A presentation given by international keynote speaker Dr. Stephen Muething from Cincinnati Children's Hospital, USA at the CHA conference The Journey, in October 2012.
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Dr. Stephen Muething - Can We Become High Reliability Healthcare Organisations?
1. The Journey Towards
Zero Harm
A Report from One Journeyman
Stephen E. Muething, MD
Vice President for Patient Safety
James M. Anderson Center
October 23, 2012
2. It Truly Is A Journey
Thank you to CHA, the CEO’s and
the Children’s Hospital’s
for sharing and learning together.
3.
4.
5. 523 Bed Medical Center
32,000 Admissions/Year
1,000,000 outpatient visits
$143 million externally funded research
12,000+ employees
31,000 Surgical Procedures (20% Inpt)
17% average annual growth over past decade
National /International partnerships
6. Today’s Discussion
Using Reliability as the Guidebook:
Process Reliability
High Reliability Culture
Employee Safety
HRO Techniques
Learning Together to accelerate the journey
Next Steps on the Journey
7. Reliability: more than Safety
No needless deaths
No needless pain
No helplessness
No unwanted waiting
No waste
Don Berwick, Institute for Healthcare Improvement
Our Safety Strategy:
Eliminate all serious harm for patients
and employees by June 30th, 2015
8. Pyramid of Harm
(Patient and Employee)
Strategy: SSE’s &
Focus on the top Lost-time
of the pyramid and Injuries
progressively move down
Serious Harm Index &
OSHA Recordable Injuries
Events of Minimal to Moderate Harm &
All Employee Injuries
Near-Miss Events
Patient and Employee
9.
10.
11. Reliable Key Processes
Dozens across organization
Standardization
Sustainability built into the system
Real-time failure awareness
Data feedback to the microsystems
Making the right thing, the easy thing
23. Characteristics of
High Reliability Organizations
1. Preoccupation with failure
Regarding small, inconsequential errors as a symptom that
something is wrong; finding the half-event
2. Sensitivity to operations
Paying attention to what’s happening on the front-line
3. Reluctance to simplify
Encouraging diversity in experience, perspective, and opinion
4. Commitment to resilience
Developing capabilities to detect, contain, and bounce-back from
events that do occur
5. Deference to expertise
Pushing decision making down and around to the person with the
most related knowledge and expertise
26. Development of a
High Reliability Culture
Leadership Developing Mindfulness
• High functioning
• Aware of all harm –
microsystems
EVERYDAY
• Executive reinforcement to • Aware of all risk –
front line. CONTINUOUSLY
• Daily and shift huddles; • Harm reduction owned by
Organizational Daily Brief front line leaders
• Multiple improvements going • Learning to find the cause
on simultaneously • Alignment of the strategic
• Just culture plan with the front line
• Managing by Prediction rather
than Reaction
27. Development of a
High Reliability Culture
Error Prevention
• Behavior training
• Reinforce via Safety Coaches
• Reinforcement and accountability by supervisor
(5:1 feedback)
• Situation Awareness
– Identify - Mitigate – Escalate
28. Pyramid of Harm
(Patient and Employee)
SSE’s &
Lost-time
Injuries
Serious Harm Index &
OSHA Recordable Injuries
Events of Minimal to Moderate Harm &
All Employee Injuries
Near-Miss Events
Patient and Employee
36. James M. Anderson Center
for Health Systems Excellence
Managing By Prediction
37. James M. Anderson Center
for Health Systems Excellence
Organization Huddle
Adopted from the US Navy
The Admirals’ Huddle on a
Carrier Task Force
• Look Back
• Look Forward
• Identify and Solve Issues
Every Morning @ 9AM
38. James M. Anderson Center
for Health Systems Excellence
Cincinnati Daily Operations
Children’s Brief
Version 8:35 AM
Department
Huddles
8:00AM
Unit-Clinic-Team
Huddles
6:30-7:45AM
39. James M. Anderson Center
for Health Systems Excellence
Three Topics
• What Happened in the Previous
24 Hours?
• What’s Predicted for the Next 24
Hours?
• Issues Which Need Resolution.
