1. Improvement Science, Reliability and Resilience:
Engaging Leaders, Clinicians, and Front Line Staff
in Improving Quality and Safety
Dr Samer Ellahham, Chief Quality Officer, Senior Consultant, Sheikh
Khalifa Medical City, Abu Dhabi,
UAE
Dr Paul Barach, Clinical Professor, Wayne State University School of
Medicine, Detroit, Michigan, USA

2. 1
We know that patient safety is
the bedrock of quality care
Institute of Medicine: Quality Care

3. Defining the issue
§ Given current cost and quality crises, understanding, measuring, contracting and being
in control of ‘value’ is going to be crucial in the decades to come.
After Virginia Mason
Value = Appropriateness
*
Quality
Costs
Safe
Effective
Patient-centered

4. Five pitfalls which cannot be addressed effectively in isolation
• Building trust
• Conflict management
• Engagement
• Accountability
• Measurement
Interrelated and fundamental to achieving reliable performance
ethically, financially, and organizationally.

5. 4
What is A System?
n A system is “a network of interdependent
components that work together to accomplish
a shared aim”
q Every system has an aim (no aim, no system)
q Every system must be managed
q Management requires “knowledge of the
interrelationships between all the components within
the system and the people who work in it”
Deming, WE. The New Economics. 1993.
Science of Improvement—Systems

6. What do we want to achieve?
How will we measure our progress?
What changes will drive our progress?
How should we modify our latest changes?
modified from: The Foundation of Improvement by Thomas W. Nolan et. al
THE MODEL FOR IMPROVEMENT

7. Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
)
PDSA Cycles – single test
Changes that
result in
improvement
Hunches,
theories
and ideas
A
S D
P
A
S
D
P
A
S
D
P
A
SD
P
PDSA cycle - single test

8. 7 Draft 4-2-04
Pediatric Cardiovascular Surgical Care
Our aim is to improve the process of cardiovascular surgical care, starting with
the child's referral for surgery and ending with the child's first post-discharge follow-up visit.
Cardiologist
Presents Case at
Cardiac Cath
Conference
Does Child
Need
Surgery?
Cardiologist
Notifies Child/
Family About
Surgery
Child Arrives for
Surgical Clinic
Visit
Child Arrives for
Pre-Op Hospital
Visit
Child Arrives for
Surgery (day of,
unless from NICU
or PICU)
(T, W, TH)
(H&P, pre-op teaching,
schedule surgery,
reserve room for
surgery )
Child and Family
Wait in Pre-op
Holding Room
(M400)
Transport child
to OR
Family to Surgical
Waiting Room
PICU Receives
Patient
Information From
Surgery, Via NP
PICU Receives
Multiple Updates
From Surgery,
Via NP
Report (what
happened in OR,
what lines, etc.)
OR team
transports child
to PICU
Child arrives in
PICU and is
stabilized
Discharged
Home (from
PICU,
Intermediate, or
Floor)
No
Surgery
Child has
Appointment with
Cardiologist
Cardiologist
Follows-Up with
Child/Family
Nurse Sets up
PICU
First Follow-Up in Clinic
(1-2 weeks post discharge)
Cardiologist
Makes Referral
for Surgery
NP Calls Family
to Answer
Questions and
Schedule Clinic
Visit
Yes
Diagnostic
Evaluation
Complete?
Completed while
Child on Table
Yes
No
Discharge
Planning Begins -
Case Managers
Pull Census
Report
Page 2
Page 3
Pre-op events
and initial
sedation
CHD detected
prenatally, in NICU,
by pediatrician, or
other modes of
presentation
Tools for Engineering Change: FLOW CHARTS
Barach P et al. Anesthesia and Analgesia, 2007

9. Tools for Engineering Change:
Cause-and-Effect Diagram
FLINK M, ET AL 2013

10. Role of the CLINICAL MICROSYSTEM
Elements of a Microsystem?
• Core team of health professionals
• Defined population of patients
• Information, EMR & information technology
• Support staff, equipment, environment
• Processes, activities specific to accomplishing the aim
• Informal differences in culture that may have dramatic influence on
ways in which new clinical care is delivered, outcomes measured
• How we speak up
• How uptake of change and improvement is handled
Mohr J, Batalden P, Barach P. Qual Saf Health Care 2004;13 Suppl
2:34-8. ; Mohr J, Barach P, 2006; Barach P, Mohr, 2007.

