Transcript Elements of an Agile Safety Culture in Health Care Sandi Gulbransen University of Utah Health Care Frank A.

Elements of an Agile Safety Culture in
Health Care
Sandi Gulbransen
University of Utah Health Care
Frank A. Drews
University of Utah
Center for Human Factors in Patient Safety
VA Salt Lake City Health Care System
Informatics, Decision-Enhancement, and Surveillance Center
 Socio-Technical Systems
 Safety
 Culture of Safety
 Components
 Safety Space
 Perspectives on improvement
 Principles of process improvement
 Task analysis and improvement in task performance
 Take away
Socio-Technical Systems
 Socio-Technical System (STS)
 Core Idea: Systems have technical and social components
 Technical system
 Machinery, processes, procedures
 Social system
 People and their habitual attitudes, values, behavioral styles and
relationships
Socio-Technical Systems
 How to strengthen a socio-technical system?
 Resilience Engineering
 Resilience
 “The ability of a system to adjust its functioning prior, during, and past
changes and disturbances to maintain operation” Hollnagel, 2011
 Assumptions
 Performance conditions are underspecified; constant adjustment to
changing conditions is required
 Safety and productivity are not independent
Safety and Safety Culture
 What is safety?
 Safety as the absence of accidents, incidents, injuries,
illnesses?
 Problem: What causes these events?
 What is within our control, and what is not? (e.g. I can control
how I drive but I cannot control how others drive).
 Definition by International Organization for Standardization
(ISO): “Safety is freedom from unacceptable risk.”
 Issue of risk vs. uncertainty
Safety and Safety Culture
 Safety culture / safety climate
 Result of Chernobyl nuclear power accident (1986)
 Rule violations and poor culture of safety as contributors
 Usually there is no intention to create unnecessary risk
 But: to get the job done safety is eroded (violation)
 Routine violations reducing safety margins
Safety and Safety Culture
Safety Culture
Commitment
Competence
Cognizance
Safety and Safety Culture
 Commitment
 Motivation to stay safe even under management changes
 Resources with regard to quantity and quality
 Competence
 The technical competence to improve safety
 Safety information system
 Cognizance
 Correct awareness of the threats to the organization
Safety and Safety Culture
 Safety space
 Continuum from resilient to brittle organizations
resilient
brittle
Safety and Safety Culture
 Over time organizations move in safety space
 Position in the safety space is a function of the number of
negative outcomes
 Resilient organizations suffer fewer negative outcomes
 Drifting towards the brittle region increases the likelihood of
accidents
 Public and/or regulatory pressures result in improvements of safety
 Moving towards the resilient region has also contrary forces
 Safety initiatives may run out of steam
 There is a diminishing return for safety improvements
 How to increase resilience?
 Learning
 Knowing what has happened
 Ability to address the factual
 Responding
 Knowing what to do
 Responding to regular and irregular disruptions
 Ability to address the actual
 Anticipating
 How to anticipate threats, developments and opportunities
 Ability to address the potential
 Monitoring
 Knowing what to look for, i.e., what can become a threat in the future
 Focus on what happens in the environment, but also what happens in
the system
 Ability to address the critical
Abilities required for resilience
Learning
(factual)
Anticipating
Responding
(potential)
(actual)
Monitoring
(critical)
 Examples from two perspectives
 Macro perspective
 Principles of process improvement
 Example: Joint replacement
 Micro perspective
 Task Analysis / improvement of task performance
 Examples: Kit development using Adherence Engineering; ICU
Display Design
Value Management System (VMS):
Toward a Learning Health System
Sandi Gulbransen
University of Utah Health Care
March 20, 2014
Outline
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Value Management System (VMS)
Principles of Lean and ISO 9001:2008
Use case
VMS as Virtuous Cycle
Data
Process
Clinical
Patient
Today
Make the best decisions with the most complete
information available – but our best information has
gaps.
Tomorrow
Make the best decisions with a better understanding
of our key processes and how they are performing.
