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System’s Thinking and Design

June 7, 2018

Cathie Norins, MHAThe Joint Commission

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Session Objectives:

• Discuss ways to improve the design of organizational structures and processes in order to facilitate the achievement of strategic goals.

• Provide a conceptual model for resolving the common organizational challenges associated with ALL systemwide processes.

• Provide implementable templates to help organizations move from a reactive, compliance model to one that is proactive and motivated to eliminate those organization-specific risks which have the greatest potential for compromising the delivery of safe, quality care.

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Framework for Today’s Discussion

• Past presentations focused on a specific chapter or a particular department (e.g. Infection Control; Medication Management; Dental Department)

• Today’s presentation will focus on a standardized framework that can be used when approaching all accreditation chapters

• Why reinvent the wheel?• Keep approaches simple; the processes are complex enough

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System Performance(Leadership is Responsible & Accountable)

Enterprisewide Core Processes

Important to Care,Treatment, Services

5 Systems of

Effective OrganizationalPerformance

Design, Implement, Improve, Oversee & Support

LD.03.02.01 LD.03.03.01 LD.03.04.01 LD.03.06.01

Safety Culture [LD.03.01.01]Passion for Safety & Quality

Beliefs, Values, Norms

Attitudes & Behaviors related to Safetyare supported, rewarded, expected

LD.03.05.01

Hardware + Software = Functioning SystemStructure + People = System

Foundation

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Nationwide Observations?

• 2017 Top Non-compliant Ambulatory Care Standards for Community Health Centers

• 28 non compliant EPs associated with key processes (IC, EC, MM, WT, PC) [See Website]

• 5 Why’s (Root Cause/Drill down)• The answers are related to the Pillars – our Leadership Standards• More and more observations being made at Leadership for this reason

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What is a process?• A systematic series of pre-determined, inter-related steps designed to

achieve a desired goal/outcome (Yellow brick road)

• Each process must be managed (orchestrated) so each step is performed correctly, in the right sequence and at the right time

• If we repeat the process the exact same way we should achieve the desired outcome every time (A Consistent Performance Level)

EP 1Step

Standard

DesiredOutcome

EP 2Step

EP 3Step

EP 4Step

EP 5Step

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What is Needed to Design a Good Process?

• A Plan is needed

• EPs are identified during a survey because• There is no Plan (There is no roadmap to follow – No Structure)• The Plan is not healthy (steps are missing; steps are not current; not site

specific) • Steps are not performed as designed or inconsistently (Variation)• Steps are not performed (Knowledge, Communication; Change Management)

• Each problematic EP is equivalent to a ‘hole’ (risk)• How many ‘holes’ can a process have without causing potential harm to

patients? Staff? Visitors?

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Every Hole Matters

• Defenses are needed for each hole

• How do you identify your potential risks (holes)?

• Do you look?• Do you have a plan to look?

• Fixing one hole when it is visible may not solve a process or system’s problem (Whack-a-mole)

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RCA: Pillar Problems

• Organization’s have outgrown their infrastructures

• Lack of Management Plans (No Structure)

• Lack of Leadership support (Allocation of time and resources)

• Conflicting or inconsistent policies and procedures • Silo Effect: Departments/divisions/sites

• Lack of coordination and integration

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Pillar Problems

• Lack of role clarification (no boundaries)

• Lack of implementation and/or significant variation observed

• Lack of monitoring and oversight (Change Management)• E = Q * A2

• Effective Results = Quality of Solution * Acceptance of Idea and Accountability of Implementation

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Healthy Plans are Needed to haveStrong, Effective and Efficient Programs

• What is a Plan?• Similar to a business plan or an executive summary

• Management Plans guide organizational operations to achieve a future state, minimize risk and support consistent, high levels of performance

• Plans assure that there is a process in place to get things done and respond to risk

• When a Plan is implemented we have a Program

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What a Plan is not

• Plans DO NOT repeat all of the Joint Commission standards

• Plans DO NOT typically detail “how” things are done; leave the details to Policies and Procedures (the ingredients)

• ECRI (Emergency Care Research Institute): Policies & Procedure Tool Kit for HRSA (www.ERCI.org)

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Characteristics of a Plan

• Easy to navigate, understand and use

• Consistent and standardized structure (Map or Recipe)

• Site Specific • Every site needs a plan• Take the primary plan and tailor to your sites • Incorporate the unique aspects and activities of the site

• Example: Fire drills and emergency drills at schools or mobile units

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Key Sections of a Plan

• What is the Purpose of the Plan? (Mission/Vision)

• What is the Scope of the Plan?

