High Reliability: Past Achievements & Continued Growth

1. High Reliability: Past Achievements & Continued Growth

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3. Glossary • AHA: American Hospital Association • APIC: Association of Practitioners in Infection Control • HAI: Healthcare Acquired Infection • HRO: High Reliability Organization • IDSA: Infection Disease Society of America • NPSG: National Patient Safety Goal • SHEA: Healthcare Epidemiology in America

4. Past Achievements

5. Achievements • Evidence-Based Standard Requirements • The HAI-Focused NPSG’s • Hand Hygiene NPSG • The Compendium

6. Achievements • The Joint Commission’s vision: Goal to promote a “Culture of Safety” in accredited health care organizations (HCO) • Standards • National Patient Safety Goals • Reporting of Sentinel Events • Expectation of Follow-up to Sentinel Event • Core measures • Supporting hospitals towards becoming a High Reliability Organization (HRO)

7. Movement Towards a HRO • Definition of a HRO: An organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk or complexity.

8. Five Characteristics High Reliability Organizations • Preoccupation with failure • Reluctance to simplify interpretation of problems • Sensitivity to operations • Commitment to resilience • Deference to expertise

9. Integration Within Organization Processes • Infection prevention & control -Center for Transforming Healthcare -Standards -National Patient Safety Goals (NPSG) addressing HAI’s & Hand Hygiene -Compendium

10. Integration of Leadership Safety Standards • Leaders implement changes in existing processes to improve the performance of the organization. • Leaders create and maintain a culture of safety and quality throughout the organization. • The hospital uses data and information to guide decisions and to understand variation in the performance of processes.

11. TJC Evidence-Based Requirements • The Joint Commission worked to transform science into evidence-based requirements (i.e. standards and NPSG’s). • A culture of safety and high reliability organizations must rely on evidence-based requirements in healthcare. • The Joint Commission’s goal is to have the standards and National Patient Safety Goals (NPSG) evidence-based. • Standards and NPSG’s are to be value driven: The HAI-focused NPSG’s are one example.

12. TJC Center for Transforming Healthcare • Participants: The nation’s leading healthcare systems. • Use a proven systematic approach to analyze specific breakdowns in patient care and discover underlying causes to develop targeted solutions that can be used to solve these complex problems. • Shares solutions with accredited organizations.

13. Main Causes Regarding Failure To Perform Hand Hygiene • Ineffective placement of dispensers or sink • Hand Hygiene compliance data not collected or reported appropriately • Lack of accountability • No “just in time” coaching • Safety Culture does not stress hand hygiene at all levels • Ineffective and/or insufficient education

14. Main Causes Regarding Failure To Perform Hand Hygiene • Hands full • Wearing gloves interferes with process • Perception that hand hygiene is not needed if wearing gloves • Health Care staff forget • Distractions • Staffing shortages

15. Development of the Compendium • The HAI*-Allied Task Force was initiated by: -Society of Healthcare Epidemiology in America (SHEA) -Infection Disease Society of America (IDSA) • Primary partners included: -American Professionals in Infection Control -The American Hospital Association -The Joint Commission

16. Development of the Compendium • Work of the Task Force began in December 2006 • Published in October, 2008 • Online: http://www.shea-online.org/about/compendium.cfm • Special edition in SHEA’s journal: Infection Control and Epidemiology , Volume 29, Supplement 1

17. Components of the Compendium • The Compendium was developed for 6 common HAI including: • Clostridium difficile infections (CDI) • Methicillin-resistant S. aureus (MRSA) • Central line-associated bloodstream infections (CLABSI) • Catheter-associated urinary tract infections (CAUTI) • Surgical site infections (SSI) • Ventilator-associated pneumonia (VAP)

18. Compendium Differences • The Compendium included the first aggregation of evidence-based recommendations for the 6 HAI’s with an implementation focus. • Collaborative effort involving: • Experts in infection prevention and control: SHEA, IDSA, APIC • The Joint Commission • American Hospital Association (AHA) • Endorsed and supported by a variety of organizations & focused on accountability

19. Using the HAI NPSG’s & Compendium Together • The HAI NPSG’s were based on the implementation strategies described in the Compendium. • The Compendium provides additional clinical detail to the requirements in the NPSG.

20. Past Achievements Summary • The Joint Commission’s focus: High reliability organizations and a “culture of safety” are required to sustain the elimination of HAI. • The Joint Commission is prepared to transform science into value driven requirements and has successfully done so with the HAI-focused NPSG’s. • The Joint Commission launched The Center for Transforming Healthcare. • The Compendium included the first aggregation of evidence-based recommendations for the 6 HAI’s in an implementation format. • The Joint Commission’s HAI-focused NPSG ‘s and the Compendium can be used together as a strategy for reducing HAI’s in organizations.

21. Future Focus: Continued Growth in High Reliability – Next Steps

22. High Reliability Organizations • HROs such as nuclear power plants, aircraft carriers, and wildland firefighting crews warrant closer attention from healthcare organizational leaders because they operate under trying conditions yet experience fewer than their fair share of problems.

23. Mindfulness Defined • Combination of ongoing scrutiny of existing expectations • Continuous refinement and differentiation of expectations based on newer experiences • Willingness and capability to invent new expectations that make sense of unprecedented events

24. Mindfulness Defined • A more nuanced appreciation of context and ways to deal with it • Identification of new dimensions of context that improve foresight and current functioning

25. Detection, Containment, Resilience • Successful HROs manage the unexpected to their identified mission • They organize themselves in such a way that they are better able to notice the unexpected in the making and halt its development • If they have difficulty halting the development of the unexpected, they focus on containing it

26. Detection, Containment, Resilience • If some of the unexpected breaks through the containment, they focus on resilience and swift restoration of system functioning.

