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August 14‐15, 2019BC Patient Safety & Quality Council, BC, Canada
Jeffrey Braithwaite, PhD, FIML, FCHSM, FFPHRCP, FAcSS, Hon FRACMA, FAHMS
Professor and DirectorAustralian Institute of Health InnovationDirectorCentre for Healthcare Resilience and Implementation SciencePresident ElectInternational Society for Quality in Health Care (ISQua)
Building resilient systems for surgical improvement
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Our mission is to enhance local, institutional and international
health system decision-making through evidence; and use
systems sciences and translational approaches to
provide innovative, evidence-based solutions to specified health care delivery problems.
Australian Institute of Health Innovation
www.aihi.mq.edu.au
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Australian Institute of Health Innovation
PIONEERING | STRATEGIC | IMPACT
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Australian Institute of Health Innovation
•Professor Jeffrey BraithwaiteFounding Director, AIHI; Director, Centre for Healthcare Resilience and Implementation Science
•Professor Enrico CoieraDirector, Centre for Health Informatics
•Professor Johanna WestbrookDirector, Centre for Health Systems and Safety Research
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I would like to acknowledge the traditional custodians of the land on which we are gathered and pay my respects to their
Elders both past and present. I would like to extend that respect to all Aboriginal
and Torres Strait Islander peoples
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Improving surgical care in AustraliaHow do we improve surgical care?
Know what the problem is, e.g. via Audit and Incident Management
And learn from things going right as well as wrong …
[Source: Discussions with Professor Cliff Hughes, AO, Cardiothoracic Surgeon]
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Australia has a number of statutory expert committees, e.g.
1. SCIDUA (Special Committee Investigating Deaths Under Anaesthesia)a. Audit of patients in NSW who died relating to an incident occurring during anaesthesia – deaths within 24 hours
2. CHASM (Collaborating Hospital’s Audit of Surgical Mortality)a. Audit of patients who died under the care of a surgeon – deaths
within 30 days of operationb. Managed by surgeons, for surgeons
Improving surgical care in Australia
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SCIDUA: Example of findings
Estimated Anaesthetic mortality per administration
[Source: Provided by Professor Cliff Hughes, AO]
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CHASM: Reported changes in surgical management of patients
2008 2009 2010 2011 2012Elective (n=738) 87% 82% 79% 94% 88%Emergency* (n=3704) 66% 64% 78% 88% 76%All*(n=4554) 69% 67% 78% 90% 79%
0%
20%
40%
60%
80%
100%
% of a
udite
d op
erative de
aths
Year of death
Proportion of audited deaths with consultant surgeon in theatre (operating, assisting or supervising)
[Source: Provided by Professor Cliff Hughes, AO]
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Improving surgical care in the Province
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Improving surgical care
“Our vision for surgical care in BC is to use evidence‐based, data‐driven
programs, to decrease complications and infections, and provide better outcomes for the 200,000 British Columbians who undergo surgery each year.”
