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Reliability Principles
CQN Asthma ProjectJanuary 14, 2010
“I have no relevant financial relationships with the manufacturers(s) of any
commercial products(s) and/or provider of commercial services discussed in this CME
activity.”
Outline
• Definition and purpose of high reliability systems
• Measuring reliability - some simple math• Reliability principles and chronic illness
care changes– How much improvement can we expect from
each?
GLOBAL CQN AIMWe will build a sustainable quality improvement infrastructure within our practice to achieve measurable improvements in asthma outcomesSpecific Aim From fall 2009 to fall 2010, we will achieve measurable improvements in asthma outcomes by implementing the NHLBI guidelines and making CQN’s key practice changes
Measures/Goals
Outcome Measures: >90% of patients well controlled
Process Measures >90% of patients have “optimal” asthma care (all of the following) assessment of asthma control using a validated instrument stepwise approach to identify treatment options and adjust therapy written asthma action plan patients >6 mos. Of age with flu shot (or flu shot recommendation)
>90% of practice’s asthma patients have at least an annual assessment using a structured encounter form
Engaging Your QI Team and Your Practice*The QI team and practice is active and engaged in improving practice processes and patient outcomes
Using a Registry to Manage Your Asthma Population *Identify each asthma patient at every visit *Identify needed services for each patient *Recall patients for follow-up
Using a Planned Care Approach to Ensure Reliable Asthma Care in the Office * CQN Encounter Form * Care team is aware of patient needs and
work together to ensure all needed services are completed
Developing an Approach to Employing Protocols * Standardize Care Processes * Practice wide asthma guidelines
implemented
Providing Self management Support
* Realized patient and care team relationship
Key Drivers
Interventions
Form a 3-5 person interdisciplinary QI Team
Formally communicate to entire practice the importance and goal of this project
Meet regularly to work on improvement
All physicians and team members complete QI Basics on EQIPP
Collect and enter baseline data
Generate performance data monthly
Communicate with the state chapter and leaders within the organization
Turn in all necessary data and forms
Attend all necessary meetings and phone conferences
Select and install a registry tool
Determine staff workflow to support registry use
Populate registry with patient data
Routinely maintain registry data
Use registry to manage patient care & support population management
Select template tool from registry or create a flow sheet
Determine workflow to support use of encounter form at time of visit
Use encounter form with all asthma patients
Ensure registry updated each time encounter form used
Monitor use of encounter form
Select & customize evidence-based protocols for your office
Determine staff workflow to support protocol, including standing orders
Use protocols with all patients
Monitor use of protocols
Obtain patient education materials
Determine staff workflow to support SMS
Provide training to staff in SMS
Assess and set patient goals and degree of control collaboratively
Document & Monitor patient progress toward goals
Link with community resources
CQN Asthma Project Practice Key Driver Diagram Version 2.0
Associates in Process Improvement, 2009Slide 5
Health System Perspective: Quantifying “Reliability”
“Reliability” = Number of actions that achieve the intended result ÷ Total number of actions taken
“Unreliability” = 1 minus “Reliability”
It is convenient to use “Unreliability” as an index, expressed as an order of magnitude (e.g. 10-2 means that the action fails to achieve its intended result 1 time in 100)
White Paper, p. 3
Associates in Process Improvement, 2009Slide 6
Un-Reliability?
What changes in the process of care delivery will change the outcome?
Assessment of asthma control
AppropriateTreatment
ImprovedOutcomes
Associates in Process Improvement, 2009Slide 8
Definition Of “Reliability”
Reliability is failure free Reliability is failure free operation over time.operation over time.
Can reliability principles be applied effectively to improve the consistent delivery of high-quality health care?
White Paper, p. 2, 3
Reliability most connected to the IOM’s dimensions for the health care system of• effectiveness (where failure can result from not applying evidence), • timeliness (where failure results from not taking action in the required time)• patient-centeredness (where failure results from not complying with patients’ values and preferences).
