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29 April Production and Operations Management Conference Reno Nevada USA
Citation preview
Dr Maria Kapsali
04/29/2011 POMS
Improving Patient Safety
How to Use Service Modularity in
Healthcare Processes to Manage
Systemic Errors
1. Healthcare error
2. Systems approaches
3. HEPM: a complex adaptive approach
4. Modularity – complementing HCAS
Appendix: The NHS
Contents
1. professional stream: law and litigations
2. human performance stream: psychology and
engineering and includes research in ergonomics and
human factors such as cognition
Problems oversimplification as it does not capture the variability in human behaviour or
the complexity in processes
focused on individuals/groups
overlook the systemic factors linking the environment to people’s actions
Health care error literature
Advantages: enhances
collective effort, addresses
most mistakes happening in
hospital operations
Systems approaches to error
Disadvantages: at this stage
frameworks are still abstract so they
are not widely operationalizable
Focus on holes within the system but
cannot distinguish which may be
critical or not
1. the environment shapes and institutionalizes action
2. discriminate between individual errors which are
inevitable and the majority which are systemic (active vs
latent failures
3. Control the systemic through controlling organizational
processes)
Systems approaches to error
Reason, J., 1995. Understanding adverse events: human factors. Qual. Saf. Health Care, 4;80-89.
Systems approaches to error
Holzmueller, C., P. Pronovost, and R. Branson. 2004. How can we learn from incidents? Critical Connections. 3(1).
HEPM: Healthcare Error Proliferation Model opertionalizes the Swiss Cheese Model to study the
complex adaptive healthcare system in four multiple
layers/discrete locations/interfaces populated with ‘holes’
where the causes of accidents are nested.
1) organizational leadership
2) risky supervision
3) situations for unsafe practices
4) unsafe performance
Complex Adaptive Systems
Palmieri, PP.A., DeLucia, P.R., Peterson, L.T., Ott, T.E., Green, A., 2008. The anatomy and physiology of error in adverse health care events, Patient Safety and Health Care Management Advances in Health Care Management, 7: 33-68.
Methods: Data Collection
Ward Data Collection Industry Data Collection
• Expert Interviews to determine the systemic causes (holes) of medical errors
• Interviews and site visits to industrial settings with similar systems holes
Design and test solutions
• Development of design briefs based on ideas from industries about systems causes
• Testing of final solutions in surgical wards
EPSRC Project: Design Out Medical Error
The five processes are: handwashing, handover, vital signs monitoring, infection control and medication
•FMEAs through focus groups to determine the most frequent medical errors in the ward processes
•Observations in the wards
Methods: Data analysis
1. Find ‘hotspots’ = critical
activities where most
harmful errors happen
2. Find which hotspots
overlap amongst the five
ward processes and are
systemic
3. Find ways to simplify or
standardise these activities
to eliminate erroneous
actions
• Identification of hotspots through:
processes maps; Combined FMEA
results – Pareto
• Use Fishbone and HEPM through
mind maps and causal chains from
content analysis
• Identification of the critical
interfaces in the adaptive complex
ward processes
• Suggestions how to modularize the
processes
Results (29 hotspots within all 5 processes)
Results: identifying the systemic causes
Handover Infection
control
Handwash Vital Signs
Monitoring
Medication
Design of wards-
buildings
Training system
and controls –
infection audits
not effective
Design of reminders
+ lack of control +
standardization (5
Moments)
Problem
standardizing the
measurements
Information accuracy
Systemic controls
through admin
information systems
Lack of
detectability of
infection
lack of systemic
controls
Staff management
Complex workforce
Logistics
Training system and
audit controls
Lack of
equipment
Training system and
controls
Training system and
controls
Technology error
Lack of information
due to admin – (from
training and notes)
Built = location +
Lack of information –
(from training and
notes)
Built = location +
Lack of information –
(from training and
notes)
Staff management
Training system and
controls
Lack of information
(from training and
notes)
Results: HEPM Root Cause Analysis – the systemic causes
Unsafe
performance
Risky Supervision Leadership
Unsafe conditions
Lack of effective
visual directions
information 'holes'
Lack of improvement
culture Avoid personal
responsibility
Ignorance
Emphasis on operational
cost and time metrics
Supervising low level -
little on the job training
Elaborate procedures
Negligence
Time
Human resource is
not invested upon
Lack of training
The Built Environment - lack of
equipment and inhibiting space
Focus on satisfying the
funders not the patients
Process
Reliability
Errors
Leadership-
design
Controls
Capacity
Performance
control
procedures
holes
Lack of facilities
Unsafe
Performance
Lack of training
Fear of blame
Time Pressure
Ignorance
CostNegligence
of important
Information
Lack of Group
SupervisionCapability
Control holes
Information
Lack of
feedback
Lack of Group Supervision
Results:
Feedback
Loop model of
the systemic
causes
Results: the activities amongst the processes overlap Modularize designing for common interfaces amongst overlapping processes 1. Information block
2. Training – routinizing3. Procedures 4. Group leadership 5. Resources 6. Negligence 7. Time
Unsafe conditions
1
7
3
4
6
2
Risky Supervision
Unsafe practices
Leadership
1
1
2
2
2
3
4
5
6
6
73
1
1
1
7
7
Suggestions
Modular designs to enhance the implementation of systemic
models of HC could use the identification of hotspots
The NHS is already modular and needs to redesign its
interfaces and especially the information and control holes
which include the registration and passing on of data
amongst the handover, vital signs monitoring and
medication processes, instead of trying to create a totally
holistic information and communication system.
Thank you
Any Questions
The NHS
• Many structural reforms affecting quality management
• Tried to turn a rigid unitary organization with a clear chain of
command from the Health Secretary to the unit manager into
a looser more flexible one, by separating into purchasers and
providers.
• The result was a quasi autonomous, multidivisional form (M-
form) with operational responsibilities separated from
strategic responsibilities
• The model of the ‘flexible firm’ pursued in these reforms and
as advocated by Atkinson (1984) has an inherent
contradiction, prescribing the combination of Taylorism and
functional flexibility in the same job design
Advantages • Managerial risks improved
• Staff interest and awareness
improved
• Decline in individualism more
teamwork
• Greater involvement in peer
reviews and monitoring
audits
• Efficiency savings
• Establishment of standards
• Quite cheap around 8% of
GDP spent on NHS
Disadvantages 1. Focus on introducing concepts
to managers less focus on how
to implement them
2. Lack of unified quality strategy
which was delegated locally
led to a fragmented system of
various performance
monitoring variations
according to Trust – the
system cannot be assessed
holistically and the guidelines
are usually vague
Effects of reforms on quality management
Morgan and Everett (2007)
Disadvantages
3. Dependence on control through performance measurements
and not on cultural change and brokerage amongst professional
silos
4. Scepticism amongst professionals towards the quality systems
which are perceived as a tool for cost cutting and control over
their individual performance – the system is based on individual
blame
5. The implementation of additional performance criteria led to
fatigue
Morgan and Everett (2007)
Disadvantages
3. Political controversy – demand and access vs efficiency control
4. Care is too often delayed, long queues and rationing
5. Community based care was not fully realized
6. Relations between general practice, public health and hospital
based acute are fragmented
7. The system works in functional compartments that leave
patients unhappy and providers frustrated
Morgan and Everett (2007)