reliability nhsiq 2014

© NHS Improving Quality 2014

Reliability

Patient Safety Team

© NHS Improving Quality 2014 Insert date/time

• Understand / appreciate the concept of reliability in healthcare

• Adopt a simple approach to: – Identify & understand reliability defects– Design & implement interventions

• Focus is on the methodology, not on specific solutions

Objectives


What are we trying to achieve?

A health care system that ensures every patient consistently receives evidence-based, effective care every time he or she needs it

Decreasing the opportunity for variation


How hard can that be?

McGlynn et al NEJM 2003; 348:2635-2645– 6712 Medical records examined– Only 55% received ‘scientifically indicated care’

All studies show << 80% reliability in delivery of intended care


1

10

100

1,000

10,000

100,000

1 10 100 1,000 10,000 100,000 1million 10million

Number of encounters for each fatality

Tota

l liv

es lo

st p

er y

ear

REGULATEDHAZARDOUS(>1/1000)

ULTRA-SAFE(<1/100K)

Health Care

Mountain Climbing

Bungee Jumping

Driving

Chemical Manufacturing

Chartered Flights

Scheduled Airlines

European Railroads

Nuclear Power


Can we deliver a reliable process?

Catastrophic processes

Blood transfusionWrong side surgeryHygiene in neutropenic patientsPost-operative counts

Highly reliable processes


Non-catastrophic processesWhat do we mean? Failure of the process does not lead to death or severe injury within

hours of the failure

Very poor reliability < 80%Loss of connection with outcomeThe resilience of biologyThe tyranny of small numbersViolation and migration

There’s no feedback


Example

• Every patient on newly started on warfarin therapy should have an INR taken every 24 hours. This result should inform the dose prescribed.

• Who has a deliberate and reliable process to achieve this and is confident it happens?

• Who doesn’t think it’s really that important?

• The policy in hospital is that staff should wash their hands on entry to the ward, between patients and on exiting the ward.

• Who thinks this happens reliably in their hospital? • Who doesn’t think it’s really that important?

Non Catastrophic Process


The consequence of our actions


Improvement Concepts Associated with Poor Reliability

• Primarily can be described as intent, vigilance, and hard work– Common equipment, standard order sheets, multiple choice

protocols, and written policies/procedures

– Personal check lists

– Feedback of information on compliance

– Suggestions of working harder next time

– Awareness and training

• Does this appear familiar?


Improvement Concepts Associated with High Reliability

• Focus on human factors

• Standardize process based on best available evidence

• Minimize variation

• Make desired action the easiest / default action

• Aids to decision making

• Reminders and scheduling built in

• Design in failure prevention, identification and mitigation


What do we mean by reliability?

• Chaos; failure in >20% of opportunities

• 80-90% reliability - >1 in 10 times the process fails. • 5 front line users can not easily articulate the process• • 95% reliability - 5 in 100 times the process fails. • 5 front line users can easily articulate the process

• 99% reliability - 1 in 100 times the process fails well designed system with low variation and cooperative relationships


Level of reliability1. Get to an 80% reliable process (today’s work)

2. Analyse Failure and re-design

3. Follow up reliability in May • Deal with the remaining 20% • Aim is to resolve 80% of the remaining 20% • Analyse failure and re-design

• 80% + 80% of 20 = 96% reliability


People make mistakes...


Making the process more reliable


Process Map & Standardisation

Identify and Prioritise Risk

Barriers and Mitigation

Test and Refine

Deliberate reliable design


System solutions

Make it easier to do the right thing

Make it harder to do the wrong thing

Spot & stop errors

reliability nhsiq 2014

Healthcare