1 © Sisters of Charity of Leavenworth Health System, Inc. All rights reserved.
Tom Peterson, MD
VP, Chief Safety Officer
Perinatal High Reliability :
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The Journey to High Reliability in Healthcare
Regulations – Compliance – Malpractice -Captive insurance boom
Evidence Based Guidelines – Clinical Protocols – Core Measures – IOM Report
Process improvement - Mandated measures
-NPSG’s ,HAC’s, Never events, VBP, MU
High Reliability 1980 – 1990 1990 – 2000 2010-2020 2000-2010 Generative
Safety is how we do business around here
Proactive
Safety leadership and values drive continuous improvement
Calculative
We have safety systems in place to manage all harm events
Reactive
Safety is important, we do a lot every time we have an accident
Pathological
Who cares as long as we’re not caught
776 aircraft destroyed in 1954 Fiscal Year
1.64
15 aircraft destroyed in 2008 0 10 20 30 40 50 60 50 65 80 08Angled Carrier Decks
Naval Aviation Safety Center NAMP est. 1959
RAG concept initiated
NATOPS initiated 1961
Squadron Safety program System Safety Designated Aircraft ACT HFC’s Class A Mish ap s/1 0 0 ,00 0 Fli gh t Hour s
Naval Aviation Mishap Rate
5
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Significant Events at US Nuclear Plants
Annual Industry Average, Fiscal Year 1988-2006
Significant Events are those events that the NRC staff identifies for the Performance Indicator Program as meeting one or more of the following criteria:
A Yellow or Red Reactor Oversight Process (ROP) finding or performance indicator An event with a Conditional Core Damage Probability (CCDP) or increase in core damage
probability (ΔCDP) of 1x10-5 or higher
An Abnormal Occurrence as defined by Management Directive 8.1, “Abnormal Occurrence Reporting Procedure”
An event rated two or higher on the International Nuclear Event Scale
American Construction Company – Worker Injury Rates
Other
HRO’s ……
0 2 4 6 8 10 12 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 Source: Nuclear Regulatory Commission Information Digest (1988 is earliest year data is available) Updated: November 2007American Hospitals
In Healthcare The Numbers Today Are Daunting….
In 2015…..
• 200-400,000 deaths caused each year to patients in American Hospitals¹
– 3rd leading cause of preventable death in the US
• 670,000 injuries every year to healthcare workers²
– Healthcare leads all industries in workers injuries
– 20-30 times higher than such industries as high rise construction and aluminum plants
2-Janocha JA, Smith RT. Workplace Safety and Health in the Health Care and Social Assistance Industry, 2003–07. Washington, DC: US Bureau of Labor Statistics; 2012
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© Sisters of Charity of Leavenworth Health System, Inc. All rights reserved.
Healthcare?
We lead in both preventable deaths to our customers
(patients) as well as injuries to our employees.
“Frankly, there is little guidance in the high reliability science and in the case studies. There’s very little guidance on how you get from our pretty mediocre state with quality, with respect to quality and safety. How do you get from low reliability to high reliability? So we have considered that problem and asked the question, how do we create blueprints, roadmaps, assistive devices that allow health care organizations to build toward high reliability? What would it take?”
Mark Chassin, M.D., President, The Joint Commission
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HRO Descriptions Can Be Confusing
• Sutcliffe and Weicke– “The 5 Principles”
– Mindfulness
• TJC – Chassin and Loeb
– Leadership – Culture – Process improvement • Amalberti – Accepting limits – Abandon autonomy
– Craftsman to equivalent actors
– Sharing risk vertically
– Managing visible risk
• Health and Safety Executive
– The 5 Principles – Anticipation and Containment
– Leadership
– Safety culture
– Continuous learning
• Admiral Hyman Rickover
– Rising standards over time (more than the minimum)
– Highly capable people trained over a wide range
– Leaders face bad news (mobilize effort, report up)
– Healthy respect for dangers
– Training is constant and rigorous
– All functions fit together
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High Reliability Organizing is an ongoing
process that is never perfect, complete, or
total.
