Dr. Stephen Muething - Can We Become High Reliability Healthcare Organisations?


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A presentation given by international keynote speaker Dr. Stephen Muething from Cincinnati Children's Hospital, USA at the CHA conference The Journey, in October 2012.

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  • Safety – YESThining evolvedMaturedPatient & EmployeeAnecdote – Psych TeamNow crossing the street – never “GET THERE”Quality – UmaCapacity/FlowOutcomesExperienceIn Common: Reliability
  • BaseballAmerican FootballAround 2 Million RegionCincinnati Children’s 23,000 AdmitsIM OP Visits12,500 Staff/Physicians2nd largest pediatric research center
  • Me: Pediatrician, Dad, SonSmall town hospitalistTactical – strategic – CCHMC elsewhere – great team
  • Positive approachGo home safeExperience I wantOutcomes – acute and chronicCapacity – ideal use of resourceNo approach
  • Journey – work our way down.SSEs: Capture and sustain attention (single digits)SHI: Expand beyond rare (100-200 year)Events: 1000-3000/yearNear Miss: 10,000-30,000
  • HPI – Kerry JohnsonNot either or – it’s all. Human Factors Culture Process Reliability
  • HPI – Kerry JohnsonNot either or – it’s all. Human Factors Culture Process Reliability
  • 1st Level: 2001 – this was our concept.I2S2, EHR, GrowthDozens across organization – also microsystemStandardization –Sustainability built into the system – process ownersReal-time failure awareness – outcomes – process – home healthData feedback to the microsystems – monthly – weekly – dailyMaking the right thing, the easy thing - currentPolicies, supplies, job aids, technology
  • Microsystem:IdentifyClarifyPrioritizeFrontline – routine work, training reinforcement
  • ACA
  • All of inpatient – Over Time
  • Individual microsystemsColor Visual
  • Explain: 14 – 181 – 2012
  • HPI – Kerry JohnsonNot either or – it’s all. Human Factors Culture Process Reliability
  • Slide Owner: Steve
  • Definition – Vision of where we’re going
  • Elimination GoalModel BehaviorsAll AccountableBuilding into FabricSSE – CEO, Board ChairSenior Leader Owns EventStart every board meeting w/SafetyTrust – Transparency
  • Execute reinforcement – CapabilityJust Culture – ReasonLearning to find the cause – Why, why
  • 63 – FY ‘0516 – FY ‘1016 – FY ‘1110 last year
  • BBPE – 1-2/weekInteraction – around 2/monthSlips/Falls – around 2/month
  • (note for Steve) Story of sailor knowing the mission on aircraft carrier
  • (note for Steve) Story of sailor knowing the mission on aircraft carrier
  • This is an overview of the SA model.
  • Slide Owner: Steve
  • TechnologyTasksOrganizationEnvironmentPeople in the middleInteraction designMatt Scanlon
  • EHR
  • Dr. Stephen Muething - Can We Become High Reliability Healthcare Organisations?

