4/4/2018

1

Journey to Excellence: Leadership for Quality and Safety

Angela Green, PhD, RN, CPHQ, FAHA, FAAN

2018 NICU Leadership Forum

• Describe high reliability principles as a

framework for excellence and leadership

methods that promote a culture of safety and

high reliability.

• Discuss strategies to engage multi-disciplinary

teams in quality and safety work.

• Describe strategies for planning, implementing,

and sustaining improvements.

Objectives

4/4/2018

2

• I have nothing to disclose.

Disclosures

5

• What is your biggest safety or quality

challenge?

– Reflect to identify yours.

– Find a partner – share your challenges.

– Form a foursome – share your challenges.

– Large group sharing

• What challenges do we have in common?

• Any unique challenges?

• Big a-has?

Safety Story: 1 - 2 - 4 all

6

Johns Hopkins All Children’s

Hospital

4/4/2018

3

• Of the 259 beds:– 97 NICU

– 28 PICU

– 22 CVICU

– 56 General Medical

– 28 Post op surgical

– 28 Hematology/Oncology, Bone

Marrow Transplant

• Over 400 Pediatric Physicians

• 29 Pediatric Specialties

8

• 1999 IOM Report – To Err is Human: Building a Safer

Health System

– Houston, we have a problem….

• ~50,000-100,000 annual US deaths due to medical errors

• Medical error 3rd leading cause of death in the US

– 440,000 annual US deaths Makary & Daniel, 2016)

The Long Sad Story……

9

• Evidence-based bundles

• Registries

• National collaboratives

– Children’s Hospitals Solutions for Patient

Safety

• Culture

• Team member-wellbeing

• Safety II

Solution Evolution

4/4/2018

4

10

About Culture….

Culture eats strategy for breakfastPeter Drucker

11

Culture

Behavior

Culture

12

• Originated in high risk industries

• “Operate under vary trying conditions all

the time and yet manage to have fewer

than their share of accidents”

Weick & Sutcliffe, 2001

High Reliability – the Back Story

4/4/2018

5

13

• Preoccupation with failure

• Reluctance to simplify

• Sensitivity to operations

• Deference to expertise

• Commitment to resilience

Weick & Sutcliffe, 2001

Chassin & Loeb, 2013

High Reliability Principles

14

• Safety as a core value

• Blame-free environment

• Collaboration

– 200% accountability

– Non-hierarchical

• Communication

– Speaking up for safety

– Questioning and welcoming questioning

Culture of Safety – Key feature of

HRO

15

• Health risks of stress and burnout

• Cognitive impact of stress

• Trickle down effect

• Practices

– Healthy diet, physical exercise, adequate

sleep

– Self-awareness

– Recharge strategies

– Network of support

– Mindfulness

Self-Care

4/4/2018

6

16

• Managing demands on time, resources

and energy

• Managing physical and emotional health

• Improving joy in work

Perlo, Balik, Swensen, et al., 2017

Team Well-Being

Burnout

Low engagement

High turnover

Higher risk of accidents

Low safety

Low quality

17

Perlo et al., 2017

18

Brainstorm

Strategies for improving joy and meaning in

work for ourselves and our teams

Think Big & Bold

4/4/2018

7

• Safety I

– Focus on ensuring as

few things as possible

go wrong

– People are a hazard

as a source of

variability

– Reactive

• Safety II

– Focus on ensuring as

many things as

possible go right

– System ability to

succeed under varying

conditions

– People are necessary

for system flexibility

and resilience

– Proactive

19

Safety II

Hollnagel, Wears & Brathwaite, 2015

20

• Builds resilience

• Nurtures positivity

• Supports system adaptability

Safety II

Nemeth, Wears, Woods, et al. 2008, Hollnagel, 2018

21

• Teamwork and Communication

– Speaking up for safety

• Proactive and reactive

• No blame and shame

• Systems approach

• Continuous learning

• Leading by example

Essential Ingredients: Culture of

Safety and High Reliability

4/4/2018

8

22

• Safety stories

• Organizational safety huddle

• Unit based huddles

• Feedback rich environment

• Rounding

• Top 10 List

• Transparency

Studer Group, 2010

Healthcare Performance Improvement, 2011

Leadership Methods for High

Reliability

23

• Begin each meeting with a safety story

– Examples

• Event of harm in your organization

• Near miss in your organization

• Strategies for speaking up for safety

• Importance of reporting

• Safety success story from your organization

• Concerns/patterns, etc.