• Who is Accountable? (Authority & Responsibility)

• How will Risks be identified? (Risk Assessment)?

• How will Risks be prioritized?

• What are the Goals/Objectives of the Plan

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Key Sections of a Plan

• How will the Plan be Communicated (Rolled out)?• Education/Training

• How will performance be monitored (Measured)?

• Emergency Response if things do not go as planned

• How will the Plan be evaluated and when?• Were we successful in influencing staff to take the desired action? (Change

Management)

• Communication Feedback Loop

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Key Sections of a Plan

• Reference Section• Specific laws, regulations, codes (Authority having jurisdiction)• Insurance • Specific evidence-based guidelines• Manufacture's instruction for use

• Other Sections of the Plan • Related Policies and Procedures• Related Standards (Joint Commission) • Attachments

• Approval Section (Current, Up-to-date)

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Assess your Plans

• Do you need to develop and write Plans?

• Do your Plans need to be revised and retooled?

• Do your Plans need some refreshing with minor changes?

• Are our Plans are fine?

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Albert Einstein

“If I had an hour to solve a problem, I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions.”

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Who should be involved?

• Who are the Best Plan Developers (Architects)• Subject matter experts• Multi-disciplinary• Conceptual/visual thinkers versus linear thinkers

• Planning/Design does not happen in a vacuum• Balloon theory

• Who are the Implementers? (Educators & Communicators)• Link training to work flow diagram

• Who are the monitors of performance and interveners if performance drifts or performance is deteriorating? (Coaches/Diplomats)

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Systems Thinking and Risk Reduction

Each chapter (process) is built on the same platform that includes a robust feedback loop for ongoing and continuous improvement

• Accountability• Risk Identification & Prioritization• Plan/Design (Law/Regs; IFU;

Evidence-based guidelines)• Implement• Monitor for effectiveness • Evaluate & Improve• Sustain Gain

Patient Centric Care

Risk Identification & Prioritization

Plan/Design

Implement

Monitor

Evaluate & Improve

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Accountability

• Staffing Pillar [LD.03.06.01 and HR]

• Roles and Responsibilities are defined clearly• ‘When everyone is responsible, no one is responsible’.

• Qualifications match the responsibilities and are defined • What skills, education, training, and experience are needed?• Knowledge of law & regulations; evidence-based guidelines; process

improvement concepts and principles; patient safety concepts

• Sufficient allocation of Time• Observation: One person for Environment of Care; Emergency Management;

Infection Control and Performance Improvement

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Scope• Understand the Process (sub-processes)

• Things to consider that may impact the Plan • Locations where process(es) occurs (Site Specific Characteristics)

• Owned site; Landlord managed site; mobile site; school-based• Hours of Operation (Day, Evening, Weekend)• Services offered• Population(s) served• Technology employed (telehealth)

• Diagram the workflow and identify who performs each step (Employees or Contractors)

• If service contracted; you are still responsible and accountable• Consider sequencing policies/procedures in order of workflow (Gaps)

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Risk Identification

• How are gaps, failures, possible hazards or potentially unsafe conditions identified?

• Speaking Up (Safety Culture – LD.03.01.01)• How are errors that are made by self and/or others revealed without punishment,

blame or being ostracized; whistleblower• Terminology: ‘Share’ versus ‘Report’; ‘Good Catch’ versus ‘Near Miss’• Leadership Patient Safety Huddles

• Surveillance Methods (Look for ‘drift’ or workarounds)• Audit (record review) Seek feedback/comments from staff • Drills or Exercises Direct Observation (Tracers

• Role of patient• How easy is it to share ideas or concerns?

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Standardize the Risk Assessment & Prioritization Process

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Risk Assessment – Emergency Management(Hazardous Vulnerability Assessment-HVA)

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REMEMBER

• Risk Assessments are the Cornerstone of ALL Plans

• Use a systematic approach to prioritize and reprioritize risks

• Risk Assessments are SITE Specific

• Risk Assessments may even be department specific • Examples:

• Locations where HLD and Sterilization performed

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Perform Risk Assessments• Core Processes (MM, EC, WT etc.)

• Culture [LD.03.01.01]• Agency for Healthcare Research and Quality’s [AHRQ] Medical Office Survey

on Patient Safety Culture [www.ahrq.gov]

• Pillar effectiveness must be evaluated annually [LD.03….]• Plan/Design• Staffing/Talent Management• Communication• Data• Change Management

• Can’t improve what we don’t assess and monitor

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Next Steps of the Plan

• Establish clear goals and measurable, time-based objectives for the prioritized risks

• Develop interventions based on evidence-based guidelines; IFU

• Keep simple

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Implementation – Education & Training

• Who is responsible for implementation?

