Transcript Safety Behavior Education Design & Implementation

First, Do No Harm:
Building a Culture of Patient
Safety at Novant Health
Physician Education
Part 1: Safety Concepts and Theory
©2009 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED
Prepared for Novant Health for their non-exclusive, internal use only.
First
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Goal and Objectives
Goal:
Understand the Novant Safety Behaviors and commit
to making them personal work habits
Objectives:
1. Describe what we mean by building and sustaining our
patient safety culture.
2. Explain why people make errors in complex systems and
how we can reduce errors from propagating through
these systems.
3. Present an overview of the Safety Behaviors here at
Novant in preparation for the second part of our CME
program
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Why are we here?
Megan
Damon
Nicholas
Molly
Lizzy
Kiko
Mary
Carson
Mary Beth Richard
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Safety Culture – “A 747 a Day”
• 2000 IOM report, To Err is Human: Building a Safer Health System
– 44,000 to 98,000 Americans dying annually from medical errors
• 98,000 = 270 people / day (747 capacity)
• 44,000 = 120 people / day (737 capacity)
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Published Cases
• HPI - a Reliability company
• Comprehensive safety culture engagement
• Over 140 hospitals nationwide
• Savannah, GA
• 500 bed academic institution
• 89% reduction in 2 years
• 50% reduction in 18 months
• AHA Quest for Quality Award 2004
• TJC Eisenberg Quality Award 2005
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SEC
A deviation from standard of care or
practice expectations that…
SM
Safety
Event
Classification
Serious Safety Event
• Reaches the patient
• Results in moderate to severe harm or death
Cause Analysis: Root Cause Analysis (RCA) Required
Precursor Safety Event
• Reaches the patient
• Results in minimal to no detectable harm
Analysis: RCA or Apparent Cause Analysis (ACA)
Serious
Safety
Events
Precursor
Safety
Events
Near Miss Safety Event
Does not reach the patient – error is
caught by a last strong detection
barrier designed to prevent event
Near Miss Safety Event
Cause Analysis: No formal
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
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SSER Calculation
SSER
SM
Serious Safety
Event
Rate
Rolling 12-month rate of Serious Safety Events per
10,000 adjusted patient days
SSER =
# SSE during past 12 months
X 10,000
# APD for past 12 months
Why a 12-month rolling average?
• Smoothes the curve for infrequent events
• Encourages sustainability in reliable safety performance (it
takes 12 months for an event to “drop out” of the average)
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SSER
1000 Bed Hospital
SM
Serious Safety
Event
Rate
SSER JAN 2005: 1.21
SSER JAN 2007: 0.34 71.9% reduction
1.40
10
9
1.20
7
6
0.80
5
0.60
4
3
0.40
2
0.20
1
8
Mar-07
Jan-07
Nov-06
Sep-06
Jul-06
May-06
Mar-06
Jan-06
Nov-05
Sep-05
Jul-05
May-05
0
Mar-05
0.00
Jan-05
Event Rate
1.00
Harmed
of Patients
NumberNumber
of Events
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Novant Health (9 hospitals)
Events
Number of Patients Harmed
Jun
May
Apr
Mar
Feb
Jan 09
0
Dec
0.0
Nov
2
Oct
0.2
Sep
4
Aug
0.4
Jul
6
Jun
0.6
May
8
Apr
0.8
Mar
10
Feb
1.0
Jan 08
12
Dec
1.2
Nov
14
Oct
1.4
Sep
Event Rate (SSER)
Rolling 12-month rate of Serious Safety Events per 10,000 adjusted patient days
SSER
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Journey to Improving Reliability
10-6
Optimized
Outcomes
Frequency of Failure
Behavior Accountability
10-5
10-4
Behavior Expectations
Knowledge & Skills – Error Prevention
Reinforce & Build Accountability
Integrated With
10-3
Process Design
Evidence-Based Best Practices
Technology Enablers
Process optimization/simplification
Tactical interventions
10-2
10-1
Time
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Why Do Events Happen?
Multiple Barriers - technology,
processes, and people designed to stop active errors
(our “defense in depth”)
Latent Weaknesses
in barriers
EVENT of
HARM
Active Errors
by individuals
result in initiating
action(s)
Two Strategies to Eliminate Safety Events:
#1 Prevent the
#2 Find and fix
human errors
system and process problems
Adapted from Dr. James Reason, Managing the Risks of Organizational Accidents, 1997
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Influencing Behaviors at the Sharp End
Design of
Design of
Policy &
Protocol
Culture
Design of
Structure
Design of
Work
Processes Design of
Technology &
Environment
Behaviors
of Individuals & Groups
“You have to manage a
system. The system doesn't
manage itself.”