Healthcare Performance Improvement, 2011

Safety Stories

24

• Daily, same time, same place

• Short, “stand up” meeting

• Data based

• Multi-disciplinary

• Focus – standard script

– Current status

– Retrospective review of safety or quality issues

– Look ahead – concerns in the next 24 hours

– Follow up on issues identified previously

Healthcare Performance Improvement, 2011

Organizational Safety Huddle

4/4/2018

9

25

• Daily or (even better) each shift

• Same principles, same script as org huddle

– Focus – unit level

Unit-based huddles

26

• Balance of positive feedback and

constructive/need to improve feedback

– 5:1 or 3:1 depending on source

– Seek opportunities to catch someone doing it right

• No sandwiching

• Situation, Behavior, Impact

– Timely

– Observations, facts

Feedback Rich Environment

Healthcare Performance Improvement, 2011;

Studer, 2010; Wetzel, 2000

• Weekly, 30-60 minutes

• Supports sensitivity to

operations

• Reinforces your

commitment to your team

and to safety

• Opportunity to

– Share information

– Promote preoccupation

with failure

– Provide reinforcement

• Focus -

– What’s working well

– Who should I recognize?

– Safety concerns or

systems/processes that

need improvement

– Do you have what you

need to do your job?

– Anything I can help you

with right now?

27

Rounding on Staff

Healthcare Performance Improvement, 2011;

Studer, 2010

4/4/2018

10

• Identify and prioritize

problems/focus areas

• Name an owner with

a due date

• Always 10

• Sample –

– Error Prevention Training

Implementation Plan

– Roll wave 2 CUSP teams

– Transition complaints to Service

Excellence

– Implement CAUTI K cards

– Plan for Overexertion work group

bundle measurement

– Risky Unit Analysis next steps

– Routine productive integrated

safety meeting

– Structure and process to support

Outpatient Care Centers

– PSQ/IP team member attending

each M&M

– Complete Armstrong Institute

Patient Safety Certificate

28

Top 10 List

Healthcare Performance Improvement, 2011

29

• Data, problems, your own mistakes

• Role models behavior for team at all levels

• Mitigates blame and shame

• Can’t fix it if we don’t know it’s broken

Transparency

30

• Reporting events and near miss events

• Speaking up for safety

– Stop the line

• Bedside report

• Hourly checks/rounding

Frontline Strategies

4/4/2018

11

31

Engaging Multidisciplinary teams

32

• Be you – authenticity matters

• Share your vision

– Engage hearts and minds

• Character, competence, caring

• Help others shine

• Recognize others, express gratitude

Are They Following You?

33

• Relationship

• Communication

• Influence

Foundation: Getting to Yes

Oh yes, I’d lOve tO wOrk On that!!!

4/4/2018

12

34

• Listen

• Consider other’s perspectives and

acknowledge their truth

• Question, welcome being questioned

• Clear, concise

– Word : unit of meaning ratio

• Many times, many ways

Communication Concepts

35

• Rationalizing

• Asserting

• Negotiating

• Inspiring

• Bridging

Influence Styles

Discovery Learning Inc., 2011

36

• Engage the heart

– Tell the stories, give the examples

– Make it personal, real and meaningful

• Engage the head

– Data!

Start with Why

4/4/2018

13

37

• Inclusive, non-hierarchical

• Empowerment

• Recognition and gratitude

– Thank you notes

• Food helps

Other Strategies for Success

38

• Councils/committees

• Dept/staff meetings

• Rounding

• Huddles

Leverage Structure

39

• Developmental opportunity

• Succession planning

• Clinical ladder, promotion & tenure, etc.

