Building a Culture of Patient Safety at Novant Health Physician Education Part 1: Safety Concepts and Theory

1. Building a Culture of Patient Safety at Novant HealthPhysician EducationPart 1: Safety Concepts and Theory First, Do No Harm: ©2009 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED Prepared for Novant Health for their non-exclusive, internal use only.

2. Objectives: Describe what we mean by building and sustaining our patient safety culture. Explain why people make errors in complex systems and how we can reduce errors from propagating through these systems. Present an overview of the Safety Behaviors here at Novant in preparation for the second part of our CME program Goal and Objectives Goal: Understand the Novant Safety Behaviors and commit to making them personal work habits 2

3. Megan Nicholas Kiko Damon Molly Mary Carson Mary Beth Lizzy Richard Why are we here?

4. Safety Culture – “A 747 a Day” • 2000 IOM report, To Err is Human: Building a Safer Health System • 44,000 to 98,000 Americans dying annually from medical errors • 98,000 = 270 people / day (747 capacity) • 44,000 = 120 people / day (737 capacity)

5. Published Cases • HPI - a Reliability company • Comprehensive safety culture engagement • Over 140 hospitals nationwide • Savannah, GA • 500 bed academic institution • 89% reduction in 2 years • 50% reduction in 18 months • AHA Quest for Quality Award 2004 • TJC Eisenberg Quality Award 2005

6. SM SafetyEventClassification SEC A deviation from standard of care or practice expectations that… • Serious Safety Event • Reaches the patient • Results in moderate to severe harm or death • Cause Analysis: Root Cause Analysis (RCA) Required Serious Safety Events • Precursor Safety Event • Reaches the patient • Results in minimal to no detectable harm • Analysis: RCA or Apparent Cause Analysis (ACA) Precursor Safety Events Near Miss Safety Event Does not reach the patient – error is caught by a last strong detection barrier designed to prevent event Cause Analysis: No formal Near Miss Safety Event © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

7. Rolling 12-month rate of Serious Safety Events per 10,000 adjusted patient days Why a 12-month rolling average? Smoothes the curve for infrequent events Encourages sustainability in reliable safety performance (it takes 12 months for an event to “drop out” of the average) SM Serious SafetyEventRate SSER # SSE during past 12 months SSER = X 10,000 # APD for past 12 months SSER Calculation

8. SM 1000 Bed Hospital Serious SafetyEventRate SSER SSER JAN 2005: 1.21 SSER JAN 2007: 0.34 71.9% reduction Number of Patients Harmed

9. Novant Health (9 hospitals) Rolling 12-month rate of Serious Safety Events per 10,000 adjusted patient days

10. Journey to Improving Reliability 10-6 10-5 10-4 10-3 10-2 10-1 Behavior Accountability Behavior Expectations Knowledge & Skills – Error Prevention Reinforce & Build Accountability Optimized Outcomes Frequency of Failure Integrated With Process Design Evidence-Based Best Practices Technology Enablers Process optimization/simplification Tactical interventions Time

11. Latent Weaknesses in barriers Multiple Barriers - technology, processes, and people - designed to stop active errors (our “defense in depth”) EVENT of HARM Active Errors by individuals result in initiating action(s) Two Strategies to Eliminate Safety Events: #1 Prevent the human errors #2 Find and fix system and process problems Why Do Events Happen? Adapted from Dr. James Reason, Managing the Risks of Organizational Accidents, 1997

12. Influencing Behaviors at the Sharp End Design of Policy & Protocol Design of Work Processes Design of Culture Design of Technology & Environment Design of Structure Behaviors of Individuals & Groups Outcomes “You have to manage a system. The system doesn't manage itself.” W. Edwards Deming "A bad system will DEFEAT a good person every time.“ W. Edwards Deming Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994)

13. As Humans, We Work in 3 Modes Knowledge-Based Performance “Figuring It Out Mode” Rule-Based Performance “If-Then Response Mode” Skill-Based Performance “Auto-Pilot Mode”

