Week 2 Assignment

Profile of a Quality Health Care Influencer

There are a number of key figures, both historically and in today’s health care field, who have influenced the growth and change of Continuous Quality Improvement (CQI).  In some cases, they have created the models that we are using currently.  In other cases, they have impacted our approach to health care quality greatly and continue to motivate and inspire us to do better.These include (but are not limited to):                                      

• Edward Deming
• Joseph Juran
• Lucian Leape
• Dr. Avedis Donabedian
• Kaoru Ishikawa
• Brian Joiner

More recently:

• Dr. Donald Berwich
• Dr. Peter Pronovost
• Dr. Atul Qawande
• Dr.Robert Wachter
• Dr. Paul Batalden
• Dr. Brent James

-Identify a key leader from this list (or another, not listed here, you wish to research).

-Present a profile of this individual and how they have impacted continuous improvement in health care.

-Identify what you believe are the three most important concepts that they have they have presented as a part of their work.

-Explain why you think these are important and how you might include them in your role today or in your future health care career.

The paper should be 750-words, have at least three references outside the assigned text and must have APA formatting. The Written Assignments must reflect college-level writing and thinking.

Note:  Attached files are shortened lecture version and it may/may not help.

Week Two, Session One Lecture – Chapters 6, 7

“There is no substitute for teamwork and good leaders of teams to bring consistency of effort along with knowledge.” -Edward Deming

Welcome to Week Two. Lecture Session One. In our first week together, we reviewed the history of CQI and how is has diffused into health care. We looked at the work that has been done and the work we have yet to accomplish.

In addition, we began our drilldown into the model and tools that we use in the CQI process. Understanding variation and its critical role in health care, and the fact that it is a foundation piece for CQI was reviewed; along with the next steps being taken through Six Sigma and Lean to further reduce variation and waste.

This week we continue our drill down, first, on the importance of teams in the CQI process (Dr. Deming’s “People Awareness” leg of the stool). Secondly, we will exam the role of the patient in the CQI process and the importance of their contributions.

Chapter Six – Understanding and Improving Team Effectiveness in Health Care

Introduction

Understanding the role of teams in health care, understanding their vital role in the CQI process, and the factors that contribute to their success are the core components of Chapter Six.

The critical role of leadership in the team process, team participation and creating a culture that supports teamwork are all reasons why Dr. Deming chose people factors as a focus for what we call his People Awareness leg of the Three-Legged stool.

Understanding and Improving the Performance of CQI Teams

Health care, by its very nature is a team process. There is almost nothing we do in the provision of care and service that does not rely on a team of individuals coming together to provide care. In addition, the primary vehicle for improving care through the use of the CQI tools is the use of teams in the CQI process.

We have talked about health care as a number of processes, that each can be broken down into steps. And, that a number of processes linked together is a system. Here we talk about “microsystems” which are one of several subsystems in a system. We might think of these as a patient care unit, or a department, such as the lab or the admitting department. Health care is made up of multiple subsystems all working together to provide care and services. Think about your own experience, or that of a family member. When we receive care, we move through numerous subsystems: the emergency department, Radiology and Lab, an in-patient unit, surgery, nursing, discharge planning etc. Good team work makes these experiences positive – or not so positive, depending on the communication, coordination and how well the people and parts work together.

If the organizational structure does not support the teams appropriately, the results may be poor communication, staff and patient dissatisfaction and in many cases, un-safe care.

Teams are critical to the success of CQI because the members of the team understand the processes of care, and their participation is essential to assure that problems get solved in a lasting way.

Team Size and Composition

CQI teams vary in size and composition, according to the problem that they are trying to solve. Members should include a supportive and knowledgeable team leader, who can bring the right structure, tools and resources to the team. Teams also need the team members who understand the day to day work contributing to the problems to be solved, as well as those individuals who may be affected by or contributing to the problem. Lastly, teams need to be staffed by individuals who understand the process and tools, for example from Quality; and those providing resources – such as data from IT.

Creating a “safe” Environment for Teamwork

One of the key requirements for a well-functioning team is a team culture that provides a “safe environment” of all participants.

Teams include individuals who have different spans of control, from leaders to staff; as well as different functions and expertise, like managers and physicians. The least “powerful” person on the team is often the one who has the knowledge and experience to bring solutions to the problem to be solved. If the environment is not “safe”, that person my never feel safe to speak up and contribute.

The leaders and those who support the team process must address this or the team will never function at its maximum capacity. Setting team norms, expectations of respect for all members and their opinions, and the recognition of their unique talents and experience are essential for a successful team process.

