Robert A. Schwab, MD Disclosures Permission for use of Just Culture material granted by David Marx, CEO of Outcome Engenuity. No conflicts of interest to disclose 2 Objectives After attending these sessions, the learner will be able to: List the three elements of safe health care Identify the two manageable components of any system involving human workers List three barriers to implementing more reliable systems of care List the five management principles of highly-reliable organizations Discuss three communication tools that enhance patient safety Distinguish between expressions of empathy and apologies 3 How Risky is Health Care? IOM 1999: 98,000 preventable hospital deaths/year OIG 2010: 100,000 preventable medicare deaths/year Journal of Patient Safety 2013: 200 400 K deaths/year Risk of death from admission to US hospital on par with: 4 OR 5 IOM 2015: Diagnostic Errors Diagnostic errors have been largely ignored in quality and safety efforts Most people will experience a diagnostic error Incidence is 5% of US adults per year Contribute to 10% of patient deaths Account for 6-17% of adverse events in hospitals 6 IOM 2015: Recommendations Facilitate more effective teamwork Enhance education and training in diagnosis Ensure that IT supports the diagnostic process Develop approaches to identify, learn, and reduce Establish work processes that support diagnosis Develop reporting and liability system that supports a learning environment 7 Elements of Safe Care Culture of Patient Safety Teamwork and Communication Predictably Dependable Systems of Care The presence of all three elements produces a HIGHLY RELIABLE ORGANIZATION 8 What If Health Care Were Safe? What If Video 9 At Your Tables: What are the barriers to having a culture of patient safety in healthcare? What steps could be taken to create a more safety-oriented culture? Be detailed and specific. Why is teamwork so difficult in healthcare? Why are systems of care so unpredictably dependable? 10 Barriers to Safety Culture ? 11 Two Assertions The foundation of health care is safety The basis for all human action is the pursuit of happiness 12 Safety Culture=Just Culture Defines expected behaviors Recognizes human limitations Creates, evaluates, and improves systems that identify, mitigate, and prevent errors Encourages error reporting and learns from errors Finds and fixes problems Expects accountability to follow predictably dependable processes 13 Two Manageable Things Safety of the system in which we work MANAGEMENT RESPONSIBILITY Behavioral choices made by workers in the system INDIVIDUAL RESPONSIBILITY NOT MANAGEABLE: OUTCOMES 14 15 Exceptional Outcomes Healthcare That Is Safe Zero Events of Harm Timely, Effective, Efficient, Equitable & Patient Centered Reliability Science Knowledge and understanding of human error and human performance in complex systems Our Clinical Covenant Keep You Safe, Heal You and Be Kind to You Will Reliability Culture Adapted from 2009 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Behaviors of Individuals & Groups Design of Culture Behaviors for Leadership Behaviors; The Promise Design of Structure Design of Technology & Environment CareConnect, barcode technology, smart pumps Design of Policies & Protocols Focus Simplify & Standardize Design of Work Processes Blueprinting Means Execution Leadership Reinforce & Build Accountability for performance expectations and Find & Fix system problems Categories of Behavior Human Error doing other than what was intended At-Risk Behavior failing to recognize risk or believing it to be justified. A result of DRIFT Acquiring expertise Multitasking and shortcuts Adopting local culture and norms Reckless Behavior acting despite recognized unjustified risk 16 Specific Actions: Safety Culture ? 17 Tell Safety Stories Begin every meeting with a moment for safety Use local stories whenever possible Be transparentuse names Can also use stories from elsewhere, or safety principles, etc. 18 Data or Story? A million deaths is a statistic. A single death is a tragedy. 