Creating a Culture of Safety and Reliability

Transcription

1 Creating a Culture of Safety and Reliability Gary R. Yates, MD Senior VP and CMO Sentara Healthcare 2011 IHI National Forum 1 Sentara Healthcare 123-year not-for-profit mission 10 hospitals; 2,349 beds; 3,700 physicians on staff 10 long term care/assisted living centers Extended stay hospital Virginia 3 Medical Groups (600 Providers) 432,600-member health plan North Carolina Sentara College of Health Sciences $3.9B total operating revenues $5.0B total assets 23,000 employees Sentara ecare HIMSS Analytics Stage 7 and HIMSS Davies Award SDI #1 Integrated Healthcare System 2009, 2010 AHA Quest for Quality award 2004, John M. Eisenberg award

2 What Will It Take? Patient Safety WalkRounds Addressed JCAHO Patient Safety Alerts Non-Punitive Approach to Reporting Crew Resource Management Strategies in Targeted Venues (e.g. bundles to reduce VAP, etc.) BUT Will This Produce Significant Sustained Reduction in Serious Safety Events & Culture Change Across the Organization? High reliability organizations (HROs) operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents. Managing the Unexpected (Weick & Sutcliffe) Risk is a function of probability and consequence. By decreasing the probability of an accident, HRO s recast a high-risk enterprise as merely a high-consequence enterprise. HROs operate as to make systems ultra-safe. 2

3 Optimizing Reliability Design to Optimize Human Performance at the point of people interface: Easy to do the right thing impossible to do the wrong thing Intuitive design Mistake proofing by design (i.e. poka yoke) Behavior Accountability Human Factors Process, Protocol &Technology Process Design Reliability Culture Resource allocation Evidence-based practice (e.g. bundles) Technology enablers Safety as the core value Behavior expectations for error prevention Collaborative Interactive Teams Leadership behaviors for reliability 2010 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Complementary Strategies Codes Outside the ICU Surgical Site Infections Central Line Infections Hand Hygiene Culture and on, and on, and on 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 3

4 Sentara Healthcare Serious Safety Event Rate Sentara Hampton Roads Hospitals % Reduction Since 2003 Event Rate J-03 M-03 M-03 J-03 S-03 N-03 J-04 M-04 M-04 J-04 S-04 N-04 J-05 M-05 M-05 J-05 S-05 N-05 J-06 M-06 M-06 J-06 S-06 N-06 J-07 M-07 M-07 J-07 S-07 N-07 J-08 M-08 M-08 J-08 S-08 N-08 J-09 M-09 M-09 J-09 S-09 N-09 J-10 M-10 M-10 J-10 S-10 N-10 J-11 M-11 M-11 J-11 S-11 Each monthly data point is a rolling 12-month average of serious events of harm expressed per 10,000 adjusted patient days Actions to Create a Reliability Culture Organization s Values & Beliefs ❷ ❶ Elevate safety NO HARM as the core value that is reflected in the words and actions of leaders, medical staff, and employees. Adopt behavior expectations for error prevention a people bundle for all (leaders, staff, and medical staff) and engrain the behaviors as individual and team work habits. Individual & Team Behaviors Our Outcomes in SAFETY as well as in quality, satisfaction, and financial performance Leader Behaviors ❸ Adopt a Leadership Method techniques for (1) reinforcing and building accountability for performance expectations and (2) detecting system problems and correcting causes Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 4

5 Safety Behaviors: People Bundle 1. Pay Attention to Detail STAR (Stop/Think/Act/Review) 2. Communicate Clearly Repeat Backs & Read Backs Clarifying Questions Phonetic & Numeric Clarifications SBAR 3. Have a Questioning Attitude Validate & Verification 4. Handoff Effectively 5P s (Patient/Project, Plan, Purpose, Problems, Precautions) 5. Never Leave Your Wingman Peer Checking Peer Coaching In VAP Prevention Process Behavior 4 for VAP Prevention 1. Elevation of the head of the bed to between 30 and 45 degrees 2. Daily sedation vacation and daily assessment of readiness to extubate 3. Peptic ulcer disease (PUD) prophylaxis 4. Deep venous thrombosis (DVT) prophylaxis (unless contraindicated) Clinical Bundle People Bundle Shown as peer check Prevents unintended slips and lapses Speak up for Safety using ARCC 5

6 Culture Embedding Mechanisms From Organizational Culture & Leadership, by Edgar Schein Primary Embedding Mechanisms What leaders pay attention to, measure, and control on a regular basis How leaders react to critical incidents and organizational crises Observed criteria by which leaders allocate scarce resources Deliberate role modeling, teaching, and coaching Observed criteria by which leaders allocate rewards and status Secondary Articulation & Reinforcement Mechanisms Organizational design and structure Organizational systems and procedures Organizational rites and rituals Design of physical space, facades, and buildings Stories, legends, and myths about people and events Formal statements of organizational philosophy, values, and creed Leveraging Senior Leaders Attention is the currency of leadership. Ronald Heifetz High Leverage Tools & Techniques for Senior Leaders High Core Value Daily Check-In Rounding to Influence (RTI) Impact Visibility, Relevance Degree of Influence Low Low Investment Time, Money, Other Resources High 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. 6

7 Culture Change: It s Different Work From The Dilemma of Foundation Leadership, by Ronald Heifetz 14 7