The Joint Commission Center for Transforming Healthcare

1. The Joint Commission Center for Transforming Healthcare Safe Lifting Conference November 15, 2012

2. Objectives • Understand the components of High Reliability. • Identify the influence of nursing and organizational culture on patient-handling practices. • Use safety culture and change management concepts to sustain success in safe-handling programs. 2

3. No Offense but…. Why is the Joint Commission here to talk about Safe Lifting??????? Our Mission: Transform health care into a high reliability industry and to ensure patients receive the safest, highest quality care they expect and deserve 3

4. Helping organizations improve healthcare and achieve high reliability Donise Musheno, RN, MS, CPHQ Center Project Lead, Black Belt 4

5. Introduction to CTH-Vision One Vision All people always experience the safest, highest quality, best-value health care across all settings. 5

6. Current State of Quality • We have focused intensely for more than a decade on improving quality and safety • Yet, quality problems still surround us • Health care associated infections • Medication errors that cause harm • Failed communication in transitions of care • More than 400,000 harmful, preventable, bad outcomes occur in hospitals every year. Source: Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW. The "To Err is Human" report and the patient safety literature. Qual Saf Health Care. 2006;15:174-178. 6

7. High Reliability Organizations Chassin, M.R. & Loeb, J.M. (2011) The ongoing quality improvement journey: next stop, high reliability. Health Affairs, 30 (4) 559-568. 7

8. Three Crucial Elements of High Reliability 8

9. Robust Process Improvement™(RPI) – A New Way in Delivering Results New Generation of Best Practices: Complex processes require RPI to produce solutions – customized to an organization’s most important causes • Usual Approaches: • “One-size-fits-all” works well only in very limited circumstances: • Process varies little from place to place • Causes of failure are few and common 9

10. Some Important Causes of Hand Hygiene Failures 1. Faulty data on performance 2. Inconvenient location of sinks or hand gel dispensers 3. Hands full 4. Ineffective education of caregivers 5. Lack of accountability  Each requires a very different strategy to eliminate

11. Causes Differ by Hospital Each letter = one hospital

12. Develop Solutions with Leading Hospitals Atlantic Health Barnes-Jewish Baylor Cedars-Sinai Cleveland Clinic Exempla Fairview Floyd Medical Center Froedtert Intermountain Johns Hopkins Kaiser-Permanente Mayo Clinic Memorial Hermann Nebraska Medical Center NY-Presbyterian North Shore-LIJ Northwestern OSF Partners HealthCare Sharp Healthcare Stanford Hospital Texas Health Resources Trinity Health Virtua Wake Forest Baptist Wentworth-Douglass 12

13. Center Operating Model Spread Project Selection Create Solutions, Pilot Test, Build Solve with Participating Organizations Determine Topic Pilot Test 1 Pilot Test 2: Integrate Solutions into TST (Beta-Testing) Launch TST

14. Confidential ● Easy to Use ● No Extra Cost Separate from Accreditation • Educational, no jargon, no special training and no knowledge of RPI methodology needed • Guides users to customized solutions. Data analysis conducted by the tool, not the user. Tool walks user through process of: • Measuring current state • Determining root causes • Selecting targeted solutions • Control of process after implementation SPREAD MECHANISM 14

15. Introduction to CTH-Projects • Project 1 – Hand Hygiene Compliance • Project 2 – Wrong Site Surgery • Project 3 – Hand Off Communication • Project 4 – Surgical Site Infections • With American College of Surgeons • Project 5 – Preventing Avoidable Heart Failure Hospitalizations • With American College of Physicians • Project 6 – Safety Culture • Project 7 – Preventing Falls with Injury • Project 8 – Reducing Sepsis Mortality • Project 9 – Medication Safety

16. Memorial Hermann’s Story: Getting to Zero • Leadership commitment to zero • MH Woodlands Hospital was among the 8 Center hospitals that carried out the hand hygiene project and got impressive results • 2010: MH committed to use TST to improve hand hygiene system-wide (12 hospitals) • Baseline (150 inpatient units) = 44% • Range (12 hospitals ): from 21% to 65% • Aim: to exceed 90% 16

17. NICU Central Line Associated Blood Stream Infections (CLABSI) Mean = 1.85 Mean = 1.07

18. Ventilator Associated Pneumonias (VAP) Mean = 0.95 Mean = 0.5

19. Woodlands:Zero Hospital Central Line Blood Stream Infections

20. Improving Transitions • Hand-off communication failed to include adequate information 41% of the time • Interventions reduced this rate to 17% • One hospital focused on the transition from its inpatient units to a nursing home BaselineImprove Inadequate hand-offs 29% <1% 30-day readmissions 21% 10% 20

21. Safety Culture and Safe Lifting Coleen Smith, RN, MBA, CPHQ Center Project Lead, Black Belt

22. Leadership High Reliability Trust RPI Improve Report Health Care Safety Culture 22

23. Why is culture important? • Lack of an optimal safety culture allows unsafe behaviors/conditions to be present, but not always identified or acted upon, before they cause harm [to patients]. “Culture is what people do when no one is looking.” Herb Kelleher, Chairman Southwest Airlines 24

