1. Learning From Defects Through Sensemaking Dr. Brad Winters, MD CUSP FOR SAFE SURGERY: SURGICAL UNIT-BASED SAFETY PROGRAM (SUSP) Sustainability Phase

2. Learning From Defects 2 SUSP Sustaining: Quick Administrative Announcements Dial into the conference line: – Dial in Number:1-800-311-9401 – Passcode: 5403 – Webinar URL: https://connect.johnshopkins.edu/susp_3/ https://connect.johnshopkins.edu/susp_3/ – Please contact your Coordinating Entity for these slides We will make a recording of this webinar available. Interact with us today – Type comments in the chat box – Or even better, speak up 2

3. Learning From Defects 3 SUSP Sustaining: Polling Question What is your role in your clinical area? – Surgeon – Quality Improvement practitioner – Infection preventionist – OR nurse – OR technician – Anesthesiologist – OR manager – Educator – Coordinating Entity 

4. Learning From Defects 4 SUSP Sustaining: Learning Objectives Describe difference between first-order and second- order problem solving Use the Learning From Defects (LFD) tool to perform second-order problem solving Explain how the LFD tool can be used to drive patient safety and quality improvement efforts Use the four LFD questions to develop and sustain an improvement effort

5. Learning From Defects 5 SUSP Sustaining: CUSP FOR SAFE SURGERY 1.Educate staff on the science of safety 2.Identify defects 3.Partner with a senior executive 4.Learn from defects 5.Improve teamwork and communication CUSP for Safe Surgery (SUSP) ADAPTIVE COMPONENTS OF SUSP

6. Learning From Defects 6 SUSP Sustaining: Polling Question Have you used the Learning from Defects tool? – Yes – No 

7. Learning From Defects 7 SUSP Sustaining: Problem Solving Hierarchy First-order Problem Solving Recovers for one patient, but does not reduce risks for future patients. Example: You get the supply from another area or you manage without it. Second-order Problem Solving Reduces risks for future patients by improving work processes and increasing compliance. Example: You create a process to make sure line cart is stocked with necessary equipment.

8. Learning From Defects 8 SUSP Sustaining: Problem Solving Goal: Long-term Solution 8 First-order problem solving Second-order problem solving What is the long-term impact on safety culture?

9. Learning From Defects 9 SUSP Sustaining: What Is a Defect? Anything you do not want to happen again.

10. Learning From Defects 10 SUSP Sustaining: Individual Mistake or System Failing? 10 Rather than being the main instigators of an accident, operators tend to be the inheritors of SYSTEM defects.... Their part is that of adding the final garnish to a lethal brew that has been long in the cooking. -- James Reason, Human Error, 1990 “ ”

11. Learning From Defects 11 SUSP Sustaining: LEARNING FROM DEFECTS

12. Learning From Defects 12 SUSP Sustaining: Questions for Each Defect What happened? From view of people involved Why did it happen? How will you reduce it happening again? How will you know the risk is reduced?

13. Learning From Defects 13 SUSP Sustaining: Polling Question Has your team used second order problem solving to fix defects (e.g. near misses, good catches)? – Yes – No 

14. Learning From Defects 14 SUSP Sustaining: What Happened? Reconstruct the timeline and reenact what happened Dig down to the reasoning and emotions behind actions and decisions Consider using visualization tools to break down complex defects and discover where steps go wrong – Process mapping – Diagrams – Sketches – Role playing Walk the process Tip: Take time to listen. Seek to understand rather than to judge. Ask clarifying questions and follow-up questions.

15. Learning From Defects 15 SUSP Sustaining: What Happened? Who was involved? What actions occurred? What were care team members thinking and feeling? What were patients thinking and feeling? What was happening at the same time? What happened that had a good outcome? What tools or technologies were being used and how? What Happened?

16. Learning From Defects 16 SUSP Sustaining: Why Did It Happen? Develop a “system perspective” to see the hidden factors that led to the event List all contributing factors and identify whether they harmed or protected the patient Build second-order problem solving skills necessary to learn from defects Tip: Process mapping will uncover workflow issues, but it won’t get at values, attitudes, and beliefs impacting a defect. Thinking about the “people side” of a defect is critical to understanding how to create lasting change. Critical to include adaptive teamwork concerns

