How to design reliable processes in Healthcare Moving to 95% Roger Resar MD Hilton Head June 2012

I have no financial or academic disclosures or conflict of interests regarding the content of this lecture Roger Resar MD Aug

Integrate daily goals with MDR to identify defects as a Education Baseline Feedback on compliance RT built into 1 hour scheduled vent checks as a) (Baptist Memorial, Memphis) Slide 3

Useful Reliability Definitions Chaotic process: Failure in greater than 20% of opportunities Unsustainable Design Reliability: (80 or 90%) 1 or 2 failures out of 10 opportunities Final Design Reliability Goal : (95% or better) 5 failures or less out of 100 opportunities (Understanding the reality that perfection is the enemy of reliable process design)

The Frontline Test 80% performance lacks consistent clear understanding of the process (5 front line process users can not easily articulate the process) 95% performance has some variation but 5 front line users can easily articulate the process (Articulation demands simplicity)

Which processes can we allow to be at 95%?

Advantages of the 95% Thinking Process designs do not require contingencies for every possible presentation With less complexity in process design the frontline test is more likely to be positive Moves away from the 100% goal which is unrealistic

Key Components to Reliable Process Design Process design must be less dependent on vigilance and hard work Process design metrics must focus on process reliability and not on benchmarked outcomes Process design must adhere to very specified and easily articulated standard components Process design must use a deliberate methodology to achieve articulated reliability goals

Improvement Concepts Associated with < 95% Performance (Primarily can be described as intent, vigilance, and hard work) Common equipment, standard order sheets, multiple choice protocols, and written policies/procedures Personal check lists Feedback of information on compliance Suggestions of working harder next time Awareness and training

Improvement Concepts Associated with 95% or better Performance ( Uses human factors and reliability science to design sophisticated failure prevention, failure identification, and mitigation) Decision aids and reminders built into the system Desired action the default (based on scientific evidence) Redundant processes utilised Scheduling used in design development Habits and patterns know and taken advantage of in the design Standardisation of process based on clear specification and articulation is the norm

Key Components to Reliable Process Design 1 Process design must be less dependent on vigilance and hard work Process design metrics must initially focus on process reliability and not on benchmarked outcomes Process design must adhere to very specified and easily articulated standard components Process design must use a deliberate methodology to achieve articulated reliability goals

Biology and System Resilience Protects Us Every defect in process does not necessarily lead to a bad outcome (examples: hand-washing, pneumovax administration, CT scan delayed, A1c not ordered) Cannot equate an acceptable outcome to a reliable process (benchmarks are frequently aggregate averages) If needed benchmark to best practice not aggregate averages Aim for 95% process reliability that is connected by science to a agreed upon outcome

Key Components to Reliable Process Design 2 Process design must be less dependent on vigilance and hard work Process design metrics must focus on process reliability and not on benchmarked outcomes Process design must adhere to very specified and easily articulated standard components Process design must use a deliberate methodology to achieve articulated reliability goals

Standardization vs Standard Work Standardization in health care commonly means everyone uses the same protocol but really must include standard work Little effort is made to create the standard work required to enjoy reliable process Standard work clearly articulates the who, what when where how and with what

Why Standardize? Contributes to building an infrastructure (who does what, when, where, how and with what) Support training and competency testing to sustain the process Achieve front line articulation of key processes by staff Allows the appropriate application of Evidence Based Medicine consistently Feedback about defects and application of learning to design is possible

The “Wrong Way” Standardization Strategies Expert meetings design comprehensive protocol using EBM over months of meetings The result of the expert meetings is a protocol considered by the team as a finished product Changes to the protocol are infrequently tolerated Standardized protocols are expected to be stand alone and the end of the design (one size fits all) Compliance strategy is Level 1(Vigelance and hard work) No expectations form leadership regarding reliability of the standardization process

New Standardization Strategies Standardize to provide the appropriate infrastructure (the how, what, where, who and when) The “what” we are standardizing is based on medical evidence The “how” does not need medical evidence but rather systems knowledge Initial standardized protocols are developed with small time investment by experts tested at a very small scale and frequently Changes to the protocol using frontline input in the initial stages should be required and encouraged Defects are studied and used to redesign the process

Standard Work Standard work allows for the training of new employees and the testing of current employees If 5 front line process users can describe the process you have a good chance to achieve 95% performance and to sustain the performance over time

Key Components to Reliable Process Design 3 Process design must be less dependent on vigilance and hard work Process design metrics must focus on process reliability and not on benchmarked outcomes Process design must adhere to very specified and easily articulated standard components Process design must use a deliberate methodology to achieve articulated reliability goals

The Reliability Design Strategy Prevent initial failure using intent and standardization Identify defects (using redundancy) and mitigate Measure and then communicate learning from defects back into the design process

The Design for Reliability Design TechniquesSteps 1-Identify the process to standardize 2-Segment the population to test the design for anomalies Step #1 Prevent initial failure by standardizing the process to achieve 80-90% reliability 1-Utilize a robust concept to make visible failures from step 1 after step 1 has achieved 80-90% reliability 2-Once the failure is identified, apply an action to mitigate the failure Step #2 Identify failures in step 1 and apply an action to achieve 80-90% for these failures 1-Identify common failures 2-Develop a method to measure and study failures 3-Utilize knowledge of common failures to redesign either step 1 or step 2 In either step 1 and/or step 2 detect the failures, and use the knowledge from analysis of the failures to redesign (step 3)

Integrate daily goals with MDR to identify defects as a change concept (step 1) Education as a concept Baseline Feedback on compliance as a concept Redundancy in the form of a check by RT built into 1 hour scheduled vent checks as a change concept (step 2) Example of using 80% and 95% change concepts to initially reach a reliability of 80% then additionally using a robust 95% change concept (redundancy) to reach 95% reliability in the 4 elements of the ventilator bundle (Baptist Memorial, Memphis) Example of 3 Step Design in Implementing the Ventilator Bundle

Key Questions To Analyze Testing and Implementation Key QuestionYour Evaluation Is the connection between goals and process clear? Is the design strategy primarily vigilance and hard work? Has some degree of segmentation been used to test the design? Is standard work with testing been part of the design? Is a design methodology being used? Are small tests of change being used in a rapid cycle? Is data collection rapid enough?