEATHS
Incidence and Costs
Costs
$ ? billion
10/30/2016
3
Voice of the Patient…
• “Know me”
• “Help me”
• “Don’t Harm Me”
Why do Adverse Events Occur?
Risk
EventAdapted from “Swiss Cheese” Model – James Reason, 1991. Reason,
J. (1990) Human Error. Cambridge: University Press, Cambridge.
Complexity in Health Care
“Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous”
- Sir Cyril Chanter
‘To Err is Human’
“We cannot change the human condition. People will always make errors and commit violations. But we can change the conditions under which they work to make these unsafe acts less likely.”
-James Reason
Fault Tolerant System -system tolerates & anticipates errors but still functions successfully…
Error must be Managed What is High Reliability?
• Extremely well focused on preventing failure, on expecting the unexpected, and on ensuring that errors don’t result in catastrophic events
• High Risk activity but low adverse event rate
Riley W, Stanley, DE, Miller, KK, McCullough M. A model for developing high reliability teams. Journal of Nursing Management, 2010; 18, 556-563.
10/30/2016
4
High Reliability Organizations
• Preoccupation with failure
• Reluctance to simplify
• Sensitivity to operations
• Commitment to resilience
• Deference to expertise
The success of HRO’s in managing the unexpected is their effort to act mindfully. This means that they are able to notice the unexpected in the making if they cannot halt the event, they focus on containing it, if they cannot contain it, they focus on restoration.
Weick and Sutcliffe (2001). Managing the Unexpected – Assuring High Performance in an Age of Complexity. San Francisco, CA: .Jossey – Bass.
What does High Reliability Look Like?
http://www.NASA.gov
• Hierarchical relationships
• Human factors varies
• Non‐core work
• Variable standards
• Fear/shame in reporting errors
• CME/ACPE, etc.
• Competence assumed
• Leadership engaged ?
• Team emphasis
• Human factors
• Core work
• Standardization
• Non‐punitive reporting
• Perpetual training
• Competence checked
• Leadership engaged
Aviation Culture HealthcareChallenges and Barriers to High Reliability for Health Care
1. Human Factors
2. Leadership
3. Communication
4. Assessment
5. Physical Environment
6. Health Information Technology-related (HIT)
7. Care Planning
8. Information Management
9. Medication Use
10.Performance Improvement
The Joint Commission. Most frequently identified root causes of sentinel events reviewed by the Joint Commission;2015. https://www.jointcommission.org
Challenges and Barriers to High Reliability for Health Care…
• Culture
• Standardization
• Complexity of health care
• Industry
• Regulatory authorities
• Politics and media
• Resources
• Procurement and logistics
• Change
Path to High Reliability-VHA Model
High Reliability in Health Care
Safety Culture
Just Culture
Leadership
High Functioning
Teams
Understand Complexity and
EOC
New Technologies
Electronic Medical Record
Computer Physician
Order Entry
Medication Record, BCMA, Smart Pumps
Evidence-Based Practice
Understand and measure current
performance
Standardization, Simplification of Care Processes
Default Processes with MD Exception
Process Optimization
and Standardization
PDSA
LEAN
Six Sigma
Frankel, A.S., Leonard, M.W., & Denham, C.R. (2006). Fair and just culture, team behavior, and leadership engagement: The tools to achieve high reliability. Health Serv Res, 41 (4 Part 2), 1690-1709.
Ikkersheim, D.E. & Berg, M. (2011). How reliable is your hospital? A qualitative framework for analysing reliability levels. BMJ Qual Saf, 20, 785-790.
High Reliability in Health Care
Safety Culture
Just Culture
Leadership
High Functioning
Teams
Understand Complexity and
EOC
New Technologies
Electronic Medical Record
Computer Physician
Order Entry
Medication Record, BCMA, Smart Pumps
Evidence-Based Practice
Understand and measure current
performance
Standardization, Simplification of Care Processes
Default Processes with MD Exception
Process Optimization
and Standardization
PDSA
LEAN
Six Sigma
10/30/2016
5
Example Cases
Kimberly Hiatt CaseKimberly Hiatt Case
Eric Cropp CaseEric Cropp Case
Men
ing
itis
Ou
tbre
ak:
Exs
ero
hilu
m r
ost
ratu
m
Example Cases
http://www.CDC.govPublic Health Image Library (PHIL)Photo: James Gathany
Example Cases
http://www.oneandonlycampaign.org/sites/default/files/upload/pdf/SIPC_insulinpen_BeAware_11x17_0.pdf
OpenOpen
JustJust
ReportReport
LearnLearn
InformInformA Positive Safety Culture
Carthey J, Clarke J. Implementing human factors in healthcare. https://www.patientsafetyfirst.nhs.uk
Just CultureDefined
• An atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information
• Individuals trust that they will not be held accountable for system failures; and are also clear about where the line must be drawn between acceptable and unacceptable behavior
Marx, D. (2001). Patient safety and the “just culture”: A primer for health care executives. Retrieved from: http://www.psnet.ahrq.gov/resource.aspx?resourceID=1582
• Major barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect towards staff, residents, and patients
• Full disclosure of medical errors helps build trust with patients and their families while supporting the clinicians involved
• The just culture ensures that individuals will not be blamed or punished for reporting unsafe conditions or adverse events while holding everyone accountable for their own behavior
Leape, L.L., Shore, M.F., Dienstag, J.L. et al. (2012). A culture of respect, Part 1: The nature and causes of disrespectful behavior by physicians. Academic Medicine, 87, 845-852.