Stages of Development

Teams go through a natural succession of stages – the CQI model and tools are designed to guide them through these stages more quickly and successfully. These stages include: Forming, norming, storming, performing, adjourning and mourning. These stages represent the phases that teams of individuals, brought together to solve a problem, sometimes for the first time, go through as a natural part of the process. Getting to know one another, their talents and expertise; adjusting to and respecting the norms of how the team will support and work together; using the CQI tool kit and data to identify the problems and solutions; putting a plan together to test their solutions; and then, finally put their plan in place, are key components of these stages.

Once the team has completed their work, the process may end, but the lessons learned by the team on how to work together respectfully, how to use the tools and methods of CQI, and especially the power of a good functioning team go on.

Culture

The changes that occur with a successful team process and how the team members will do their work caring for patients and working together moving forward, are a critical part of the building of a culture of excellence. Culture is defined as: the values, beliefs, assumptions, norms and goals and vision for an organization. It is sometimes called the “personality” of an organization; or how we act when no one is looking.

The goal, over time is to create that “culture of excellence” – we will talk more about this in Session Two this week.

Rewards and Recognition

Lastly, well-functioning teams need resources like time and expertise as well as rewards and recognition for the hard work they do.

Learning Organzations

Strong organizational and team leadership are key to assure good communication, decision-making and organizational learning based on the successful CQI efforts.

Effective teams: constantly look for new information to improve their performance; are open to new ideas and seek them out; include people with new expertise and different perspectives; ensure all team members are engaged in continuous training and learning; and continue to grow by reviewing past performance and lessons learned from their efforts and the efforts of others.

Conclusion

It is said that organizations continue to improve “one team at a time”. By using and sharing what the teams have learned and continuously seeking opportunities to improve – the culture of the organization is transformed.

Chapter 7 – The Role pf the Patient in Continuous Quality Improvement

“It is more important to know the sort of patient that has a disease than what sort of disease that the patient has.” -Dr. William Osler

Introduction

We have discussed the criticality of placing the patient at the center of the care process. We have also discussed how important it is to the CQI process to involve those who understand the care and service processes the we are trying to improve. So, where is the patient – the one who receives that care service, in the CQI process?

Chapter Seven presents ways we can further involve the patient in the CQI process at all levels, with evidence from actual programs that have enhanced care and made it safer. Although the patient is our primary customer, historically, they have been left out of the process when care is planned, designed and improved. The traditional role of the Board of Directors made up of community members and former patients, has been to represent the patient and the community in that process. However, we have learned how important it is to how we design and provide care that we enlist the patient’s voice in the process. From preventing errors, to designing and improving processes that meet the needs of the patient, we have begun to recognize the key role that the patient can play.

In addition, with the emergence of technology, access to information related to health care, public reporting of health care quality information, and the high-profile reporting of medical errors, the patients are demanding to play more of a role in all of our key processes. This has created an opportunity and a need to involve the patient in our CQI process.

Methods for Involving Patients in CQI

Three levels of involvement for the patient were presented:

1) Micro-level – the informed patient self-managing their care and partnering with care givers;

2) Meso-level – involving the patient in the design and ongoing improvement of care, such as involving patients in planning for new facilities and services; and

3) Macro-level – Engaging the patient in the process of identifying and helping to prevent errors – there is much work being done nationally and internationally on these efforts.

Moving away from involving patients only through after-care surveys or follow-up on complaints, a model for involving patients in a more active way was presented. This model, the M-APR model, primarily focuses on identification and prevention of medical errors, involving patient at all levels.

This model presents two dimensions:

1) Active- Proactive – directly involves the patient in identifying, confronting and addressing sources of errors prior to their occurrence. Examples may include patients on the hospital’s Patient Safety Committee as well as training patients and families to actively address errors such as asking staff to wash their hands before providing care.

2) Passive – Reactive – inviting patients to participate with the investigation and follow-up to near misses or errors after they occur as well as with the complaint resolution process. Some organizations have invited patients to share their stories, as we saw with the Josie King Story.

Examples of Patient Involvement

Examples were presented of formal processes that have been very successful in engaging patients such as:

· Kaiser Permanente – Partners in health care which engages patients with chronic illness to participate as full partners in their care processes;

· Joint Commission National Patient Safety Goals – The Joint Commission requires organizations to involve patients in the active process of identifying and preventing errors and provides training and tool kits; and

· From Partners to Owners – The SouthCentral Foundation in Alaska is directly engaging patients and the community to re-design the care process to better meet their needs.

