Lessons from Wildlife ;Training on Quality, Safety and High Reliability systems in Healthcare. By Dr Olasimbo Davidson

1. M 8
LESSONS
LESSONS FROM THE SERENGETI-
BEHAVIOR SHAPING FACTORS FOR
BUILDING RELIABLE SYSTEMS

2. LEARNING OBJECTIVES
 What participants will learn
 1.Participants will gain a clearer understanding of the 5 building Blocks
of Reliable systems
 2. The 5 building blocks include- Structure, Protocol, Culture,
Process and
Intuitive Environment
Participants will also-
3. learn about the different types of health system structures and how to
establish reliable structures
4.Gain valuable insights about protocols and policies and why we need
them

3. LEARNING OBJECTIVES
5.Understand components of a Quality-focused culture
and how to create a sustainable culture
6. Understand how care delivery tasks can be broken
down into healthcare processes that are designed to
reduce errors and improve patient safety
7.Learn how to create an intuitive environment which
can help us identify improvements which reduce
threats to patient safety

4. PRE-TEST- True or false
 1.
 The following are examples of health system structures that can Impact patient safety
 & clinical error prevention;-
 a.) Location of the labour room in the hospital b).piped oxygen system c). Board of Directors
d).water treatment plant
 2. When trying to prevent wrong site surgery, a hospital’s protocol or policy could include;- a.)
delegation of the surgery to only highly qualified surgeons b). Early morning surgeries only,
c). Patient to be allowed to stay awake during surgery d).pre-surgery marking on the relevant
site
 3. A Head of department desiring to promote a quality culture in her department should ;-
 a.) Ask patients to report health professionals who make mistakes b).Ensure that errors are
reported anonymously c). Reward people who suggest effective ways of improving the
quality of their work d.) hold sessions to discuss and identify the root causes of mistakes

5. PRE-TEST- True or false
 Examples of work processes that may lead to medication error prevention
include;-a).Using two people to verify prescriptions before administering an
IM or IV injection b). Separating look-alike & sound-alike medications, c).Hiring
only interns to man the pharmacy d).Ensuring that all prescriptions are sent to
the pharmacy electronically
 5. To promote an intuitive nursing care environment, the matron of a hospital
could a). Check the CCTV on the wards regularly b). Collate and discuss
preventable nursing errors daily c) Establish a staff suggestion box system
d).avoid discussing patient feedback so that her staff will not be offended

6. WHAT IS A HEALTH SYSTEM? & STRUCTURE?
A health system, also sometimes
referred to as health care system or
as healthcare system, is the
organization of people, institutions, and
resources that deliver health care
services to meet the health needs of
target populations. In some
countries, health system planning is
distributed among market participants.
Wiki
A Health system can exist at a
national, state, local government or
organizational level

7. AND a HEALTH CARE STRUCTURE?
 Every Healthcare SYSTEM has a STRUCTURE ,
 The STRUCTURE is made up of all the KEY
COMPONENTS within the HEALTH system
 According to the WORLD HEALTH
ORGANIZATION;-
 The exact configuration of services varies
from country to country,
 Also according to WHO- BASIC components
or STRUCTURES of a health system
 in all cases requires a robust financing
mechanism; a well-trained and adequately
paid workforce; reliable information on
which to base decisions and policies; well
maintained facilities and logistics/ supply
chains to deliver quality medicines and
technologies.
Structure of a health
system

8. Lessons from the Serengeti- What are these monkeys doing?? What key
behaviors demonstrated here can also help us improve safety structures in healthcare?

9. TWO LESSONS- SEARCHING MUST PRECEDE FINDING & TWO PAIRS OF
EYES are BETTER than ONE‘
Improving Detection with Reliable SURVEILLANCE STRUCTURES in Health Care
 SURVEILLANCE IS NOT JUST ABOUT LOOKING FOR
ABNORMAL TRENDS OR ANOMALIES
 SURVEILLANCE WORKS BEST WHEN MULTIPLE
MECHANSIMS ARE IN PLACE TO ENSURE THAT
MULTIPLE HEALTHCARE PROFESSIONALS ARE
CHECKING SIMULTANEOUSLY OR IN SEQUENCE
FOR THE SAME IRREGULARITIES or ERRORS
 ONE MONKEY CHECKING ANOTHER MONKEY
WITH 10 PARASITES- HAS A 1 IN 10 Chance of
finding one parasite
 TWO MONKEYS checking the same monkey
have a 2 in 10 or 1 in 5 chance of detecting one
parasite each. Chances of detection improve by
50%
 Three monkeys checking the same monkey
have a 3 in 10 chance of detecting one parasite
each
 SURVEILLANCE IS AN INFORMATION STRUCTURE
Pharmacist 1
receives a
prescription
and checks
for
completeness,
dosage errors,
frequency etc
Pharmacist 2
cross checks
prescription
and retrieves
the
medication
from the shelf
Pharmacist 3
crosschecks
the
prescription
and the
medication
before
dispensing to
patient

10. TO RECAP - How has the Information surveillance
structure using 3 pharmacists improved error detection ?
PHARMACIST 1 is positioned to SEARCH
for & FIND
a variety of Prescribing errors including
wrong dose, wrong frequency, inappropriate
drug, wrong route, wrong combinations,
wrong timeframe etc illegible writing error
Pharmacist 2 while retrieving the
medication is checking for all of the ABOVE
plus medication expiry date, drug name
alignment with prescription, strength
alignment with prescription, packaging
errors