[Source: BC Patient Safety & Quality Council (2019) Surgical Improvement. https://bcpsqc.ca/improve‐care/surgical‐improvement/]
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Improving surgical care
• Surgical Quality Action Network (SQAN) – engage patients and track and evaluate patient outcomes through the National Surgical Quality Improvement Program
• Nearly 450 health care providers have joined SQAN
[Source: BC Patient Safety & Quality Council (2019) Surgical Improvement. https://bcpsqc.ca/improve‐care/surgical‐improvement/]
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Improving surgical care
• Saved more than 12,000 bed days over a 5 year period
• Coordinates and aligns with Ministry of Health’s Surgical Services Strategy, the Surgical Action Plan, and Measurement System for Physician Quality Improvement
[Source: BC Patient Safety & Quality Council (2019) Surgical Improvement. https://bcpsqc.ca/improve‐care/surgical‐improvement/]
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Lessons from around the world on improvement
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A series on international health reform
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A series on international health reform
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A series on international health reform
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A series on international health reform
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A series on international health reform26 chapters, 14 mentions of
surgical procedures
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A series on international health reform26 chapters, 14 mentions of
surgical procedures
58 chapters, 17 mentions of
surgical procedures
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A series on international health reform26 chapters, 14 mentions of
surgical procedures
58 chapters, 17 mentions of
surgical procedures
57 chapters, 12 mentions of
surgical procedures
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Contributors
• 161 contributing authors from over 60 countries
• Five low-income, 22 middle-income, 35 high-income healthcare
systems, covering two-thirds of the world’s 7.4 billion people
• The authors’ tasks were to:
Chose an exemplar of success and analyse
their case
Identify the main lessons learnt
Advance recommendations
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The Americas
GuyanaElderly patient care
EcuadorImproving hospital management
ChileCreating symbolic capital and institutional motivation for success
CanadaImproving stroke outcomes through accreditation
BrazilQuality improvement
ArgentinaGovernment legislation and non-government initiatives
MexicoMonitoring and evaluation system for health reform
The United States of AmericaImproving safety in surgical care
VenezuelaMision Barrio Adentro (“Inside the Ghetto Mission”) national primary care program
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IsraelElectronic health records and the health information exchange program
IrelandInnovative treatment of hemophilia
Germany‘Healthy Kinzigtal’ population-based health care system
FranceCare-centered approach: increasing patients’ feelings of safety
FinlandeHealth in clinical practice
EstoniaReform in primary health care
EnglandThe role of the National Institute for Health and Care Excellence (NICE)
AustriaStroke-units
ItalyManagement of pharmaceutical innovation
MaltaMedical training and regulation
Netherlands‘Prevent harm, work safely’ program
NorwayStandardization of measuring and monitoring adverse events
Northern IrelandImproving maternal and pediatric care
SwitzerlandCollaborations to improve patient safety
SpainOrgan donation and transplantation
SerbiaChild abuse and neglect
ScotlandPartnership and collaboration prompting collaboration
RussiaLegislative improvements to improve health care quality
PortugalHospital Acquired Infection
TurkeyNational healthcare accreditation system
SwedenResearching and learning from clinical data
WalesShared decision making in practice and strategic improvements
Denmark Pathways for Cancer patients
Europe
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RwandaCommunity-based health insurance
GhanaArresting the medical brain drain
NamibiaQuality management model
NigeriaThe responsive health delivery system
South AfricaRegulation of healthcare establishments via a juristic body
West Africa (Guinea, Liberia, and Sierra Leone)Ebola affected countries
Africa
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QatarQatar Early Warning System (QEWS) for deteriorating patients
PakistanRole allocation, accreditation and databases e.g., cardiac surgery database
OmanAl-Shifaelectronic health record system
LebanonSocial innovation and blood donations
The Gulf States(Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, the United Arab Emirates):Procuring pharmaceuticals and medical supplies from GCC countries
IranThe wide ranging reforms of the Health Transformation Plan
The United Arab EmiratesSingle payment system
YemenImprovement of basic health services in Yemen: a successful donor-driven improvement initiative
JordanHealth Care Accreditation Council
AfghanistanImproving hospital services: implementing minimum standards
Eastern Mediterranean
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JapanHealth insurance
IndiaPublic-private partnership to increase safety and affordability of care
ChinaSelf-service in tertiary hospitals
AustraliaBetween the flags rapid response system in emergency departments
Papua New GuineaProvincial health authorities
MalaysiaMaternal health
New ZealandKo AwateaOrganization for innovation and quality improvement
FijiStrengthening primary care
Hong KongCare for elderly patients after hospital discharge
TaiwanImprovements in information technology
South-East Asia and the Western Pacific
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Key messages
• Positive deviance approach: what goes right is important to understand
• All health systems provided a success story, regardless of wealth, political structure, and available resources
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• Learning across geographical borders: Close neighbours and other countries
• Learning across professional roles: Many stakeholders
• Learning across disciplines:Aged, acute, community care
Learning across boundaries and borders
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Improvement takes place in complex adaptive systems
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Properties of complexity
1. Agents2. Interacting3. Self-organised4. Collective5. Networks6. Rules7. Emergence
[Braithwaite 2010; Braithwaite 2015. Gaps in systems]
8. Uncertainty9. Adaptive10. Dynamical11. Bottom up12. Transitional13. Feedback14. Path dependence
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So, if your mental model is this …
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But healthcare really looks like this …
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Simple Complicated Complex Chaotic
The Cynefin Framework
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Simple Complicated Complex Chaotic
Examples in healthcare
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Participants: what are your experiences of
complexity?
