Brad Winters, MD May 6 , 2014

DRAFT – final pending AHRQ approval

SUSP Sustainability Phase:Learning From Defects Through

Sensemaking

Brad Winters, MD

May 6, 2014

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DRAFT – final pending AHRQ approval2

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Polling Question

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What is your role in your clinical area?– Surgeon

– Quality Improvement practitioner

– Infection preventionist

– OR nurse

– OR technician

– Anesthesiologist

– OR manager


Describe difference between first-order and second-order problem solving

Use the Learning From Defects (LFD) tool to perform second-order problem solving

Explain how the LFD tool can be used to drive patient safety and quality improvement efforts

Use the four LFD questions to develop and sustain an improvement effort

Learning Objectives


Polling Question

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Have you used the Learning from Defects tool?-Yes

-No


First-orderProblem Solving

Second-orderProblem Solving

Recovers for one patient, but does not reduce risks for future patients.

Example: You get the supply from another area or you manage without it.

Reduces risks for future patients by improving work processes and increasing compliance.

Example: You create a process to make sure line cart is stocked with necessary equipment.

Problem Solving Hierarchy

Activity: Share an example in the chat of common first-order problem solving in your work area.


What is the long-term impact on patient safety culture?

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Problem Solving Goal

First-order problem solving addresses

immediate need, but does not improve

patient safety culture

Second-order problem solving addresses future needs and improves overall

patient safety culture


Anything you do not

want to happen again.

What is a Defect?


Individual Mistake or System Failing?

Rather than being the main instigators of an accident, operators tend to be the inheritors of SYSTEM defects. . . . Their part is that of adding the final garnish to a lethal brew that has been long in the cooking.

-- James Reason, Human Error, 1990

“

”

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Questions for Each Defect

Polling Question: Has your team learned from a defect?

What happened?From view of person involved

Why did it happen?

How will you reduce it happening again?

How will you know the risk is reduced?

1234


Walk the process

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Reconstruct the timeline and reenact what happened

Dig down to the reasoning and emotions behind actions and decisions

Consider using visualization tools (ie. process mapping, diagrams, sketches or role playing) to break down complex defects and discover where steps go wrong

What Happened?

Tip: Take time to listen. Seek to understand rather than to judge. Ask clarifying questions and follow-up questions.


What Happened

?Who was involved?

What actions

occurred?

What were care team members

thinking and feeling?

What were patients

thinking and feeling?

What was happening

at the same time?

What happened that had a

good outcome?

What tools or

technologies were

being used and how?

What Happened?


Develop a “system perspective” to see the hidden factors that led to the event

List all contributing factors and identify whether they harmed or protected the patient

Instrumental in building second-order problem solving skills necessary to learn from defects

Why Did It Happen?Critical to include adaptive teamwork concerns

Tip: Process mapping will uncover workflow issues, but it won’t get at values, attitudes, and beliefs impacting a defect. Thinking about the “people side” of a defect is critical to understanding how to create lasting change.


Prioritize most important contributing factors and most beneficial interventions

Implement principles of safe design

Safe design principles apply to both technical tasks and adaptive team work

How Will You Reduce Risk of Happening Again?

Tip: Take advantage of your diverse team!• Senior Executive’s big picture view of the organization and

knowledge of resources• Team members’ connections throughout organization• Frontline staff with particular insight into the defect


Think low barrier / high impact matrix

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Prioritize Interventions

High Impact

Low Impact

Low Barrier High Barrier


Pick a contributing factor to address first

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How Will You Reduce Risk Reoccurring?


Patient safety is a property of systems.

Apply principles to both technical tasks and adaptive teamwork.

Teams make wise decisions when input is diverse, independent and encouraged.

Principles of Safe Design

Principles Of Safe Design

1. Standardize Care

2. Create Independent Checks

3. Learn From Defects


Strongest

STRENGTH OFINTERVENTION

Weakest

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Building Resiliency into Intervention

Forcing functions and constraints

Automation and computerization

Standardization and protocolsChecklists and independent check

systemsRules and policies

Education and information

Vague warnings – Be more careful!