They are committed to safety at the highest
level….and adopt a special approach to its
pursuit.
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It is more accurate to think about high
reliability as a
dynamic process of organizing
rather than being an “HRO”. Pursuing and
achieving reliability is a continuous, ongoing
accomplishment.
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Journey to Improving Safety & Reliability...
10-6… 10-5 10-4 10-3 10-2 10-1 Process, Protocol &Technology Resource allocation
Evidence-based practice (e.g. bundles)
Technology enablers
Focus and simplify (protocols, guidelines)
The “blunt end” barriers
Reliability Culture
Safety as the core value, Leadership commitment
A 1000 safety champions
Behavior expectations for error prevention
Collaborative Interactive Teams
Building resiliency
Mindfulness
The Mindset of Failures, Accountability
Design to Optimize Human Performance at the point of people interface:
Easyto do the right thing –impossibleto do the wrong thing
Mistake proofing/Human factors
Industry standards
The occurrence is viewed as a failure
An HRO
High reliability is a mindset – Prevention is everything
“Strong responses to all weak signals” “The occurrence is viewed as a failure”
High reliability is being resilient, responding to the needed
changes
“The responses and shared learnings are immediate, and do not alter operations” “Committed to resilience”
High reliability is always learning new ways, new skills – continuous learning
“Learning new skills, learning from events, and sharing learning” “Refuses to follow simplified processes”
High reliability exists only when leadership owns the process, fully commitment.
“The CEO (unit supervisor) knows all of his/her events” .
High reliability requires a robust safety culture.
“There is not one safety officer, there are 2000 of them”
High reliability is a journey……..
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High Reliability Examples
• Anytime someone was injured, the top executive had to report it within 24 hrs to O’Neill, and
have a plan or action so it would not happen again.
• The presidents had to hear from their VP’s as soon as an injury happened
• So the VP’s needed to be in constant communication with their floor managers…..
• ….and the floor managers had to get workers to raise warnings as soon as they saw a problem, and keep a list of suggestions nearby…
• So each unit had to build new communication systems that made it easy for the lowliest of worker to immediately get an idea to the loftiest of executives.
• The safety habits developed spilled into other areas of the organization, and the workers lives …..
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High Reliability Thinking in Sports
• The team was 12-2 the year before, finished 5th in the nation. Their defense was second best in
the nation.
A Defensive Back says this year:
• I'm part of a team, something bigger than myself,”
• "We've got to get better at tackling. We all make tackles, but we want to make every tackle. One isn't just OK, every tackle needs to be made. We've got to tackle in space and teams are gonna try to test our safeties, our secondary as a whole. They did last year and had some success with that. This year I feel like we have to better ourselves in every aspect.”
“Perfection is not attainable, but if we chase perfection,
we can catch excellence.”
The Bar Coding HRO Mindset
• One hospital set 90% as their goal for bar coding all medications with every patient before administering a medication
• Another hospital set 95% as a goal to reach but
claimed there was too much push back and excuses explained by staff of how they could not reach a higher goal.
• The next hospital set 98% as a new goal, and received significant pushback, until the CEO stepped in and said “100% is all we will accept”. Find a way to achieve it.”
• That hospital is now focused 98% bar coding and
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High Reliability in a Dietary Department
“Victory Over Injury”
• Staff made commitment to become a safety culture
– Reminders daily at every meeting about safety
– Rewards set up for lengths of time without
incidents
– Made days without incidents longer for rewards
for two years
– One year without incident reward set
• HRO methods
– Daily huddles led by supervisor
– Every day with a safety brief – read to staff,
posted on bulletin board
– Each person in the huddle every day has to
give a safety tip
– Everyone shows they have their cutting gloved
on
– Points toward a reward are given daily when
they show they have their gloves
– Days until next reward is verbalized daily and
posted in the break room
• Outcomes: 0 OSHA recordable injuries in 2 years
0 1 2 3 4 5 6 7 8 9 10 2007 2008 2009 2010 2011 2012 2013 2014 2015 Nu m b er of E ven ts P er Year
Food Services Annual OSHA and Non-OSHA Events
OSHA Events Return To Work Program Initiated Food Services Made Associate Safety and Daily Huddles a Priority
Food Services has not had an OSHA recordable event since February, 2013!!