Conclusion

With the challenges we are facing to further improve safety and care, the active involvement of patients and the community are essential components.

Week Two Lecture Two Chapters 9-11

Chapter 9 – Assessing Risk and Preventing Harm in the Clinical Microsystem

“To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.”

· Sir Liam Donaldson

Introduction

We were introduced in Week One to the “real impact” of quality and patient safety as we reviewed the video of Sorrell King describing her experience and the loss of her daughter, Josie. We will now drill down in the next two chapters, learning more about medical errors, their continuing effects, and the efforts being made to understand, classify and reduce them.

We have learned that because of its complexity, health care is a high-risk environment. We are humans taking care of humans and therefore, errors will occur. Much progress as been made since To Err Is Human was introduced in 1999, but we still have a long way to go.

We learned in 1999, and through extensive research that not only is health care as hazardous as bungee jumping or mountain climbing; today, medical errors are the third most common cause of death in the United States, led only by cancer and heart disease.

The initial data from To Err Is Human told us:

· 2.9% – 3.9% of all hospital patients experience an adverse event each year;

Of those experiencing an adverse event:

· 53% – 58% are attributable of errors;

· 27% – 29% are attributable to negligence; and

· Between 8.8% – 13.6% of the events results in death, most result in disability lasting up to 6 months.

This could be equated to the crash of a 747 every day!

Updated figures (2010), tell us that medical care is complex, expensive, and at time dangerous, resulting in:

· Hospital patients, worldwide, are harmed 9.2% of the time, with death occurring in 7.4% of these events; and

· It is estimated that 43.5% of these harm events are preventable.

The financial costs too, are staggering: up to $29 billion attributable each year, an average of $4700 per patient admission.

We are also aware that reporting is often challenging, these numbers are probably underestimated.

We see that current levels of harm are unacceptable. Let’s explore how we can utilize risk/prevention management to build systems that reduce errors and keep them from reaching patients.

Definitions

Let’s begin with some important definitions: Clinical risk prevention/management is the culture, processes, and structure directed to managing potential and actual risks and events.

The strategies used in clinical risk prevention/management include:

1) Identifying risk – assessing and identifying what is going wrong or may go wrong;

2) Analyzing risk – data collection and analysis to understand what is occurring; and

3) Controlling risk – diligently managing and preventing problems from occurring that bring harm or potential harm to the patient.

Risk management events may be characterized as:

· accidents – design flaws in processes, human errors – people taking care of people; and

· organizational accidents – poorly designed processes, errors of commission or omission; breakdowns in safeguards and failing to learn from incidents and near misses.

Introduction to the “Swiss Cheese” Model

The “Swiss Cheese Model”, devised by James Reason in 2000 (see slide 20) presents an illustration of the path that a medical error can take and how it may reach the patient.

The slices of cheese represent the types of safeguards we have in place, such as procedures, physical barriers and information sharing. The holes in cheese represent what we know from research: human factors research tells us that because of the complexity of health care and the major role of humans in providing care, we will have break downs These may include procedures that are not followed, faulty equipment or a break downs in communication. If any one of these “holes” line up just right, there will be an error that may reach the patient and cause harm.

Risk management acknowledges that errors do occur, despite our safeguards – it is our job to prevent them, keep them from reaching the patient and learn from them.

Near Misses

The concept of near misses is a vital one – those errors that occur, but do not reach the patients. Near misses occur 3-300 times more often than adverse events – this provides us a golden opportunity to identify them and learn from them!

We learned about the variation in health care that exists and how care is delivered in Week One. Unless we reduce or eliminate variation whenever possible, it can create dangerous situations that can manifest themselves in near misses, which we can learn from. If we do not learn from near misses, they may eventually surface as harmful events.

The Risk Management Model

Models have been devised that help us plan to avoid errors and learn from then if they do occur. One such model was created by William Haddon, the first Director of the National Highway Safety System in 1992.

His model has two parts:

· factors to consider including human factors, equipment and physical/socioeconomic environmental factors; and

· phases for events including pre-event, event, and post event phases.

This model provides a framework to understand how we can address errors and their prevention in each phase. Examples are provided in Chapter 9 (see slide 28).

High Reliability Organizations

Research has shown us that organizations that are ‘highly reliable” and designed to reduce the chance of errors have characteristics that are similar and translate into “a culture of safety and high reliability”.