    1. 1. The Journey Towards Zero Harm A Report from One Journeyman Stephen E. Muething, MD Vice President for Patient Safety James M. Anderson Center October 23, 2012
    2. 2. It Truly Is A JourneyThank you to CHA, the CEO’s andthe Children’s Hospital’sfor sharing and learning together.
    3. 3. 523 Bed Medical Center32,000 Admissions/Year1,000,000 outpatient visits$143 million externally funded research12,000+ employees31,000 Surgical Procedures (20% Inpt)17% average annual growth over past decadeNational /International partnerships
    4. 4. Today’s Discussion Using Reliability as the Guidebook:  Process Reliability  High Reliability Culture Employee Safety HRO Techniques Learning Together to accelerate the journey Next Steps on the Journey
    5. 5. Reliability: more than Safety No needless deaths No needless pain No helplessness No unwanted waiting No waste Don Berwick, Institute for Healthcare ImprovementOur Safety Strategy: Eliminate all serious harm for patientsand employees by June 30th, 2015
    6. 6. Pyramid of Harm (Patient and Employee)Strategy: SSE’s &Focus on the top Lost-timeof the pyramid and Injuriesprogressively move down Serious Harm Index & OSHA Recordable Injuries Events of Minimal to Moderate Harm & All Employee Injuries Near-Miss Events Patient and Employee
    7. 7. Reliable Key Processes Dozens across organization Standardization Sustainability built into the system Real-time failure awareness Data feedback to the microsystems Making the right thing, the easy thing
    8. 8. Key Processes VAP Bundle CLA-BSI Bundle Pressure Ulcer Bundle Safe Medication Practices CA-UTI Bundle Etc, etc, etc………..
    9. 9. CONFIDENTIAL Real Time Failure AwarenessPatient Safety Sept. 9- Sept. 15 Employee Safety Sept 14 – Sept 20Events of Harm ISSUE PAST FY 13 FY12CA-BSI WEEK YTD YTD9/10 A5N9/10 A5S Total OSHA Recordable cases: 4 48 599/11 B6HI - Lost-Time 1 7 2VAP - Blood Borne Pathogen Exposures 1 15 189/2 B6HI (disease progressedto classify this week – effective - Slips, Trips, Falls 0 4 6date 9.2) - Patient Interaction 1 4 8SSI9/1 (upon review – met criteria Late Incident Reports 2 28 N/Afor SSI) (These are incidents called in to 803- Until OUCH beyond the day of injury) 2/23/13
    10. 10. Data Feedback To Microsystems
    11. 11. Data Feedback To Microsystems
    12. 12. Making The Right Thing, The Easy Thing
    13. 13. No aviation fatalities… No crashes… No nuclear leaks… No Serious Harm
    14. 14. Characteristics of High Reliability Organizations1. Preoccupation with failure Regarding small, inconsequential errors as a symptom that something is wrong; finding the half-event2. Sensitivity to operations Paying attention to what’s happening on the front-line3. Reluctance to simplify Encouraging diversity in experience, perspective, and opinion4. Commitment to resilience Developing capabilities to detect, contain, and bounce-back from events that do occur5. Deference to expertise Pushing decision making down and around to the person with the most related knowledge and expertise
    15. 15. Senior Leadership “Owns” Safety
    16. 16. Transparency
    17. 17. Development of a High Reliability CultureLeadership Developing Mindfulness• High functioning • Aware of all harm – microsystems EVERYDAY• Executive reinforcement to • Aware of all risk – front line. CONTINUOUSLY• Daily and shift huddles; • Harm reduction owned by Organizational Daily Brief front line leaders• Multiple improvements going • Learning to find the cause on simultaneously • Alignment of the strategic• Just culture plan with the front line• Managing by Prediction rather than Reaction
    18. 18. Development of a High Reliability CultureError Prevention• Behavior training• Reinforce via Safety Coaches• Reinforcement and accountability by supervisor (5:1 feedback)• Situation Awareness – Identify - Mitigate – Escalate
    19. 19. Pyramid of Harm(Patient and Employee) SSE’s & Lost-time Injuries Serious Harm Index & OSHA Recordable Injuries Events of Minimal to Moderate Harm & All Employee Injuries Near-Miss Events Patient and Employee
    20. 20. Employee Safety
    21. 21. Top 3:Blood Borne Pathogen ExposurePatient InteractionSlips/Trips/Falls
    22. 22. Structures & Techniques From HRO’S
    23. 23. • Pre-Briefs/Debriefs• Checklists• Flattening Hierarchy• Standardizing Communication• Huddle• Situation Awareness
    24. 24. James M. Anderson Center for Health Systems ExcellenceManaging By Prediction
    25. 25. James M. Anderson Center for Health Systems Excellence Organization HuddleAdopted from the US Navy The Admirals’ Huddle on a Carrier Task Force • Look Back • Look Forward • Identify and Solve Issues Every Morning @ 9AM
    26. 26. James M. Anderson Center for Health Systems ExcellenceCincinnati Daily OperationsChildren’s Brief Version 8:35 AM Department Huddles 8:00AM Unit-Clinic-Team Huddles 6:30-7:45AM
    27. 27. James M. Anderson Center for Health Systems Excellence Three Topics• What Happened in the Previous 24 Hours?• What’s Predicted for the Next 24 Hours?• Issues Which Need Resolution.
    28. 28. James M. Anderson Center for Health Systems ExcellenceDepartments Reporting Out on Daily Operations BriefEmployee Safety RadiologyInpatient & ICUs Family RelationsSurgery (Liberty too) LaboratoryEmergency Department Infection Control(Liberty too) Supply ChainOutpatient Information SystemsPsychiatry (A4C2 too) Protective ServicesHome Health Care FacilitiesPharmacy OthersRespiratory
    29. 29. James M. Anderson Center for Health Systems ExcellenceInpatient Huddles
    31. 31. Situation Awareness Model Family Bedside Microsystem Organization concerns Team Team TeamHigh risktherapies Intern Watch Stander Rapid Senior Resident ResponsePEWS>5 Safety Team Bedside Watch StanderWatcher nurse (MPS and SOD) PCF/Manager at 800, 1600 & 100 Reliable escalation ofCommunication risk concern Rapid assessment and Attending communication with primary team 43
    32. 32. SituationAwareness projectgo-live
    33. 33. Learning Together Start With One State
    34. 34. Expanding Scope to Eliminate HarmAcross US Children’s Hospitals (2012) Spread (2012) Share network best Create National practices with all (2012) Children’s Network Disseminate at national meetings (2012) Expand network to include 26 leading children’s Develop strategies with (2008-2011) hospitals outside Ohio national organizations Develop Ohio Network (Phase I) (2012) Active improvement work Add 50 hospitals (Phase II) Initial HAC improvement work on 10 HACs to data sharing and network SSE reduction; efforts to learning opportunities (2013) address organizational culture Efforts to address organizational culture Establish other regional Creation of pediatric patient collaboratives (2013) harm index “All Teach, All Learn” Develop mentor hospitals 8 33 83
    35. 35. Adopting Common Behaviors 48
    36. 36. Thank you Questions? stephen.muething@cchmc.orgCincinnatichildrens.org/andersoncenter
    37. 37. Human Factors
    38. 38. SEIPS Model Pascale Carayon et al.
    39. 39. Questions? Thank You stephen.muething@cchmc.org http://cincinnatichildrens.org/andersoncenter /