Create Wins

4/4/2018

14

40

• Huddles

• Rounding

• Communication boards

• Newsletters

• Meetings

• E-mail

• Etc., etc., etc.

Communication Strategies

41

• Time

• Access to data

• Engage experts/key stakeholders

A Word About Resources

42

• Charter

• Leader and co-leader

• Sponsor

• Goal oriented, data-based

• Meeting structure

• Accountability structure

– Deliverables with timelines

– Plan for manage barriers

Structure and Process: Doing the

Work

4/4/2018

15

43

• Leverage

– Desire for excellent care

• If that doesn’t work

– Leverage relationships

– Create win-win situations – maintenance of

certification and/or promotion & tenure

– I’ll help you, if you’ll help me….

Engaging Physicians

44

• Inclusive, non-hierarchical approach

• Empowerment & deference to expertise

• Creating wins

• Structure and process for doing the work

• Share progress

• Celebrate accomplishments and

milestones

• Acknowledge leaders and key contributors

Essential Ingredients: Engaging the

Team

45

Improvement Strategies

4/4/2018

16

46

• Focus on event reporting as a learning tool

• Encourage (and recognize) reporting of

events and near miss events

• Close the loop on events

– Including with staff who reported/submitted

• Tell the stories

– Impact of reporting

More Culture: Reporting Culture

47

• Individual, team, department, organization,

and system issues

• We fail our patients and teams when the

only response is – discussed with

individuals involved.

– Other options?

Event Follow Up

48

• You’ve noticed an increased frequency of

event reports identifying that central line

tubing was not labelled according to policy.

– What questions do you have?

– How might you get more information?

– What are some possible reasons for this

occurring? (think individual, department,

organization)

– How can you close the loop?

Case Study

4/4/2018

17

49

IHI Model for Improvement

IHI, 2018

50

• Healthy preoccupation with failure

• Routine sources of data

– Dashboards

– Event reporting system

– Collaboratives and registries

• Sensitivity to operations

– Concerns expressed by staff

– Improvement teams

• Other sources?

Knowing What’s Broken

51

• Associated risk

• Frequency

• System defects make repeat events likely

• Provocative and plausible challenges

• External motivators

Prioritization

4/4/2018

18

52

• Form the team

• Set aims/goals

• Establish measures

• Select change

• Test change Implement change

• Spread changeIHI, 2018

Houston….we have a problem

53

• We’ve talked about that….

• Ownership and empowerment matters!

Form the team

54

• Specific

• Measurable

• Actionable

• Relevant

• Timebound

Set SMART Goals

Improve CLABSI bundle reliability

Improve CLABSI bundle reliability from a baseline of 70% to greater than or equal to 90% by December 2019.

4/4/2018

19

55

• Labelling all lines for central administration

is part of your CLABSI prevention bundle.

Your organization has a goal of achieving

greater than 90% compliance with all

bundle elements. Upon review, your

team’s compliance is 73%.

Case Study – Adding on

56

• Outcome

– Peripheral IV infiltration rate

• Process

– Adherence to the prevention bundle

• Balancing

– Changes that may occur in response to

intended change, but are not the focus of the

change

– Number of central line days

Establish Measures

57

• Weakest and most frequently employed–

education and policy change

• Reminders, visual or auditory cues

• Make it easy to do the right thing

– Package tubing label with infusion when

dispensed

• Make it hard or impossible to do the wrong

thing

– Digoxin ordering option – micrograms only

Select/Plan Changes

4/4/2018

20

58

Tool: Cause & Effect Diagram

IHI, 2017

59

• As you contemplate possible tests of

change to improve compliance with tube

labelling, you construct a cause and effect

diagram. Identify possible interventions by

category -

– People

– Environment

– Materials

– Methods

– Equipment

Case Study – Adding On

60I

Tool: Driver Diagram

IHI, 2017

4/4/2018

21

61

• Plan, Do, Study, Act

• Rapid Cycle Tests of Change

• Start small, scale up

• Engage key stakeholders (deference to

expertise)

• Listen and use feedback (sensitivity to

operations)

Test, Implement and Spread Change

- PDSA

62

In God we trust, all others must bring data.

