© NHS Improving Quality 2014
Reliability by Design
Patient Safety Team - NHSIQ
© NHS Improving Quality 2014
Today
• Recap on reliability
• Learn from efforts to date
• Consider human factors and reliab...
© NHS Improving Quality 2014
Homework!
• Decide on a process to work on:
• measure current reliability using a small scale...
© NHS Improving Quality 2014
Why are Processes Not Working?
• Reliance on vigilance and hard work
• Use of benchmarks and ...
© NHS Improving Quality 2014
Non-catastrophic
Processes
•Definition: Failure of the process does not lead to death or
seve...
© NHS Improving Quality 2014
Improvement Concepts Associated
with ≤ 80% Performance
• Primarily can be described as intent...
© NHS Improving Quality 2014
Improvement Concepts Associated
with 95% Performance
• Focus on human factors
• Standardised ...
© NHS Improving Quality 2014
The Way Forward –
Can Medicine be Standardised?
• What about the art of medicine?
• Patients ...
© NHS Improving Quality 2014
Why do we Vary?
• Because the patient needs variation from a
standardised process
• OR
• Beca...
© NHS Improving Quality 2014
Variation in Healthcare;
A Major Cause of Error and Harm
• Erodes reliability and quality
• C...
© NHS Improving Quality 2014
Level of Reliability
1. Get to 80% reliable in step 1 by standardising your process
• 2. Get ...
© NHS Improving Quality 2014
Practically, that means:
1. Describing your high level process and area of most defects
then ...
© NHS Improving Quality 2014
A Quick Test of Standardisation
• Choose an area:
• ask 5 members of staff how the process wo...
© NHS Improving Quality 2014
Success of Step 1
• Success is standardisation of this step: how we
do this around here
• Con...
© NHS Improving Quality 2014
Paradigms and Habits
• Stuck on an escalator
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Reliability by design

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Patient safety team, NHS Improving Quality, reliability by design

More at: http://www.nhsiq.nhs.uk/improvement-programmes/patient-safety.aspx

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Reliability by design

  1. 1. © NHS Improving Quality 2014 Reliability by Design Patient Safety Team - NHSIQ
  2. 2. © NHS Improving Quality 2014 Today • Recap on reliability • Learn from efforts to date • Consider human factors and reliability • Design a process using human factors • Using FMEA to identify where to focus • Develop a charter to accelerate your improvement work
  3. 3. © NHS Improving Quality 2014 Homework! • Decide on a process to work on: • measure current reliability using a small scale audit and asking 5 users to describe the process • familiarise yourselves with the process, observe • measure the system capability using the approach Matt described • start doing PDSAs in order to standardise to achieve 80% reliability • look back to your notes from core module to guide you in the selection of your test population and in setting the aim. • Your storyboard should reflect this work on standardisation.
  4. 4. © NHS Improving Quality 2014 Why are Processes Not Working? • Reliance on vigilance and hard work • Use of benchmarks and an acceptance of sub-optimal outcomes • Clinical autonomy, variation and permissive culture • Little deliberate design using reliability concepts
  5. 5. © NHS Improving Quality 2014 Non-catastrophic Processes •Definition: 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 • Violation and migration • There is no feedback
  6. 6. © NHS Improving Quality 2014 Improvement Concepts Associated with ≤ 80% Performance • Primarily can be described as intent, vigilance, and hard work • Written policies/procedures • Personal checklists • Feedback of information on compliance • Suggestions of working harder next time • Awareness and training
  7. 7. © NHS Improving Quality 2014 Improvement Concepts Associated with 95% Performance • Focus on human factors • Standardised process based on best available evidence • Minimised variation • Make desired action the easiest /default action • Use existing habits and patterns in system design • Design in failure prevention, identification and mitigation
  8. 8. © NHS Improving Quality 2014 The Way Forward – Can Medicine be Standardised? • What about the art of medicine? • Patients are different • This is not like making aircraft • I do not want to practice cook-book medicine • We can standardise our processes • Allows cognitive capacity to be used for those who do not fit the standardised process • Variation is based on patient need
  9. 9. © NHS Improving Quality 2014 Why do we Vary? • Because the patient needs variation from a standardised process • OR • Because the clinician does it their way on that day • OR • Because there is not a deliberately designed process
  10. 10. © NHS Improving Quality 2014 Variation in Healthcare; A Major Cause of Error and Harm • Erodes reliability and quality • Creates wide performance margins • Unreliable administrative and clinical support systems • Training bias • Permissive clinical autonomy • Can be reduced without insulting professional autonomy • Standardisation allows focus on patient variation
  11. 11. © NHS Improving Quality 2014 Level of Reliability 1. Get to 80% reliable in step 1 by standardising your process • 2. Get 80% of the failures dealt with in step 2 and 3 by designing barriers and mitigations • 80% + 80% of 20 = 96% reliability • 3. Analyse failure and redesign
  12. 12. © NHS Improving Quality 2014 Practically, that means: 1. Describing your high level process and area of most defects then choose a segment and identify the components 2. Hypothesis and PDSA to achieve 80% reliability with standardisation 3. Hypothesis and PDSA to achieve 95% reliability with barriers and mitigation
  13. 13. © NHS Improving Quality 2014 A Quick Test of Standardisation • Choose an area: • ask 5 members of staff how the process works • if you get more than 2 different answers you have a chaotic process • Example: • who administers the 0-60 minute pre-op antibiotics? • how do you check the angle of the bed head for ventilated patients? • how do we patient observations? • can you describe the central line bundle?
  14. 14. © NHS Improving Quality 2014 Success of Step 1 • Success is standardisation of this step: how we do this around here • Consensus standardisation • Reduced variation • Improved reliability • Improved safety • Improved efficiency and productivity • 80% reliability achieved
  15. 15. © NHS Improving Quality 2014 Paradigms and Habits • Stuck on an escalator

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