What High Reliability is not:
ie, a quality improvement method focused on
efficiency and productivity like Six Sigma, Total Quality Management, or LEAN. Rather, high reliability is a
creation of a culture and processes that radically
reduce system failures and effectively respond when failures do occur
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Can a Perinatal Unit be Like a Commercial
Airline?
What the Airlines have done since 2001:
• 34,000 flights per day
• 0 deaths in past 15 years in large domestic carriers
• How?
– 80% of accidents due to human error
– All crew members have a say in safety issues
– Improved communication/interactions (CRM)
– Standardized procedures, checklists are valued
– Restriction on amount of time flying without sleep
– Simulators and required trainings
– Learn from near misses with increased reporting nationally
Characteristics of an HRO
What Allows for the Continuous Dynamic Organizing ?
• Leadership – all levels
• Culture
• Transparency/reporting
• Systems thinking
• Accountabilities
• Continuous learning
• Infrastructures that allow Prevention (anticipation) and Containment (resiliency – detection and correction)
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Common Causes in Perinatal Harm Events
• System complexity
• Normalization of Deviance
• Production Pressures
• Hierarchy – Hero worship
• Sleep Deprivation
• Harmful/abusive behavior
OB Safety Initiatives
Safety Culture and Reliability Roadmap
Reduce Serious Safety Events by
80%
Key Drivers (based on HRO Principles)
Problem Anticipation
Prevention
Detection
Correction
•Safety Champions (coaches) identified on
each unit
•Near Misses reviewed in safety huddles or at staff
meetings •Board rounds (Daily huddles) in MBU and L&D
Day/Night (review each patient and concerns and collaborate on plan of care)
•Handoffs in room Mindful Leadership Containment of Unexpected Events Continuous learning Culture •Daily leadership rounds with patients •Ability of Labor and Delivery to go on “OB
divert” •Safety staffing
huddles
•OB peer review program •OB metrics (Elective
Induction, exclusive breastfeeding) •System Perinatal safety
collaborative •Reporting events (Pearls)
•Debriefs
•Critical events training for all of
W&C services •NERT Training •Skills Fairs •Cause analysis Active “Debrief Program” throughout Women’s services. Debriefs happen with trained team within the shift of occurrence-Anyone
can call a debrief RCA’s
Specific Interventions and Tactics
Containment Anticipation
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Creating A Perinatal High Reliability Unit
• Trainings
– Training in cause solving
– Regular simulations (CETT, low fidelity) – Training in human error prevention – CRM or Team trainings
• Tools and Structures
– Efficient, easy reporting system
– Daily huddles (board rounds)
– De-briefs (Swarms)
– Standardized language, protocols, policies, medications
– Safety committee/coaches
– Purposeful rounding
• Safety Behaviors
– Peer checking and coaching, supporting the team – Clear communications
– Stopping in the face of uncertainty – Focus
– Always a questioning attitude
• Culture to Achieve
– Transparency, high near miss reporting rates, zero is the expectation – Shared learnings
– Lowered power distance – Multiple safety champions – Unit leadership
It Doesn’t Matter What the Occurrence or the
Department Is…
• Preventable infections • Medication error • Delay in care • Admission to hospital • Fire in the OR• Back injury to associate
• Serious preventable safety event
• Checklist use
• Power outage in IT
• Patient fall
• Hand washing
• Bar coding
• A needle stick injury
……it’s how much value you put on keeping it
from happening.
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