• Who is responsible for signing off competencies? • Is there evidence the person has the current skills, knowledge or

education? • Avoid: Blind leading the blind

• An individual is deemed competent to obtain a B/P as evidenced by ‘what’?

• Guideline selected is followed in Medical and Dental• Problem: Checklist with topics “Infection Control”

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Develop Performance Monitors

• Staff knowledge and skills• What is the frequency of direct observation? (Ex: 2X/year/EE

performing HLD)

• Level of participation

• Inspection, maintenance and testing• Performance Measure: Equipment is functioning 95% of the time. • If 160 work hours/month (5 days * 8) then the x-ray unit is not working

for 8 hours. How many patients impacted? Cost? Is 95% good enough?

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Use Data to Strengthen and Improvethe Process [LD.03.02.01]

• Lots of data collected (Data Rich)

• Data needs to be transformed into meaningful and useful information for informed decision making (Information Poor)

• EX: Data from multiple sites needs to be aggregated; graphed over time so patterns and trends, process stability and variation can be identified

• When a problem is identified, apply your diagnostic tools and skills (RCA)

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Data Analysis and Improvement

• What is the magnitude of the problem?

• Is there a problem with the design or implementation of the process?• Why didn’t X wash his/her hands?• Joint Commission's Center for Transforming Healthcare identified 41

different causes for poor hand hygiene

• What is the importance/significance of each cause?(Risk Stratification)

• Seek and find Solutions for Each cause (Diagnostic Accuracy)• Each cause requires a different, specific intervention (Joint Commission's

Targeted Solutions)

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Data Analysis and Improvement

• Roll out intervention(s) for the specific cause

• Monitor for effectiveness

• Establish a method to sustain the gains over time

Tip: The key to effective improvement is to identify the root cause(s) of the problem so the MOST effective intervention can be deployed

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What is the Role of the Committee?• Usually where the data is presented

• Frequent Observations: • Minutes look more like Activity Reports

• Can the same result be achieved by sending a memo?• Lack of discussion (analysis) of data and action steps

• No Plan (Purpose/Charter not understood)• Decision making body or recommending body• Strategic or Operational

• Participants • Leaders and management only; not multi-disciplinary, no front-line staff or patients• Attendance is low or varies (Do we have the right people on the committee?)

• Size• Meeting Frequency

• Speed of Change (Quarterly versus bimonthly or monthly

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Consider standardizing the format for committee meeting minutes

• Minutes are a communication tool to record important events, decisions, discussions, conclusions and actions so there is something accurate to refer back to rather than just relying on memories

• Try action-oriented minutes

• Drives agendas and improves the Committee’s effectiveness

• Can someone unfamiliar with the topic present the report?

WHAT WHO WHEN

Staff minutes and attachments to staff

John Specific Date

Topic, Event orRisk AT

TM

TargetGoal

Actual Performance

Discuss

Conclusion & Recommendation

Target Date

Responsible Person

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Evaluate Plan Effectiveness

• Annual evaluation or whenever there is significant change

• Example: New site location, new service. How many processes?

• Similar to an annual physical

• The process is better today as evidenced by…

• Vulnerabilities/Risks

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Learning Organization(The process feeds back on itself)

Risk Identification & Prioritization

Plan/Design

Implement

Monitor

Improve

Evaluate

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Sustain the Gains

• Sustained improvement requires sustained attention

• Not a ‘project’ that can be cast aside; it is a way of life (DNA)

• Establish a Control Plan

• Assign a Process Owner • Assign responsibility for monitoring performance and intervening if

performance begins to deteriorate or drift

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So NOW is the time to strengthen your Pillars

• Take the time to review, revise and update your Plans

• Remember:• Plans are more than a compliance exercise• Plans should bring value to the organization • Plans are the structural foundations of your key systems and processes• Plans are the method to maintain and continually improve the safety

and quality of care/services provided by the organization.

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Questions

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Thank you for partnering with us in your continuous journey to provide high quality care for health center

populations.

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• These slides are current as of May 31, 2018. The Joint Commission and the original presenter reserve the right to change the content of the information, as appropriate.

• The Joint Commission reserves the right to review and retire content that is not current, has been made redundant, or has technical issues.

• These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

• These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter and The Joint Commission.

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