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Essentials of Reliability in Healthcare
- 1. Quality Improvement Introduction to Reliability This material (Comp 12 Unit 3) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013. This material was updated in 2016 by Johns Hopkins University under Award Number 90WT0005. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/
- 2. Introduction to Reliability Learning Objectives • Discuss the basic concepts of reliability. • Understand what makes organizations highly reliable. 2
- 3. What Is Reliability? • “The extent to which an experiment, test, or measuring procedure yields the same results on repeated trials.” (Webster’s Dictionary) • “Reliability principles, used to design systems that compensate for the limits of human ability, can improve safety and the rate at which a system consistently produces desired outcomes.” (Nolan, T., Resar, R., Haraden, C., Griffin, F.A.) 3
- 4. Which Clinic Would You Prefer? 3.01 Chart. Courtesy of Dr. Anna Maria Izquierdo-Porrera. 4
- 5. How Do We Measure Reliability? • Reliability = # of actions that achieve the intended result ÷ total # of actions taken • Reliability is expressed as an order of magnitude. – Unstable process: more than 1–2 defects per 10 attempts. – 10-1: 1–2 defects per 10 attempts. – 10-2: 1–2 defects per 100 attempts. – 10-3: 1–2 defects per 1000. – 10-4: 1–2 defects per 10,000. – 10-5: 1–2 defects per 100,000. – 10-6: 1–2 defects per 1,000,000. – And so on. 5
- 6. Examples of Reliability in Health Care 3.02 Table. 6
- 7. Strategies to Improve Reliability 7
- 8. Example: Improvement of Diabetes Care • Guideline recommendation: >3 Hemoglobin A1c every 2 years. • You are tasked with improving the rate of patients being tested appropriately. • Because you are in the HIT department, you will use HIT tools to improve the reliability of the process. 8
- 9. Prevention of Failure • Strategies: – Using intent and standardization. – Segmentation. • Tools: – Basic standardization. – Best practice guidelines, tools, and techniques. – Memory aids, such as checklists. – Feedback mechanisms regarding compliance with standards. – Awareness campaigns. 9
- 10. Identification and Mitigation • Strategies – Human factor changes. • Redundancy – Independent double checks. • Tools – Reduce fatigue and distraction. – Schedule key tasks. – Take advantage of habits and patterns. – Decision aids and reminders built into the system. – Differentiation. – Constraints. – Affordances. 10
- 11. Redesign for Success • Understand where the failure is occurring. • Determine the remedy. – Failure modes: o What could go wrong? – Failure causes: o Why would the failure happen? – Failure effects: o What would be the consequences of each failure? 11
- 12. Bundles • A “bundle” is a group of interventions related to a disease process that, when executed together, result in better outcomes than when implemented individually. • Providing each element of care within a bundle leads to more reliable care for patients. 12
- 13. Example: Diabetes Care Bundles • What would you include in a diabetic bundle? • The example of a good diabetic bundle is that used to enhance reliability at CareSouth Carolina. • It includes: BMI, education, 2 HgbA1c tests, LDL test, use of statin. 13
- 14. Introduction to Reliability Summary • Designing a reliable system is a stepwise process that requires the incorporation of prevention of failure, identification and mitigation of failure, and system redesign from failure. • Different processes require different levels of reliability. 14
- 15. Introduction to Reliability References — 1 References Elgert, S. Reliability Science: Reducing the Error Rate in Your Practice. These seven principles can help ensure that your patients receive the right care at the right time every time. Fam Pract Manag. 2005 Oct;12(9):59-63. Merriam-Webster’s Dictionary. Available from: http://www.merriam- webster.com/dictionary/reliability Nolan, T., Resar, R., Haraden, C., Griffin, F.A. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. Available from: www.IHI.org Reliability: Sepsis Management Bundle. Available from: http://www.ihi.org/knowledge/Pages/Measures/ReliabilitySepsisManagementBundle.a spx When Good Enough Isn’t … Good Enough: The Case for Reliability. Institute for Healthcare Improvement. Available from:http://www.ihi.org/resources/Pages/ImprovementStories/WhenGoodEnoughIsnt GoodEnoughTheCaseforReliability.aspx 15
- 16. Introduction to Reliability References — 2 Charts, Tables, Figures 3.01 Chart: Which Clinic Would You Prefer? Courtesy Dr. Anna Maria Izquierdo-Porrera. 3.02 Table: Examples of Reliability in Health Care. Courtesy Dr. Anna Maria Izquierdo- Porrera. Images Slide 7: Strategies to Improve Reliability. Adapted from Nolan, T., Resar, R., Haraden, C., Griffin, F.A. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. Available from: www.IHI.org 16
- 17. Quality Improvement Introduction to Reliability This material (Comp 12 Unit 3) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013. This material was updated in 2016 by Johns Hopkins University under Award Number 90WT0005. 17
Editor's Notes
- Welcome to Quality Improvement: Introduction to Reliability.
