The Path to Safe

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The Path to Safe Reliable Care

• Michael Leonard, MD
• Colorado Patient Safety Coalition
• November 9, 2006

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The Healthcare Horizon

• The Perfect Storm increasing demand, decreasing
  providers, resource constraints
• Safety Quality harm, variation, clinical
  outcomes
• Changing Expectations providers / patients
• Transparency regulators, business, the public

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LEADERSHIP
PATIENTS
HUMAN FACTORS
RELIABILITY
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What Does Exceptional Leadership Look Like ?
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Effective Leaders

• Model the values
• Their actions are consistent with their messages
• Tell front line workers safe care is important
  and their core business
• Are the difference between success and failure

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Effective Leaders

• Connect with front line staff
• Know the elevator speech
• Drive a very crisp, focused message through the
  organization with uniform consistency
• Are confident, but humble
• Listen more than they talk

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Engaging Physicians

• Lets do it differently and better
• Lets make your day simpler, safer and easier
• What are the things that get in the way of you
  delivering optimal care?
• WIIFM

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Why Collaboration Teamwork is Essential to Safe
Care Good People Working in Complex Systems
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Human Cognition

• Human are reproducibly fallible
• We think on 3 levels
• -Automatic
• -Rule Based
• -Knowledge based
• Each thinking level leads to errors
• -Slips and Lapses
• -Rule Based Errors
• -Knowledge Based Errors
• Rasmussen and Reason

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Inherent 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 cell phones and
  driving

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Complex System
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Systemic Migration of Boundaries Deviation is
Normal
VERY UNSAFE SPACE
LOW Individual Benefits HIGH
ACCIDENT
HIGH Production Performance
LOW
Rene Amalberti, MD, PhD
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Fair and Just Culture

• What are the rules?
• Does everyone know them?
• How do we differentiate an individual with a
  problem from a good person set up to fail in an
  unsafe system?
• The critical importance of having one set of rules

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Drawing the Bright Line
Malicious Substance Use Violation of Rules
Repeat Events
remediate
Competency Substitution Test
Safe Harbor Systems Approach
Reason, J.
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Effective Teamwork and Communication
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Effective Communication Requires

• Structured communication SBAR
• Assertion/ Critical Language key words, the
  ability to speak up and stop the show
• Psychological safety an environment of respect
  effective leadership

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The Need for Teamwork

• Clinical medicine is an extremely complex
  environment with
• Surprises
• Uncertainty
• Incomplete information
• Interruptions and multitasking
• What are the surprises in your world?

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Where do Things Fall Through the Cracks ?

• Systems information, tests, diagnoses
• Communication especially hand-offs
• Failure of planning
• Failure of recognition
• Failure to rescue

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Real Risk Management

• Catastrophic birth injury
• Missing MIs in clinics and ERs
• Surgical misadventure
• Failure to diagnose breast, lung, colon,
  prostate, skin

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What Do Patients Want After a Medical Error ?

• An honest explanation.
• An apology.
• A guarantee it wont happen to anyone else.
• Lexington VA experience.

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A Simple Arthroscopy

• 45 y/o healthy woman, wanted to ski more
• Friday afternoon, last case for Chief of
  Orthopedics
• OR running late, 26 rooms
• Two nurses moved to ortho to do no brainer case
• They have never worked in orthopedics

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• Repeatedly interrupted
• Team disrupted by anesthesiologist wanting EKG
  recording paper
• Working with people they didnt know
• Loud music in the room
• .. with epi

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MD RN Different Communication Styles

• Nurses are trained to be narrative and
  descriptive
• Physicians are trained to be problem solvers
  what do you want me to do just give me the
  headlines
• Complicating factors gender, national culture,
  power distance, prior relationship
• Perceptions of teamwork depend on your point of
  view

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Reliable Processes of Care

• Current state lots of variation
• Do the basics every time
• Support the expertise dont waste it on
  busywork
• Toyota Lean, Six Sigma

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The Aviation Experience

• Safety initiative (CRM) began in 1979 after
  series of crew error accidents
• 70 of accidents - flight crew error
• Majority of accidents - captain flying
• Today - captain manages problem, first officer
  flies

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High Reliability

• Preoccupation with Failure
• Reluctance to Simplify
• Commitment to Resilience
• Deference to Expertise
• Sensitivity to Operations

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Rapid Response Teams

• Hospitalist/ intensivist, ICU nurses, RT
• Early warning system
• Primary indication provider is uncomfortable
• Australian experience 65 reduction in-hospital
  cardiac arrest, 24 reduction in overall hospital
  mortality

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What Difference can an RRT Make?