Lean/Value Improvement
ISO 9001:2008
Customer defined value
Customer focused
Leader as teacher
Leadership
Everyone solves problems
Involvement of people
Understand the value stream
Process approach
System optimization:
reduce waste
System approach to management
Pursue perfection
Continual improvement
Make problem visible
Factual approach to decision making
1. Document
What we do
5. Correct or
Prevent
2. Record
What we did
The fix
4. Non
conformity
What didn’t
work
3. Audit
How well we
do it
Physician Lead: Chris Pelt, MD
Sponsor: Charles Saltzman, MD
Joint Replacement:
Value Driven Care Process
Multidisciplinary Team:
Nursing
Physical Therapy
Ambulatory Clinic
Case Management
Value Engineering
Decision Support
EDW
Quality & Patient Safety
DAILY WORK
RECORD
DOCUMENT
What we did
What we do
Joint Replacement Care Process
Patient Information
Policies
Procedures
Guidelines
Bylaws
=
Early Mobilization
Incomplete Discharge Orders
Daily
Activity
+
Chart
Activity
EXTERNAL AUDITS
AUDIT
DAILY WORK
How well we do it
No specific audits
>
INTERNAL AUDITS
=
+
Opportunity for Improvement
EXTERNAL AUDITS
NONCONFORMITY
AUDIT
IDENTIFY
How well we do it
What didn’t work
>
INTERNAL
AUDITS
INTERNAL
AUDITS
X
=
X
X
+
X
EXTERNAL AUDITS
REPORT
Early Mobilization Prioritized –
Change of PT Shifts
Updated discharge order set
Patient Selection pre-op re: post op
SNF, Rehab, HH
CORRECT
The fix
>
INTERNAL AUDITS
=
+
Perfect Care Metric - VMS
EXTERNAL AUDITS
PREVENT
CORRECT
PREVENT
How we keep it
From happening
The fix
>
INTERNAL AUDITS
=
+
Perfect Care Composite: Joint Replacement
National Metrics
Local Metrics
30 day readmission
Early mobility
8 SCIP measures
ED visit within 90 days
35 HAC/PSI metrics
Discharge unit
Anesthesia technique
Results
Patient Care and Average Cost
Interpret
Analyze
Feedback
Virtuous
1
Cycles
Assemble
Change
Interpret
Identify nonconformity
or preventive action
Analyze
Feedback
Monitor process
performance
Metrics and drivers
Find opportunity
Make it easy to do
the right thing
Assemble
Change
Identify change for
sustained improvement
Best practices – internal
and external
Agility
Reactive
Projects
PDSA cycles
Proactive
Lean Management
Virtuous cycles
 Understanding of key processes
 Metrics that will drive change
 Actionable information at POC
 Extensible to other organizations
Journey to Learning Systems
LHS Considerations1
VMS Elements
Evolutionary approach
(less is more)
Management review
(existing infrastructure)
Design for adaptation
Actionable information at POC
Embrace the fractal
Attend to all parts of virtuous cycle
Framework for structured approach
Attend to all domains
Understanding local system as reference
for extending
Engage all stakeholders
1Friedman,
C. Informatics for the Nationwide Learning Health System, 1/27/2014
There is a way to do it
better – find it.
-Thomas Edison
Task analysis
and
improvement in task performance
Frank A. Drews
University of Utah
Center for Human Factors in Patient Safety
VA Salt Lake City Health Care System
Informatics, Decision-Enhancement, and Surveillance Center
With
Aaron Angelovic, Jonathan Bakdash,
Alexa Doig, Brittany Mallin
Adherence and Violations
 Procedure violations
 Common problem in many industries
 Routine violations
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Person perceives an alternative, more efficient way to perform task
Lack of feedback
External (social) pressures reinforce routine violations
 Violation producing conditions
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Perceived low likelihood of detection
Inconvenience
Time pressure
Design for Adherence
 Central line maintenance: A trivial task?
