how to apply concepts of resilience and safety ii to...

“INTO THE WEEDS”

How to apply concepts of resilience and Safety II

to improve performance.

Lacey Colligan MD MSc FAAP Consultant, Dartmouth Hitchcock Medical Center

Sharp End Advisory LLC IHI Workshop 10 December 2014

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No Disclosures Grateful Acknowledgment:

the Center for Kvalitet Region Syddanmark Denmark

Regions of Denmark E. Hollnagel PhD

J. Hounsgaard HRD, IRCA

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Overview

• Models

• How a way of thinking (model) about of your system can be useful.

• Methods

• How a new method may augment your performance improvement efforts.

Retired Danes at lunch (65yo +)

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Start with a system Model

Why use a system model? • Traditional: in order to predict and control system

• Philosophical: in order to understand system

• Practical: gain shared vocabulary and methods so that we can communicate about our system

“Essentially all models are wrong,

but some are useful.” – Box GEP and Draper NR (1987)

Empirical Model Building and Response Surfaces.424.

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Model of STS

Underlying Philosophy Tracta-

ble?

COMPLICATED LINEAR

Descartes

17thC Rationalism

sum components analytic method “Reason is the chief test and source of Knowledge”

Y

COMPLEX NON-LINEAR

Serra and Zanarini, 1990

Cilliers, 1998

“complex” and “simple” can be our distance in system

components PLUS

theirinterdependent relationships in a non-linear manner

N

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Model Case 1: No Double Lumens

• Double lumen umbilical central lines are life-saving for sick newborns, especially prematures.

• No double lumens, on “back order”.

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Model Case 1: No Double Lumens

• AE1: surgical cut-down for CHD patient.

• AE2: exchange of single lumen for double lumen on day 3 after birth.

• NM1: “borrowed” double lumen from Transport team.

• “Moral Distress” meeting convened over inadequate supply availability. Rose to Level of Chief Nursing Officer.

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2x

“STORE FRONT” NICU STORE ROOM

Complicated Linear (WAI)

Supply Chain

DIRECT PATIENT CARE ©Sharp End Advisory, LLC

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Complicated Linear WAI/WAD:

Pull-Push

Transparency

Precision

Production Smoothing

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Complex Non-linear (WAI)

Neonatal Nursing

NICU STORE ROOM

1. POD 2.BEDSIDE CARTS

3.PROCEDURE CARTS

4.CUPBOARDS

Get your supplies…..

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Complex Non-linear(WAD)

1. POD 2.BEDSIDE CARTS

3.PROCEDURE CARTS

4.CUPBOARDS 5. SOMEWHERE ELSE

Get your supplies…..

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Complex Non-linear(WAD)

1. POD 2.BEDSIDE CARTS

3.PROCEDURE CARTS

4.CUPBOARDS 5. SOMEWHERE ELSE

Get your supplies…..

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Complex Non-linear WAD:

Searching Secret

Networks and Stashes

Hiding/Hoarding

Information Seeking ©Sharp End Advisory, LLC

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Inter-dependent Relationships

Complicated Linear Supply Chain

Complex Non-linear Neonatal Nursing

• Priority is patient care

• Pull-Push coupling (tight) • Transparency • Precise counting

• Priority is patient care

• Loose coupling • Little transparency • Worker adaptations erode

counting • Patient requirements erode

counting

Supply Availability is

CONTROLLED

Supply Availability is

EMERGENT

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2x

1. POD 2.

BEDSIDE

CART

“

Complicated Linear

Complex Non-linear

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2x

1. POD 2.

BEDSIDE

CART

“

Complicated Linear

Complex Non-linear

• Training? • Increased sanctions? • Patient Technicians? 30% understaffed.

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1. Reallocate stockists so that one is dedicated to Pediatrics. – Supply personnel are "embedded”.

– Enables two way communication thus improving FEEDBACK.

2. Supply chain extends reach. – Stockist stocks all satellite supply stations.

– Ensures precise counting.

Cost of PCA’s & wasted Nursing time justifies additional infrastructure (carts).