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Complexity Science in Health Care: A WHITE PAPER
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Everyone struggles with complexity: Lynch Syndrome
Screen
High risk
Refer
Work‐as‐imagined:
[Source: Taylor et al 2016]
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Start/End of Process
No. of patients
Time data
Key:
Work as imagined
NO REFERRAL
Referral to a private clinic or another public
genetics service
Refer to genetics service?
Patient attends appointment at HCC
Seen at HCC
Yes
Patient agrees to referral
Yes
Yes
No
Referral made to HCC
Not seen No
High risk Low risk
Yes
Screening test
+16 119
0
<5 days
<14 days
14
2
2
2
0
Clinicians thought there there would be around 15‐20
patients
Clinicians thought there may be some
patients who would attend private clinics
Clinicians thought only 1 or 2 would
be missed
Clinicians thought there was a wait list to be seen
Clinicians thought referrals could be made up to 18 months after
surgeryClinicians thought there may be some
patients who would not attend
Example: Lynch Syndrome
[Source: Taylor et al 2016]
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•Audit and feedback (which can lead to small but potentially important changes in provider behaviour)
• Local opinion leaders (the best way to make use of local opinion leaders is unclear)
•On‐screen point of care reminders (which can lead to small to modest improvements in provider behaviour)
What works? EPOC evidence
[Sources: EPOC; Flodgren et al 2011; Balas et al. 2000]
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• Interventions to promote safe and effective use of medicines by consumers (no single beneficial strategy can be identified)
• Educational outreach (AKA academic detailing) (consistent, small and potentially important impacts on prescriber behaviour)
• Tailored intervention strategies to change health practitioner performance (small to moderate impacts, but the effect is variable)
What works? EPOC evidence
[Sources: EPOC; Flodgren et al 2011; Balas et al. 2000]
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Cultures of care and teamwork
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What’s culture?
• Culture: sets of beliefs, ideas, practices and behaviours
• “The way we think around here”• “The way we do things around here”• Our: worldview, assumptions, outlook, norms, values• The collective things we agree on, taking these things
for granted
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Culture –a model
[Braithwaite, 2011]
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Culture in complex systems: The tip of the iceberg
[Source: based on a conceptualisation by Sackmann, 1991]
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• The characteristics of surgeons,
doctors, nurses and allied
health professionals
• Despite MDT, they are tribal!
And there’s books on this
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Culture – an update• Is there a relationship between organisational
culture and patient outcomes? Who believes …
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Culture – an update• Is there a relationship between organisational
culture and patient outcomes? Who believes …• The answer is yes: across 62 studies
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2012 2014
TCRN – Eastern Sydney
[Long et al. 2016. Structuring successful collaboration]
2017
Each dot represents a TCRN member, each line a collaborative tie
2015
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But …
Admin 1
Admin 10
Admin 11
Admin 12
Admin 2
Admin 3
Admin 4
Admin 5
Admin 6
Admin 7
Admin 8 Admin 9
Allied health 1
Allied health 2
Allied health 3
Allied health 4
