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Aviation Technology Solutions
Reducing Healthcare ErrorsSafety Management Systems (SMS)
and Safety Risk Management
Aviation Technology Solutions
Topics
• Introductions
• About JDA
• Health Care and Aviation
• Comparative Data
• System Complexity Impact
• Heinrich Safety Triangle
• Building Safer Healthcare System
• SMS
• First Steps
• Safety Culture
• Benefits
Aviation Technology Solutions
Why Are We Here?
To engage in a dialogue and get feedback about the potential application
and benefit of Aviation‟s Safety Management System to
Healthcare Patient and System Safety Challenges.
Aviation Technology Solutions4
Aviation Technology Solutions
Similarities• Significant Infallibility Issues
• Personnel Hierarchy
• Interacting Components Working
Together
• Rapid Introduction of Complex New
Technologies
• Redundancies and Backups
• Several Links in Mishap Chains
• Response to Errors - Usually
Punishment
• Safety vs. Production and/or
Throughput
• Significant Litigation Potential
DifferencesAviation Has
• Greater Inherent Reporting
Incentive (Pilots)
• More Prescriptive, Less
Judgmental Operating
Environment
• More Media and Political Attention
– Fear of Flying
• More Robust Data Collection
Infrastructure
• Independent (Non-Adversarial)
Mishap Investigation
• Federal vs. State Law
HealthCare and Aviation
Aviation Technology Solutions
Part 121 Fatal Accident Rate
(Part 121 Onboard Fatal Accidents; 5 year moving average)
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Fa
talit
y A
ccid
en
ts p
er
10
Mill
ion
De
pa
rtu
res
83% Fatality Accident
Rate Reduction
• Regulations, Policies and Programs
• Aircraft and System Design
• Crew Resource Management
• Human Factors
• Data Collection, Analysis and Corrective Action
• Checklists
• Training
Aviation Drove Down Accident Rate
Safety Management System (SMS) Key to lowering accident rate
Aviation Technology Solutions
Human Error
PersonalFactors
600
30
10
1
Incidents
Accidents
Serious Accidents
Fatal Accident
Heinrich Safety Triangle
Mandatory Reporting
Voluntary Reporting
Culture OrganizationalProceduresTrainingEquipment
Design
Causal Factors
Aviation Technology Solutions
• Public Disclosure
• Job Sanctions and/or Enforcement
• Criminal Sanctions
• Civil Litigation
Areas That Discourage Voluntary Data Collection, Analysis, and Sharing
Aviation Technology Solutions
• More System Interdependencies Large, complex, interactive system Tightly coupled Hi-tech components Continuous innovation
• Safety Issues More Likely to Involve Interactions Between System Parts
FACILITIES
PEOPLE
MATERIALS
TOOLS
PROCEDURES
SOFTWARE EQUIPMENT
Increasing Complexity
Aviation Technology Solutions
Effects of Increasing Complexity
More “Human Error”
• System More Likely to be Error Prone• More Unanticipated Situations• Scenarios Where Non Standard Procedures No
Longer Work
Aviation Technology Solutions
HealthcareMedical Error
“Errors made by Doctors and other medical caregivers cause 44,000 to 98,000 deaths a year”
“Hospital infections , many considered preventable, take another 100,000 lives”
Mistakes involving medications injure 1.3 million patients annually in the US according to the FDA
“Avoidable failures continue to plague us in healthcare – in almost every realm of organized activity”
“The volume and complexity of knowledge today has exceeded our ability
to properly deliver it to people – consistently, correctly and safely”
“What will it take to fix healthcare? Start by getting the facts”
Aviation Technology Solutions
“If you keep doing what
you‟re doing…you‟re going
to keep getting what you
got!”
Yogi Berra
Aviation Technology Solutions
“The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into
the system.”
Institute of Medicine, Committee on Quality of Health Care in America, 1999
To Err Is Human
Building Safer Healthcare System
Aviation Technology Solutions
Institute of MedicineCommittee on Quality of Health Care in America
Recommendations
• Leadership
• Mandatory and Voluntary Error Reporting Systems
• Implement Safety Systems
• Tools
• Data
• Accountability
• Transparency
• Protocols
Aviation Technology Solutions
Safety Management System (SMS)
1. Systematic and comprehensive process for the proactive management of safety risks.
2. Integrates operations, technical services with financial and human resource management.
3. Needs to be top priority.
4. Safety culture and management commitment key!
Aviation Technology Solutions
Implementing SMS
1. Provides :
• Deal with events so valuable lessons are applied to improve safety and efficiency.
• Capacity to anticipate and address safety issues before they are incidents or accidents.
2. Instills inter-dependent culture among employees and management.
3. Reduces losses and improves productivity.
Aviation Technology Solutions
SMS Pillars
1. Safety Policy & Objectives
2. Safety Risk Management
3. Safety Assurance
4. Safety Promotion
Aviation Technology Solutions
SMS Pillar 1 Safety Policy & Objectives
• Safety Policy Senior Management’s overall safety commitment and strategy
Framework to put organization and responsibility in place.
