Sandi Gulbransen University of Utah Health Care Frank A. Drews University of Utah Center for Human Factors in Patien

1. Elements of an Agile Safety Culture in Health Care Sandi Gulbransen University of Utah Health Care Frank A. Drews University of Utah Center for Human Factors in Patient Safety VA Salt Lake City Health Care System Informatics, Decision-Enhancement, and Surveillance Center

2. Socio-Technical Systems • Safety • Culture of Safety • Components • Safety Space • Perspectives on improvement • Principles of process improvement • Task analysis and improvement in task performance • Take away

3. Socio-Technical Systems • Socio-Technical System (STS) • Core Idea: Systems have technical and social components • Technical system  • Machinery, processes, procedures • Social system  • People and their habitual attitudes, values, behavioral styles and relationships 

4. Socio-Technical Systems • How to strengthen a socio-technical system? • Resilience Engineering • Resilience • “The ability of a system to adjust its functioning prior, during, and past changes and disturbances to maintain operation” Hollnagel, 2011 • Assumptions • Performance conditions are underspecified; constant adjustment to changing conditions is required • Safety and productivity are not independent

5. Safety and Safety Culture • What is safety? • Safety as the absence of accidents, incidents, injuries, illnesses? • Problem: What causes these events? • What is within our control, and what is not? (e.g. I can control how I drive but I cannot control how others drive). • Definition by International Organization for Standardization (ISO): “Safety is freedom from unacceptable risk.” • Issue of risk vs. uncertainty

6. Safety and Safety Culture • Safety culture / safety climate • Result of Chernobyl nuclear power accident (1986) • Rule violations and poor culture of safety as contributors • Usually there is no intention to create unnecessary risk • But: to get the job done safety is eroded (violation) • Routine violations reducing safety margins

7. Safety and Safety Culture Safety Culture Commitment Competence Cognizance

8. Safety and Safety Culture • Commitment • Motivation to stay safe even under management changes • Resources with regard to quantity and quality • Competence • The technical competence to improve safety • Safety information system • Cognizance • Correct awareness of the threats to the organization

9. Safety and Safety Culture • Safety space • Continuum from resilient to brittle organizations resilient brittle

10. Safety and Safety Culture • Over time organizations move in safety space • Position in the safety space is a function of the number of negative outcomes • Resilient organizations suffer fewer negative outcomes • Drifting towards the brittle region increases the likelihood of accidents • Public and/or regulatory pressures result in improvements of safety • Moving towards the resilient region has also contrary forces • Safety initiatives may run out of steam • There is a diminishing return for safety improvements

11. How to increase resilience? • Learning • Knowing what has happened • Ability to address the factual • Responding • Knowing what to do • Responding to regular and irregular disruptions • Ability to address the actual

12. Anticipating • How to anticipate threats, developments and opportunities • Ability to address the potential • Monitoring • Knowing what to look for, i.e., what can become a threat in the future • Focus on what happens in the environment, but also what happens in the system • Ability to address the critical

13. Abilities required for resilience Learning (factual) Anticipating (potential) Responding (actual) Monitoring (critical)

14. Examples from two perspectives • Macro perspective • Principles of process improvement • Example: Joint replacement • Micro perspective • Task Analysis / improvement of task performance • Examples:Kit development using Adherence Engineering; ICU Display Design

15. Value Management System (VMS):Toward a Learning Health System Sandi Gulbransen University of Utah Health Care March 20, 2014

16. Outline • Value Management System (VMS) • Principles of Lean and ISO 9001:2008 • Use case • VMS as Virtuous Cycle

18. Today Make the best decisions with the most complete information available – but our best information has gaps. Tomorrow Make the best decisions with a better understanding of our key processes and how they are performing.

21. Joint Replacement:Value Driven Care Process Physician Lead: Chris Pelt, MD Sponsor: Charles Saltzman, MD Multidisciplinary Team: Nursing Physical Therapy Ambulatory Clinic Case Management Value Engineering Decision Support EDW Quality & Patient Safety

22. DOCUMENT • What we do DAILY WORK • RECORD • What we did Joint Replacement Care Process Patient Information Early Mobilization Incomplete Discharge Orders Policies Procedures Guidelines Bylaws + = Daily Activity Chart Activity

