Introduction to High-Reliability & Zero Harmsofi.ucla.edu/workfiles/Documents/Intro to HRO and Zero...• A high reliability organization is an organization that has… • Succeeded

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Introduction toHigh-Reliability & Zero Harm

Anet Sinanyan, MHA, CPHQPatient Safety ManagerOctober 2019

Leading the Way to …

Overview• Patient Safety Story• Harm in Healthcare• High-Reliability Organizations• Zero Harm• UCLA Health’s Journey - Examples• What U Can Do• UCLA Resources• Questions

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A UCLA Health Patient Safety Story ….

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An eight week old NICU patient was brought to MRIwith two nurses, a resident, and a respiratory therapist(RT). Before bringing the patient to the MRI room, theRT was setting up the neonate ventilator near the 3Tesla (T) magnet. Radiology staff communicated tothe RT that he had the ventilator too close to the MRImachine. However, RT was certain that the ventilatorpole was an acceptable distance from the MRI machineand that the ventilator was MRI compatible. Uponbringing the patient into the MRI room, the ventilatorpole and apparatus were sucked into the MRI magnet.Fortunately, the neonate was not connected to theventilator. Therefore, there were no injuries to thepatient or staff.

Presenter

Presentation Notes

Key points: learning from mistakes; share near misses/failures to ultimately improve safety for patients and staff.

A UCLA Health Patient Safety Story ….

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Findings:• Device had recently gone out for maintenance and

outside company inadvertently replaced parts withmetal on an MRI compatible ventilator

• Screw connecting pole to wheels was loose• Safety concerns communicated but dismissed

Presenter

Presentation Notes

Key points: learning from mistakes; share near misses/failures to ultimately improve safety for patients and staff.

Harm in Healthcare

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Harm in Healthcare

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This is the WHYfor High-Reliability

and Zero Harm Initiatives

What is High-Reliability?

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• High Reliability means….•Consistent excellence in quality and safety across ALLservices maintained over long periods of time. - TJC


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• A high reliability organization is an organization that has…• Succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity.

Commercial Aviation

Nuclear Aircraft Carriers

Air Traffic Control


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Presenter

Presentation Notes

Culture: HRO healthcare organizations demonstrate that they possess more than just policies and procedures; they have philosophies and cultures. Errors must be accepted as evidence of system flaws not character flaws. Until and unless then happens, it is unlikely that any substantial progress will be made in reducing medical errors. Cultural barriers impede progress. Staff cannot fear retribution if they report errors & near misses. RPI: Safety doesn’t mean more controls in a work system, it means better work systems

Framework for HROs in Healthcare

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Cultural Maturity Model

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Presenter

Presentation Notes

Advancement in patient safety requires a shift from a reactive approach to a total systems approach to safety.

Key Components of HRO Cultures

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•Fair and Just Response (Just Culture)•Trust •Collegial Teamwork•Personal Commitment to Safety

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What is Zero Harm?

First, we achieve zero for a daythen, for a week, then a month and at some point zero for a year…

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Zero Harm is the goal!How we achieve this goal depends on the consistency of our everyday practices and behaviors….

• Hand hygiene• Two patient identification• Medication reconciliation• Time – out• Safe patient handling • Etc…

UCLA Health Examples

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• Leadership• Daily Safety Huddle (proactive approach to safety – active daily management)• HS Patient & Staff Safety Oversight Committee

• Leadership Rounding

• Culture• Team STEPPS

• Just Culture Training• Daily Safety Huddle• Culture of Safety Surveys

• Robust Process Improvement (Learning)• Lean Academy . SOFI Tableau Dashboard• Root Cause Analysis . PI Projects

What U Can Do• Make Harm Visible

• Utilize SOFI dashboard to identify vulnerabilities• Transparently communicate safety events; share patient safety stories

• Have a close back look for communicating changes associated with safety events

• Have a questioning attitude

• Implement Just Culture• Encourage “mess-up, fess-up” as a cultural norm• Have systems approach as a response to error• Report risks identified

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What U Can Do• Build a Culture of Safety

• Consistently demonstrate safety behaviors / daily actions• Round with caregivers and providers• Daily huddles• Encourage speaking up• Promote a questioning attitude• Communicate clearly and respectfully• Connect your daily tasks to high-reliability and zero-harm• Develop incremental goals for reaching zero harm

“We are what we repeatedly do; Excellence is no an act but a habit” -Aristotle

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Next Steps• Patient Safety Stories• Continuous Just Culture Training• “Zero Harm” Certificates• Personal Commitment • More to Come in 2020

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UCLA Resources

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UCLA Resources

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UCLA Resources

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UCLA Resources

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Thank you for your commitment to Zero Harm!

Questions?

Leading the Way to …