Triple Play A Healthcare Strategy for Break-throughs in Safety, Quality, and Reliability

Transcription

1 Triple Play A Healthcare Strategy for Break-throughs in Safety, Quality, and Reliability Eastern Carolina Regional Symposium 4 Sep 2013 This material is a proprietary document of Healthcare Performance Improvement LLC. Reproducing, copying, publishing, distributing, presenting, or creating derivative. Phone: Page 1

2 Objectives 1. Define reliability and high reliability. And describe how high reliability enables healthcare delivery, a complex system, to be safe, effective and patient-centered. 2. Describe the three steps for culture change using a behavior-based model. 3. Explain the role of feedback to people within a complex system has in building and sustaining a high reliability organization. 4. Describe how the Collegial Interactive Team (CIT), training in-situ using evidence-based protocols with human factors, can accelerate change in complex systems and assure sustained improvement. Slide 3 Reliability re li a bil i ty [ri-lahy-uh-bil-i-tee] A probability that a system will yield a specified result Slide 4 Phone: Page 2

3 Slide 5 High reliability organizations (HROs) operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents. Managing the Unexpected (Weick & Sutcliffe) Risk is a function of probability and consequence. By decreasing the probability of an accident, HRO s recast a high-risk enterprise as merely a high-consequence enterprise. HROs operate as to make systems ultra-safe. Slide 6 Phone: Page 3

4 Five Principles of HROs Preoccupation with Failure Operating with a chronic wariness of the possibility of unexpected events that may jeopardize safety by engaging in proactive and preemptive analysis and discussion Sensitivity to Operations Paying attention to what s happening on the front-line Ongoing interaction and information-sharing about the human and organizational factors that determine the safety of a system as a whole Reluctance to Simplify interpretations Taking deliberate steps to question assumptions and received wisdom to create a more complete and nuanced picture of ongoing operations Commitment to Resilience Developing capabilities to detect, contain, and bounce back from errors that have already occurred, before they worsen and cause more serious harm Deference to Expertise During high-tempo operations, decision-making authority migrates to the person or people with the most expertise with the problem at hand, regardless of rank From Vogus & Sutcliffe, The Safety Organizing Scale, Medical Care, 45/1, Jan 2007, p Slide 7 Health Affairs 2011;30: Slide 8 Phone: Page 4

5 Slide 9 Reliability Culture - Genius of the AND Safety Focus + performed as intended consistently over time = No Zero Harm Mishaps Proven Evidence-Based Tactical Process Doctrine Bundles + performed as intended consistently over time Mission = Clinical Excellence Effectiveness Patient Centered +????? + performed as intended consistently over time RELIABILITY CULTURE Failure Prevention performed as intended consistently over time = Satisfaction = Intended outcome Slide 10 Phone: Page 5

6 Event Rate Triple Play Changing Behaviors Set Expectations Educate & Build Skill Reinforce & Build Accountability ALL RIGHTS RESERVED. Slide 11 Making It Happen & Making it Stick 100% Awareness Skill Acquisition Habit Formation 20% Leadership Influence Performance Time ALL RIGHTS RESERVED. 2 Years Slide 12 Phone: Page 6

7 Performance Triple Play Slide 13 Rapid Cycle Feedback Learning is doing with feedback Optimal Feedback Cycle Do Feedback Traditional Feedback Cycle Time ALL RIGHTS RESERVED. Slide 14 Phone: Page 7

8 Simulation Continuum Build real-time simulation as a leadership competency! Simulation in the Lab Simulation at the Line Technical Skills Is there any technical skill that does not also require non-technical skills? NO! Eliminate technical simulation in isolation! Technical + Non-Technical Skills Best Use Non-Technical Skills (Individual & Team) Off-Line Education & Training Initial education on new concepts; intensive skill development Pre-Job Briefing Location Classroom, training lab, meeting On-the-job Nature Objective-bound Time-bound Prep Time Longer Short to none Real-Time Sim Teaching on the Spot Real-Time Simulation Reinforcement and application of known concepts; development of critical thinking and analytical problem solving Touch Time Longer (>30 minutes, typically hours) Short (30/60/90 seconds; typically <5 minutes) Frequency Episodic; longer time between sessions Often; shorter time between touches Facilitator Trained instructors or manager Manager or coworker Costs Salary of instructors/learners; supplies None To build and reinforce technical skills and critical thinking skills ALL RIGHTS RESERVED. Slide 15 Types of Simulation Lower Fidelity Sim Size of data point indicates relative numbers of people through the program in a unit time Frequency (repetitions) 60 Second Sim Real-time Sim Resiliency Sim Protocol In-situ Sim Protocol Sim Learning Value Logistical Complexity Slide 16 Phone: Page 8

9 Doing with Feedback Slide 17 A Triple Play What you do every day is what you do in an emergency. Joe Martin, Battalion Chief - LAFD Sim Center Sim Center In-Situ Sim Technical skills Team skills Protocol EBM + human factors Technical + CIT skills Environment A fool s choice: o technical skills in isolation, or o team skills in isolation Perfect practice makes perfect. Practice only makes permanent. The Gossman Center for Advanced Healthcare Simulation Slide 18 Phone: Page 9

