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?
2
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
>X
XX
VMO
VISIT
min
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RN
R1
X XX
X X
RN
X
X
X
X
R
1
X
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R R R
2 3 2
R
2
P P
CODE
IN
WARD
AGENCY
X
X
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PHARM
DAY
X X
X
R
4
R
4
R
5
X
X
X
X
X
X
DAY 2
A
A
X
X
X
X
X
X
X
R
1
R
1
X
X
X
R
6
R
7
R
6
R
6
R
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R
1
0
R
1
0
P
R
1
2
R
1
1
R
3
A
R
3
P
*
A
X
X
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DAY3
A
A
X
3
*
A
A
X
X
X
P
*
DAY 1
X
X
X
DAY4
A
A
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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