1. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Identifying and Mitigating Barriers and Hazards Armstrong Institute for Patient Safety and Quality Presented by: Ayse P. Gurses, PhD Assistant Professor, Human Factors Engineer

2. Learning Objectives To learn how to identify hazards/ barriers in a healthcare work system To understand how to develop a systematic approach to eliminate or reduce the effects of these barriers/ hazards Armstrong Institute for Patient Safety and Quality 2

3. Terminology Harm (adverse) events No harm events Near misses Hazard: Source of danger but does not contain any likelihood of an undesired impact Risk analysis: Detailed examination of –what hazards can happen –how likely a hazard will happen –what are the consequences, if such a hazard happens in the system Armstrong Institute for Patient Safety and Quality 3

4. Terminology Barriers: Work factors that affect the overall performance of the system. -May affect safety of care, compliance with evidence based practice, efficiency, effectiveness, profitability, quality of work life (e.g., stress, fatigue) -Hazards: a subset of barriers that affect “safety” Armstrong Institute for Patient Safety and Quality 4

5. Safety Engineering Build safety into design of health care systems Proactively identify hazards in the system before errors and accidents occur Develop risk management strategies Armstrong Institute for Patient Safety and Quality 5

6. Hazard and Barrier Identification/ Analysis Tools: Reactive Archival records Event reporting Root cause analysis Armstrong Institute for Patient Safety and Quality 6

7. Identifying Hazards and Barriers: Proactive Work system analysis or process mapping (variations, workarounds, steps skipped, etc.) Observations Interviews or focus groups Brainstorming Heuristic analysis What-if checklists Armstrong Institute for Patient Safety and Quality 7

8. What to Observe? Physical layout Disconnects and surprises (e.g., automation surprises) Distractions Ambiguities Workarounds Team behaviors (e.g. situation awareness, shared mental model) Information tool characteristics Extreme, unexpected, unfamiliar cases Feedback mechanisms Variations in conducting tasks Fit to the job (e.g., task- technology fit) Armstrong Institute for Patient Safety and Quality 8

9. Systems Engineering Initiative for Patient Safety (SEIPS) Model Carayon, P., Hundt, A.S., Karsh, B.-T., Gurses, A.P., Alvarado, C.J., Smith, M. and Brennan, P.F. “Work System Design for Patient Safety: The SEIPS Model”, Quality & Safety in Health Care, 15 (Suppl. 1): i50-i58, 2006.

10. Observation Tool for Identifying Hazards TaskPeopleToolsEnvironmentOrganizational structure AmbiguitiesWorkaroundsConsequencesRisk management strategies currently used Armstrong Institute for Patient Safety and Quality 10

11. Interviews/ Focus Groups What could go wrong? How badly will it go wrong? How do you think that patients can be harmed in this unit while taken care of? If you could change a few things in your unit to improve patient safety, what would they be? What safeguards are in place to prevent errors? Armstrong Institute for Patient Safety and Quality 11

12. Workarounds as potential barriers/hazards Armstrong Institute for Patient Safety and Quality 12

13. Barriers/ Hazards by Pictures Armstrong Institute for Patient Safety and Quality 13

14. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 How to Use This Methodology to Improve Processes of Care?

15. Compliance with Evidence-Based Guidelines Consistent compliance with evidence-based guidelines is challenging yet critical to patient safety. Need for interdisciplinary approach to improve compliance From human factors point of view: Compliance as “systems property.” GOAL: To identify and eliminate/mitigate the effects of barriers to compliance with guidelines

16. Remove unnecessary lines Wash hands prior to procedure Use maximal barrier precautions Clean skin with chlorhexidine Avoid femoral lines Evidence-based Behaviors to Prevent CLABSI

17. Steps of Barrier Identification and Mitigation Tool (BIM)* Step 1: Assemble the interdisciplinary team Step 2: Identify barriers –Observe the process –Ask about the process –Walk (simulate) the process Step 3: Summarize barriers in a Table Step 4: Prioritize barriers Step 5: Develop an action plan for each prioritized barrier. * Gurses et al. (2009) A practical tool to identify and eliminate barriers to evidence-based guideline compliance. Joint Commission Journal on Quality and Patient Safety 35(10):526-532

18. Step 2: Identify Barriers Observe the Process –Include different lenses – nurse, infection control, human factors/ QI expert conducting observations –Why is it difficult to comply? –Steps skipped, work-arounds

19. Step 2: Identify Barriers Ask about the process: Ask staff –whether they are aware of/ agree with the guideline –what some of the leading problems and barriers encountered in their unit that may hinder compliance with this guideline? –Have any suggestions to improve compliance with the guideline –Specific questions (e.g., How do you find out the date that a central venous catheter was inserted to a patient?)

