dr. stephen muething - can we become high reliability healthcare organisations?

The Journey TowardsZero Harm

A Report from One Journeyman

Stephen E. Muething, MDVice President for Patient Safety

James M. Anderson Center

October 23, 2012

It Truly Is A Journey

Thank you to CHA, the CEO’s and the Children’s Hospital’sfor sharing and learning together.

523 Bed Medical Center32,000 Admissions/Year 1,000,000 outpatient visits$143 million externally funded research

12,000+ employees31,000 Surgical Procedures (20% Inpt)17% average annual growth over past decadeNational /International partnerships

Today’s Discussion Using Reliability as the Guidebook:

Process Reliability High Reliability Culture

Employee Safety HRO Techniques Learning Together to accelerate the journey Next Steps on the Journey

Reliability: more than Safety

No needless deaths No needless pain No helplessness No unwanted waiting No waste Don Berwick, Institute for Healthcare Improvement

Our Safety Strategy: Eliminate all serious harm for patients and employees by June 30th, 2015

SSE’s &Lost-timeInjuries

Serious Harm Index &OSHA Recordable Injuries

Events of Minimal to Moderate Harm & All Employee Injuries

Near-Miss EventsPatient and Employee

Pyramid of Harm(Patient and Employee)

Strategy:Focus on the topof the pyramid andprogressively move down

Reliable Key ProcessesDozens across organizationStandardizationSustainability built into the systemReal-time failure awarenessData feedback to the microsystemsMaking the right thing, the easy thing

Key Processes

VAP Bundle CLA-BSI Bundle Pressure Ulcer Bundle Safe Medication Practices CA-UTI Bundle Etc, etc, etc………..

Real Time Failure AwarenessPatient Safety Sept. 9- Sept. 15

Events of HarmCA-BSI9/10 A5N9/10 A5S9/11 B6HI

VAP9/2 B6HI (disease progressed to classify this week – effective date 9.2)

SSI9/1 (upon review – met criteria for SSI)

Employee Safety Sept 14 – Sept 20

ISSUE PAST WEEK

FY 13 YTD

FY12YTD

Total OSHA Recordable cases: 4 48 59

- Lost-Time 1 7 2

- Blood Borne Pathogen Exposures 1 15 18

- Slips, Trips, Falls 0 4 6

- Patient Interaction 1 4 8

Late Incident Reports(These are incidents called in to 803-OUCH beyond the day of injury)

2 28

N/AUntil

2/23/13

CONFIDENTIAL

Data Feedback To Microsystems

Data Feedback To Microsystems

Making The Right Thing, The Easy Thing

No aviation fatalities…

No crashes…

No nuclear leaks…

No Serious Harm

Characteristics of High Reliability Organizations

1. Preoccupation with failureRegarding small, inconsequential errors as a symptom that something is wrong; finding the half-event

2. Sensitivity to operationsPaying attention to what’s happening on the front-line

3. Reluctance to simplifyEncouraging diversity in experience, perspective, and opinion

4. Commitment to resilienceDeveloping capabilities to detect, contain, and bounce-back from events that do occur

5. Deference to expertisePushing decision making down and around to the person with the most related knowledge and expertise

Senior Leadership “Owns” Safety

Transparency

Development of a High Reliability Culture

Developing Mindfulness• Aware of all harm –

EVERYDAY• Aware of all risk –

CONTINUOUSLY• Harm reduction owned by

front line leaders• Learning to find the cause • Alignment of the strategic

plan with the front line

Leadership• High functioning

microsystems

• Executive reinforcement to front line.

• Daily and shift huddles; Organizational Daily Brief

• Multiple improvements going on simultaneously

• Just culture• Managing by Prediction rather

than Reaction

Development of a High Reliability Culture

Error Prevention• Behavior training• Reinforce via Safety Coaches• Reinforcement and accountability by supervisor

(5:1 feedback)• Situation Awareness

– Identify - Mitigate – Escalate

SSE’s &Lost-timeInjuries

Serious Harm Index &OSHA Recordable Injuries

Events of Minimal to Moderate Harm & All Employee Injuries

Near-Miss EventsPatient and Employee

Pyramid of Harm(Patient and Employee)

Employee Safety

Top 3:Blood Borne Pathogen ExposurePatient InteractionSlips/Trips/Falls

Structures & Techniques From HRO’S

• Pre-Briefs/Debriefs• Checklists• Flattening Hierarchy• Standardizing Communication• Huddle• Situation Awareness

James M. Anderson Center for Health Systems Excellence

Managing By Prediction

James M. Anderson Center for Health Systems Excellence

The Admirals’ Huddle on aCarrier Task Force• Look Back• Look Forward• Identify and Solve Issues

Every Morning @ 9AM

Organization HuddleAdopted from the US Navy

James M. Anderson Center for Health Systems Excellence

Daily Operations Brief8:35 AM

Department Huddles

8:00AM

Unit-Clinic-Team Huddles6:30-7:45AM

CincinnatiChildren’s

Version

James M. Anderson Center for Health Systems Excellence

• What Happened in the Previous 24 Hours?

• What’s Predicted for the Next 24 Hours?

• Issues Which Need Resolution.

Three Topics

James M. Anderson Center for Health Systems Excellence

Employee SafetyInpatient & ICUs Surgery (Liberty too)Emergency Department (Liberty too)OutpatientPsychiatry (A4C2 too)Home Health CarePharmacyRespiratory

Departments Reporting Out on Daily Operations Brief

RadiologyFamily RelationsLaboratoryInfection ControlSupply ChainInformation SystemsProtective ServicesFacilitiesOthers

James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence

Inpatient Huddles

SITUATION AWARENESS

Bedside nurse

InternWatch Stander

Senior Resident

Watch StanderPCF/Manager

Safety Team(MPS and SOD)

at 800, 1600 & 100

Family concerns

High risk therapies

Watcher

PEWS>5

Communication concern

RapidResponse

Reliable escalation of riskRapid assessment and communication with primary team

Attending

Bedside Team

Microsystem Team

OrganizationTeam

43

Situation Awareness Model

Situation Awareness project go-live

Learning Together

Start With One State

Develop Ohio NetworkInitial HAC improvement work

SSE reduction; efforts to address organizational culture

Creation of pediatric patient harm index

Create National Children’s NetworkExpand network to include 26 leading children’s hospitals outside Ohio (Phase I)

Active improvement work on 10 HACs

Efforts to address organizational culture

“All Teach, All Learn”

Develop mentor hospitals

Spread Share network best practices with all (2012)

Disseminate at national meetings (2012)

Develop strategies with national organizations

(2012)

Add 50 hospitals (Phase II) to data sharing and network learning opportunities (2013)

Establish other regional collaboratives (2013)

Expanding Scope to Eliminate Harm Across US Children’s Hospitals

(2008-2011)

(2012)

(2012)

8 33 83

National Children’s Network Phase I Hospitals: 33

48

Adopting Common Behaviors

James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence

Thank you

Questions?

stephen.muething@cchmc.orgCincinnatichildrens.org/andersoncenter

Human Factors

SEIPS Model

Pascale Carayon et al.

Questions?

Thank Youstephen.muething@cchmc.org

http://cincinnatichildrens.org/andersoncenter/