• Safety Objectives
Leadership
Training
Measurable Safety Targets
Lessons Learned
Non-Punitive Reporting System
Aviation Technology Solutions
SMS Pillar 2Safety Risk Management (SRM)
Risk Matrix Model
• Comprehensive approach for managing risk throughout organization
• Five Phases
1. Describe the System
2. Identify Hazards
3. Determine Risk
4. Assess & Analyze Risk
5. Treat Risk
Aviation Technology Solutions
SMS Pillar 3Safety Assurance
• Continual Program Assessment• Data, management and utilization• Non-Punitive Safety Reporting System• Program audits
Internal External
• Lessons learned
Aviation Technology Solutions
SMS Pillar 4Safety Promotion
• Training & education
• Safety competency & continuous improvement
• Safety communication
• Safety culture development
Aviation Technology Solutions22
sms-demo2.com
Ability to Collect and Manage Data
All employees contribute
Aviation Technology Solutions
Safer Healthcare: Three Stage Process
Implement Safety Enhancements –
System wide
DataAnalysis
Set SafetyPriorities
Achieve consensus on
prioritiesIntegrate into
existing work and distribute
Agree onproblems and interventions
Aviation Technology Solutions
SMS First Steps
• Determine Safety Culture
Top Management Commitment
Communicate purpose/objective
Survey staff/employees
Interview representative set of employees
Collect, analyze and report results
• Conduct Safety Gap Analysis
Already in place vs. SMS
Identify strengths and shortfalls
• Compile and Report Results
• Develop SMS Plan
Good gauge of safety culture is"How we do things around here.”
Aviation Technology Solutions
Safety Culture AssessmentNeed
• Problem:
Management focuses on solving operational safety issues by
implementing process and procedural changes.
Effectiveness can be negatively affected by culture-related factors.
• Solution:
Safety Culture Assessment (SCA) conducted by Organizational
Development Specialists.
Provides both quantitative and qualitative data re: prevailing beliefs,
attitudes and behaviors within company toward safety.
Aviation Technology Solutions
Safety Culture AssessmentPurpose
• SCA identifies:
Existing safety concerns within organization.
Perceptions that may exist toward current safety
posture.
Likely amount of resistance, if any, to planned
operational change(s).
How best to build the “human” into organization‟s
mission, vision, values & objectives.
Aviation Technology Solutions
Safety Cultural Assessment Methodology
• Qualitative Data
Group and one-on-one interviews with employees at all levels of organization.
• Quantitative Data Survey Example
Online safety survey accessible to all employees.
• Reports
Written and oral presentation.
• Strategic planning
Session with management to craft action plan for addressing identified issues.
Aviation Technology Solutions
„Choose all that apply” Questions –How Staff/Employees Describe Culture
• Perceptions of safety
culture varied across
employee groups.
• Physicians saw
culture in
unfavorable terms
while other groups
were more mixed
Top 4 Safety Descriptors %
Total Excl. Physicians:
Safety conscious 41%
Under resourced 40%
Reactive 39%
Lot of analysis, little action 38%
Physicians:
Blaming 71%
Disorganized 70%
Reactive 67%
Inconsistent accountability 65%
Aviation Technology Solutions
Data Breakdown by Functional Group How Staff/ Employees Report Safety Concerns
• Employees reported
that they generally felt
comfortable reporting
safety issues.
• Of those who had
taken online survey,
60% indicated they
had reported safety
issue
Reporting
VehicleDoctors Nurses Med Techs Pharm
%
Reported83% 36% 64% 31%
„Voluntary‟ 73% 5% 94% 13%
Supervisor 21% 91% 44% 87%
Other 12% 0% 6% 6%
TOC 9% 2% 6% 3%
Hotline 2% 2% 0% 3%
Admin 20% 5% 6% 6%
Aviation Technology Solutions
How Staff/Employees Felt Mgmt Dealt
With Reported Safety Concerns
• In reporting
safety
issues,
experience
across
employee
groups
varied
Employee‟s
ExperienceDoctors Nurses Med Tech Pharm
# Respondents 448 42 16 31
Acknowledged,
but no action30% 36% 25% 32%
Felt heard 22% 48% 19% 35%
Glad I did 17% 31% 13% 35%
Indifference 22% 5% 31% 10%
Issue addressed 9% 24% 9% 19%
Blamed 9% 2% 19% 6%
Punished 5% 2% 8% 3%
Aviation Technology Solutions
Conflicting Views of
Mgmt vs. Functional Groups
31
Aviation Technology Solutions
SMS Will…
• Establish meaningful safety policies, goals and objectives• Create individual accountability for safety• Demonstrate leadership regarding safety principles• Launch processes for risk measurement, hazard
identification and mitigation• Develop collegial interactive teams & improved
communications process • Implement non-punitive reporting; encourage “lessons
learned”• Lower accidental patient deaths and incidents• Reduce injury and damage claims costs; better productivity• Lower Operating Costs
Aviation Technology Solutions
4720 Montgomery LaneSuite 950
Bethesda, MD 20814www.jdasolutions.aero
301-941-1460