19 Our Brains Are Wired For Story Narrative and Neuroscience 20 Oops A Drama in Four Acts THE PLAYERS: Arnold Jones 1 47 yo patient of Dr. Hart Arnold Jones 2 67 yo patient of Dr. Hart Dr. Strong Hart cardiologist, specialist in EP studies Annie N. Everytask receptionist for Dr. Hart Tumany Balzintheair scheduling specialist Sly Tlee Cynical admitting clerk THE PLACE: Midwestern city, urban hospital, heart hospital, Spring, Act I Friday, Office, 4 pm Dr. Hart schedules an accessory pathway ablation procedure on Arnold Jones 1 for Monday morning. Mr. Jones is told that he will be called on Sunday with instructions As per procedure, Ms. Everytask retrieves the Jones file, but mistakenly selects Jones 2; the file is forwarded to scheduling 22 Act II Jones 2 Home, Sunday Mr. Jones 2 receives a call from Balzintheair, informing him that he is to arrive at admitting at 8:30 am on Monday to have his cardiac procedure. Mr. Jones 2 is unaware of the need for the procedure, but since he does have cardiac disease, he agrees to show up at the appointed time. 23 Act III Office, Monday am Ms. Everytask receives a call from Jones 1, asking why he was not called as was promised. Ms. Everytask tells him that he was called, to which he replies in the negative, stating that he was home all evening. Ms. Everytask informs him that he still has time to arrive at admitting at 8:30, so he leaves for the hospital. 24 Act IV, Scene i - Admitting Jones 2 arrives at admitting. Using paperwork from the scheduling office, Mr. Cynical follows procedure, asking Mr. Jones his name, date of birth, and purpose of visit. He notes that the DOB on the paperwork does not match that given by the patient, requests photo ID, and then assumes that once again scheduling has gotten it wrong, so he changes the paperwork 25 Act IV, Scene ii - Admitting Cynical asks for the next patients name, etc and is told Arnold Jones, here for procedure by Dr. Hart. DOB matches the previous paperwork, to which Cynical replies Oh, He races to the procedure suite and discloses the error just as Jones 2 is being wheeled through the doors. (Curtain) 26 What Went Wrong? We failed to ID the wrong patient Because the wrong file was pulled Because there was no name alert Because there was no dual-identifier Because there was no culture of stopping the line when dual-identifiers dont match Because the reliability of information transfer was traditionally poor 27 Why would Cynical change the paperwork? Because the patient showed him a photo ID Because he did not want to disappoint the patient Because he was afraid the doctor would yell at him Because it was not hard to believe that the information was incorrect 28 Change Management Failure Modes (Schwab) Failure ModeContribution to FailureFocus in Change Effort Knowledge do we know how? Do we have the skill set? 10%50% Feasibility can we do it? Is the process designed for success? 50%30% Belief do we think it is important? 40%20% Belief is particularly important for highly-educated people with multiple competing priorities. Belief motivates the acquisition of knowledge. Attention to feasibility ensures reliability and sustainability of the change. 29 Storys Role in Change Management Story is the vehicle that allows us to move from knowledge to belief. Robert Schwab, MD 30 Second Specific Action: Daily Safety Briefing Same time each day All major departments clinical and nonclinical Structured template NOT the time for stories Stand up Look back, look forward Goals are: Shared mental model Risk awareness 31 Creating A Shared Mental Model Patient Safety Briefing 32 33 Why Is Teamwork So Difficult? ? 34 Teamwork What is a Team? A collection of individuals working toward a common purpose An assembly of complementary skills that produce synergy, or more than could be accomplished by summing the individual contributions A common language that facilitates performance 35 Teams in Health Care The pursuit of individual happiness will frequently be at odds with the needs of any collective enterprise In a highly regulated, complex, risky industry based upon compassion, altruism, and empathy (and thus self-sacrifice), the pursuit of individual happiness can be dangerous 36 Communication Failure contributes to 75% of serious adverse events 90% of caregivers fail to speak up when witnessing unsafe acts by colleagues 37 Silence Kills 38 Silence Kills 39 Silence Kills 40 Barriers to Communication Discipline-specific variation in training Time Practice Style Technology More complexity Less humanity Less proximity Aversion to confrontation/argumentation 41 A Sneak Peek Crucial Confrontations 42 Crucial Conversations What you dont talk out, you will act out. The pool of shared meaning is the birthplace of synergy. Argumentation ideally, a process by which two parties present claims that are discussed and accepted or refuted in an attempt to reach an agreeable solution. IT SHOULD BE A COLLABORATIVE EFFORT 43 Editorial Comment Nurses lack critical thinking skills Nurses dont know whats going on with the patients Why? Could it be because doctors no longer take the time to round with nurses and/or to discuss the therapeutic plan with them? 44 Why Are Systems So Undependable? ? 