• 50 reduction in non-ICU arrests (Buist, BMJ 02)
• Reduced post-operative emergency ICU transfers
  (44) and deaths (37) (Bellomo, CCM 04)
  
• Reduction in arrest prior to ICU transfer (4
  v 30 ) (Goldhill, Anest 99)

Rothschild, 2004
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The Vertical High Risk

• OR briefings, teamwork, observation
• OB teamwork, standards, simulation
• ICU daily goals, teamwork
• ED standardize high risk care, teamwork
• Med- Surg RRT, teamwork, literacy
• Others

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Highly Reliable Perinatal Unit

• SBAR to communicate
• MD always comes when RN/ midwife requests
• Definition of fetal well being
• Common definition of fetal heart tracing
• Practicing for emergencies

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Safety and Reliability in the ED

• Discrete list of high risk diagnoses
• Do the basics every time
• Link systematic processes of care with effective
  teamwork and communication

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ICU Safety

• Teamwork and communication
• Where are the pebbles in your shoes?
• Daily goals are they the same by the next
  morning
• What are the reliable processes of care
• What does the culture look like?

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Surgical Safety

• Human Factors briefings, critical language,
  everyones names on the board, debriefing
• The Glitch Book
• Systematic processes- antibiotics, normothermia,
  glucose control, DVT, beta blockers

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What Lessons Can We Learn From Excellence in
Industry ?

• Truly exceptional organizations Southwest
  Airlines, Toyota, Alcoa all have the same
  properties
• Everyone is treated with respect every day
• Employees have the tools and flexibility to do
  the job
• The work is recognized and acknowledged

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Patients Families in the Game
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What Does it Look Like to the Patient ?

• Do they understand?
• Do we care?
• Do we know what we are doing?
• Do we take the time for relationships?

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Health Literacy

• Do you have a systematic approach to detecting
  and managing this problem?
• Its a huge problem silent, pervasive, huge
  ramifications
• Rx Ask Me Three, Teach Back

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HUMAN FACTORS

• Briefings
• Appropriate Assertion
• Situational Awareness
• Debriefing
• Common Mental Model

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Setting the Stage

• Vascular surgeon doing new, complicated procedure
  endovascular aortic stent - in CV lab
• I dont have any pride invested here. I just
  want to get this right, so if you think of
  anything helpful or see me doing anything wrong,
  please let me know.

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I know the names of all the personnel that I
worked with during my last shift
 
of respondents who agreed
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Briefings - Key Elements Checksheet

• Got the persons attention
• Made eye contact, faced the person
• Introduced self
• Used persons name familiarity is key !
• Asked knowable information
• Explicitly asked for input
• Provided information
• Talked about next steps
• Encouraged ongoing monitoring and cross-checking

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One Example of Collaborative Care

• Interdisciplinary (everyone present at one time)
• Patient and family included as part of the team
• Consistent pattern of communication and decision
  making (Collaborative Communication Cycle)
• Respectful, open environment flat hierarchy
• Specific attention to system glitches

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All Case Operative Mortality Concord Expected
(NNE Risk Model) Concord Observed Salem
Observed
(Onset of collaborative care at red arrow)
(Onset of collaborative care at green arrow)
All Case Mortality (percent)
(4.8) Concord Expected
(2.1) Concord Observed
(0.3) Salem Observed
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Time to extubation (Concord )
Hours 10
8
6
4
2
1998 1999 2000 2001
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Briefing Example
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Situational Briefing Model

• S-B-A-R
• Situation
• Background
• Assessment
• Recommendation

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SBAR Example

• Situation We have a 48 year-old man with aortic
  valve endocarditis that may involve the proximal
  aorta
• Background He developed endocarditis after
  dental work one month ago without antibiotics.
  His echo shows multiple vegetations and an
  abscess between the aortic and mitral annulae

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• Assessment Fulminant endocarditis that may
  extend into the artic root. He may need both an
  aortic valve and root replacement. Extremely high
  risk - I have quoted him a 50 mortality
• Recommendation Well get femoral arterial access
  in case his aorta is too rotten to clamp. Once we
  can explore the abscess well know how big this
  is going to be

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Assertion - What is it?

• Individuals speak up, and state their
  information with appropriate persistence until
  there is a clear resolution.

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Assertion

• Model to guide andimprove assertion inthe
  interest of patient safety

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Expert Decision Making

• Expert pattern matching against large mental
  library, quick, accurate if confirm correct
  answer
• Novice library is empty slow, error prone
  process
• Certain Diagnoses are Favored- Frequent, Recent,
  Serious
• Heuristics

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Critical Language

• Key phrases understood by all to mean stop and
  listen to me we have a potential problem
• United Airlines CUS program Im concernedIm
  uncomfortablethis is unsafe Im scared
• Allina I need some clarity