- The Objectives for Introduction to Reliability are to: Discuss the basic concepts of reliability. Understand what makes organizations highly reliable.
- In its most basic definition, reliability is the ability to get the same result when you repeat a test or process. However, when applied to health care, it includes a number of additional factors. Reliability in health care is a tool to design a safe and consistent system. It also tackles one of health care’s fallibilities: the limits of human ability.
- Consider these two hypothetical clinics. They are working on improving their patient care. Although the average is exactly the same for both clinics, Clinic 1 has a wider range. This means that although one month they do well, the following month they do much worse. Clinic 2’s range of outcomes is smaller. The graph shows the progression of the two clinics. Clinic 1 has a wide range of outcomes (from 1 to 3), and the other, Clinic 2, has a narrow range of outcomes (from 1.9 to 2.1).
- To measure reliability, divide the number of actions that achieved the intended result by the total number of actions taken. Reliability measures are presented as an order of magnitude. An unstable process is defined as a process with more than one to two defects per 10 attempts. 10-1 describes a process with one to two defects per 10 attempts and so on. Measuring reliability is also useful to describe the design of the system. The characteristics of systems that perform at 10-1, for instance, are different from those that perform at 10-3.
- The use of beta blockers for patients with acute myocardial infarction and the testing of hemoglobin A1c in diabetic patients are some of the least reliable processes. Reliability of the system improves when considering outcomes such as deaths in risky surgery, neonatal mortality, and deaths in routine anesthesia. The most reliable processes underline outcomes such as deaths from major radiotherapy machine failures or from seismic noncompliance.
- To compensate for human limitations, the IHI framework employs a three-tiered strategy. The first line of defense is to prevent the failure from occurring in the first place. The second is to identify and mitigate failure. The last step is to redesign the system.
- The guidelines for the care of diabetes recommends that all diabetic patients have their blood tested at least three times every two years for the levels of hemoglobin A1c. You work in a clinic where the rate of testing is between 70 percent and 80 percent. You are in the HIT department and have become part of the team tasked with improving the reliability of diabetes care. Although you can suggest any strategy to improve, you will be expected to focus in HIT solutions. Given the rate provided, what is the reliability of the current process? If you said “unstable process” you are correct. Why? Because if there are 10 tests with only a 70 to 80 percent reliability measurement — that means there are between two and three errors per 10 tests. Recall that we said (on slide 6) that an unstable process is defined as a process with more than one to two defects per 10 attempts.
- There’s a growing body of evidence that clinicians are distracted and interrupted constantly during the course of care, and that they can grow fatigued during prolonged shifts. Fatigue and distraction can impede them from preventing failures. There are two major strategies to prevent failure: use of intent and standardization and segmentation. There are several tools that can be used to support standardization. Basic standardization — such as using preconfigured order sheets, guidelines, and practice standards — can assist in this regard. Other tools can include techniques that support human memory such as checklists, additional training and education, and feedback mechanisms that support standards compliance. Finally, awareness campaigns can be very effective in bringing nonstandard practices to light. As an IT professional, you will be asked to assist in these efforts using technology, strategies, and tools to support prevention of failure. During the prevention of failure phase, you can also consider segmentation. A segmentation approach involves selecting a portion of the population, which can be clearly defined (e.g., disease, admission routes, physician, language, etc.) and identifying it as the target of change. The use of tools such as these can take you from an unstable process to a process that performs at 10-1 reliability — recalling that 10-1 reliability means one to two defects per 10 attempts. In order to further improve reliability, you will need to turn to identification and mitigation strategies.