 Maintenance requires more than 25 steps
 Breakdowns in maintenance can result in central
line associated bloodstream infection (CLABSI)
Design for Adherence
 Adherence Engineering to reduce Violations
Design for Adherence
 A procedure: Central line maintenance
 Status quo
 Current equipment does not support clinicians
 Opportunity to redesigning the task / equipment based on
Human Factors
Design for Adherence
 Building an alternative
 Integrating checklist into equipment to support adherence to
best practices
 Applying AE principles
 Multi step approach
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Involvement of Infusion Team Members / Physicians
Involvement of Manufacturer
Involvement of HF Engineers
Iterative design and evaluation process
 Virtuous cycle
New Kit
Non-Sterile Portion
Small size
Sterile Portion
Results
 Clinical data
 CLABSI rates
 Pre-intervention
 CLABSI rate: 3.23 / 1000 patient line days
 Post-intervention
 CLABSI rate: 0 / 1000 patient line days
 Incident rate ratio = 0 (95% CI:0-0.63; p<.01)
Results
Best Practice
Odds Ratio / 95% CI
Significance
Hand Sanitization
4.86
2.45-9.62
p < .0001
Chlorhexidine Scrub
Duration
7.6
2.26-25.59
p < .0001
Anti-Microbial Bandage 0.7
Application
0.14-3.57
p = .69
Catheter Hub
Disinfection
p < .0001
7.85
4.14-14.9
Pre-intervention n = 107, Post-intervention n = 85
Design for Adherence
 Discussion
 Clear improvement in adherence to best practices
 Fewer item omissions / errors
 Reduction in CLABSI
Development
of a
Patient Monitor for Critical Care
ICU display
 Two step approach
 Semi-structured interviews with ICU nurses
 Goal: Understanding the limitations of current displays
 Design
 Involvement of nurses, physicians, cognitive
psychologists
 Iterative design process
 Evaluation study
Interviews to inform design
 Interview
 Focus on experience with current displays
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Confusing variables
Missing information
Error
Relevance of trend information
Patient variability
Usability
Interviews to inform design
 Results (emerging themes)
Themes
Example statement
Data acquisition /
processing
Data processing leads to frequent false alarms
Data / event integration
Marking events as explanation for changes in vital signs
Only contextual information allows for detection of artifacts
Data interpretation
Applying meaning to variables
Monitoring trends in
numerical data
Trend functions are not routinely used, not accessible
Defaulting to memory for trend assessment
Need to visualize interrelationships between intervention and
physiologic variables
Usability issues
Small font size
Color coding of variables is not consistent
Cables should be color coded for ease of use and troubleshooting
Interviews to inform design
 Discussion
 Current monitor equipment does not support
integrated patient assessment
 Slow, piecemeal-wise processing
 Increases cognitive load
 Information needs are not met
 Trend information not immediately available
 High information access costs
Design of the display
 Design process
 Focus on most commonly monitored patient
variables
 Trending information
 Configural approach (patient centered variability)
Septic shock
Evaluating the display
 Study Design
 IV:
 Display (configural vs. traditional display)
 4 scenarios (Septic shock, pulmonary embolism, early sepsis,
normal)
 DV:
 Time for nursing diagnosis
 Percentage of correct diagnoses
 Percentage of trend data being accessed in traditional display
condition
 Participants
 40 ICU nurses (25 female)
Evaluating the display
 Results (Time to
diagnosis)
 Significant
differences for all
scenarios but
early sepsis
Evaluating the display
 Results
(Percentage
correct
diagnoses)
 Significant
differences for for
septic shock and
pulmonary
embolism; trend
for stable
Evaluating the display
 Discussion
 Configural display leads to
 Improvement in time for diagnosis
 Improvement in quality of diagnosis
 Up to 24 % improvement in correct diagnoses
 Nurses appear not to use trend information if not
readily available
Summary
 To facilitate the development of a agile safety culture
there is a need for both perspectives
 Macro perspective
 Operations perspective
 Micro perspective
 Perspective on human performance
 Sustainable safety improvement only with both in
tandem
 Learning is only possible if we allow for it
 Continuous effort, continuous change
 Responsive