W. Edwards Deming

You can’t manage what you can’t measure.

Peter Drucker

63

• Pareto charts

• Track progress over time

– Run charts

– Statistical control charts

Displaying Data

4/4/2018

22

64

Tool: Pareto Chart

IHI, 2017

65

Tools: Bar Graphs and Run Charts

66

Tool: Statistical Control Chart

4/4/2018

23

67

• Transparency

• Dashboards

• Money shot for improvement - track data

over time

– run charts and statistical control charts

– trend requires 5 or more consecutive points in

the same direction

– centerline shift requires 6 or more points

above or below the median

IHI, 2018

Displaying Data

68

• Long-term ownership

• Maintain preoccupation with failure

• Follow the data

– Respond trends, significant changes

• Display data publicly

• Report outcomes to committees/councils

Sustain

69

• Use huddles and rounds to reinforce,

discuss progress and celebrate success

• Recognize key contributors

Sustain

4/4/2018

24

70

• Strong reporting culture

• Goal oriented, data based

• Small tests of change, then scale up

• Accountability structure

Essential Ingredients – Improvement

Strategies

71

What will you

Stop?

Start?

Continue?

Back Home Story

Questions, Sharing…..

4/4/2018

25

73

• Chassin, MR., Loeb, JM. (2013). High-Reliability Health Care: Getting There from

Here. The Millbank Quarterly, 91(3), 459-490.

• Discovery Learning, Inc. (2011). Influence Style Indicator.

www.discoverylearning.com.

• Healthcare Performance Improvement. (2011). High Reliability Leadership Methods.

Adapted for SPS.

• Hollnagel, E. (2008). Safety-II in Practice. London and New York: Routledge.

• Hollnagel, E., Wears, RL, Brathwaite, J. (2015). From Safety-I to Safety-II: A White

Paper. The Resilient Health Care Net: University of Southern Denmark, University of

Florida, Macquarie University.

• Institute for Healthcare Improvement. (2018). Extranet Help: Tools for Data Analysis.

http://www.ihi.org/help/extranet/Pages/extHelpDataAnalysis.asp.

• Institute for Healthcare Improvement. (2018).

http://www.ihi.org/resources/Pages/HowtoImprove/default.asp.

• Institute for Healthcare Improvement. (2017). QI Essentials Toolkit.

References

74

• Kohn, LT., Corrigan, J., Donaldson, MS., (eds). 2000. To Err is Human: Building a

Safer Health System. Washington DC: National Academies Press.

• Makary, MA., Daniel., M. (2016). Medical Error – The Third Leading Cause of Death

in the US. British Medical Journal, 353, i2139.

• Nemeth, CP, Wears, RL, Woods, DD et al. (2008). Minding the Gaps: Creating

Resilience in Healthcare. In: Henriksen, K., Battles, JB., Keyes, MA et al. (Eds).

Advances in Patient Safety: New Directions and Alternative Approches (Vol3),

Performance and Tools. Rockville, MD: AHRQ.

• Perlo, J., Balik. B., Swensen, S., Kabcenell, A., Landsman, J., Feeley, D., (2017). IHI

Framework for Improving Joy in Work. IHI White Paper. Cambridge, MA: Institute for

Healthcare Improvement.

• The Studer Group (2010). The Nurse Leader Handbook: The Art and Science of

Leadership. Gulf Breeze, FL: Fire Starter Publishing.

• Weick, KE., Sutcliffe, KM. (2001). Managing the Unexpected: Assuring High

Performance in an Age of Complexity. San Francisco: Jossey-Bass.

• Wetzel, S., (2000). Feedback That Works: How to Build and Deliver Your Message.

Greensboro, NC: Center for Creative Leadership.

References