Associates in Process Improvement, 2009Slide 9
Levels of Reliability
Level Reliability Success Rate Failures in 10,000 actions
1 10-1 80%-95% 1500-2000
2 10-2 96%-99.5% 50-1499
3 10-3 99.6% - 99.95% 5-49
4 10-4 99.96%-99.995 0.5-4
10-5 99.996 – 99.9995 0.1-0.4
10-6 >99.9996 <.1
White Paper, p. 4
Human Factors EngineeringRené Amalberti: Premises
• “Unconstrained” human performance (guided by personal discretion, only) is worse than 10-
2
• “Constrained” human performance can reach 10-2 to 10-3
Associates in Process Improvement, 2009Slide 11
No
system
bey
on
d
this
po
int
10-2 10-3 10-4 10-5 10-6
Civil Aviation
Nucleur Industry
Railways (France)
Chartered FlightHimalayamountaineering
Road Safety
Chemical Industry (total)
Fatal risk
Medical risk (total)
Blood transfusion
Anesthesiology ASA1
Cardiac Surgery Patient ASA 3-5
Fatal Iatrogenic adverse events
No limit on discretion
Microlight or helicopters spreading activity
Excessive autonomy of actors
Craftmanship attitude
Ego-centered safety protections, vertical conflicts
Loss of visibility of risk, freezing actions
Increasing safety margins
Becoming team player
Agreeing to become « equivalent actors »
Accepting the residual risk
Accepting that changes can be destructive
Very unsafe Ultra safe
René Amalberti
White Paper, p. 3-4
Amalberti’s Reliability Framework
Associates in Process Improvement, 2009Slide 12
Exercise
1. Review the goals on your improvement project.
2. What Level of reliability are you targeting on your project?
10-1
10-2
10-3
How reliable is the collaborative?
Alabama Data
What can we learn from variation across states?
Alabama Oregon
Ohio
Level 2 Reliability at CCCHAsthma Action Plan
How are they doing it? Optimal Care at CCCH
Components of a ProcessHave Known Failure Rates
Level 1 (80-90%) Reliability
• Team focus on the outcome goal
• Working harder
• Feedback of information on performance
• Awareness and training
• Standardize decision-making (e.g., guidelines)
Level 1 Reliability Concepts in CQN
• Team focus on the outcome goal: – Team aim and goals.
• Working harder: – Collaborative participation
• Feedback of information on performance: – Monthly measurement and feedback of results
• Awareness and training: – Training of practice physicians and staff
• Standardize decision-making: – Algorithms for severity classification, control,
medications
% of children screenedLevel 1 Reliability
Level 2 (95%) Reliability
• Real time identification of failures (“identify and mitigate”)
• Checklists and observation
• Redundancy
• Making the “right thing” the “easy thing”
• Standardization of process
Level 2 (95%) Reliability Embedded in CQN Key Drivers
• Real time identification of failures– Auditing and daily review of failures
• Checklists and observation– Templates (structured encounter form)
• Redundancy– Planned care (e.g., pre-clinic huddle involving nurses)– Monthly population review using registry for care management– Patients empowered to participate in pre-visit planning
• Making the “right thing” the “easy thing”– Protocols– Default to the appropriate option: Patients get asthma encounter form
whether physician orders or not. – Standing “flu shot” orders
• Standardization of process– Protocols and defined roles for template use (e.g., front desk, nurse)– Defined staff roles (includes hiring, training, performance evaluation)
Desired OutcomeLevel 2 Reliability
Pct asthma pts w ith current f lu vaccine
0
2040
6080
100
Pct of asthma patients w ith 3 care components
0
2040
6080
100
Pct of asthma patients w ith action plan
0
2040
6080
100
Level 3 (99%) Reliability• Preoccupation with failure:
– Real time awareness of failures– “Process Owner” for patient education– Measure days between serious events (e.g., ED visits)
• Reluctance to simplify interpretations: – Learning from each failure and from those doing
better.
• Sensitivity to operations:– Support the front line (e.g., practice coaches)
• Deference to expertise: – Avoid a strict “Top-Down” Culture
Desired Outcome:Level 3 Reliability
“Robust Design”
Outcomes+Situational factors
Process/control factors
•Optimal care•QOL•Admissions
• Level 1 Components• Level 2 Components• Level 3: Mindfulness
• Severity of problem• Values/habits/lifestyle• Preferences• Support system• Resource availability
THANK YOU
QUESTIONS?
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