EN 1
EN 2
EN 3
EN 4
EN 5
EN 6
Jr dr 1
Jr dr 10
Jr dr 11
Jr dr 12
Jr dr 13
Jr dr 14
Jr dr 15
Jr dr 16
Jr dr 17
Jr dr 18
Jr dr 19
Jr dr 2
Jr dr 20
Jr dr 21
Jr dr 22
Jr dr 23
Jr dr 24
Jr dr 25
Jr dr 26
Jr dr 27
Jr dr 28
Jr dr 29
Jr dr 3
Jr dr 30
Jr dr 4
Jr dr 5
Jr dr 6
Jr dr 7
Jr dr 8
Jr dr 9
Jr RN 1
Jr RN 10
Jr RN 11
Jr RN 12
Jr RN 2
Jr RN 3
Jr RN 4
Jr RN 5
Jr RN 6
Jr RN 7
Jr RN 8
Jr RN 9
Sr dr 1
Sr dr 2
Sr dr 3
Sr dr 4
Sr dr 5
Sr dr 6
Sr dr 7
Sr nurse 1
Sr nurse 10
Sr nurse 11
Sr nurse 12
Sr nurse 13
Sr nurse 14
Sr nurse 15
Sr nurse 16
Sr nurse 17
Sr nurse 18
Sr nurse 19
Sr nurse 2
Sr nurse 20
Sr nurse 21
Sr nurse 22
Sr nurse 3
Sr nurse 4
Sr nurse 5
Sr nurse 6
Sr nurse 7
Sr nurse 8
Sr nurse 9Sr RN 1
Sr RN 10
Sr RN 11
Sr RN 12
Sr RN 13 Sr RN 14
Sr RN 2
Sr RN 3
Sr RN 4
Sr RN 5
Sr RN 6
Sr RN 7
Sr RN 8
Sr RN 9
Ward asst 1
Ward asst 2
[Creswick, Westbrook and Braithwaite, 2009]
• Problem solving networks in an ED
Nurses DoctorsAllied healthAdmin and support
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But …
[Creswick, Westbrook and Braithwaite, 2009]
• Medication advice-seeking networks in an ED
Nurses DoctorsAllied healthAdmin and support
Admin 1
Admin 10
Admin 11
Admin 12
Admin 2
Admin 3
Admin 4
Admin 5
Admin 6
Admin 7
Admin 8
Admin 9
Allied health 1
Allied health 2
Allied health 3
Allied health 4
EN 1
EN 2
EN 3
EN 4
EN 5
EN 6
Jr dr 1
Jr dr 10
Jr dr 11Jr dr 12
Jr dr 13
Jr dr 14
Jr dr 15Jr dr 16
Jr dr 17
Jr dr 18
Jr dr 19
Jr dr 2
Jr dr 20
Jr dr 21Jr dr 22
Jr dr 23
Jr dr 24
Jr dr 25
Jr dr 26
Jr dr 27
Jr dr 28
Jr dr 29
Jr dr 3
Jr dr 30
Jr dr 4
Jr dr 5
Jr dr 6
Jr dr 7
Jr dr 8
Jr dr 9
Jr RN 1
Jr RN 10
Jr RN 11
Jr RN 12
Jr RN 2 Jr RN 3
Jr RN 4
Jr RN 5
Jr RN 6
Jr RN 7
Jr RN 8
Jr RN 9
Sr dr 1
Sr dr 2
Sr dr 3
Sr dr 4
Sr dr 5
Sr dr 6
Sr dr 7
Sr nurse 1
Sr nurse 10
Sr nurse 11
Sr nurse 12
Sr nurse 13
Sr nurse 14
Sr nurse 15
Sr nurse 16
Sr nurse 17
Sr nurse 18
Sr nurse 19
Sr nurse 2
Sr nurse 20
Sr nurse 21
Sr nurse 22
Sr nurse 3Sr nurse 4
Sr nurse 5
Sr nurse 6
Sr nurse 7
Sr nurse 8
Sr nurse 9
Sr RN 1
Sr RN 10
Sr RN 11
Sr RN 12
Sr RN 13
Sr RN 14
Sr RN 2
Sr RN 3
Sr RN 4
Sr RN 5
Sr RN 6Sr RN 7
Sr RN 8
Sr RN 9
Ward asst 1
Ward asst 2
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But …
[Creswick, Westbrook and Braithwaite, 2009]
• Socialising networks in an ED
Nurses DoctorsAllied healthAdmin and support
Admin 1
Admin 10
Admin 11
Admin 12
Admin 2
Admin 3
Admin 4
Admin 5
Admin 6
Admin 7
Admin 8
Admin 9
Allied health 1
Allied health 2 Allied health 3
Allied health 4
EN 1
EN 2
EN 3
EN 4
EN 5
EN 6
Jr dr 1
Jr dr 10
Jr dr 11
Jr dr 12
Jr dr 13
Jr dr 14
Jr dr 15
Jr dr 16
Jr dr 17
Jr dr 18
Jr dr 19
Jr dr 2
Jr dr 20
Jr dr 21
Jr dr 22
Jr dr 23
Jr dr 24
Jr dr 25
Jr dr 26
Jr dr 27
Jr dr 28
Jr dr 29
Jr dr 3
Jr dr 30
Jr dr 4
Jr dr 5
Jr dr 6
Jr dr 7
Jr dr 8
Jr dr 9Jr RN 1
Jr RN 10
Jr RN 11
Jr RN 12
Jr RN 2
Jr RN 3
Jr RN 4
Jr RN 5
Jr RN 6Jr RN 7
Jr RN 8Jr RN 9
Sr dr 1
Sr dr 2
Sr dr 3
Sr dr 4
Sr dr 5
Sr dr 6
Sr dr 7 Sr nurse 1
Sr nurse 10
Sr nurse 11
Sr nurse 12
Sr nurse 13Sr nurse 14
Sr nurse 15
Sr nurse 16
Sr nurse 17
Sr nurse 18
Sr nurse 19
Sr nurse 2
Sr nurse 20
Sr nurse 21
Sr nurse 22
Sr nurse 3
Sr nurse 4
Sr nurse 5
Sr nurse 6
Sr nurse 7
Sr nurse 8
Sr nurse 9
Sr RN 1Sr RN 10
Sr RN 11
Sr RN 12
Sr RN 13
Sr RN 14
Sr RN 2
Sr RN 3
Sr RN 4
Sr RN 5
Sr RN 6
Sr RN 7
Sr RN 8
Sr RN 9
Ward asst 1Ward asst 2
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These studies signal better
teamwork, trust andcollaboration
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Culture – game plan
• You want individuals or groups to have a
better culture?
• Or improve their capacity to recognise their
own cultural characteristics?
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• Or make your current culture work better?
