Emerging Trends in Safety and Quality David Mayer, MD Corporate Vice-President Quality and Safety MedStar Health Safety Moment video 2 Largest Healthcare System in Mid-Atlantic Region Ten hospitals 150 Outpatient sites of care 30,000 MSH Associates National Center for Human Factors Engineering MedStar Research Institute Nationally Recognized Simulation Center (SiTEL) MedStar Institute for Innovation (MI2) Over 1000 Residents 162,000 Inpatient Admissions 762,000 Inpatient Days 1,492,000 Outpatient Visits 215,000 Home Health Visits MedStar Health 3
Emerging Trends in Safety and Quality High Reliability Human Factors Engineering Transparency Patient and Family Partnerships 4 Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective, and potentially dangerous. Sir Cyril Chantler, Dean of London s Guy s Hospital 5 Why Do We Need High Reliability In Healthcare? 6
Cockpit video 7 High Reliability Safety Culture High-reliability organizations (HROs): Subset of hazardous organizations that have operated nearly error-free for very long periods of time. Karlene Roberts (1990) 8 Time lapse video 9
High Reliability in the Air Despite over two million passengers boarding 36,000 flights every day across the globe, on February 11, 2013, the New York Times was able to report Airline Industry at Its Safest since the Dawn of the Jet Age. 10 High Reliability at Sea High Reliability in Healthcare? Healthcare, in contrast is an industry that has grown to expect and accept errors and patient harm as normal. It is considered an inherent risk that comes with the wonderful new advances that healthcare can offer its patients. 12
High Reliability Organizations HRO s use tools, techniques and behaviors proven to reduce risk and improve outcomes. HRO s are characterized by mindful practices that detect and respond faster to unexpected events and unsafe conditions. Over 1000 hospitals across the US are at different stages of their High Reliability Journey. April 16, 2014 13 High Reliability in Healthcare Safety Moments Leadership Safety Walk Rounds Daily Safety Huddles Good Catch Mondays Sixty Seconds for Safety Full Engagement Leadership Training (2,400 Leaders) All MSH associates (27,000 Associates) 14 Collective Mindfulness Goals of mindful practice: To become more aware of one s own mental processes, listen more attentively, become flexible, and recognize bias and judgments, and thereby act with principles and compassion. 15
What can you do? Be mindful of real or potential safety issues and report any near misses and unsafe conditions Be proactive Be reliable Be a hero 16 HRO video 17 Why Do We Need Human Factors Engineering In Healthcare? 18
Why Do We Need Human Factors Engineering in Healthcare? Credit to Raj Ratwani 19 Human Factors Engineering and Patient Safety We cannot change the human condition but we can change the conditions under which humans work. James Reason 20 Picture Human Factors in Healthcare Credit to Terry Fairbanks 21
Credit to Terry Fairbanks Credit to Terry Fairbanks
"Just Culture is the balance between the Science of Safety and Accountability" We must ask what is responsible, not who is responsible. The aim of safety work is not to judge people for not doing things safely, but to try to understand why it made sense for people to do what they did against the background of their engineered and psychological work environment. If it made sense to them, it will for others too. Sidney Dekker "Just Culture is the balance between the Science of Safety and Accountability" Calls for accountability themselves are, in essence, about trust. Accountability is fundamental to human relationships. If we cannot be asked to explain why we did what we did, then we somehow break the pact that all people are locked into. Being able to offer an account for our actions is the basis for a decent, open, functioning society. Sidney Dekker Importance of Having a Just Culture
Annie video 28 Why Do We Need Transparency in Healthcare? 29 Galbraith video 30
Transparency in Healthcare Transparency (Honesty and Trust) 31 Transparency in Healthcare Transparency (Honesty and Trust) Transparency in Outcomes 32 Transparency in Healthcare There is a Magic that occurs when we are transparent and share our outcomes Paul Levy 33
Transparency in Healthcare Transparency (Honesty and Trust) Transparency in Outcomes Transparency in Reporting 34 Transparency in Healthcare Transparency (Honesty and Trust) Transparency in Outcomes Transparency in Reporting Transparency in Communications Informed consent/shared decision-making Disclosure after harm 35 36
Definition of Professionalism AAMC & NBME: Altruism Honor and Integrity Caring and Compassion Respect Responsibility Accountability Excellence and Scholarship Leadership 37 Definition of Professionalism AAMC & NBME: Altruism Honor and Integrity Caring and Compassion Respect Responsibility Accountability Excellence and Scholarship Leadership 38 Walt Kelly 1970
Can there be a Principled Approach? Barriers Benefits 40 Can there be a Principled Approach? Barriers Money Reputation Shame and blame Loss of control Loss of license Resource intense Uncertainty Benefits 41 Can there be a Principled Approach? Barriers Money Reputation Shame and blame Loss of control Loss of license Resource intense Uncertainty Benefits Maintain trust Learn from mistakes Improve patient safety Employee morale Psychological well-being Accountability Money 42
Condition Predicate to a Principled Approach 43 Condition Predicate to a Principled Approach Courage and Leadership 44 45
Principled Approach What patients want to hear: Recognition: investigation The truth Regret: apology if necessary Prevention of similar harm to others Remedy ( benevolent gestures ) 46 Implementing a principled approach to adverse patient events Decide upon and adopt full disclosure principles We will provide effective and honest communication to patients and families following adverse events We will apologize and compensate quickly and fairly when inappropriate medical care causes injury We will defend medically appropriate care vigorously We will reduce patient injuries and claims by learning from the past Credit to Rick Boothman, CRO, University of Michigan 47 Elements of a Transparent Response to Unanticipated Outcomes ( Seven Pillars ) Reporting Immediate and continued communication (patients, families and care teams) Investigation and discovery Apology with remediation (when appropriate) Process and performance improvement Data tracking and analysis Education 48
49 National Recognition of the Seven Pillars Program 50 October 7, 2011 51
October 7, 2011 52 Why Do We Need Patient Partnerships in Healthcare? 53 MedStar Patient and Family Advisory Council for Quality and Safety (PFACQS) Rosemary Gibson Marty Hatlie Helen Haskell Sorrell King Carole Hemmelgarn Knitasha Washington Michael Millenson Patty Skolnik David Skolnik Victoria Nahum Armando Nahum 54
MedStar Health PFACQS Initiatives Hired H2PI to lead our system PFACQS roll-out Clear purpose in the charter that creates focus on Quality and Safety, hence the PFACQS name Direct Connection to C-Suite/Board High Reliability Journey Informed consent/shared decision-making Grand Rounds - council members as presenters 55 Medstar Health PFACQS Initiatives Good catch program; Josie King Hero Award Stories, narratives and video work (e.g. Sixty Seconds for Safety) Transparency journey (e.g. Website re-design) Patient activated RRT team work Research Seven Pillars/CANDOR implementation (AHRQ/HRET/AHA) We Want to Know 56 Patient Partnership System Patient and Family Advisory Council for Quality and Safety (PFACQS) 10 Hospital PFACQS Ambulatory PFACQS 57
WeWant2Know@Medstar.net Safety Moment Hemmelgarn video 60
Telluride Patient Safety Summer Camp Tenth Annual Roundtable: The Power of Change Agents: Teaching Caregivers Effective Communication Skills to Overcome the Multiple Barriers to Patient Safety and Transparency June 8 th June 18 th, 2014 Telluride, CO 61