11. TO RECAP - How has the Information
surveillance structure using 3 pharmacists
improved error detection ?
Pharmacist 3 prior to dispensing the
medication is checking Everything
Pharmacists 1 & 2 have checked PLUS
patient identifiers to eliminate wrong
patient error, wrong drug,
contraindications error
LESSON- Surveillance structures are critical
for complex systems
A lone pharmacist working alone may
therefore pick up fewer than 1% of 15
hidden errors per task while on duty-
while the three pharmacists working in
sequence can detect approx. 75% of
hidden errors

12. Lessons from the Serengeti- What key behaviors are demonstrated
here?

13. TWO LESSONS- 1.Unidirectional teamwork improves outcomes 2, Within a TEAM,
the Strong (eg experienced) can shield the weak (eg inexperienced)

14. HOW THESE LESSONS APPLY IN HEALTHCARE- THE MULTI TEAM SYSTEM (MTS) IS A
GOVERNANCE STRUCTURE THAT IMPROVES QUALITY, SAFETY & HEALTH OUTCOMES

15. TO RECAP- A MULTI TEAM SYSTEM (MTS) IS BETTER THAN A LONE RANGER
STRUCTURE BECAUSE… …? (HINT - mention all lessons learnt so far)

16. Can you recognize the other common structures in
healthcare?

17. What about PROCESSES- the Way we get things done

18. TIME OUT !!- Process Game- team leader to select a team and
give each member the same task

19. WHAT DID WE SEE? How does this compare to the TASK OF HANDWASHING –
A task should have specific and standardized Steps or processes

20. Lessons from the Serengeti- What is the most consistent pattern of behavior in
all these lion attack scenarios?

21. Lessons – 1. Process of performance must have a standard and
2. Output is consistent when all team members comply
 A Healthcare process that controls variation and
ERRORS must be standardized
 This means that team members adopt the BEST
PRACTICE or manner of approach and ALL team
members THEN COMPLY with the agreed way
carrying out the process
 In healthcare JUST as for HANDWASHING, there
are numerous STANDARDS that have been set by
international quality agencies regarding HOW
PROCESSES of CARE should be carried out

22. Lets see the INTERNATIONAL PATIENT SAFETY GOALS as an
example

23. How do POLICIES OR PROTOCOLS HELP US BUILD
RELIABLE SYSTEMS?
 ONCE THE ORGANIZATION DETERMINES
HOW THE PROCESS SHOULD BE CARRIED
OUT ……
 THEN THE NEXT STEP SHOULD BE
DOCUMENTATION SO THAT TEAM MEMBERS
CAN REMEMBER WHAT TO DO
 AND
 SO THAT NEW MEMBERS CAN LEARN THE
WAY THE PROCESS SHOULD BE
IMPLEMENTED
 ALL DEPARTMENTS MUST HAVE POLICIES FOR
ALL THEIR MAJOR WORK PROCESSES

24. What is a Quality & SAFETY CULTURE and how does it
improve care delivery?
 Example- in Many African cultures
and Asian cultures, people have a
customized manner of greeting
 Bending over to touch the other
person’s feet or kneeling down etc
or even bowing from the waist as in
Japanese culture
 A Quality and safety culture
involves the WHOLE organization
adopting a LIFESTYLE and set of
NORMS or behaviors considered
necessary for maintaining a SAFE
environment

25. Creating an intuitive environment that improves SAFETY-
Interpret this chart-
NB This is data from a real patient safety study in 3 hospitals in Lagos
0 5 10 15 20 25 30 35 40
wrong patient given medications
wrong medical record sent to the Doctor
wrong result in patient record
Mislabelled histopath sample
wrong patient in theatre
wrong patient in radiology
wrong patient transfused with blood
wrong physiological readings in medical record
Affirmation rates for single episode and multiple episode errors related to patient identification within last 6 months
Hospital G Hospital R Hospital S

26. So what can we say?- An intuitive work environment can
only exist in a Learning environment that collects
information about errors and mistakes
INVESTIGATE ALL INCIDENTS!!!
AVOID A BLAME CULTURE!! FIND OUT THE ROOT CAUSES

27. ROOT CAUSE ANMALYSIS USING THE
FIVE WHYS
 Problem- GLORY MATERNITY AGEGE) POST PARTUM HEMORRHAGE USUALLY LEADS TO POOR
OUTCOMES IN OBYN
1ST WHY- WHY DOES THE HOSPITAL RECORD HIGH RATES OF PPH?
BECAUSE MANY PATIENTS HAVE RISK FACTORS FOR PPH
2ND WHY – WHY DOES THE HOSPITAL RECORD HIGH RATES OF PPH?
BECAUSE AT RISK PATIENTS ARE NOT IDENTIFIED DURING ANC
3RD WHY- WHY ARE AT RISK ANC PATIENTS NOT IDENTIFIED?
BECAUSE NO RISK PROFILING SYSTEM IS IN PLACE
4TH WHY- WHY IS THERE NO RISK PROFILING SYUSTEM?
BECAUSE INEXPERIENCED AUXILLARY NURSES ARE IN CHARGE OF ANC
5TH WHY- WHY ARE INEXPERIENCED AUXILLARIES IN CHARGE OF ANC?
BECAUSE THE HIRING PROCESS AND MANPOWER STRUCTURE ARE BOTH FAULTY

28. ROOT CAUSE ANALYSIS using a FISH BONE-
Think of possible root causes of errors in your structures, processes,
policies, culture & learning environment

29. SO TO IMPROVE Quality & Safety in your organization-
Remember your Lessons from the Serengeti
THANK YOU for listening !