1. Reliable Process Design LS3 29 th - 30 th September

2. Reliable Process Design Aim of this session To help teams complete their improvement journey to reliability by understanding how to design reliable processes.

3. Reliable Process Design Remember this … “Reliability” is the extent of failure-free operation over time. (David Garvin – Harvard Business School)

4. Reliable Process Design We need our processes to be 95% reliable If patients are to be safe and their outcomes improved the processes that you follow must be at least reliable 95 % of the time What we want is that at least 95 % of the time the process, for example hand hygiene, will be carried out as it should be

5. Reliable Process Design Reliability Strategy Level 1 Prevent Initial Failure (Achieves 80% reliability) –Segmentation –Using intent and standardisation Level 2 Identify failure and mitigate (Achieves 95% reliability) –Human factor changes –Redundancy function Level 3 Redesign from failure modes –Identify critical failures using FMEA and then redesign prevent identify redesign

6. Reliable Process Design Level 1: Prevent Initial Failure Intent and Standardisation Common equipment Standard orders Standard rooms Memory aids, personal check lists Awareness Training Compliance –feedback

7. Reliable Process Design Why Standardise? Contributes to building an infrastructure (who does what, when, where, how and with what) Makes training and competency assessment easier Each of those involved can describe and execute the process in the same way –Opt out vs. Opt in Feedback about defects for learning further re design is possible

8. Reliable Process Design Healthcare processes Desired – variation based on clinical criteria, no individual autonomy to change the process, process owned from start to finish, can learn from defects before harm occurs, constantly improved by collective wisdom - variation Current - Variable, lots of autonomy not owned, poor if any feedback for improvement, constantly altered by individual changes, performance stable at low levels Terry Borman MD Mayo Health System

9. Why intent & standardisation is not enough… …we are all human! Factors Affecting Human Vigilance –Fatigue –Environmental Conditions –Task Design –Psychological Conditions –Competing Demands

10. Reliable Process Design Error is Inevitable Because of Human Limitations * Limited memory capacity – 5-7 pieces of information in short term memory * Negative effects of stress – error rates * Tunnel vision * Negative influence of fatigue and other physiological factors * Limited ability to multitask – mobile phones and driving

11. Reliable Process Design Level 2: Identify failure and mitigate Human factor changes and redundancy functions Decision aids & reminders –built into the system – e.g. call patients day before, using checklists and alarms Differentiation –reduce confusion –e.g. color coding, sizing parts differently Constraints –restrict or limit the performance of certain actions –e.g. petrol v diesel nozzles Affordances –provide clear visual or other sensory clues – e.g. outward opening door with push-plate and no handle

12. Reliable Process Design Identify failure and mitigate Human factor changes and redundancy functions Make desired action the default Create intentional redundancy Schedule key tasks such as discharges Take advantage of habits and patterns Agreement among doctors and nurses to follow and learn from standard processes

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

14. Reliable Process Design Where to start?

15. Reliable Process Design Identify your topic What outcome do you want to improve? What processes are linked to the outcome? Remember: S + P =O

16. Reliable Process Design Identify pilot area “Stack the cards in your favour!” Clearly identify –Who – be explicit –What - be specific –Where, and –when

17. Reliable Process Design 5 – 6 steps maximum to enable understanding of the process Identify at which step most of the defects occur (actual or hypothesised) Create a high level flow chart startfinish

18. Reliable Process Design Put it Together You have a pilot area, with an articulated process goal, a clear outcome goal connected to the process with some good medical evidence. In addition you have now set up a theoretical design using the prevent, identify, mitigate and with the knowledge of failures how to redesign Now you need to design your first test of change and Determine the tempo of change you will “dance to ”

19. Reliable Process Design The improvement journey: teams’ perspective Initial focus of work should be on “getting the process right” with a known connection to an outcome You will take a process to an agreed upon level of reliability within a specified timeline – keep going till you get there! You will use reliability design principles in improvement work, not just hard work and vigilance You will develop good designs by using rapid cycle small tests of change

20. Reliable Process Design A useful reference Obtain via the IHI website: http://www.ihi.org/IHI/Results/WhitePapers/

21. Reliable Process Design In conclusion…

22. Reliable Process Design In conclusion… Any questions? After Lunch – Your examples, ideas, problems Anything else you think we should cover?