- HIT offers a variety of options for identifying failure and reducing its impact. These options are aimed at changing the human factors and introducing a degree of redundancy. As we discussed previously, clinicians are distracted and interrupted constantly during the course of care. They also can grow fatigued during prolonged shifts. There is a growing body of research evidence that provides estimates of an error rate of 10-2 when people are performing under duress — even as they self-report that they believe that they are doing their best work. To be highly reliable, systems must be designed to compensate for the limits of human ability. An obvious first step to identify and mitigate is the reduction of fatigue and distraction in all individuals involved in care. The limit of the number of continuous hours a provider can work or the limitation of interruptions during decision-making moments, such as during rounds. The scheduling of key tasks is another tool to change the human factor. Meetings at the beginning of every shift or clinic day help plan for specific activities and increases reliability. Also consider taking advantage of habits and patterns. Decision aids and reminders built into the system are another tool to be used. Examples of very effective decision aids are standing orders. Differentiation of information, such as changing the color of overdue items to red, help change human factors. Finally, constraints and affordances, when built into the system, are an important aspect of identification and mitigation. Constraints make it difficult to do the wrong thing, such as alarms. Consider a system that will not allow you to prescribe a drug that is marked as a patient’s allergy until you fill two screens of information with reasons and rechecks. Affordances make the desired action the default. It is easier to do the right thing because there are clear visual and other sensory clues or electronic flags. Finally, you will add some redundancy to the system. However, redundancy needs to be added with care. You do not want to overburden your staff with repeated tasks. Examples of redundancy are independent double-checks. They are used for processes that represent a higher risk, such as transfusions or amputations, and thus require a higher reliability.
- Finally, high-reliability organizations redesign for success. They understand where the failure in the system is occurring (through analytic methods such as root cause analyses) and determine the remedy. It’s absolutely critical that we understand where the failure is occurring so that we can figure out the remedy. You may have heard early reports of a particular brand of automobile that was accelerating suddenly when their drivers insisted that they were in parking gear. Some of these runaway cars killed or injured people, so the manufacturers redesigned their gearboxes so that the cars couldn’t be taken out of park unless the driver’s foot is on the brake. Even if the driver is confused, the car will not let him make a mistake. Just think how many more people would have been injured or killed if the company had decided to argue incessantly about who or what was at fault!
- For example, you might be asked to recommend IT solutions to prompt clinicians to ensure that they implement the ventilator bundle for all mechanically ventilated patients. A “bundle” is a group of interventions for particular patient populations that, when executed together, result in better outcomes than when implemented individually. The ventilator bundle requires that we elevate the head of the bed of the patient 30 degrees, that we have daily vacations from sedation and assessment of the patient’s readiness to extubate, measures to prevent stomach ulcers and blood clots, and daily mouth care. Providing each element of care within a bundle leads to more reliable care for patients. Your assistance in finding the best ways to remind clinicians of these measures within the electronic health record will be invaluable.
- You could truly incorporate a number of measures into a bundle for diabetic care. A good example is the work of CareSouth Carolina. CareSouth Carolina is a private, nonprofit health and human services provider located in the Pee Dee region of South Carolina. They have conducted transformational work ensuring reliability of a significant amount of their processes. Their diabetic bundle includes: recording body-mass index (BMI), diabetes mellitus (DM) education, two hemoglobin A1c (HbA1c) measures in past year, LDL cholesterol measure in last year, and patients on statin (if over 40). Essentially, in building a bundle, you should ask yourself, “I know checking two hemoglobin A1c will help me meet guidelines, but which changes will help me improve their morbidity and mortality when used in combination?”
- This concludes Introduction to Reliability. In summary, designing a reliable system is a stepwise process that requires the incorporation of prevention of failure, identification and mitigation of failure, and system redesign from failure. We have also learned that different processes require different levels of reliability.
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