17. Learning From Defects 17 SUSP Sustaining: How Will You Reduce Risk of Happening Again? Prioritize most important contributing factors and most beneficial interventions Implement principles of safe design Apply safe design principles to both technical tasks and adaptive team work Tip: Take advantage of your diverse team! Senior executive and surgeon’s big picture view of the organization and both knowledge of and access to resources Team members’ connections throughout organization Frontline staff with particular insight into the defect Tip: Take advantage of your diverse team! Senior executive and surgeon’s big picture view of the organization and both knowledge of and access to resources Team members’ connections throughout organization Frontline staff with particular insight into the defect

18. Learning From Defects 18 SUSP Sustaining: Prioritizing Interventions High Impact Low Impact Low Barrier High Barrier Think low barrier / high impact matrix

19. Learning From Defects 19 SUSP Sustaining: How Will You Reduce Risk Reoccurring? Major Contributor Minor Contributor Occurs Rarely Occurs Often Good Intervention Target Pick a contributing factor to address first

20. Learning From Defects 20 SUSP Sustaining: Principles of Safe Design Patient safety is a property of systems. Apply principles to both technical tasks and adaptive teamwork. Teams make wise decisions when input is diverse, independent and encouraged. Standardize Care Create Independent Checks Learn from Defects

21. Learning From Defects 21 SUSP Sustaining: Strongest STRENGTH OF INTERVENTION Weakest Forcing functions and constraintsAutomation and computerizationStandardization and protocolsChecklists and independent check systemsRules and policiesEducation and informationVague warnings – Be more careful! Building Resiliency into Intervention Not all interventions are created equal

22. Learning From Defects 22 SUSP Sustaining: Strive for concise, clear and relevant messages Avoid information overload in all manners of disseminating information Share a concise message with a clear focus relevant to specific audience needs Experiential learning with hands-on approach will be far more effective at motivating change than an automated email dense with data Email Blast Lecture Hands- on Training Team Meetings Not All Education Is Created Equal Either

23. Learning From Defects 23 SUSP Sustaining: How Will You Know Risks Were Reduced? Do staff know about the interventions? Are staff using the interventions as intended? Do staff believe risks were reduced? Use data driven metrics whenever possible Tip: Identify ways to measure success. Data is king, however subjective evaluations can provide valuable information. Ask your frontline staff about intervention compliance and effectiveness.

24. Learning From Defects 24 SUSP Sustaining: Share Success Stories Summarize findings and changes over time – Hospital Patient Safety Culture Survey (HSOPS) – Safety Attitudes Questionnaire (SAQ) Share - Provide updates on initiatives and success stories to maintain engagement Share de-identified analysis with others in collaborative (pending institutional approval) Tip: Make staff safety assessments (refers to asking staff how the next patient will be harmed) available at all times. The team should review feedback on an ongoing basis.

25. Learning From Defects 25 SUSP Sustaining: HOW DO WE ACHIEVE SUSTAINABILITY? Sustainability is dependent upon ongoing safety assessment exercises.

26. Learning From Defects 26 SUSP Sustaining: Gearing Up Rolling Through Wrapping Up Your team will likely have many phases of learning from defect simultaneously What’s Next?

27. Learning From Defects 27 SUSP Sustaining: NORMAL TROUBLE: TURN OVER HAPPENS Executive Exodus And Staff Turn Over

28. Learning From Defects 28 SUSP Sustaining: Turn Over Happens Personnel turnover impacts all areas of organization – Frontline staff and clinicians – Executive officers – SUSP team members Invite new team members as defects evolve Rotate existing team members as needed Cultivate a depth of people with diverse experiences and exposures

29. Learning From Defects 29 SUSP Sustaining: Key Takeaways Focus on systems, not people Prioritize Use safe design principles Go a mile deep and an inch wide rather than mile wide and inch deep Pilot test Learn from defects on a regular basis Ask staff regularly what defects need attention

30. Learning From Defects 30 SUSP Sustaining: Action Plan Review the Learning from Defects tool with your team Review a defect in your operating rooms Select one defect per month Consider using in surgical morbidity and mortality conferences Post the stories of reduced risks (with data!!) Share with others

31. Learning From Defects 31 SUSP Sustaining: References Pronovost P, Cardo D, Goeschel C, et al. A research framework for reducing patient harm. Oxford Journals. 2011;52(4): 507-513. PMID: 21258104. Bagian JP, Lee C, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv 2001;27:522-32. Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf 2006;32(2):102-108. Pronovost PJ, Wu Aw, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med 2004;140(12):1025-1033. Reason J. Human Error. Cambridge, England: Cambridge University Press, 2000. Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008;299:685-87.