Proposal: identify assumptions and design targeted intervention

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METHODS are based on Models

Model Method Accident Investigation

Goal

Sum of components Decomposition works COMPLICATED LINEAR

Find holes in system

Construct barriers / defenses

COMPLEX NON-LINEAR

Sum of components

+ Relationships between components Decomposition does not work

Find couplings/ complex interactions

Monitor / manage performance variability

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Method Safety Principles Goal of work

Complicated Linear:

RCA/HFMEA

Direct causality Latent conditions Sequence matters Retrospective

matters

• Construct barriers / defenses

Complex Non-linear

FRAM/STAMP

Success=failure Variability Emergence Resonance Conflicting Demands

Monitor/ manage performance variability

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Method Safety Principles Goal of work

Complicated Linear:

RCA/HFMEA

Direct causality Latent conditions Sequence matters Retrospective

matters

• Construct barriers / defenses

Complex Non-linear

FRAM

Success=failure Variability Emergence Resonance Conflicting Demands

Monitor/ manage performance variability

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Efficiency-Thoroughness Trade-Off (ETTO) Thoroughness=

Time to think • Recognising situation • Choosing and planning • Consider outcome

RISK?

• Miss new event • Neglect pending

actions

Efficiency= Time to do

• Implementing plans • Executing actions

RISK? • Miss preconditions • Erode controls

• Confirmation bias Negotiating Conflicting Goals © Erik Hollnagel, 2012

1. The Equivalence of Successes and Failures

2. The Principle of Approximate Adjustments

FRAM Principles

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Performance variability is why

things go right

Performance variability is why things go wrong

Workers adjust their work to the situation.

Resources are always limited.

Because of these limitations, adjustments are always approximate.

Success = Failure and Adjustments

23 ©Erik Hollnagel

1. The Equivalence of Successes and Failures

2. The Principle of Approximate Adjustments

3. The Principle of Emergence

FRAM Principles

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Emergence

Safety in Healthcare is an Emergent Property

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1. The Equivalence of Successes and Failures

2. The Principle of Approximate Adjustments

3. The Principle of Emergence

4. The Principle of Functional Resonance

FRAM Principles

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Classical Resonance

• Ancient Greece

• Oscillations include

– frequency

– amplitude

• Forcing function

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Stochastic Resonance

• Early 1980’s

• No forcing function

• Random noise

• Outcome is non-linear

From http://www.joannaleng.com/

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Functional Resonance

• Hollnagel (2004, 2012,2014)

• Variability that results

from multiple approx. adj.

• Detectable outcome (signal)

that emerges from the unintended interaction of the everyday variability of multiple signals

• Considers outcomes that are non-causal (emergent) and non-linear (disproportionate)

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©Erik Hollnagel

FRAM: a Method to Tackle CAS Includes Values/Culture

30 ©Erik Hollnagel

n.b. Safety Culture reflected in Control

FRAM Applications

1. Retrospective: how something did happen (an event), build an instantiation;

2. Prospective: how anything can happen;

3. Assess the impact of variabilities in a re-design (ex. LEAN)

4. Facilitate work across cross-disciplines.

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Case: CLABSI prevention bundle • Extensive training in use

of checklist

• Checklist compliance excellent

• Work as Imagined looks good…… BUT minimal improvement (Work as Done)

http://www.jointcommission.org/CLABSIToolkit

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Executive Leadership

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Implementation of Bundle

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Line Placement WAD

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Controls of safety culture, and resources from education and stocked cart removed for clarity of diagram.

Operator/ Doc

Nurse

Instantiation 1: ETTO

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Controls of safety culture, and resources from education and stocked cart removed for clarity of diagram.

Time pressure disrupts ability to do both functions.

Instantiation 2: Disruptive Physician

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Controls of safety culture, and resources from education and stocked cart removed for clarity of diagram.

Instantiation 3: Fractured team rotations: discuss

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Controls of safety culture, and resources from education and stocked cart removed for clarity of diagram.

Questions?

Lacey Colligan MD MSc lcolligan@sharpend.solutions 39

1893-1912

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