Transcript mmihorz
MASTERING JIGSAWS AND WHY
MECCANO MAY NOT APPLY
ANYMORE
Essential skills for the 21st century
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IMPROVING PATIENT SAFETY
What tools do we have to manage patients better?
Why do we need to re-learn the skills of jigsaws?
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REASON
2006
RCA
BAGIAN
INCIDENT FORMS
SENTINEL
EVENTS
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LUCIEN LEAPE
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SO WHAT DOES THIS MEAN?
Serious commitment to the structure to promote patient
safety.
Abundance of tools to measure
Reasonable data about source of problems
Recognise change has to occur
So why is there still a problem?
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CHALLENGES OF MODERN HEALTHCARE
Ageing population; age no barrier to care
Increased demand
Shorter stay
Increased expectations
Many types of available care; really expensive
Consumer interest
External review and analysis
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REALITIES OF MODERN CARE
Less time in hospital
Devolved and decentralised care; how do you ensure care?
Virtual care; Team-based care
But who is in charge?
Role evolution
Who is accountable?
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REALITIES OF MODERN CARE
Busier lifestyle; shorter shifts; safe hours
More handovers
Medical review?
Part of the past: is every patient seen; ? Grand word rounds
Clinical staff
Very limited and aging resource
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REALITIES OF MODERN CARE
Staff suspicious of management interest in safety
Colleges now talking re-certification
Is bureaucracy taking over?
Nurses now ‘pseudo-doctors’
Is this the real agenda?
Is clinical governance just window dressing?
Why do we seem to have less with which to do more?
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REALITIES OF MODERN CARE
Less continuity in hospitals
More incidents reported
More clinical time spent in admin
Senior clinicians advising children to go into banking
Can’t bat, can’t bowl………
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We have all the pieces
They are not all designed to fit together, we just have
what we have
We need some good perspective to find the pieces that fit
together
We need some jigsaw skills
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CLINICAL INDICATORS
ACHS
Incident reporting
Education
Clinical outcome
data
Preadmission clinic
Change and
improvement
S
A
F
E
T
Y
Insurer notification
Sentinel event
reporting
Staff
Informed consent
Policies and
procedures
Improved safety
Communication
RCA
VMOs
Patient assessment
Open disclosure
Clinical
Practice guidelines
QUALITY
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PUTTING THE JIGSAW TOGETHER
Clinical leadership
Personal accountability
Broader system view
Care about outcomes
Communication at macro and micro level
Communication between colleagues
Feedback and real performance review
Understanding about error
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HOW DO YOU KNOW THERE IS A PROBLEM?
BUSY
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VMO
VISIT
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RN
R1
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RN
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AGENCY
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PHARM
DAY
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DAY 2
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DAY3
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DAY 1
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DAY4
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A
A
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WILL THE SYSTEMS SAVE US?
Three Australian Whistle blowing Sagas : lessons for
internal and external regulation
Faunce and Bolsin MJA 2004; 181 (1): 44-47
•Each investigation arose after whistleblowers alerted
politicians directly, having failed to resolve the problems using
existing intra-institutional structures.
•None of the substantiated problems had been uncovered or
previously resolved by extensive accreditation or national
safety and quality processes; in each instance, the problems
were exacerbated by a poor institutional culture of selfregulation, error reporting or investigation.
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WILL THE SYSTEMS SAVE US?
Three Australian Whistle blowing Sagas : lessons for
internal and external regulation
Faunce and Bolsin MJA 2004; 181 (1): 44-47
• Even after substantiation of their allegations, the
whistleblowers, who included staff specialists, administrators
and nurses, received little respect and support from their
institutions or professions.
• Increasing legislative protections indicate the role of
whistleblowers must now be formally acknowledged and
incorporated as a “last resort” component in clinicalgovernance structures.’
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CURRENT SOLUTIONS TO
INCIDENT ‘REVIEW’
Create a policy
Re-assign duties
Create more forms
Give to NUM to fix
Education program
Counselling staff
Collect more incident data
Get more training
Unclear roles and responsibilities; no system of care
No communication; no accountability; no support; poor equipment;depressing at work
Angry; no trained staff ; unhappy at home; no reliable resources;
Too many patients; poor manager skills; too busy; undervalued;
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Change in management-again;cranky doctors;demanding patients; bad rosters
HUMAN FACTORS THEORY
People make mistakes
Complex and dangerous tasks undertaken by
people are inevitably fraught with risk
We are inherently bad at estimating risk
and making risk based decisions
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ERROR IN HEALTHCARE
We know error will occur.
We cannot engineer it out of the system.
What we can do however is design our systems to
account for the error.
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BUILDING BETTER SYSTEMS
Professionals do not fail because they want to, but
because:
Humans are forever imperfect
Systems which are not constructed to safely
absorb anticipatable human mistakes are doomed
to foster expensive and disastrous accidents
caused by those mistakes
You cannot order people not to make mistakes
John Nance 1999
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BUILDING EFFECTIVE TEAMS
Need to understand how people work
Requires mutual respect and understanding
Open communication based on mutual respect
Clear roles and responsibilities
Accountability to the team
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MANAGE FOR THE REALITY
Short shifts and short stays
Clarity of orders
Lack of clinical experience
Nurses can’t mind read any more
Need for feedback
Need for encouragement
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PUT IN USEFUL PROCESSES
Micro / level
Roles and responsibilities
Clear expectations from clinical staff
Plan for busy
Plan for short staffing
Admin support for UM
Standards for daily processes – seen every day/ write in the
notes?
Who is in charge? All day every day?
Manage for the reality of short shifts
Manage for the reality of the Y generation
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PUT IN USEFUL PROCESSES
Macro level
Engage with medical staff especially VMOs
Listen to medical staff; take the flak but hear the value
Resource clinical governance initiatives
Take time to look at data, not just collect it
See the issues not just the individual
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BETTER SOLUTIONS TO INCIDENT REVIEW
More clear system of care
Trained staff
Equipment plan
Clear roles and responsibilities
Better communication
Plan for being busy
Better rosters
Commitment to reliable resources
Escalation process
Manger skills
training
Doctors more involved
Unhappy at home
Too many patients; still busy; Change in management-again;
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JIGSAWS
Take time to find the pieces in your area
Look at them then group them
Put them into useful patterns
Look from a distance to see if they look good and work
well
Proceed
Check
Keep looking for the one piece to fix the key component
Keep checking and looking for afar
Then enjoy!
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Safety is not yet within our grasp
But it is within our reach
Prof. Lucien Leape
Melbourne 2006
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