These characteristics include:

· Leadership commitment (there comes leadership again!);

· Trust in communication;

· Shared importance of safety;

· Teamwork and support/encouragement; and

· Non-punitive reporting and analysis.

Culture of Safety

These characteristics help create a path to a culture where “it is easy to do the right thing, and hard to do the wrong thing”.

Building such a culture is not easy and requires consistent and sustained leadership and support. If efforts are not consistent, over time, the culture will erode.

Communication of the importance of these factors, the success of teams, the results of the learnings from incidents and near misses are also a critical part to the efforts to substance the culture over time.

One of the positive changes that has occurred in the risk management/prevention approaches over the past twenty years is the disclosure of errors to patients and families, even if no harm is experienced. In the past, there was little sharing because of malpractice and other concerns, but this is now a regulatory requirement and has led to an opportunity to provide immediate support for patients, families and staff involved in errors and the opportunity to learn lessons from their occurrence.

Conclusion

We know that we have a work environment that is inherently complex and high risk. Applying the learnings from the key concepts and tools from risk prevention/management, and, from the value of establishing and maintain a culture of safety are critical steps in helping health care move toward an error free environment.

Your Role as a Patient Safety Leader/Champion

Your role, as a leader in health care can really impact these efforts over time. You are and will be the role models in this process. Engaging with staff in the efforts to reduce risk and errors is critical as your role as a leader now and in the future.

To help you with this, there are a list of questions provided for leaders to ask. (see slides 44- 46)

You are the future champions for safe care!

Chapter 10 – Classification and the Reduction of Medical Errors

Human fallibility is like gravity, weather, and terrain, just another foreseeable hazard.

· J.T. Reason

Introduction

Chapter 10 provides us with an overview of the work being done to classify medical errors so we can better understand them and reduce their numbers.

Just as we learned in week one, before we can improve our processes, we must be able to break them down into steps, study them, and then begin the efforts to improve them.

The study of, and classification of medical errors can help us create a “common language” to understand the similarities that occur in errors, and then begin the process to reduce their numbers or eliminate them.

We have learned that because health care is so complex and so heavily reliant on human resources, errors will occur. Our goal is to identify them before they reach the patient. The work that is being done to study and classify errors is an important step to that goal.

In Chapter 10, we will review the “whys” for the classification of errors, key definitions and applications, and revisit some additional core components of a culture of safety.

Health care has benefited from the work done in other industries in the study of errors such as aviation and nuclear power. We have learned much about the value of classification, mitigation and planning for errors; and transparency and sharing of lessons learned.

We reviewed the data on errors in health care and understand why the need to reduce errors is so vital. By understanding human errors and their contribution to medical errors, we are given the opportunity to plan and implement barriers that help avoid them.

Terms and Definitions

Having a foundation to understand errors begins with some common definitions:

· Error – “The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”;

· Adverse event – “(A)n injury that was caused by medical management (rather than the underlying disease) and that prolonged the hospitalization, produced a disability at discharge, or both”;

· Preventable adverse event – “(A)n adverse event that could have been prevented using currently available knowledge and standards”;

· Sentinel event – Patient safety event that reaches a patient and results in death, permanent harm, or severe temporary harm and intervention required to sustain life;

· Never events or Serious Reportable Events – 29 serious events identified by the National Quality Forum “which are extremely rare medical errors that should never happen to a patient”;

· Incident – “An unplanned, undesired event that hinders completion of a task and may cause injury, illness, or property damage or some combination of all three in varying degrees from minor to catastrophic”; and

· Near miss – “(A)n event that could have had adverse consequences but did not and was indistinguishable from fully fledged adverse events in all but outcome”.

By standardizing language, definitions and conceptual frameworks, we can optimize our study, improvement methods, and knowledge on patient safety.

We can identify trends, detect patterns and develop error prevention and mitigation tools and strategies that can be shared across the health care industry.

Swiss Cheese Model – Classification Factors

In Chapter 9, we reviewed “The Swiss Cheese Model” introduced by James Reason. His model further breaks down errors for classification by:

· Skill based errors – when the action made does not turn out as intended, such as an experienced nurse administering the wrong medication by picking up the wrong syringe;

· Rule Based Errors – actions that do not achieve their intended outcome due to the incorrect application of a rule or plan, such as proceeding with the extubation of a patient too soon, because of an incorrect application of guidelines; and

· Knowledge based mistakes – actions that failed due to knowledge deficits, such as prescribing the wrong medication because of incorrect knowledge of the drug.