"A bad system will
DEFEAT a good person
every time.“
W. Edwards Deming
W. Edwards Deming
Outcomes
Adapted from R. Cook and D. Woods,
Operating at the Sharp End: The Complexity of Human Error (1994)
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As Humans, We Work in 3 Modes
Knowledge-Based Performance
“Figuring It Out Mode”
Rule-Based Performance
“If-Then Response Mode”
Skill-Based Performance
“Auto-Pilot Mode”
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Skill-Based Performance
What You’re Doing At The Time:
Very routine, frequent tasks that you can do without
even thinking about it – like you’re on auto-pilot
Errors We Experience
Error Prevention Strategy
Slip – Errors of commission –
the act is performed wrong
Lapse – Errors of omission –
you fail to do what we meant
to do
Stop and think before acting
Fumble – Motor skill errors
3 in 1,000 acts performed in error
(pretty reliable!)
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Rule-Based Performance
What You’re Doing At The Time:
Responding to a situation by recalling and using a rule
that you learned either through education or experience
Errors You Experience
Error Prevention Strategy
Used the wrong rule – You were
taught or learned the wrong response
for the situation
Educate about the right rule
Misapplied a rule – You knew the
right response but picked another
response instead
Think a second time
Non-compliance – Chose not to
follow the rule (usually, thinking that
not following the rule was the better
option at the time)
Reduce burden, increase risk
awareness, improve coaching
1 in 100 choices made in error
(not too bad!)
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Knowledge Based Performance
What You’re Doing At The Time:
Problem solving in a new, unfamiliar situation.
You come up with the answer by:
• Using what we do know
• Taking a guess
• Figuring it out by trial-and-error
Errors You Experience
You came up with the wrong
answer
(a mistake)
Error Prevention Strategy
STOP and find an expert who
knows the right answer
30-60 of 100 decisions made in error
(yikes!)
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Power Distance
Geert Hofstede’s Power Distance
• Extent to which the less powerful expect and
accept that power is distributed unequally
• Measure of interpersonal power or influence
superior-to-subordinate as perceived by the
subordinate
• Leads to strong Authority Gradients, which is the
perception of authority as perceived by the
subordinate
USA
• Moderate to low PD (38th of 50 countries)
• Surgeons & anesthesiologists view low
• Nurses view as significantly higher
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Korean Airlines Flight 801
Fatigue
Minor
Bad
Technical
Weather Failure
High
Power
Distance
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Authority Gradient
 Perception of authority as
perceived by the subordinate
 Culturally imbedded & handed
down
 Requires active measures to
overcome in order to
communicate clearly & share vital
information
Dr.
MD
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Crew Resource Management
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Assertiveness
• The willingness to state and
maintain a position until convinced
otherwise by facts
– Requires initiative and courage to act
Behavior Continuum
PASSIVE
ASSERTIVE
OVER-AGGRESSIVE
‘Too nice’
Actively involved
Dominating
Procrastinates
Ready for action
Intimidating
Avoids conflict
Useful contributor
Abusive
‘Along for the ride’
Speaks up
Hostile
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Five Principles of High Reliability
Organizations (HROs)
Three Principles of Anticipation
Preoccupation with Failure
Regarding small, inconsequential errors as a symptom that
something’s wrong
Sensitivity to Operations
Paying attention to what’s happening on the front-line
Reluctance to Simplify
Encouraging diversity in experience, perspective, and opinion
Two Principles of Containment
Commitment to Resilience
Developing capabilities to detect, contain, and bounce-back from
events that do occur
Deference to Expertise
Pushing decision making down and around to the person with the most
related knowledge and expertise
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Novant Safety Behaviors &
Error Prevention Tools
1. Practice with a Questioning Attitude
A. Stop, Reflect & Resolve in the face of uncertainty
2. Communicate Clearly
A. Use SBAR-Q to share information
B. Communicate using three-way repeat backs and read backs
C. Use phonetic and numeric clarifications
3. Know & Comply with Red Rules
A. Practice 100% compliance with Red Rules
B. Expect Red Rule compliance from all team members
C. If compliance with a Red Rule is not possible, STOP action
until any uncertainty can be resolved
4. Self-check: Focus on Task
A. Use the STAR technique
5. Support Each Other
A. Cross-check and Assist
B. Use 5:1 Feedback to encourage safe behavior
C. Speak up using ARCC – “I have a concern”
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Novant Contact Information
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Sue DeCamp-Freeze
Senior Director Clinical Improvement
(704) 210-5767
[email protected]
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Catherine Fenyves
Patient Safety Manager
(704) 384-9329
Email: [email protected]
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