45 Barriers to Health Care Reliability Permissive clinical autonomy Design does not match reliability goals Response to failure is ineffective Vigilance as key design element of processes and process improvement 46 Patient Safety and Swiss Cheese 47 Hierarchy of Reliability Standardize the process (policies, procedures, order sets, education) Apply controls to aid success (decision support, reminders, teamwork, defaults) Detect error Mitigate error Prevent error 48 Detection 49 Mitigation 50 Prevention 51 Johns Hopkins Hospital Cost of engineering an error out of a system: 12 FTEs working for 3 months Conservative estimate: $200,000 52 53 HRO: What It Takes 54 Characteristics of HROs Sensitivity to Operations Situational awareness Preoccupation with Failure Risk is everywhere Deference to Expertise Regardless of rank, who knows the most? Resilience Assess and respond quickly; improvise solutions Reluctance to Simplify Complex work requires complex solutions 55 Leadership in HRO Find and Fix Problems Learn to anticipate Learn to investigate Learn to diagnose Commit Resources Create a Learning Organization Hold Staff Accountable for Safe Practice Set clear understandable expectations tied to MVV Provide adequate training Round, reinforce, provide and ask for feedback 56 Key Tools for HRO STAR Repeat and Read Back Ask Clarifying Questions Phoenetic and Numeric Information Transfer SBAR CUS Cross-check 5:1 Feedback 57 Morning Safety Briefing Med/Surg Unit We had a code on the unit last nighta 50 year old patient 3 days post VATS procedure. He apparently suffered a bradycardic arrest, was resuscitated, and transferred to the ICU. The surgeon has been notified and believes that there was a delay in responding to the bradycardia. He also did not realize that we utilize electronic dysrhythmia monitoring and is unhappy about it. 58 Background Information Hospital uses computerized monitoring that detects dysrhythmias and notifies nurses via vocera Hospital budget is inadequate to fund full-time monitoring by trained techs There is no space available for a centralized monitoring station Backup to current system is charge nurse or unit secretary who can watch monitors from nurses station Alarm fatigue is thought to be a problem on unit 59 Working In Groups Discuss this incident and develop an investigative plan for addressing it using the Just Culture and HRO principles that we have discussed as a guide. You are not trying to fix the problem here, you are trying to diagnose. You should have a series of questions at the end of your discussion. I will provide answers when we reconvene. 60 Working In Groups Now, using the information you have acquired from the investigation, develop a plan to address the problem. We will share each tables solutions when we reconvene, and I will share how the hospital in question addressed the issue. 61 Adverse Events Local stories relevant Reveal weaknesses in the existing Systems of care Teamwork, communication Culture Insights can allow reflective education and cultural change to occur 62 Event Management System Comprehensive program to anticipate, detect, mitigate, respond, communicate, investigate, disclose and offer remedy when an adverse event occurs. Dont wait for an event to stimulate creation of the system 63 Barriers to Good Event Management Failure to prepare patients for risks Misunderstanding of apology Culture of failure and unprofessionalism Fear of being sued 64 When Something Goes Wrong, What Do You Want? Acknowledgement of Inconvenience Im sorry This sucks for you Information Avoid surprises What happened and why How will we prevent it in the future Remedy How can we lessen your inconvenience and retain your loyalty? 65 What No One Wants To be ignored To have the error rationalized AND SO, The legalistic deny and defend approach to health care mishaps feeds the fire and leads to the very outcome that our strategy is designed to avoid lawsuits. 66 But, there is good news Your mother was right Doing the right thing: Makes patient feel better Makes patient care better Makes you feel better Saves money Reduces lawsuits 67 Elements of Event Management Manage expectations Express empathy for victims of unexpected outcomes Investigate to determine if errors occur Disclose the results of the investigation Apologize if appropriate Offer remedy if appropriate Stay engaged and continue caring 68 Does Event Management Work? Apology/sympathy laws Admission of guilt laws Mandatory disclosure laws University of Michigan Plaintiffs bar cites program as money saving Doctors cite program as factor in retention 69 Summary Tell patients what to expect, including what can go wrong Recognize and report errors Empathize and communicate and care for the patient every step of the way Find out what happened and why Tell your patient everything Take responsibility Try to make it right 70