20. Step 2: Identify Barriers Walk the process –Try to comply with the guideline using simulation or, if appropriate, under real circumstances. Armstrong Institute for Patient Safety and Quality 20

21. Types of Barriers Provider –Knowledge, attitude –Current practice habits Guideline-related –Applicability to patient population –Evidence supporting guideline –Ease of compliance System –Inadequate or poorly designed tools and technologies –Poor organizational structure (e.g., staffing, policies) –Inadequate leadership support –Unit/hospital culture –Inadequate feedback mechanisms –System ambiguities Other

22. Barrier Identification Form CONTRIBUTING FACTORSBARRIER(S)POTENTIAL ACTIONS Provider Current practice habits : What do you currently do (or not do)? Lines rarely discussed on daily interdisciplinary rounds Add lines section to rounding form. Guideline Ease of complying with guideline How does this guideline impact the workload? System Tools & technologies Are necessary supplies and equipment available and used appropriately? Materials (full drapes) were missing from the line cart for an afternoon procedure (cart restocked at night). Physical environment How does the unit’s layout affect compliance? MD walked through busy hallway to wash hands at closest sink before procedure. Make sinks more convenient? Performance monitoring and feedback mechanism How does the unit know it is consistently (and appropriately) applying the guideline? No mechanism to monitor central line use and provide feedback Review central line use at monthly unit meetings. Other

23. Barrier Summary and Prioritization BarrierRelation to Guideline SourceLikelihood Score * Severity Score † Barrier Priority Score ‡ Target for this QI cycle? Difficult for providers to cleanse their hands prior to performing central line insertion Hand washingObserve Ask 4312Yes Central line cart missing items (especially late in the afternoon) Full barrier precautions and clean skin with chlorhexidine Observe Walk 339Yes * Likelihood score: How likely will a clinician experience this barrier? 1.Remote 2. Occasional 3. Probable 4. Frequent † Severity score: How likely will experiencing a particular barrier lead to non-compliance with guideline? 1.Remote 2. Occasional 3. Probable 4. Frequent ‡ Barrier priority score = Likelihood score X Severity score

24. Development of Action Plan *Potential impact score: What is the potential impact of the intervention on improving guideline compliance? 0. No impact 1. Low 2. Moderate 3. High 4. Very high † Feasibility score: How feasible is it to take the suggested action? 0. Not feasible 1. Low 2. Moderate 3. High 4. Very high ‡ Action priority core = Potential impact score X Feasibility score Prioritized barriers Potential Actions SourcePotential Impact Score * Feasibility Score † Action Priority Score ‡ This QI cycle? Action Leader Performance Measure (Method) Follow- up Date Difficult for providers to cleanse their hands prior to performing central line insertion Install sinks in rooms Observe300No Place alcohol- based hand sanitizer in rooms Observe Ask Walk 4416YesKM Compliance with hand cleaning (observation) 2 months

25. Hazard/Barrier Reduction Strategies: Summary Simplify and standardize when you can –Make it easier for people to do the right thing (e.g., central line insertion cart) Create independent checkpoints Learn from mistakes and successes Think about “sustainability” of interventions Armstrong Institute for Patient Safety and Quality 25

26. References Carayon et al. (2006) Works system design for patient safety: the SEIPS model. Quality and Safety in Health Care 15: i50 - i58. Gurses et al. (2009) A practical tool to identify and eliminate barriers to evidence- based guideline compliance. Joint Commission Journal on Quality and Patient Safety 35(10):526-532 Gurses et al. (2008) Systems ambiguity and guideline compliance, Quality and Safety in Health Care 17:351-359 Gurses et al. (2010) Using an interdisciplinary approach to identify factors that affect clinicians’ compliance with evidence-based guidelines. Critical Care Medicine Forthcoming. Pronovost et al. (2008). Translating evidence into practice: a model for large scale knowledge translation. British Medical Journal 337:a1714 Thompson et al. (2008) View the world through a different lens: shadowing another Joint Commission Journal on Quality and Patient Safety 34, 614-618(5).

27. References Battles and Lilford (2003). Organizing patient safety research to identify risks and hazards. QSHC 12:ii2-ii7. DeRosier et al. (2002). Using health care failure mode and effect analysis TM. Joint Commission Journal on Quality Improvement. 28: 248-267. Marx and Slonim (2003). Assessing patient safety risk before the injury occurs. QSHC. 12:ii33-ii38. Armstrong Institute for Patient Safety and Quality 27

28. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Questions? agurses1@jhmi.edu