23. AUDIT • How well we do it EXTERNAL AUDITS DAILY WORK No specific audits > INTERNAL AUDITS = +

24. AUDIT • How well we do it Opportunity for Improvement EXTERNAL AUDITS • NON-CONFORMITY • What didn’t work IDENTIFY > X X X X INTERNAL AUDITS INTERNAL AUDITS = +

25. CORRECTThe fix EXTERNAL AUDITS Early Mobilization Prioritized – Change of PT Shifts Updated discharge order set Patient Selection pre-op re: post op SNF, Rehab, HH REPORT > INTERNAL AUDITS = +

26. CORRECTThe fix Perfect Care Metric - VMS EXTERNAL AUDITS • PREVENT • How we keep it • From happening PREVENT > INTERNAL AUDITS = +

27. Perfect Care Composite: Joint Replacement

28. Results Patient Care and Average Cost

29. Interpret Analyze Feedback Virtuous Cycles1 Assemble Change

30. Interpret Identify nonconformity or preventive action Analyze Monitor process performance Metrics and drivers Feedback Find opportunity Make it easy to do the right thing Assemble Identify change for sustained improvement Change Best practices – internal and external

31. Agility • Understanding of key processes • Metrics that will drive change • Actionable information at POC • Extensible to other organizations Projects PDSA cycles Lean Management Virtuous cycles Proactive Reactive

32. Journey to Learning Systems 1Friedman, C. Informatics for the Nationwide Learning Health System, 1/27/2014

33. There is a way to do it better – find it. -Thomas Edison

34. Frank A. Drews University of Utah Center for Human Factors in Patient Safety VA Salt Lake City Health Care System Informatics, Decision-Enhancement, and Surveillance Center With Aaron Angelovic, Jonathan Bakdash, AlexaDoig, Brittany Mallin • Task analysis • and • improvement in task performance

35. Adherence and Violations • Procedure violations • Common problem in many industries • Routineviolations • Person perceives an alternative, more efficient way to perform task • Lack of feedback • External (social) pressures reinforce routine violations • Violation producing conditions • Perceived low likelihood of detection • Inconvenience • Time pressure

36. Design for Adherence • Central line maintenance: A trivial task? • Maintenance requires more than 25 steps • Breakdowns in maintenance can result in central line associated bloodstream infection (CLABSI)

37. Design for Adherence • Adherence Engineering to reduce Violations

38. Design for Adherence • A procedure: Central line maintenance • Status quo • Current equipment does not support clinicians • Opportunity to redesigning the task / equipment based on Human Factors

39. Design for Adherence • Building an alternative • Integrating checklist into equipment to support adherence to best practices • Applying AE principles • Multi step approach • Involvement of Infusion Team Members / Physicians • Involvement of Manufacturer • Involvement of HF Engineers • Iterative design and evaluation process • Virtuous cycle

40. New Kit Non-Sterile Portion Small size Sterile Portion

41. Results • Clinical data • CLABSI rates • Pre-intervention • CLABSI rate: 3.23 / 1000 patient line days • Post-intervention • CLABSI rate: 0 / 1000 patient line days • Incident rate ratio = 0 (95% CI:0-0.63; p<.01)

42. Results Pre-intervention n = 107, Post-intervention n = 85

43. Design for Adherence • Discussion • Clear improvement in adherence to best practices • Fewer item omissions / errors • Reduction in CLABSI

44. Development of a Patient Monitor for Critical Care

45. ICU display • Two step approach • Semi-structured interviews with ICU nurses • Goal: Understanding the limitations of current displays • Design • Involvement of nurses, physicians, cognitive psychologists • Iterative design process • Evaluation study

46. Interviews to inform design • Interview • Focus on experience with current displays • Confusing variables • Missing information • Error • Relevance of trend information • Patient variability • Usability

47. Interviews to inform design • Results (emerging themes)

48. Interviews to inform design • Discussion • Current monitor equipment does not support integrated patient assessment • Slow, piecemeal-wise processing • Increases cognitive load • Information needs are not met • Trend information not immediately available • High information access costs

49. Design of the display • Design process • Focus on most commonly monitored patient variables • Trending information • Configural approach (patient centered variability) Septic shock

50. Evaluating the display • Study Design • IV: • Display (configural vs. traditional display) • 4 scenarios (Septic shock, pulmonary embolism, early sepsis, normal) • DV: • Time for nursing diagnosis • Percentage of correct diagnoses • Percentage of trend data being accessed in traditional display condition • Participants • 40 ICU nurses (25 female)