40. James M. Anderson Center
for Health Systems Excellence
Departments Reporting Out on
Daily Operations Brief
Employee Safety Radiology
Inpatient & ICUs Family Relations
Surgery (Liberty too) Laboratory
Emergency Department Infection Control
(Liberty too) Supply Chain
Outpatient Information Systems
Psychiatry (A4C2 too) Protective Services
Home Health Care Facilities
Pharmacy Others
Respiratory
41. James M. Anderson Center
for Health Systems Excellence
Inpatient Huddles
43. Situation Awareness Model
Family Bedside Microsystem Organization
concerns Team
Team Team
High risk
therapies Intern
Watch Stander Rapid
Senior Resident Response
PEWS>5
Safety Team
Bedside Watch Stander
Watcher nurse (MPS and SOD)
PCF/Manager at 800, 1600 & 100
Reliable escalation of
Communication risk
concern Rapid assessment and
Attending communication with
primary team
43
46. Expanding Scope to Eliminate Harm
Across US Children’s Hospitals
(2012)
Spread
(2012)
Share network best
Create National practices with all (2012)
Children’s Network Disseminate at national
meetings (2012)
Expand network to include
26 leading children’s Develop strategies with
(2008-2011) hospitals outside Ohio national organizations
Develop Ohio Network (Phase I) (2012)
Active improvement work Add 50 hospitals (Phase II)
Initial HAC improvement work
on 10 HACs to data sharing and network
SSE reduction; efforts to learning opportunities (2013)
address organizational culture Efforts to address
organizational culture Establish other regional
Creation of pediatric patient collaboratives (2013)
harm index “All Teach, All Learn”
Develop mentor hospitals
8 33 83
54. Questions?
Thank You
stephen.muething@cchmc.org
http://cincinnatichildrens.org/andersoncenter
/
Notas del editor
Safety – YESThining evolvedMaturedPatient & EmployeeAnecdote – Psych TeamNow crossing the street – never “GET THERE”Quality – UmaCapacity/FlowOutcomesExperienceIn Common: Reliability
BaseballAmerican FootballAround 2 Million RegionCincinnati Children’s 23,000 AdmitsIM OP Visits12,500 Staff/Physicians2nd largest pediatric research center
Me: Pediatrician, Dad, SonSmall town hospitalistTactical – strategic – CCHMC elsewhere – great team
Positive approachGo home safeExperience I wantOutcomes – acute and chronicCapacity – ideal use of resourceNo approach
Journey – work our way down.SSEs: Capture and sustain attention (single digits)SHI: Expand beyond rare (100-200 year)Events: 1000-3000/yearNear Miss: 10,000-30,000
HPI – Kerry JohnsonNot either or – it’s all. Human Factors Culture Process Reliability
HPI – Kerry JohnsonNot either or – it’s all. Human Factors Culture Process Reliability
1st Level: 2001 – this was our concept.I2S2, EHR, GrowthDozens across organization – also microsystemStandardization –Sustainability built into the system – process ownersReal-time failure awareness – outcomes – process – home healthData feedback to the microsystems – monthly – weekly – dailyMaking the right thing, the easy thing - currentPolicies, supplies, job aids, technology
Microsystem:IdentifyClarifyPrioritizeFrontline – routine work, training reinforcement
ACA
All of inpatient – Over Time
Individual microsystemsColor Visual
Explain: 14 – 181 – 2012
HPI – Kerry JohnsonNot either or – it’s all. Human Factors Culture Process Reliability
Slide Owner: Steve
Definition – Vision of where we’re going
Elimination GoalModel BehaviorsAll AccountableBuilding into FabricSSE – CEO, Board ChairSenior Leader Owns EventStart every board meeting w/SafetyTrust – Transparency
Execute reinforcement – CapabilityJust Culture – ReasonLearning to find the cause – Why, why
63 – FY ‘0516 – FY ‘1016 – FY ‘1110 last year
BBPE – 1-2/weekInteraction – around 2/monthSlips/Falls – around 2/month
(note for Steve) Story of sailor knowing the mission on aircraft carrier
(note for Steve) Story of sailor knowing the mission on aircraft carrier
This is an overview of the SA model.
Slide Owner: Steve
TechnologyTasksOrganizationEnvironmentPeople in the middleInteraction designMatt Scanlon