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The Science of Patient Safety Dr. Mohamed Mosaad Hasan MD, MPH, CPHQ, CPPS, GBSS
Objectives Outline major principles for systems thinking and reliable design Describe human error categories and explain ways in which human factors engineering impacts safe process design Differentiate improvement models that have been utilized outside and inside of the healthcare industry
CASE #1 35 year old male Seeking opthamology referral Lab results for a different patient were reviewed
CASE #2 • 52 year old patient • History of GI bleeds and ulcers • Prescribed an NSAID
Hazards • Hazard activities (i.e., behaviors) or conditions that pose threat of harm • Sometimes hazards lie hidden in the system, and sometimes they are quite obvious
Healthcare World before 1999-2000 • Quality/safety assumed to be excellent. • No business case to improve safety/quality. • No local expertise, research or best practices. • Little concerted effort by board, C-suite or physicians to improve quality/safety • Combination of wrong mental model and no incentive leads to predictable results
Healthcare World Now • Growing business case for safety/quality • Steady progression from relatively weak pressures (social pressure, accreditation w/ low chance to fail, transparency), eventually settling on “all of the above” plus payment changes • Capacity building: people, tools, measures and IT • Transition from quality/safety to value • Recognition of need to remake delivery system to survive/succeed in new healthcare world
Why Is This So Hard? • Medicine is complex • High degree of uncertainty • Care across the continuum is challenging • Diversity of workforce and complexity of patients
Definition of Insanity Insanity: doing the same thing over and over again and expecting different results. Albert Einstein
Error Causation and Prevention Most preventable harm to patients receiving healthcare today is caused by the unsafe acts of the various Practitioners who are trying to help them.
Human Error – James Reason
Systems Thinking Refers to thinking in terms of: Interdependencies Interactions Sequences
Systems Thinking Provides a conceptual framework to help see and understand relationships Helps to avoid simplistic solutions to complex problems Focus on interdependencies
Reliability Science Definition of Reliability: “the extent to which an experiment, test, or measuring procedure yields the same results on repeated trials” By Institute for Healthcare Improvement “Failure free operation over time” Relation to IOM’s aims: effectiveness, timeliness, and patient-centeredness.
High Reliability Organization (HRO) Organizations despite functioning in complex, hazardous environments, have very low error rates Examples: airline industry, nuclear power, chemical plants, aircraft carriers. One small error can lead to catastrophic consequences for not only the employees but also for the general public.
PRINCIPLES OF RELIABILITY SCIENCE Anticipation: used to detect an error before it occur. Containment: control the consequences of errors
Checklists and other Systems Let me read your order Back to you.
The Culture of Low Expectations “We suspect that these physicians and nurses had become accustomed to poor communication and teamwork. A ‘culture of low expectations’ developed in which participants came to expect a norm of faulty and incomplete exchange of information [which led them to conclude] that these red flags signified not unusual, worrisome harbingers but rather mundane repetitions of the poor communication to which they had become inured.” Drs. Mark Chassin and Elise Becher Annals of Internal Medicine, 2002
Human Factors • Human factors engineering focuses on human beings and their interaction with each other, products, equipment, procedures, and the environment. • Human factors leverages what we know about human behavior, abilities, limitations, and other characteristics to ensure safer, more reliable outcomes.
Forcing Functions Be more careful, or…. Redesign the breaks
Error Proofing 1. Simplification 2. Standardization 3. Reduce reliance on memory 4. Improve access to information 5. Use forcing functions and constraints
Error Proofing 6. Use visual controls 7. Leverage high-performance teams 8. Deploy redundancies 9. Eliminate environmental factors 10. Make errors more visible
PI approaches Common Characters Planned Systematic Collaborative Organization-wide
Planned ORGANIZED DOCUMENTED
Systematic PLANNING PRIORITIZATION ASSESSMENT IMPLEMENTING MAINTENANCE
ORGANIZATION WIDE ALL LEADERS ENTIRE ORGANIZATION IMPORTANT FUNCTIONS
COLLABORATIVE DEPARTMENTS SETTINGS DISCIPLINES
Model for Improvement Three Questions 1) What is the aim? 2) How will we know a change is an improvement? 3) What changes can we make that will result in an improvement?
SHEWHART (PDCA) AND DEMING MODEL (PDSA) P = PLAN D = DO (PILOT) CHECK OR STUDY ACT
36 Shewhart Cycle Plan Do Check Act Identify customer needs/expectations Describe the current process Measure and analyze data Identify improvement opportunities Identify root causes of problems Generate and choose solutions Plan and implement a pilot of the solutions Evaluate results of pilot Draw conclusions Standardize the change Monitor the change and hold the gains The Tradiotnal PDCA Model
FOCUS – PDCA MODEL F = FIND A PROBLEM O = ORGANIZE TEAM C = CLARIFY YOUR KNOWLEDGE ABOUT THE PROCESS U = UNDERSTAND SOURCES OF VARIATION S = SELECT THE PROCESS IMPROVEMENT PLAN THE NECESSARY STEPS DO ALL NECESSARY TO IMPLEMENT CHECK THE RESULT OF ACTION ACT FULLY IMPLEMENT (Useful for REDESIGN of a new process or QI)
F. O .C.U.S. Organize ad hoc (task force) team: Identify & involve stakeholders (e.g. physicians, nurses, administrative …etc) Cover all related departments to the improvement initiative Select team members who best do or know the process to be improved 40 O
F.O.C.U.S. Clarify current process & desired outcomes: Fully understand the current process by all team member Draw flow chart to clarify the process variation/problem Collect data from all affected areas relevant to process & desired outcomes 41 C
F.O.C.U.S. Understand Process Variation, Root Causes & Desired Outcomes
F.O.C.U.S. Select the best practice procedure: Analyze alternative solutions related to process improvement Choose the best solution that will achieve desired outcome Develop approval with a summary of required information about expected outcomes, resources needed, time-frame, responsibilities ..etc 43 S
P.D.C.A. Plan the improvement project:
P.D.C.A. Do the improvement project:
P.D.C.A. Check the results:
P.D.C.A. Act to hold gains or re-adjust FOCUS_PDCA
Lean Methodology LEAN: An effective approach for improving patient safety by process design that improves reliability through standard work, mitigation, and continuous improvement
Focus Area of Lean Lean: Lean pioneered by Toyota, focuses on the efficient operation of the entire value chain. Focus areas: Remove non-value added steps to: Reduce cycle time Improve quality Align production with demand Reduce inventory Improve process safety and efficiency
Core Attributes for Safe, Reliable Systems • Well-defined workflows • Mistake-proofing principles • Measurement strategy • Team members who share responsibility to provide safe, reliable care
The Science of Patient Safety • New concepts: science of error causation (“systems thinking”), complex systems, human factors, cognitive psychology, applied informatics… • New attitudes: teamwork, discipline, professionalism, balancing “no blame” with accountability, disclosure… • New skills: error analysis, leadership, change management...
“We think that the anxiety, demoralization, and sense of loss of control that afflict too many healthcare professionals today directly come not from finding themselves to be participants in systems of care, but rather from finding themselves lacking the skills and knowledge to thrive as effective, proud, and well-oriented agents of change in those systems…. A physician equipped to help improve healthcare will be not demoralized, but optimistic; not helpless in the face of complexity, but empowered; not frightened by measurement, but made curious and more interested; not forced by culture to wear the mask of the lonely hero, but armed with confidence to make a better contribution to the whole.” Berwick and Finkelstein, Acad Med, 2010