11. Stages in safety culture and impact on change
CALCULATIVE
We have systems in place to
manage all hazards
PROACTIVE
Safety leadership and values drive
continuous improvement
REACTIVE
Safety is important, we do a lot
every time we have an accident
PATHOLOGICAL
Who cares as long as
we're not caught
GENERATIVE (High Reliability Orgs)
HSE is how we do business
round here

13. High Reliability Organizations
• Environment rich with potential for errors
• Unforgiving social and political environment
• Learning through experimentation difficult
• Complex processes
• Complex technology
Weick, KE and Sutcliffe, KM, 1999

14. Mindfulness and Safety in HRO’s
1. Preoccupation with failure
Regarding small, inconsequential errors as a
symptom that something is wrong; finding the
half-event
2. Sensitivity to operations
Paying attention to what’s happening on the front
line at the shop floor
3. Reluctance to simplify
Encouraging diversity in experience, perspective,
and opinion
4. Commitment to resilience
Developing capabilities to detect, contain, and
bounce-back from events that do occur
5. Deference to expertise
Pushing decision making down to the
person with the most related knowledge and
expertise

15. Part 1: Clinical and corporate governance: delivering
quality reliably
1. Per opname, per ligdag, etc. Figuur naar Nolan 2000.
Chaotic process
‘Reliable’ process
Defining the issue
The level of patient safety is often defined as the probability of administering adverse
events to a patient.
The probability of adverse events is related to the probability of errors in a process.
§ Since a healthcare process always consists of multiple steps, and every step has an
error-probability, even for a small error-probability the chances of having an error-free
process are very low.
Error
rate
Steps in process
I II III IV V VI VII
0,1 0,90 0,81 0,73 0,66 0,59 0,53 0,48
0,05 0,95 0,90 0,86 0,81 0,77 0,74 0,70
0,01 0,99 0,98 0,97 0,96 0,95 0,94 0,93
0,001 1,00 1,00 1,00 1,00 1,00 0,99 0,99
Source: Nolan, T.W. (2000). System changes to improve patient safety. British Medical Journal. 320, pp. 771-73.

16. Definition Defect rate
‘Chaotic’ processes More than two defects out of 10 (less than 80% success)
10-1 One or two failures out of 10 (80% to 90% success)
10-2 Five failures or less out of 100 opportunities (95% success)
10-3 Five failures or less out of 1,000 opportunities (99.5% success)
‘High reliability’ organizations
§ According to the leaders interviewed, a high reliability organization is an organization
that is extremely well focused on preventing failure, on expecting the unexpected.
§ A high reliability organization ensures that the errors that unavoidably will occur will not
result in catastrophic events.
§ This results in a low defect rate and a predictably outstanding performance.

17. Delivering quality reliably
§ Doctors are typically responsible for clinical excellence and Boards have no/limited
influence over quality.
§ What does ‘in control’ mean according to the interviewees?
- Methodically measuring care outcomes.
- Understanding the key drivers of these outcomes.
- Understanding how to make these outcomes best of class.
- Systematically preventing avoidable harm to patients.
We score on the top of most lists. But are we ‘in
control’ yet? No…we can do better.
Mike Harper,
Executive Dean of Clinical Practice,
The Mayo Clinic
“
“

18. Four building block towards a ‘high reliability’ healthcare organization
The definition of a high
reliability organization
extends beyond patient
safety to encompass quality
care – and ultimately value.
‘High reliability’
organizations:

19. Building block 1: A culture devoted to quality
Being satisfied with average can lead one to slowly
start to accept the most appalling levels of quality
Malcolm Lowe-Lauri,
CEO of Royal North Shore Hospital in Australia
“
§ Build trust and respect for each other’s roles.
§ Take a constructive approach to errors rather than blaming people.
§ Zero tolerance to any breaches of safety, with an aversion to being average
§ Board members should not defer to professionals.
§ Penetrate the ‘concrete floor’ separating clinicians and management.
“

20. Building block 2: Responsibility and accountability
A zero tolerance for complacency is crucial… We have
created an open, transparent, trusting culture, and if
something goes wrong we delve into it, report on it, learn
from it and share these lessons.
Mary Jo Haddad,
President and CEO,
SickKids Hospital, Toronto
“
§ Clarify responsibility for outcomes and reporting structures.
§ Patient pathways should have identifiable owners and teams.
§ The Board should set the tone by making outcomes the key objective.
§ Internal audit monitors and works to improve governance processes.
§ Front line staff know what is most important, so measures should be developed
bottom-up.
“

