1. DRAFT – final pending AHRQ approval SUSP Sustainability Phase: Learning From Defects Through Sensemaking Brad Winters, MD May 6, 2014 1

2. DRAFT – final pending AHRQ approval 2 Quick Administrative Announcements You need to dial into the conference line: –Dial in Number:1-800-311-9401 –Passcode: 8376 –Webinar URL:https://connect.johnshopkins.edu/r33npeupiig/https://connect.johnshopkins.edu/r33npeupiig/ Please contact your Coordinating Entity for a copy of these slides if you have not already received them We will make a recording of this webinar available. We want you to interact with us today. You can: –Type comments in the chat box. –Or even better, speak up.

3. DRAFT – final pending AHRQ approval Polling Question 3 What is your role in your clinical area? –Surgeon –Quality Improvement practitioner –Infection preventionist –OR nurse –OR technician –Anesthesiologist –OR manager

4. DRAFT – final pending AHRQ approval 4 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 Learning Objectives

5. DRAFT – final pending AHRQ approval Polling Question 5 Have you used the Learning from Defects tool? -Yes -No

6. DRAFT – final pending AHRQ approval 6 First-order Problem Solving Second-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. 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. Problem Solving Hierarchy Activity: Share an example in the chat of common first-order problem solving in your work area.

7. DRAFT – final pending AHRQ approval What is the long-term impact on patient safety culture? 7 Problem Solving Goal First-order problem solving addresses immediate need, but does not improve patient safety culture Second-order problem solving addresses future needs and improves overall patient safety culture

8. DRAFT – final pending AHRQ approval Anything you do not want to happen again. What is a Defect?

9. DRAFT – final pending AHRQ approval Individual Mistake or System Failing? 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 “ ” 9

10. DRAFT – final pending AHRQ approval 10 Questions for Each Defect Polling Question: Has your team learned from a defect? What happened? From view of person involved Why did it happen? How will you reduce it happening again? How will you know the risk is reduced?

11. DRAFT – final pending AHRQ approval Walk the process 11 Reconstruct the timeline and reenact what happened Dig down to the reasoning and emotions behind actions and decisions Consider using visualization tools (ie. process mapping, diagrams, sketches or role playing) to break down complex defects and discover where steps go wrong What Happened? Tip: Take time to listen. Seek to understand rather than to judge. Ask clarifying questions and follow-up questions.

12. DRAFT – final pending AHRQ approval 12 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?

13. DRAFT – final pending AHRQ approval 13 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 Instrumental in building second-order problem solving skills necessary to learn from defects Why Did It Happen? Critical to include adaptive teamwork concerns 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.

14. DRAFT – final pending AHRQ approval 14 Prioritize most important contributing factors and most beneficial interventions Implement principles of safe design Safe design principles apply to both technical tasks and adaptive team work How Will You Reduce Risk of Happening Again? Tip: Take advantage of your diverse team! Senior Executive’s big picture view of the organization and knowledge of resources Team members’ connections throughout organization Frontline staff with particular insight into the defect Tip: Take advantage of your diverse team! Senior Executive’s big picture view of the organization and knowledge of resources Team members’ connections throughout organization Frontline staff with particular insight into the defect

15. DRAFT – final pending AHRQ approval Think low barrier / high impact matrix 15 Prioritize Interventions High Impact Low Impact Low BarrierHigh Barrier

16. DRAFT – final pending AHRQ approval Pick a contributing factor to address first 16 How Will You Reduce Risk Reoccurring?

17. DRAFT – final pending AHRQ approval 17 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. Principles of Safe Design Principles Of Safe Design 1.Standardize Care 2.Create Independent Checks 3.Learn From Defects Principles Of Safe Design 1.Standardize Care 2.Create Independent Checks 3.Learn From Defects

18. DRAFT – final pending AHRQ approval Strongest STRENGTH OF INTERVENTION Weakest 18 Building Resiliency into Intervention Forcing functions and constraintsAutomation and computerizationStandardization and protocolsChecklists and independent check systemsRules and policiesEducation and informationVague warnings – Be more careful! Not all interventions are created equal.

19. DRAFT – final pending AHRQ approval Strive for Concise, Clear and Relevant Messages 19 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 Not All Education Is Created Equal Either Email Blast Lecture Hands- on Training Team Meetings

20. DRAFT – final pending AHRQ approval 20 Do staff know about the interventions? Are staff using the interventions as intended? Do staff believe risks were reduced? Data driven metrics should be the goal whenever possible How Will You Know Risks Were Reduced? 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.

21. DRAFT – final pending AHRQ approval 21 Summarize findings and changes over time –Hospital Patient Safety Culture Survey (HSOPS) –Safety Attitudes Questionnaire (SAQ) Share - Provide updates on initiatives, goals and success stories to maintain engagement Share de-identified analysis with others in collaborative (pending institutional approval) Share Success Stories 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.

22. DRAFT – final pending AHRQ approval 22 HOW DO WE ACHIEVE SUSTAINABILITY? Sustainability is dependent upon ongoing safety assessment exercises.

23. DRAFT – final pending AHRQ approval Patient safety culture requires constant vigilance 23 Ongoing Key Questions Poll: Have you asked your frontline staff these questions? How often do you / they answer these questions? How is the next patient going to be harmed? What can I do to prevent that harm? Your Mantra!

24. DRAFT – final pending AHRQ approval Your team will likely be in many phases simultaneously. 24 What’s Next? Winding Up Rolling Through Wrapping Up

25. DRAFT – final pending AHRQ approval 25 CASE STUDY: TURNOVER HAPPENS Executive Exodus and Staff Turnover

26. DRAFT – final pending AHRQ approval 26 Personnel turnover impacts all areas of organization –Frontline staff and clinicians –Executive officers –Team members Invite new team members as defects evolve Rotate existing team members as needed CUSP teams need a depth of people with diverse experiences and exposures Turnover Happens

27. DRAFT – final pending AHRQ approval 27 CASE STUDY: RENAL TRANSPLANT Communicating for Patient Safety

28. DRAFT – final pending AHRQ approval 28 Case Study: Renal Transplant Knowledge, Skills & Competence Anesthesiology attending not notified of the transfusion. Wrist band checks with stamp plate were not done at multiple points. Knowledge, Skills & Competence Anesthesiology attending not notified of the transfusion. Wrist band checks with stamp plate were not done at multiple points. Unit Environment Near simultaneous emergent events, change of two different provider groups at same time. No independent check. Unit Environment Near simultaneous emergent events, change of two different provider groups at same time. No independent check. Other Factors Hospital environment: Transfer across units Patient characteristics: High acuity Task characteristics: Blood check-in only as good as existing identity documents. Other Factors Hospital environment: Transfer across units Patient characteristics: High acuity Task characteristics: Blood check-in only as good as existing identity documents. Create independent checks, encourage patient safety culture initiatives, add system constraints like barcoding technologies Stagger staff changes Formalize hand-offs between departments Stagger staff changes Formalize hand-offs between departments Ensure hand-off process supports emergencies System Failures Opportunities For Improvement

29. DRAFT – final pending AHRQ approval 29 Focus on systems, not people Prioritize Use Safe design principles Go mile deep and inch wide rather than mile wide and inch deep Pilot test Learn from defects on a regular basis Answer the 4 questions Key Takeaways

30. DRAFT – final pending AHRQ approval 30 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 Action Plan

31. DRAFT – final pending AHRQ approval 31 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. 31 References