• Consider this …
Culture – game plan
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• Use a change model [that fits your purpose?]• Take some baseline measures of your culture
[Anecdotal? Survey? Observational? External review?]
• Enroll colleagues
• Create a critical mass of support
Culture – game plan
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• Develop a vision and game plan• Vision: what will your new culture look like?• Who will help you shape it?• Who will hinder your efforts?• By when will you hope to achieve it?• What steps will you take?
Culture – game plan
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Leadership behaviours
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LeadershipWhat does this
equation mean?
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L(H) ≠ Σ (m1, m2 … mn)
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Resolving the equation
• L(H) ≠ Σ (m1, m2 … mn) means: the leadership in the health sector [L(H)] is not the same [≠] as the sum of [Σ] all the management activities [(m1, m2 … mn)] that take place
• But in the health systems we know there is too much short term management and not enough longer term leadership
[Braithwaite, Leadership in Health Services, 2008]
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So, leadership is more
than the sum of its management parts
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64
In surgery: qualities of a good leader• Empathy• Consistency• Honesty• Direction• Communication• Flexibility• Conviction
[Source: https://www.leadership-toolbox.com/characteristic-of-leadership.html]
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Think about how you
influence the culture as a leader
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Finally … resilient health care
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Safety-I and Safety-II
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Safety-I and Safety-II
The amazing thing about health care
isn’t that it produces adverse events in
10% of all cases, but that it produces safe
care in 90% of cases
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Safety-I – where the number of adverse outcomes is as low as
possibleTrying to make sure things
don’t go wrong
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Safety-II – where the number of acceptable outcomes is as
high as possibleTrying to make sure things go
right
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Few people have ever looked at why things go right so often
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So:
Can we shift the emphasis to a more positive approach?
To make sure things will go right more often?
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Policy-makers, executives, managers, legislators,
governments, boards of directors, software designers,
safety regulation agencies, teachers, researchers …
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Policy-makers, executives, managers, legislators,
governments, boards of directors, software designers,
safety regulation agencies, teachers, researchers …
Are you on this list?
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The blunt end tries to …
shape, influence, nudge behaviour
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What they do seems perfectly logical, obvious
and feasible
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In health care, those doing WAI have designed,
mandated or encouraged a bewildering range of tools, techniques and methods, to
reduce harm to patients.
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E.g., root cause analysis, hand hygiene campaigns, failure modes effects analysis ...
