Identifying and Mitigating Barriers and Hazards

1. Identifying and Mitigating Barriers and Hazards Armstrong Institute for Patient Safety and Quality Presented by: Ayse P. Gurses, PhD Assistant Professor, Human Factors Engineer

2. Learning Objectives • To learn how to identify hazards/ barriers in a healthcare work system • To understand how to develop a systematic approach to eliminate or reduce the effects of these barriers/ hazards Armstrong Institute for Patient Safety and Quality

3. Terminology • Harm (adverse) events • No harm events • Near misses • Hazard: Source of danger but does not contain any likelihood of an undesired impact • Risk analysis: Detailed examination of • what hazards can happen • how likely a hazard will happen • what are the consequences, if such a hazard happens in the system Armstrong Institute for Patient Safety and Quality

4. Terminology • Barriers: Work factors that affect the overall performance of the system. • May affect safety of care, compliance with evidence based practice, efficiency, effectiveness, profitability, quality of work life (e.g., stress, fatigue) • Hazards: a subset of barriers that affect “safety” Armstrong Institute for Patient Safety and Quality

5. Safety Engineering • Build safety into design of health care systems • Proactively identify hazards in the system before errors and accidents occur • Develop risk management strategies Armstrong Institute for Patient Safety and Quality

6. Hazard and Barrier Identification/ Analysis Tools: Reactive • Archival records • Event reporting • Root cause analysis Armstrong Institute for Patient Safety and Quality

7. Identifying Hazards and Barriers: Proactive • Work system analysis or process mapping (variations, workarounds, steps skipped, etc.) • Observations • Interviews or focus groups • Brainstorming • Heuristic analysis • What-if checklists Armstrong Institute for Patient Safety and Quality

8. What to Observe? • Information tool characteristics • Extreme, unexpected, unfamiliar cases • Feedback mechanisms • Variations in conducting tasks • Fit to the job (e.g., task-technology fit) • Physical layout • Disconnects and surprises (e.g., automation surprises) • Distractions • Ambiguities • Workarounds • Team behaviors (e.g. situation awareness, shared mental model) Armstrong Institute for Patient Safety and Quality

9. Systems Engineering Initiative for Patient Safety (SEIPS) Model Carayon, P., Hundt, A.S., Karsh, B.-T., Gurses, A.P., Alvarado, C.J., Smith, M. and Brennan, P.F. “Work System Design for Patient Safety: The SEIPS Model”, Quality & Safety in Health Care, 15 (Suppl. 1): i50-i58, 2006.

10. Observation Tool for Identifying Hazards Armstrong Institute for Patient Safety and Quality

11. Interviews/ Focus Groups • What could go wrong? How badly will it go wrong? • How do you think that patients can be harmed in this unit while taken care of? • If you could change a few things in your unit to improve patient safety, what would they be? • What safeguards are in place to prevent errors? Armstrong Institute for Patient Safety and Quality

12. Workarounds as potential barriers/hazards Armstrong Institute for Patient Safety and Quality

13. Barriers/ Hazards by Pictures Armstrong Institute for Patient Safety and Quality

14. How to Use This Methodology to Improve Processes of Care?

15. Compliance with Evidence-Based Guidelines • Consistent compliance with evidence-based guidelines is challenging yet critical to patient safety. • Need for interdisciplinary approach to improve compliance • From human factors point of view: Compliance as “systems property.” • GOAL: To identify and eliminate/mitigate the effects of barriers to compliance with guidelines

16. Evidence-based Behaviors to Prevent CLABSI • Remove unnecessary lines • Wash hands prior to procedure • Use maximal barrier precautions • Clean skin with chlorhexidine • Avoid femoral lines

17. Steps of Barrier Identification and Mitigation Tool (BIM)* • Step 1: Assemble the interdisciplinary team • Step 2: Identify barriers • Observe the process • Ask about the process • Walk (simulate) the process • Step 3: Summarize barriers in a Table • Step 4: Prioritize barriers • Step 5: Develop an action plan for each prioritized barrier * Gurses et al. (2009) A practical tool to identify and eliminate barriers to evidence-based guideline compliance. Joint Commission Journal on Quality and Patient Safety 35(10):526-532 .

18. Step 2: Identify Barriers • Observe the Process • Include different lenses – nurse, infection control, human factors/ QI expert conducting observations • Why is it difficult to comply? • Steps skipped, work-arounds

19. Step 2: Identify Barriers • Ask about the process: Ask staff • whether they are aware of/ agree with the guideline • what some of the leading problemsand barriers encountered in their unit that may hinder compliance with this guideline? • Have any suggestions to improve compliance with the guideline • Specific questions (e.g., How do you findout the date that a central venous catheter was inserted to a patient?)

20. Step 2: Identify Barriers • Walk the process • Try to comply with the guideline using simulation or, if appropriate, under real circumstances. Armstrong Institute for Patient Safety and Quality

21. Types of Barriers • Provider • Knowledge, attitude • Current practice habits • Guideline-related • Applicability to patient population • Evidence supporting guideline • Ease of compliance • System • Inadequate or poorly designed tools and technologies • Poor organizational structure (e.g., staffing, policies) • Inadequate leadership support • Unit/hospital culture • Inadequate feedback mechanisms • System ambiguities • Other

22. Barrier Identification Form

23. Barrier Summary and Prioritization • *Likelihood score: How likely will a clinician experience this barrier? • Remote 2. Occasional 3. Probable 4. Frequent • †Severity score: How likely will experiencing a particular barrier lead to non-compliance with guideline? • Remote 2. Occasional 3. Probable 4. Frequent • ‡Barrier priority score = Likelihood score X Severity score

24. Development of Action Plan *Potential impact score: What is the potential impact of the intervention on improving guideline compliance? 0. No impact 1. Low 2. Moderate 3. High 4. Very high †Feasibility score: How feasible is it to take the suggested action? 0. Not feasible 1. Low 2. Moderate 3. High 4. Very high ‡Action priority core = Potential impact score X Feasibility score

25. Hazard/Barrier Reduction Strategies: Summary • Simplify and standardize when you can • Make it easier for people to do the right thing (e.g., central line insertion cart) • Create independent checkpoints • Learn from mistakes and successes • Think about “sustainability” of interventions Armstrong Institute for Patient Safety and Quality

26. References • Carayon et al. (2006) Works system design for patient safety: the SEIPS model. Quality and Safety in Health Care 15: i50 - i58. • Gurses et al. (2009) A practical tool to identify and eliminate barriers to evidence-based guideline compliance. Joint Commission Journal on Quality and Patient Safety 35(10):526-532 • Gurses et al. (2008) Systems ambiguity and guideline compliance, Quality and Safety in Health Care 17:351-359 • Gurses et al. (2010) Using an interdisciplinary approach to identify factors that affect clinicians’ compliance with evidence-based guidelines. Critical Care Medicine Forthcoming. • Pronovost et al. (2008). Translating evidence into practice: a model for large scale knowledge translation. British Medical Journal 337:a1714 • Thompson et al. (2008) View the world through a different lens: shadowing another Joint Commission Journal on Quality and Patient Safety 34, 614-618(5).

27. References • Battles and Lilford (2003). Organizing patient safety research to identify risks and hazards. QSHC 12:ii2-ii7. • DeRosier et al. (2002). Using health care failure mode and effect analysisTM. Joint Commission Journal on Quality Improvement. 28: 248-267. • Marx and Slonim (2003). Assessing patient safety risk before the injury occurs. QSHC. 12:ii33-ii38. Armstrong Institute for Patient Safety and Quality

28. Questions? agurses1@jhmi.edu