Not all interventions are created equal.


Strive for Concise, Clear and Relevant Messages

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Avoid information overload in all manners of disseminating information

Share a concise message with a clear focus relevant to specific audience needs

Experiential learning with hands-on approach will be far more effective at motivating change than an automated email dense with data

Not All Education Is Created Equal Either

Email Blast Lecture

Hands-on

Training

Team Meetin

gs


Do staff know about the interventions?

Are staff using the interventions as intended?

Do staff believe risks were reduced?

Data driven metrics should be the goal whenever possible

How Will You Know Risks Were Reduced?

Tip: Identify ways to measure success. Data is king, however subjective evaluations can provide valuable information. Ask your frontline staff about intervention compliance and effectiveness.


Summarize findings and changes over time– Hospital Patient Safety Culture Survey (HSOPS)

– Safety Attitudes Questionnaire (SAQ)

Share - Provide updates on initiatives, goals and success stories to maintain engagement

Share de-identified analysis with others in collaborative (pending institutional approval)

Share Success Stories

Tip: Make staff safety assessments (refers to asking staff how the next patient will be harmed) available at all times. The team

should review feedback on an ongoing basis.

Valerie Hartman

I added the safety culture graph at the end of the presentation. If it can be helpful in addressing Kristina's comment, it will be easy to move. If not, delete. :)


HOW DO WE ACHIEVE SUSTAINABILITY?

Sustainability is dependent upon ongoing safety assessment exercises.

Kristina Weeks

Consider deleting this slide. We may be cutting the presenter short. It makes sense as a transition slide but doesn't have much content


Patient safety culture requires constant vigilance

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Ongoing Key Questions

Poll: Have you asked your frontline staff these questions? How often do you / they answer these questions?

How is the next patient going to be harmed?

What can I do to prevent that harm?

Your Mantra!


Your team will likely be in many phases simultaneously.

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What’s Next?

Winding Up

Rolling Through

Wrapping Up

Kristina Weeks

is there a way to make this graphic depict that teams are likely to be in 2 or more of these at the same time? these concepts make some sense


CASE STUDY: TURNOVER HAPPENS

Executive Exodus and Staff Turnover


Personnel turnover impacts all areas of organization– Frontline staff and clinicians

– Executive officers

– Team members

Invite new team members as defects evolve

Rotate existing team members as needed

CUSP teams need a depth of people with diverse experiences and exposures

Turnover Happens


CASE STUDY: RENAL TRANSPLANT

Communicating for Patient Safety


Case Study: Renal Transplant

Knowledge, Skills & CompetenceAnesthesiology attending not notified of the transfusion. Wrist band checks with stamp plate were not done at multiple points.

Unit EnvironmentNear simultaneous emergent events, change of two different provider groups at same time. No independent check.

Other FactorsHospital environment: Transfer across unitsPatient characteristics: High acuityTask characteristics: Blood check-in only as good as existing identity documents.

Create independent checks, encourage patient safety culture initiatives, add system constraints like barcoding technologies

Stagger staff changesFormalize hand-offs between departments

Ensure hand-off process supports emergencies

System FailuresOpportunities For Improvement


Focus on systems, not people

Prioritize

Use Safe design principles

Go mile deep and inch wide rather than mile wide and inch deep

Pilot test

Learn from defects on a regular basis

Answer the 4 questions

Key Takeaways


Review the Learning from Defects tool with your team

Review a defect in your operating rooms

Select one defect per month

Consider using in surgical morbidity and mortality conferences

Post the stories of reduced risks (with data!!)

Share with others

Action Plan


Bagian JP, Lee C, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv 2001;27:522-32.

Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf 2006;32(2):102-108.

Pronovost PJ, Wu Aw, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med 2004;140(12):1025-1033.

Reason J. Human Error. Cambridge, England: Cambridge University Press, 2000.

Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008;299:685-87.

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References

Documents

Brad Winters, MD May 6 , 2014