And there are lots of others …
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Meanwhile work is getting done, often despite all
the policies, rules and mandates
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WAD—workarounds
Glove placed over a smoke alarm, as it
kept going off due to nebulisers in
patients’ rooms
Plastic bags placed over shoes to workaround the
problem a of gumboot (welly) shortage
A leg strap holding an IV to a pole, as
the holding clasp had broken
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Doctors in Emergency Departments in a study:
• Were interrupted 6.6 times per hour• Were interrupted in 11% of all tasks• Multitasked for 12.8% of the time
[Westbrook et al. 2010. Qual Saf Health Care]
WAD—fragmentation
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• Spent on average 1:26 minutes on any one task
• When interrupted, spent more time on tasks
• And … failed to return to approximately 18.5% of interrupted tasks
Doctors in EDs in a study:
[Westbrook et al, 2010, Qual Saf Health Care]
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Encourage resilience
1. Look at what goes right, not just what goes wrong2. When something goes wrong begin by
understanding how it (otherwise) usually goes right3. Be proactive about safety - try to anticipate
developments and events4. Be thorough, as well as efficient (the ETTO
principle)
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Discussion: comments, questions, observations?
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Australian Institute of Health Innovation
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Complexity Science/ GenomicsDr Kate ChurrucaDr Louise EllisDr Janet LongDr Stephanie BestDr Hanna Augustsson
Human Factors and ResilienceDr Robyn Clay-WilliamsDr Elizabeth AustinDr Brette BlakelyTeresa WinataDr Amanda Selwood
Health OutcomesA/Prof Rebecca MitchellDr Reidar LystadDr Virginia Mumford
AcknowledgementsNHMRC Partnership Centre for Health System SustainabilityJoanna HoltProf Yvonne ZurynskiDr Trent YeendDr K-lynn Smith
Implementation ScienceProf Frances RapportDr Patti ShihMia BierbaumDr Emilie AutonDr Mona FarisDr Andrea SmithDr Jim Smith
CareTrack Aged/ Patient SafetyA/Prof Peter HibbertDr Louise WilesMs Charlie MolloyPei Ting
NHMRC CRE Implementation Science in OncologyDr Gaston ArnoldaDr Yvonne TranDr Bróna Nic Giolla EaspaigDr Klay Lamprell
Admin and project supportSue Christian-HayesJackie MullinsChrissy ClayCaroline Proctor
Research supportMeagan WarwickDr Wendy JamesGina LamprellJess Herkes
Research CandidatesChiara PomareElise McPhersonHossai GulKristiana LudlowZeyad MahmoudSheila PhamKatie AdriaansLuke TestaRenuka Chittajallu
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2019 – Delivering Resilient Health
Care
2018 ‐ Healthcare Systems: Future Predictions for Global
Care
2017 ‐ Health Systems Improvement Across the Globe: Success Stories from 60 Countries
2017 ‐ Reconciling Work‐as‐imagined and work‐as‐done
2016 ‐ The Sociology of Healthcare Safety and
Quality
2015 ‐ Healthcare Reform, Quality and Safety: Perspectives, Participants, Partnerships and Prospects in 30
Countries
2015 ‐ The Resilience of Everyday Clinical Work 2013 ‐ Resilient Health Care 2010 ‐ Culture and Climate in
Health Care Organizations
Recently published books
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Forthcoming books
Gaps: the Surprising Truth Hiding in the In‐between Surviving the Anthropocene
Working Across Boundaries RHC Vol 5
Counterintuitivity: How your brain defies logic
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Email: [email protected]
AIHI website: http://aihi.mq.edu.au
Web: http://www.jeffreybraithwaite.com/
Wikipedia: http://en.wikipedia.org/wiki/Jeffrey_Braithwaite
Contact DetailsJEFFREY BRAITHWAITE PhD
NameCompanyTitle
PhoneEmail
Founding DirectorAustralian Institute of Health InnovationDirectorCentre for Healthcare Resilience and Implementation ScienceProfessorFaculty of Medicine and Health Sciences, Macquarie UniversitySydney, AustraliaPresident ElectInternational Society for Quality in Health Care (ISQua)