1. Comprehensive Unit Based Safety Program    A webinar series for QI Managers, Nurse Leaders and others supporting healthcare improvement in Wisconsin’s hospitals    August 2013

2. A Four Part Series 2 Part I – May 14 The Science of Safety and forming the CUSP team Part II – June 11 The Staff Safety Assessment & Safety Huddles Part III – July 9 Identifying Defects Part IV – August 13 Learning from Defects

3. Learning From Defects I.Review 30 Action Items II.Learning From Defects Tool: The mini- Root Cause Analysis WHA Improvement Workbook: 1-6 to 1-7 III. Reinforcing the Approach IV. Sustain and Spread 3

4. Action Item Review – Part III 4 ACTION ITEMS Prioritize findings from the Staff Safety Assessments (if you haven’t done so already) Conduct a Barrier Assessment using the Barrier Identification and Mitigation (BIM) Toolkit for one of your findings (WHA Workbook section 5-4 and 5-5) Schedule or conduct a Culture Check-up based on your “worst” AHRQ scores (WHA Workbook section 5-2)

5. Identifying Defects Poll Did you conduct a barrier assessment? Y/N Did you conduct a Culture Check-Up? Y/N Open discussion after poll closes regarding what teams found from the above processes. 5

6. What is a Defect? Defined: Anything you do not want to have happen again 6

7. Where To Detect Defects Adverse event reporting systems Sentinel events Infection rates Complications How the next patient will be harmed? (Staff Safety Assessment) 7

8. Utilizing The Learning From Defects Tool Provides a structured approach to identify the types of systems that contributed to the defect Use as part of the CUSP team meetings Use at Morbidity & Mortality Rounds 8

9. Learning From Defects Tool - Four Questions 1.What happened? – From the view of the person involved 2.Why did it happen? 3.What will you do to reduce the chance it will occur? 4.How do you know that you reduced the risk that it will happen again? 9

10. What Happened? Reconstruct the timeline and explain what happened Put yourself in the place of those involved, in the middle of the event as it was unfolding Try to understand what they were thinking and the reasoning behind their actions/decisions Try to view the world as they did when the event occurred Source: Reason, 1990; 10

11. Why Did It Happen? Develop lenses to see the system factors that lead to the event Often result from production pressures Damaging consequences may not be evident until a “triggering event” occurs Source: Reason, 1990; 11

12. What Will You Do To Reduce The Chance It Will Occur? Prioritize most important contributing factors and most beneficial interventions Safe design principles – Standardize what we do − Eliminate defect – Create independent check – Make it visible Safe design applies to technical and team work 12

13. How Do You Know Risks Were Reduced? 13 Did you create a policy or procedure? Do staff know about the policy or procedure? Are staff using the procedure as intended? – Behavior observations, audits Do staff believe risks were reduced?

14. Learning From Defects Walk Thru Exercise 14

15. Initial Staff Safety Assessment Findings 15 4South Staff Safety Assessment Results

16. Suggested Interventions Staff had many ideas on how to reduce falls on the unit involving: Bed Side rails Patient Environment Education Process changes Communication 16

17. Incorporating The LFD Tool The next CUSP meeting the team started the Learning from Defects Tool 17

18. Section One Of The LFD Tool To answer section one the team needed to understand if there were any common themes/risk factors related to the falls on this unit. Reviewed 12 months of fall data: – 90% of falls occurred on night shift, within 1 hour of change of shift, and on weekends – Nurses reported they had forgotten to turn bed alarm back on after giving care. – Less nurses/staff around seemed to predict increased risk for fall or day shift could compensate for bed alarms off when they had more staff around 18

19. Section Two Of The LFD Tool 19

20. Summarizing Section Two Responses 20 Team factor- adequate communication during care w/ ancillary staff 55 Caregiver factor- distractions lead to patients bed alarm not turned on 55

21. Developing The Interventions 21 Add column to report sheet for patients with high fall risk 5 5 Every 4 hours staff will check Hill-Rom system to ensure bed alarms are on 5 4 Independent double check for bed alarms

22. Developing An Action Plan 22 Add column to report sheet to communicate high fall risk to ancillary staff Rosemary9/15/09 Develop checklist to allow staff to document that bed alarm on every 4 hours* Stacey 9/15/09 *Timed with shift change- 02:00, 06:45, 14:45, 18:45, 22:45 - Clerical associate responsible for checking at all times except 02:00 - Charge RN responsible for 02:00 check

23. Falls Alarm Checklist 23

24. Remember to Engage and Educate 24 Team started engaging and educating staff as soon as falls identified as defect to work on for CUSP project.

25. How Will You Know Patients Are Safer? Disclaimer information here… 25 Measureable Results

26. Monitoring Project Interventions 26 Evaluate NDNQI 10 th Percentile

27. Post Intervention Evaluation 27 Evaluate: Seven months prior to intervention Mean - 2.85 falls per 1,000 patient days Seven months after the intervention Mean - 1.33 falls per 1,000 patient days 50% reduction in falls Extremely low burden intervention

28. Getting The Word Out Summarize findings – Create a 1 page summary of 4 questions or – Case Summary Form Share within your organization Keep this available for easy future reference 28

29. Alternative To LFD Tool 29

30. 30

31. Applying Learning From Defects Elsewhere Morbidity and Mortality Conferences Select 1 or 2 meaningful cases Invite everyone who touches the process, including administrators Summarize the event Identify hazardous systems Close the loop (issue, person, follow-up) Share what you learn 31

32. 32 Testing ideas before implementing changes Change ideas Measurement Aims Model for Improvement

33. CUSP Sustainability and Spread Focus on systems and processes not people Prioritize & focus (you can’t fix everything at once) Use safe design principles Better to spend time on one case and really learn from it (Go a mile deep and inch wide rather than mile wide and inch deep) Do small tests of change before implementing (many tests) Commit to learning from one defect per quarter Answer the Learning From Defect questions (four) 33

34. Learning From Defects Homework Review the Learning From Defect tool with your CUSP team Review defects in your unit Select one defect per quarter to learn from Consider using in morbidity and mortality conferences Post the stories of risks that were reduced Share with others 34

35. Learning From Defects Resources Learning From Defects Investigation Tool Case Summary Form Learning From Defects to Enhance Morbidity and Mortality Conferences Abstract (http://ajm.sagepub.com/content/24/3/192.a bstract)http://ajm.sagepub.com/content/24/3/192.a bstract 35

36. Action Item Review – Part III 36 ACTION ITEMS Use the Learning From Defects Tool to review a defect; Document what the team learned from reviewing the defect Determine how you will continue to engage staff on the CUSP work Develop a plan to sustain CUSP work within your unit - Start with quarterly action items. Watch for the CUSP Series Evaluation Survey

37. Thank You! Questions? 37