Reason further breaks down his error topology by identifying whether an error occurred from a simple lapse of memory, taking a short cut on a procedure, or an intentional violation such as drug or alcohol use. Later in this chapter, we will review the creation of a “Just Culture” as a part of our culture of safety. Reason’s breakdown helps lead us away from the approach that was taken in the past when an error occurred: looking for who is to blame rather than trying to understand the breakdown in the system or processes. As we learned from Dr. Deming, errors almost always occur because of the processes in place, not the people in the processes.

Reason suggested that most accidents can be traced to one or more domains: organizational influences, supervision, pre-conditions or a specific act. We see these depicted as the holes in the swiss cheese in Reason’s model.

Classification System Examples

There has been a great deal of work on classification systems from other industries, we will review four which share a number of common features:

HFAC – Human Factors Analysis Classification; The Joint commission Patient Safety Taxonomy; The WHO’s International Classification for Patient Safety; and the SEIPS – The Systems Engineering Initiative for Patient Safety.

HFAC – This is a broad human error framework that utilized Reason’s Model with similar action domains. (See Slide 70 for a depiction of this model.) As Reason stated, “if any one of the failures is corrected leading up to the adverse event, it is thought that the event may be prevented.” This model, as with Reason’s, helps organizations identify possible breakdowns in the whole system to create potential interventions to avoid them.

The Joint Commission created its model in 2005 to assist organizations to evaluate incidents to understand ways to avoid adverse events. It also allowed the Joint Commission to share common causes related to the events reported to them to inform the whole industry about possible risks and interventions to avoid adverse events.

WHO’s ICPS – The Who started with the Joint Commission model and has created an opportunity to classify events internationally to inform the world-wide health care industry of risks and mitigation opportunities.

SEIPS – Allows a pictorial opportunity to show how microsystems interact with one another and how risks are a part of a large system of care. (See Slide 77)

Countermeasures

Because of the research around these models and others, and the work done in other industries, actions have been identified called counter measures, to assure appropriate responses to risk and human errors. Simulation has been introduced to health care in the last 10 years, similar to flight simulation in the aviation industry and helps organizations plan for and practice responses to incidents. The TeamStepps Model, often used in the military, is an example of a whole group of actions and tools that help caregivers work more effectively as a team to prevent errors.

Other examples of some countermeasures are: the checklists that we discussed in week one; attention getters, like the yellow bracelets placed on patients who are at risk for falls; and, error detection – such as the systems built into electronic health records to alert caregivers of a possible drug-drug interaction.

High Reliable Organizations – Characteristics

As we noted in Chapter 9, organizations that have adopted these tools and methods successfully and have created environments that have built-in safe guards and a strong patient safety culture are known as high reliable organizations.

Along with the characteristics noted in Chapter 9, research has identified common features that are found in these organizations which include:

· A focus on errors in their earliest manifestations while avoiding disasters;

· Trying to understand processes in depth, not focusing on simplification;

· Emphasizing knowledge of operations and learning on the front line;

· Building resilience to overcome errors that do occur; and

· Listening to and respecting experience and expertise that exists at the operational level.

James Reason also identified attributes that contribute to high reliability:

1. The culture values reporting. No adverse events are hidden. They are taken as opportunities to learn.

2. The culture is just. No scapegoating or shooting the messenger.

3. The culture is flexible. Information flows freely and higher rank individuals respect local expertise.

4. The culture values learning. New understanding is actively sought and valued.

Just Culture

Let’s take a little time to explore the concept of a “just culture” – it has been recognized that creating such a culture around reporting and evaluation of incidents also contributes to a patient safety culture as well as high reliability organizations.

Reason’s methods to systematically identify caregiver actions (in errors) include – are these actions: Unintended errors, risky actions, reckless actions, malicious actions, or impaired judgment?

Whichever action is found to be true from the list above, – a different action is taken by management.

The rule of thumb in a just culture, when evaluating a caregiver’s action is: if three caregivers with similar skills and knowledge would do the same thing in similar circumstances.

A just culture moves away from a culture of blame to an atmosphere that builds trust, emphasizes accountability and encourages reporting.

Conclusions

We have much to learn from industry and the work they have done around classification and error reductions.

The aviation industry has evidenced a dramatic reduction in errors and incidents since they began their seminal work on human factors. Although more and more people fly every year, since 1950, their fatalities have fallen every decade since the 1050’s.

Classification, analysis and transparency in sharing information allows us to progress toward the goal of zero medical errors that harm patients.