24. What is the impact? • The price of avoidable harm1: • $17.1 billion in 2008 • On average, the cost per medical error was $11,366. • The price of unsafe patient handling: • Direct and indirect costs associated with only back injuries: • Estimated to be $20 billion annually2 1Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1 Billion Problem: The Annual Cost of Measurable Medical Errors. Health Affairs 30 (4): 596-603, April 2011 2United States Dept. Of Labor Statistics http://www.osha.gov/SLTC/healthcarefacilities/safepatienthandling.html 25

25. What is the impact? • In 2010, nursing aides, orderlies, and attendants had the highest rates of MSDs3: • 27,020 cases--which equates to an incidence rate (IR) of 249 per 10,000 workers • More than seven times the average for all industries. 3United States Dept. Of Labor Statistics http://www.osha.gov/SLTC/healthcarefacilities/safepatienthandling.html 26

26. The myth: • For decades, we were persuaded that we could avoid back injuries simply by using “ergonomic” manual lifting techniques and performing abdominal strengthening exercises. • We now know better, but…. 27

27. The Safety Culture Project 28

28. Project Goals • Increase recognition • And reporting, triage, action and communication • Increase the quality and effectiveness of the communication • What happened to our report? • Increase the effectiveness of the actions • Is this going to prevent a recurrence? 29

29. “The adult human form is an awkward burden to lift or carry. [I]t has no handles, it is not rigid, and is susceptible to severe damage if mishandled or dropped.”1 1 Anonymous. The nurse’s load (editorial). Lancet 1965; II:422-3. 30

30. How does culture relate to safe lifting? • Acceptance and buy-in of the technological and procedural • Recognition of errors, close calls and disregard of procedures • Barriers to use • Policy adherence • Learn from close calls • Change in focus to prevention • Errors will never be completely eliminated 31

31. How Have Others Done It? “High reliability organizations”manage very serious hazards extremely well Commercial aviation, nuclear power What do they all have in common? Highly effective process improvement Fully functional safety culture Discover and fix unsafe conditions early “Collective mindfulness” 32

32. Swiss Cheese theory of causation 33

33. Success in Safe Handling • Follow solid, well-understood policies • Partial or optional buy-in will not lead to success • BUT—education and training are not enough 34

34. Success in Safe Handling • Leaders establish a safety-oriented culture that supports caregivers to perform safe handling. • Peer safety leaders/Lift champions • Ability to report injuries/errors/near misses without fear of being blamed. • Learning Culture • Leadership then follows up and communicates 35

35. And don’t forget… • Change management techniques are crucial. 36

36. Change Management Application for Safety: Yours and Others Dawn Allbee Director of Corporate Robust Process Improvement Master Change Agent

37. “Change is good. You go first.” — Dilbert 38

38. 39

39. Robust Process Improvement (RPI) • Six Sigma • Lean • Change Management 40

40. To Get Effective Results • Consider the solution and the human side of change: • How will people accept the change? • What if they don’t? • How will people be accountable for the change? • What if they aren’t? 41

41. Change Management Challenges • Lack of team engagement • Lack of key stakeholder support • Resistance • Lack of buy-in • How do we sustain the gains? 42

42. Why do we need to change? • Why is the change important? • Demonstrate the need to change • What does the data show? • Who or what is driving the initiative? • What are the threats if we do nothing? • What are the opportunities with success? • Create a sense of alignment • Do we all see the same problem? • Do we all share the same goals? 43

43. Demonstrate the Need Six Sigma Performance 99% Good (3.8 Sigma) 99.99966% Good (6 Sigma) • Unsafe drinking water for almost 15 minutes each day • 52 incorrect site surgeries for every 5,000 surgeries • Two short or long landings at a major airport each day • 10,000 wrong drug prescriptions per 1 million filled each year • Unsafe drinking water for one minute every seven months • 1.7 incorrect site surgeries every 500,000 surgeries • One short or long landing every five years at a major airport • 3.4 wrong prescriptions per 1 million filled each year

44. What will the future state look like? • If you had a crystal ball and could go into the future, what would you see? • What behaviors would we see more of? • What behaviors would we see less of? • Create a vision for the direction you want to move • A picture paints 1,000 words • Develop key words and phrases for the team to use when describing the vision • To motivate and energize 45

45. Engaging Key Stakeholders • Identify key stakeholders and gauge their support • Utilize early adopters to build additional support • Identify resistance early and have a plan of action to address • Where is resistance coming from? • Why is there resistance? • Understand stakeholder concerns and identify wins 46

46. Identifying Resistance What Resistance Do You Hear/See? Know who your key stakeholders are and what’s important to them! 47

47. Sustain the GainsIf You Don’t Actively Make the Change Last, It Won’t • What will happen here if someone lets go? 48

48. Keys to Sustaining the Gains • Energize your key stakeholders • Know where resistance may be hiding • Actively make change last • Align management practices with the change • Ensure continued leadership support 49

49. Can we operationalize the change? • It looks good on paper, but do we have the structure in place to support the change? • Right people and skill sets • Right incentives • Right message and medium to communicate • Right technologies • Right organization structure 50

50. Leadership Commitment and Support • Ever hear the phrase “Follow the Leader”? • Leadership commitment and support is crucial to any change initiative • Leadership support is maintained throughout the project • Leadership’s involvement in change initiatives • Shows importance of change • Helps others move through change initiatives • Helps reduce resistance • People focus their time, passion, and energy on things that are important to them 51