POMS  improving patient care through modularity
Upcoming SlideShare
Loading in...5
×
 

Like this? Share it with your network

Share

POMS improving patient care through modularity

on

  • 773 views

29 April Production and Operations Management Conference Reno Nevada USA

29 April Production and Operations Management Conference Reno Nevada USA

Statistics

Views

Total Views
773
Views on SlideShare
773
Embed Views
0

Actions

Likes
0
Downloads
3
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

POMS improving patient care through modularity Presentation Transcript

  • 1. Improving Patient Safety How to Use Service Modularity in Healthcare Processes to Manage Systemic Errors
    Dr Maria Kapsali
    04/29/2011 POMS
  • 2. Contents
    1. Healthcare error 2. Systems approaches 3. HEPM: a complex adaptive approach 4. Modularity – complementing HCAS Appendix: The NHS
  • 3. Health care error literature
    professional stream: law and litigations 2. human performance stream: psychology and engineering and includes research in ergonomics and human factors such as cognition
    Problems
    oversimplification as it does not capture the variability in human behaviour or the complexity in processes
    focused on individuals/groups
    overlook the systemic factors linking the environment to people’s actions
  • 4. Systems approaches to error
    the environment shapes and institutionalizes action
    discriminate between individual errors which are inevitable and the majority which are systemic (active vs latent failures
    Control the systemic through controlling organizational processes)
    Advantages: enhances collective effort, addresses most mistakes happening in hospital operations
    Disadvantages:at this stage frameworks are still abstract so they are not widely operationalizable
    Focus on holes within the system but cannot distinguish which may be critical or not
  • 5. Systems approaches to error
    Reason, J., 1995. Understanding adverse events: human factors. Qual. Saf. Health Care, 4;80-89.
  • 6. Systems approaches to error
    Holzmueller, C., P. Pronovost, and R. Branson. 2004. How can we learn from incidents? Critical Connections. 3(1).
  • 7. Complex Adaptive Systems
    HEPM: Healthcare Error Proliferation Model opertionalizes the Swiss Cheese Model to study the complex adaptive healthcare system in four multiple layers/discrete locations/interfaces populated with ‘holes’ where the causes of accidents are nested. 1) organizational leadership 2) risky supervision 3) situations for unsafe practices 4) unsafe performance
    Palmieri, PP.A., DeLucia, P.R., Peterson, L.T., Ott, T.E., Green, A., 2008. The anatomy and physiology of error in adverse health care events, Patient Safety and Health Care Management Advances in Health Care Management, 7: 33-68.
  • 8. Methods: Data Collection
    • FMEAs through focus groups to determine the most frequent medical errors in the ward processes
    • 9. Observations in the wards
    EPSRC Project: Design Out Medical Error
    The five processes are: handwashing, handover, vital signs monitoring, infection control and medication
  • 10. Methods: Data analysis
    Find ‘hotspots’ = critical activities where most harmful errors happen
    Find which hotspots overlap amongst the five ward processes and are systemic
    Find ways to simplify or standardise these activities to eliminate erroneous actions
    Identification of hotspots through: processes maps; Combined FMEA results – Pareto
    Use Fishbone and HEPM through mind maps and causal chains from content analysis
    Identification of the critical interfaces in the adaptive complex ward processes
    Suggestions how to modularize the processes
  • 11. Results (29 hotspots within all 5 processes)
  • 12. Results: identifying the systemic causes
  • 13. Results: HEPM Root Cause Analysis – the systemic causes
    Leadership
    Risky Supervision
    Emphasis on operational cost and time metrics
    Focus on satisfying the funders not the patients
    Lack of training
    Human resource is not invested upon
    Elaborate procedures
    Supervising low level - little on the job training
    Unsafe performance
    Lack of improvement culture
    Avoid personal responsibility
    information 'holes'
    The Built Environment - lack of equipment and inhibiting space
    Time
    Negligence
    Lack of effective visual directions
    Ignorance
    Unsafe conditions
  • 14. Controls
    Negligence
    Performance control
    procedures
    Time Pressure
    Cost
    Errors
    Unsafe
    Performance
    Fear of blame
    Process
    Leadership-design
    Reliability
    holes
    of important Information
    Ignorance
    Lack of training
    Capacity
    Lack of Group Supervision
    Capability
    Lack of facilities
    Lack of Group Supervision
    Control holes
    Lack of feedback
    Information
    Results: FeedbackLoop model of the systemic causes
  • 15. Risky Supervision
    1
    2
    6
    3
    Leadership
    3
    7
    1
    1
    2
    Unsafe practices
    4
    6
    5
    2
    Results: the activities amongst the processes overlap
    Modularize designing for common interfaces amongst overlapping processes
    Information block
    Training – routinizing
    Procedures
    Group leadership
    Resources
    Negligence
    Time
    Unsafe conditions
    7
    2
    1
    6
    1
    3
    7
    1
    7
    4
  • 16. Suggestions
    Modular designs to enhance the implementation of systemic models of HC could use the identification of hotspots
    The NHS is already modular and needs to redesign its interfaces and especially the information and control holes which include the registration and passing on of data amongst the handover, vital signs monitoring and medication processes, instead of trying to create a totally holistic information and communication system.
  • 17. Thank you
    Any Questions
  • 18. The NHS
    Many structural reforms affecting quality management
    Tried to turn a rigid unitary organization with a clear chain of command from the Health Secretary to the unit manager into a looser more flexible one, by separating into purchasers and providers.
    The result was a quasi autonomous, multidivisional form (M-form) with operational responsibilities separated from strategic responsibilities
    The model of the ‘flexible firm’ pursued in these reforms and as advocated by Atkinson (1984) has an inherent contradiction, prescribing the combination of Taylorism and functional flexibility in the same job design
  • 19. Advantages
    Disadvantages
    Managerial risks improved
    Staff interest and awareness improved
    Decline in individualism more teamwork
    Greater involvement in peer reviews and monitoring audits
    Efficiency savings
    Establishment of standards
    Quite cheap around 8% of GDP spent on NHS
    Focus on introducing concepts to managers less focus on how to implement them
    Lack of unified quality strategy which was delegated locally led to a fragmented system of various performance monitoring variations according to Trust – the system cannot be assessed holistically and the guidelines are usually vague
    Effects of reforms on quality management
    Morgan and Everett (2007)
  • 20. Disadvantages
    3. Dependence on control through performance measurements and not on cultural change and brokerage amongst professional silos
    4. Scepticism amongst professionals towards the quality systems which are perceived as a tool for cost cutting and control over their individual performance – the system is based on individual blame
    5. The implementation of additional performance criteria led to fatigue
    Morgan and Everett (2007)
  • 21. Disadvantages
    Political controversy – demand and access vs efficiency control
    Care is too often delayed, long queues and rationing
    Community based care was not fully realized
    Relations between general practice, public health and hospital based acute are fragmented
    The system works in functional compartments that leave patients unhappy and providers frustrated
    Morgan and Everett (2007)