Safety II in a large healthcare system Safety II in Practice Workshop Safety II in a large healthcare system Rollin J. “Terry” Fairbanks MD, MS Vice President, Quality & Safety, MedStar Health Founding Director, National Center for Human Factors in Healthcare Professor of Emergency Medicine, Georgetown University

Patient & Family Impact The Safety I Approach Proactive Proactive Reactive Safety Event Primary Prevention Secondary Prevention Tertiary Prevention Realities of Actual Context Design System for High Quality and Safety, Low Risk Identify and Mitigate Existing Hazards *Recover and Learn from Events *Care for Patients & Family Patient & Family Impact We found literally hundreds of predictive events in our reporting system” –Chief Pharmacy Officer, Clarion Health Oppy here- Finish thought on quality, then put stake in ground; then do safety quickly,  Oct/Nov we said– say, we need to move Maryland, now how do we do it Big picture Coming out of this with “I will statement”  review charts– don’t let this be an update make it a discussion I should not say I know the answer– say I’ll lead– what I need from dev and exexution

The Safety I Approach #2 #1 #3 Consideration of Risk To: Patients Severity of Damage #2 #1 #3 Consideration of Risk To: Patients Associates Family & Visitors Organization (Weighs impact, risks, and cost) Likelihood of Occurrence Add quality information

The Safety I Approach Primary Prevention Secondary Prevention Safety Event Tertiary Prevention Design System for High Quality and Safety, Low Risk Identify and Mitigate Existing Hazards (Safety Data Science) Recover and Learn from Events Event & Error Reports Risk Mgt /Claims Data Workers Comp AHRQ SOPS HCAPS Open & Safe Discussion Safety Huddle Notes Peer Review, OPPE Patient Complaints SSE/Near Miss Reviews Good Catch Program EMR Analytics Insurance/Risk org’s Marketing Feedback Pharmacy-Formulary/ID NRC Picker comments Google/Zocdoc/etc Follow-Up Calls Physician Satisfaction Surveys People Selection Training (initial/ongoing) Expectations/Guidelines System/Technology/Process Safety Culture Clinical Excellence Patient Satisfaction Process Design Standard Work Device Selection Built Design Event Response (CANDOR) SUO--Early Notifications Early Learning--Reviews Care for Pt & Family Optimize Care Communication Disclosure +/- apology Bill Holds Care for Caregiver Impact Change/Learning System-focused (PDCA) People-focused Learning Learning Learning Learning

Analytics Action Insights PSE Trends Insights Understand hazards Pt Complaints Prioritize response Event Reviews Qualitative Trending Quantitative Natural Language Processing Human Factors Analysis Data Visualization Clinical Review Systematize action Risk Mgt Data Action Team Assign Task Team Peer Review IP Audits Design Effective & Sustainable Solution Huddle Data Data Science & Analytics Implement Good Catch SOP, SCS Surveys Monitor now & later Vizient Also add: informart (claims data, demographics), new SSE Database: Integrate multiple databases, NLP solutions, ability to analyze freetext and unstructured and qualitative data, data visualizations.

The Safety II Approach Ransomware Story Cord Compression Story

The Safety II Approach What is necessary to do Safety II in HC environment? (or, what will prohibit it?) Leadership culture Ability to adapt