21. Building block 3: Optimizing and standardizing processes
Guidelines are typically forgotten half of the time, so we
made standardization the automatic, default way of doing
things around here.
Brent James,
Chief Quality Officer,
Intermountain Healthcare, US
“
§ There is deep resistance towards standardization in healthcare.
§ Standard operating procedures provide a foundation for clinicians to apply finer
clinical analysis.
§ Align measurement, roles and culture, and introduce standard pathways and
operating procedures.
§ Apply evidence-based, user-friendly processes, with scrutiny and double checks.
“

22. Building block 4: Measurement
We constantly face the issue of limited documentation, yet
we work around that, and obtain data through different
methods. We measure to improve, to be better than the rest.
Dr. Panigrahi,
Head of Medical Operations,
Fortis Healthcare, India
“
§ Measurements must relate to patient outcomes such as prevention practices, re-
admissions, length-of-stay and satisfaction.
§ Data should be fed back to the owners of clinical pathways to enable continuous
improvement.
§ Over-measurement can cause data overload.
§ International benchmarking should raise standards.
§ IT is vital – but lack of IT infrastructure is no excuse for lack of measurement.
“

23. Towards a ‘high reliability’ organization
Phase 0: Unrestrained
individual autonomy of
professionals.
Phase 1: Constrained
individual autonomy.
Phase 2: Constrained
collective autonomy
(teams).
Phase 3: Teams with
strong situational
awareness.
Most healthcare
organizations are in
stages 0 or 1.

24. Conclusions from leading providers interviewed
§ Being in-control of quality can cut costs dramatically and is the surest way to
delivering high value healthcare.
§ The journey is an evolutionary process and none of the organizations felt they had
really become a high-reliability organization in all its dimensions.
§ Many of the organizations interviewed are at stage 2 reliability, 'collective
professionalism' with none of them fulfilling the characteristics of a high-reliability
organization.
§ Within organizations, variations occur (e.g. higher reliability in the OR and ICU) than
other departments that may be operating at Phase 1.
§ Yet, professionals, regulators and the public aspire that acute hospitals function at
Phase 2, with high risk processes such as the OR, ICU, ED at phase 3.

25. The tension between internal and external reporting
§ The number of required measures is expanding rapidly.
§ Many regulatory measures are considered irrelevant, wasting time
and resources.
§ Measures are often too detailed and low-level, and do not paint a
picture of the overall value of care.
When Boards or regulators have too limited a focus on
measures, the whole dashboard may be green while the house
is on fire
Neil Thomas,
Audit Partner,
KPMG in the UK
“
“

26. Conclusion: Characteristics of a high reliability healthcare system
§ Achieving and measuring outcomes and safety is systematic.
§ Teams – not individuals – should be responsible for quality, with standardized
processes.
§ Internal and external measurements and reporting converge around what is best
for the patient.
§ Common international standards for care – and for auditing.

27. .
Conclusion: 10 actions towards high reliability
Embrace the 4 building blocks: measurement; responsibility and accountability; culture; process
optimization and standardization.
1
Measure outcomes that matter most to patients.2
Give individuals responsibility for clinical and financial outcomes.3
Align measurement with care pathways and lines of reporting.4
Zero tolerance to complacency.5
Adopt appropriate IT to optimize measurement and processes.6
External reporting should be simpler and cover important patient outcomes.7
Risk-adjust measurements, to enable better benchmarking.8
Provide independent assurance via internal and external audits.9
Certification is often the most appropriate way to assure safety.10

29. Keys to creating a safe organization
1. Measure the right processes and safety outcome measures at the right level.
2. Align these measures with clear responsibilities and accountabilities for safety.
3. Combine zero tolerance with an openness to learning.
4. Make processes secure, and owned by staff with appropriate authority.

30. Five pitfalls which cannot be addressed effectively in isolation
• Building trust
• Conflict management
• Engagement
• Accountability
• Measurement
Interrelated and fundamental to achieving reliable performance
ethically, financially, and organizationally.

31. Small Group Exercise: Crate and Review
Engagement Plans

32. Reflective Journaling Questions
Write a thoughtful paragraph or two about what
you learned from today’s experience. Some
possible questions to address:
• What did you learn about improvement and
safety?
• How will you sustain the gains?
• What are your next goals on your journey as a
change leader for improvement?

33. Please contact us at Email:
samerellahham@yahoo.com
pbarach@gmail.com