10 Non-Technical Skills Non-technical skills describe how people interact with technology, environment, and other people. These skills are similar across a wide range of job functions. These skills include attention, information processing, and cognition. Generic non-technical skills: Situational awareness Attention Communication repeat backs call outs phonetic & numeric clarification clarifying questions inquiry, advocacy, assertion Critical thinking Protocol use Decision-making Flin, O Connor, and Crichton Safety at the Sharp End Slide 19 Collegial Interactive Teams (CIT) The most advanced approach to human reliability in complex systems. The standard tools for CIT s promote: Thinking preventing misjudgment and decisionmaking error Thinking together anticipating and managing the unexpected, preventing group-think Resiliency recognizing the team is off the success path and getting back on a path and intended for training of natural work teams in simulation. Slide 20 Phone: Page 10

11 Collegial Interactive Teams (CIT) = Tone + Tools Context Patient focused like we re caring for a loved one Collegiality Greetings & introductions Eye contact & open body language Relationships Team goals use we and us vs. I and you Confidence in Speaking Up Cross Monitoring peer checking & peer coaching If anyone regardless of role or experience senses a problem that would compromise safe, quality care, I expect you to speak up. Coordination Who s in charge Roles & responsibilities Brief>Execute>Debrief pocket card in-hand Communication Information ready & in hand 3-way repeat backs Clarifying questions Phonetic/numeric clarifications SBAR for requests Slide 21 A Triple Play What you do every day is what you do in an emergency. Joe Martin, Battalion Chief - LAFD Sim Center Sim Center In-Situ Sim Technical skills Team skills Protocol EBM + human factors Technical + CIT skills Environment A fool s choice: o technical skills in isolation, or o team skills in isolation Perfect practice makes perfect. Practice only makes permanent. The Gossman Center for Advanced Healthcare Simulation Slide 22 Phone: Page 11

12 Protocol Selection Criteria 1. Uplifting for participants so they want more 2. Targeted reduction in patient harm 3. Targeted reduction in risk 4. Targeted increase in reliability (safety/quality) 5. New facility or equipment or services or personnel 6. Infrequently performed or complex 7. Spread to new unit or new professional group Slide 23 More Ideas ED OR OB Adult trauma Adult resuscitation Fetal monitoring Pediatric trauma Pediatric resuscitation Emergent C-section Adult resuscitation Malignant hyperthermia Shoulder dystocia Pediatric resuscitation Airway management Neonate resuscitation Sepsis Post-partum hemorrhage Adult resuscitation More for resiliency: 1. Sponge counts wrong in procedural areas 2. Time-out not done or done incorrectly in procedural areas 3. Sepsis in ED or Med-Surg (nursing-medical staff conflict resolution) 4. Code Blue response with infrequent/complex complication(s) 5. Contra-indicated procedure / therapy under time pressure Slide 24 Phone: Page 12

13 Everything should be as simple as possible, but not simpler. Albert Einstein From Concept to Construct: Focus & Simplify to Improve Human Performance Slide 25 Human Factors Integration in Guidance Document Design People Guidance Documents Human Factors Integration Slide 26 Phone: Page 13

14 Policies, Procedures & Job Aids Policies Define required high-level expectations Fewer in number Informational and reference use Typically no more than one (1) page Procedures & Job Aids Define action steps and provide tools to achieve policy expectations Continuous and reference use Slide 27 Focus & Simplify Two Components Work Process Simplification (Steps 1-7) Before writing or revising a procedure Mapping the current work process Assessing the process for risk and ineffectiveness Changing the process to reduce risk and improve effectiveness Procedure Simplification (Steps 8-12) A procedure structure that Clearly articulates action steps Highlights points of risk Provides appropriate detail for experienced and new employees Use of job aids to pull out of procedures the tools and references needed to accomplish a complex or infrequently-performed task Slide 28 Phone: Page 14

15 Slide 29 Debrief Structure Checklist approach for leading an AAR Review the objective. What were we trying to do e.g. smooth patient transfer, successful resuscitation, IT system upgrade, etc. Reconstruct the event. Have the team review the evolution, walking through just the objective facts of what happened in enough detail for a common understanding of what occurred. Review the reconstruction for differences between what was supposed to happen and what actually did. Why there were differences? Capture the things we want to sustain and possibly spread to others: Capture what we can improve and have others learn from? Wrap up: Give each participant a last chance to comment on their own actions, team behavior, or system design. Recap for the group 3 things we want to sustain and 3 things we want to improve Document and hand-off to process owners for appropriate follow up action. Slide 30 Phone: Page 15

16 Debrief Technique Debrief leads to new frames or reframing Debrief leads to new actions Frames Actions Results Source: Rudolph & Simon, There is No Such Thing as a Non-Judgmental Debrief, Simulation in Healthcare, Spring Slide 31 Slide 32 Phone: Page 16

17 Reliability in Quality and Safety Slide 33 Today we have changed our OR forever. Elissa Orcutt Benefis Hospital, Director Surgical Services Slide 34 Phone: Page 17

18 QUESTIONS? Slide 35 Contact Information Scott Knapp Tel: (757) Healthcare Performance Improvement 5041 Corporate Woods Drive, Suite 180 Virginia Beach, VA Tel: (757) Slide 36 Phone: Page 18