Transcript Document

When processes go wrong;
designing for 95% reliability
Kevin Stewart
Medical Director
QIPP Safe Care workstream
About me
• Since September 2010
– Medical Director, QIPP Safe Care Program
• 2009-2010
– Quality Improvement Fellow, Institute for Healthcare
Improvement, Cambridge, MA, USA*
• 2005-2009
– Medical Director, Winchester & Eastleigh NHS Trust
*funded by the Health Foundation
Overview
• Feedback from
incident review
• Revision of concepts
• Human Factors
• Thinking about level 3
• Homework
Principles
• There are no “quick fixes”
– This stuff is difficult
• The blame culture is deeply ingrained in;
– Our professions
– Healthcare
– Wider society
• There is a difficult balance between
accountability and a “just” culture
Homework time!
Incident investigations, RCAs
• What were the common
recommendations?
• Are these level 1, 2 or 3?
• How confident are we that these will
prevent recurrence?
My list
• “Remind the nurses to always check the
call bell”
• “Emphasise the importance of good
handover to on-call teams”
• “re-audit use of hand gel”
• “Ensure falls training is available to all
staff”
• ..etc…
Reliability definitions
Reliability
levels
Chaotic
Level 1
Number of
failures
More than 2 in
10
1 failure in 10
Percentage
success
Les than 80%
Level 2
1 failure in 100 90-99%
Level 3
1 failure in
1000
90%
99-99.9%
How reliable is healthcare?
• Most healthcare
processes are, at
best, implemented in
80-90% of indicated
instances
• …probably reflecting
reliance on Level 1
measures
Are there any obvious
exceptions?
What about…
• Blood transfusion?
• Paediatric anaesthesia?
• Chemotherapy
administration?
• Cardiac arrest calls?
Designing for reliability
• Level 1
– Intent, vigilance, hard work, audit, discipline
• Level 2
– Design of processes informed by reliability
science and knowledge of human factors
• Level 3
– System-wide focus on becoming a highly
reliable organisation
Designing for reliability
• Level 1
– Is mostly about individual action
• Level 2
– Is about working on the process
• Level 3
– Is about working on the whole system
Human Factors
• “The study of the way humans relate and
react to the world around them with the
aim of improving performance”
– Combines psychology, physiology,
behavioural science, engineering etc
• Derived from design work to improves
safety of WW2 aircraft
Human Factors
• Used widely in “safety-critical” industries
– Airlines, F1, air traffic control, nuclear,
defence etc
• Also used widely in advertising &
marketing
• In healthcare has tended to be used in
“high tech” areas (ITU etc)
PS
• We use HF all the time in real life, e.g
– Child care
– Caring for patients with dementia
– Our own daily routines
– etc
Basic HF principles
• Human performance follows predictable
patterns
• Individual performance capacity is limited
• Individual performance can be severely
impaired by external factors
• Systems should be designed around
knowledge of these principles
Have you ever….?
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Put the wrong fuel in the car?
Sent an e mail to the wrong person by mistake?
Deleted the wrong document?
Locked yourself/your keys in/out?
Forgotten to lock the door?
Given a patient the wrong medicine?
• And if so, when??
Factors affecting human attention
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Fatigue
Stress, anxiety, fear
Competing demands
Environmental conditions
– Clutter, motion, poor lighting, noise
• Too many handoffs
• Shift work
Designing to overcome Human Factors
• Avoid reliance on memory, vigilance and
hard work
• Simplify and standardise
• Use cues
• Make the desired action the default
• Take advantage of habits and patterns
• Use constraining and forcing functions
• Build in redundancy
Using what we know about memory
Visual and auditory cues
Standardise
Constraining and forcing functions
Redundancy
Example
• Patients diagnoses with sepsis in A&E had
delays up to 7 hours before the first dose
antibiotics.
• ..resulting in;
– Increased ITU admission
– Increased mortality
– Prolonged length of stay
Example
• Audit showed;
– Delays in getting blood cultures
– Delays in cannulation
– Delays in getting the right antibiotics
prescribed
– Delays in administration of antibiotics
– Confusion between A&E and MAU staff
about antibiotics
What should we do?
The Deterioration Recognition (DR)
Box
With thanks to Dr Matt Inada-Kim
Winchester
With thanks to Dr Matt Inada-Kim
Winchester
Human failure taxonomy
Human failures
Intended actions
Violation - Intended consequences
When the person decided to act without
complying with a known rule or procedure
Unintended actions
Errors - Unintended consequences
Mistakes
When the
person does
what they meant
to, but should
have done
something else
Adapted from HSE, after J Reason
Lapses
When the
person forgets to
do something
Slips
When the person does
something, but not
what they meant to do
J Reason 1990
Why do we fail?
• Current systems in healthcare are highly
dependent on level 1 measures; intent,
vigilance, hard work
• We focus on outcomes, so only measure the
process where there is catastrophic failure
• We miss process defects where the patient does
well despite the system (rather than because of
it)
• We don’t really analyse failures and learn from
them systematically
Level 3 reliability
• Usually only achieved by system-wide
approaches
• Organisations in some industries (air,
nuclear etc) have achieved this
• Difficult to identify healthcare examples in
the UK
– ? Virginia Mason, Mayo Clinic in the US
Level 3 and beyond
• To improve reliability beyond level 2
usually requires fundament system
redesign
• Based on Failure Modes and Effects
analysis which analyses process failures
in detail and changes the systems
accordingly
IHI 3 step design for reliability
1. Prevent initial failure
-Use intent and standardisation
2. Identify failures and mitigate
-Use redundancy function
3. Critical failure analysis
-Identify critical failures then redesign system
IHI design for reliability
Prevent initial
failure
Identify failures
and mitigate
Measurement
Redesign
Critical failure analysis
For next week…
Review your incident report or RCA
again.
Think how you might re-write it to
include at least one Human Factors
Level 2 action.
Summary
• At best, most healthcare processes deliver
level 1 reliability (i.e. around 90% success)
• Hard work, vigilence, training & audit is
unlikely to make this any better
• Level 2 (human factors) changes, can deliver
up to 90-99% success
• To get more reliable than this requires
organisation-wide change
Acknowledgements
• Frank Federico & Carol Haraden, IHI
• IHI white paper “Improving the reliability of healthcare” at
www .ihi.org
• Nolan T “System change to improve patient safety” BMJ
2000;320. 771-3