Just CultureWhy Bother?
10/30/2016
6
• Staff satisfaction surveys suggest that frontline staff do not really understand what a non-punitive reporting system means
• Supervisory staff were unequipped to address errors in a non-punitive way because most had been educated and socialized within the old model of error management and reporting
• Employees disciplined using a punitive approach without the full benefit of a systems analysis
Connor, M., Duncombe, D., Barclay, E., Bartel, S., Borden, C., Gross, E., Miller, C. Ponte, P. (2007). Creating a fair and just culture: One institution’s path toward organizational change. Jt Comm J Qual Safe, 33, 617-624.
Just CultureDriving Forces
DriftVigilance - Complacency Continuum
Vigilance ComplacencyYearsMonthsEntry
time DRIFT
“Creative Commons Matt Bush of South Africa is a Modern Free Solo Climber” by Red Bull is licensed under CC By SA 4.0Pexels are licensed under the Creative Commons Zero (CC0) license.
• Response to error is based on the type of behavior associated with the error– Human error
• slips, lapse, mistake
– At-risk behavior • taking shortcuts
– Reckless behavior • ignoring required safety steps
Just CultureResponse
How we do it
Policy
Reckless Behavior
Conscious disregard of unreasonable risk
At-Risk Behavior
A choice: risk not recognized or believed reasonable
Human Error
Inadvertent action: slip, lapse, mistake
Console Coach PunishLearn Learn Learn
Managing Behaviors Tool
Adapted from: Marx, David. Outcome Engenuity. What does our model of accountability look like? Available from: https://www.outcome-eng.com/getting-to-know-just-culture/Adapted from: Leonard MW, Frankel A. The path to safe and reliable healthcare. Patient Educ Couns. 2010 Sep;80(3):288-292.
Communication Tool The Error Management Pyramid
TRAPERROR
AVOIDERROR
MITIGATEERROR
BriefingDebriefingChecklistInquiry & AdvocacyStandardizationFatigue Management
Closed Loop CommunicationRedundant Double CheckTime OutTeam Monitoring & Crosschecking
Just Culture Immediate ReportingStandardized Procedures
Adapted from Helmreich RL, Merritt AC, Wilhelm JA (1999). The evolution of Crew Resource Management training in commercial aviation. International Journal of Aviation Psychology, 9(1), 19-32.
10/30/2016
7
High Reliability Team Behaviors
Situational Awareness
Closed Loop Communication
Standardized Communication
Shared Mental Model
Rule – Based decision making
Riley, W., Stanley, D.E., Miller, K.K., McCullough, M., A model for developing high reliability teams – Journal of Nursing Management 2010; 18: 556-563Amalberti, R., Auroy, Y., Berwick, D., Barach, P., Five System Barriers to Achieving Ultrasafe Health Care – Annals of Internal Medicine 2005; 142: 756-764
Countermeasures
Acknowledgements
Algorithms / Tools
Checklists / Algorithms
Briefings
Situational Awareness Threat Management
Checklist Use
Safer SystemsSafer
SystemsMental
WorkloadMental
Workload
DistractionsDistractions
EnvironmentEnvironment
Physical DemandsPhysical Demands Product
DesignProduct Design
Teams Teams
Process DesignProcess Design
Carthey J, Clarke J. Implementing human factors in healthcare. https://www.patientsafetyfirst.nhs.uk
Human Factors Targets
Heuristic Evaluation Tool
43
10/30/2016
8
Strategic Road Map-Auto Example Key Points
• A Positive Patient Safety Culture is the Path to High Reliability in Health Care
• ‘To err is Human’
• Challenges and Solutions:– Human Factors
– Leadership
– Communication
• Leadership is critical to success
• Focus on sustainment
• The journey is long
Know SafetyNo Harm
Answers To Self-Assessment Questions
• Medical errors may be the third leading cause of death in the U.S. (True)
• A fault tolerant system is not capable of functioning successfully when an error occurs. (False)
• Checklists are effective in developing a shared mental model for a team. (True)
Closing Remarks
Bruce McIntosh, Pharm.D.VA National Center for Patient Safety