Do our patients consistently receive evidence-based, effective care every time he or she needs it? This presentation discusses the concepts associated with high reliability:

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Reliability
Patient Safety Team

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• Understand / appreciate the concept of reliability in healthcare
• Adopt a simple approach to:
– Identify & understand reliability defects
– Design & implement interventions
• Focus is on the methodology, not on specific solutions
Objectives

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What are we trying to achieve?
A health care system that ensures every patient
consistently receives evidence-based, effective care every
time he or she needs it
Decreasing the opportunity for variation

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How hard can that be?
McGlynn et al NEJM 2003; 348:2635-2645
– 6712 Medical records examined
– Only 55% received ‘scientifically indicated care’
All studies show << 80% reliability in delivery of
intended care

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1
10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1million 10million
Number of encounters for each fatality
Totalliveslostperyear
REGULATEDHAZARDOUS
(>1/1000)
ULTRA-SAFE
(<1/100K)
Health Care
Mountain
Climbing
Bungee
Jumping
Driving
Chemical
Manufacturing
Chartered
Flights
Scheduled
Airlines
European
Railroads
Nuclear
Power

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Can we deliver a reliable
process?
Catastrophic processes
Blood transfusion
Wrong side surgery
Hygiene in neutropenic patients
Post-operative counts
Highly reliable processes

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Non-catastrophic processes
What do we mean?
Failure of the process does not lead to death or severe injury within
hours of the failure
Very poor reliability < 80%
Loss of connection with outcome
The resilience of biology
The tyranny of small numbers
Violation and migration
There’s no feedback

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Example
• Every patient on newly started on warfarin therapy should have an INR
taken every 24 hours. This result should inform the dose prescribed.
• Who has a deliberate and reliable process to achieve this and is confident
it happens?
• Who doesn’t think it’s really that important?
• The policy in hospital is that staff should wash their hands on entry to the
ward, between patients and on exiting the ward.
• Who thinks this happens reliably in their hospital?
• Who doesn’t think it’s really that important?
Non Catastrophic Process

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The consequence of our actions

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Improvement Concepts Associated with Poor Reliability
• Primarily can be described as intent, vigilance, and hard
work
– Common equipment, standard order sheets, multiple choice
protocols, and written policies/procedures
– Personal check lists
– Feedback of information on compliance
– Suggestions of working harder next time
– Awareness and training
• Does this appear familiar?

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Improvement Concepts Associated with High
Reliability
• Focus on human factors
• Standardize process based on best available evidence
• Minimize variation
• Make desired action the easiest / default action
• Aids to decision making
• Reminders and scheduling built in
• Design in failure prevention, identification and mitigation

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What do we mean by reliability?
• Chaos; failure in >20% of opportunities
• 80-90% reliability - >1 in 10 times the process fails.
• 5 front line users can not easily articulate the process
•
• 95% reliability - 5 in 100 times the process fails.
• 5 front line users can easily articulate the process
• 99% reliability - 1 in 100 times the process fails well designed
system with low variation and cooperative relationships

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Level of reliability
1. Get to an 80% reliable process (today’s work)
2. Analyse Failure and re-design
3. Follow up reliability in May
• Deal with the remaining 20%
• Aim is to resolve 80% of the remaining 20%
• Analyse failure and re-design
• 80% + 80% of 20 = 96% reliability

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People make mistakes...

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Making the process more reliable

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Process Map &
Standardisation
Identify and
Prioritise Risk
Barriers and
Mitigation
Test and Refine
Deliberate reliable design

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System solutions
Make it easier to do
the right thing
Make it harder to do
the wrong thing
Spot & stop errors