14. Skill-Based Performance Error Prevention Strategy Errors We Experience Stop and think before acting Slip – Errors of commission – the act is performed wrong Lapse – Errors of omission – you fail to do what we meant to do Fumble – Motor skill errors 3 in 1,000 acts performed in error (pretty reliable!) • What You’re Doing At The Time: • Very routine, frequent tasks that you can do without even thinking about it – like you’re on auto-pilot

15. Rule-Based Performance Error Prevention Strategy Errors You Experience Educate about the right rule Used the wrong rule – You were taught or learned the wrong response for the situation Think a second time Misapplied a rule – You knew the right response but picked another response instead Reduce burden, increase risk awareness, improve coaching Non-compliance – Chose not to follow the rule (usually, thinking that not following the rule was the better option at the time) • What You’re Doing At The Time: • Responding to a situation by recalling and using a rule that you learned either through education or experience 1 in 100 choices made in error (not too bad!)

16. Knowledge Based Performance Error Prevention Strategy Errors You Experience STOP and find an expert who knows the right answer You came up with the wrong answer (a mistake) Lack of • What You’re Doing At The Time: • Problem solving in a new, unfamiliar situation. You come up with the answer by: • Using what we do know • Taking a guess • Figuring it out by trial-and-error 30-60 of 100 decisions made in error (yikes!)

17. Power Distance • Geert Hofstede’s Power Distance • Extent to which the less powerful expect and accept that power is distributed unequally • Measure of interpersonal power or influence superior-to-subordinate as perceived by the subordinate • Leads to strong Authority Gradients, which is the perception of authority as perceived by the subordinate • USA • Moderate to low PD (38th of 50 countries) • Surgeons & anesthesiologists view low • Nurses view as significantly higher

18. Korean Airlines Flight 801 High Power Distance Minor Technical Failure Bad Weather Fatigue

19. Authority Gradient • Perception of authority as perceived by the subordinate • Culturally imbedded & handed down • Requires active measures to overcome in order to communicate clearly & share vital information MD Dr.

20. Crew Resource Management

21. Assertiveness • The willingness to state and maintain a position until convinced otherwise by facts • Requires initiative and courage to act Behavior Continuum PASSIVE ASSERTIVEOVER-AGGRESSIVE ‘Too nice’ Actively involvedDominating ProcrastinatesReady for action Intimidating Avoids conflictUseful contributorAbusive ‘Along for the ride’Speaks upHostile

22. Five Principles of High Reliability Organizations (HROs) Three Principles of Anticipation Preoccupation with Failure Regarding small, inconsequential errors as a symptom that something’s wrong Sensitivity to Operations Paying attention to what’s happening on the front-line Reluctance to Simplify Encouraging diversity in experience, perspective, and opinion Two Principles of Containment Commitment to Resilience Developing capabilities to detect, contain, and bounce-back from events that do occur Deference to Expertise Pushing decision making down and around to the person with the most related knowledge and expertise

23. Novant Safety Behaviors & Error Prevention Tools • Practice with a Questioning Attitude • A. Stop, Reflect & Resolve in the face of uncertainty • Communicate Clearly • A. Use SBAR-Q to share information • B. Communicate using three-way repeat backs and read backs • C. Use phonetic and numeric clarifications • Know & Comply with Red Rules • A.Practice 100% compliance with Red Rules • B. Expect Red Rule compliance from all team members • C.If compliance with a Red Rule is not possible, STOP action until any uncertainty can be resolved • Self-check: Focus on Task • A. Use the STAR technique • Support Each Other • A. Cross-check and Assist • B. Use 5:1 Feedback to encourage safe behavior • C. Speak up using ARCC – “I have a concern”

24. Novant Contact Information Sue DeCamp-Freeze Senior Director Clinical Improvement (704) 210-5767 sldecamp-freeze@novanthealth.org Catherine Fenyves Patient Safety Manager (704) 384-9329 Email: cmfenyves@novanthealth.org