27. Signal Detection • The difference between HROs and other organizations in managing the unexpected often occurs in the earliest stages, when the unexpected may give off only weak signals of trouble • The overwhelming tendency is to respond to weak signals with a weak response • Mindfulness preserves the capability to see the significant meaning of weak signals

28. Blame Game • Executives often manage the unexpected by blaming it on someone, usually on someone else.

29. Detection • It is the failure both to articulate important mistakes that must not occur and to organize in order to detect them that allows unexpected events to spin out of control.

30. Processes HROs Use to Manage the Unexpected • Anticipating and becoming aware of the unexpected • Preoccupation with failures rather than successes • Reluctance to simplify interpretations • Sensitivity to operations • Containing the unexpected when it occurs • Commitment to resilience • Deference to expertise

31. Not Error-Free • HROs develop capabilities to detect, contain, and bounce back from those inevitable errors that are part of an indeterminate world • The signature of an HRO is not that it is error-free, but that errors don’t disable it. • Resilience is a combination of keeping errors small and of improvising workarounds that keep the system functioning.

32. Starting Small • Trouble starts small and is signaled by weak symptoms that are easy to miss, especially when expectations are strong and mindfulness is weak. • Small moments of inattention and misperception can escalate swiftly into unmanageable trouble.

33. Expectations • To have an expectation is to envision something, usually for good reasons, that is reasonably certain to come about . • To expect something is to be mentally ready for it. Every deliberate action you take is based on assumptions about how the world will react to what you do.

34. Expectations • Expectancies form the basis for virtually all deliberate actions because expectancies about how the world operates serve as implicit assumptions that guide behavioral choices. • Expectations provide a significant infrastructure for everyday life. They are like a planning function that suggests the likely course of events.

35. Expectations • We actively seek out evidence that confirms our expectations and avoid evidence that disconfirms them. • We tend to overestimate the validity of expectations currently held. • The continuing search for confirming evidence postpones your realization that something unexpected is developing.

36. Unpleasant Experiences • Evidence shows that when something unexpected happens, this is an unpleasant experience. • Part of managing the unexpected involves anticipating these feelings of unpleasantness and taking steps to minimize their impact.

37. Mindlessness • When people function mindlessly they don’t understand either themselves or their environments, but they feel as though they do. • A silent contributor to mindlessness is the zeal found in most firms for planning. Plans act the same way as expectations. They guide people to search narrowly for confirmation that the plan is correct. • Mindlessness is more likely when people are distracted, hurried, or overloaded.

38. Mindlessness • A tendency toward mindlessness is characterized by a style of mental functioning in which people follow recipes, impose old categories to classify what they see, act with some rigidity, operate on automatic pilot, and mislabel unfamiliar new contexts as familiar old ones • A mindless mental style works to conceal problems that are worsening.

39. Expectations and Planning • If you understand the problems that expectations create, you understand the problems that plans create. • A preoccupation with plans and planning makes it that much harder to act mindfully. • Mindfulness is essentially a preoccupation with updating, grounded in an understanding that knowledge and ignorance grow together.

40. Power of a Mindful Orientation • Redirects attention -from the expected to the irrelevant -from the confirming to the disconfirming -from the pleasant to the unpleasant -from the more certain to the less certain -from the explicit to the implicit -from the factual to the probable -from the consensual to the contested

41. Mindless Control Systems • It is impossible to manage any organization solely by means of mindless control systems that depend on rules, plans, routines, stable categories, and fixed criteria for correct performance.

42. Mindless Control Systems • No one knows enough to design such a system so that it can cope with a dynamic environment. • Designers who want to hold dynamic systems together have to organize in ways that evoke mindful work.

43. Error Reporting • A necessary component of an incident review is the reporting of an incident. And research shows that people need to feel safe to report incidents or they will ignore them or cover them up. • HROs increase their knowledge base by encouraging and rewarding error reporting.

44. Resilience • To be resilient is to be mindful about errors that have already occurred and to correct them before they worsen and cause more serious harm. • Resilience encourages people to act while thinking or to act in order to think more clearly. • Resilience is about bouncing back from errors and about coping with surprises in the moment.

45. Mindless/Mindful Investments • To manage the unexpected is to be reliably mindful, not reliably mindless. • Those who invest heavily in plans, standard operating procedures, protocols, recipes, and routines tend to invest more heavily in mindlessness than in mindfulness.

46. Culture • Culture is a pattern of shared beliefs and expectations that shape how individuals and groups act • Descriptions of safety culture often read like lists of banal injunctions to “do good.” • Culture will affect what you see and how you interpret it • Culture change takes a long time • A safety culture is an “informed culture” – James Reason

47. Four Subcultures • The problem is that candid reporting of errors takes trust and trustworthiness. Both are hard to develop, easy to destroy, and hard to institutionalize. • Reporting Culture • Just Culture • Flexible Culture • Learning Culture

48. Four Subcultures • Reason (James) argues that it takes four subcultures to ensure an informed culture. Assumptions, values, and artifacts must line up consistently around the issues of: • What gets reported when people make errors or experience near misses (reporting culture) • How people apportion blame when something goes wrong (just culture) • How readily people can adapt to sudden and radical increments in pressure, pacing, and intensity (flexible culture) • How adequately people can convert the lessons that they have learned into reconfigurations of assumptions, frameworks, and action (learning culture)”

49. Sustained High Performance • If you update and differentiate the labels you impose on the world, the unexpected will be spotted earlier and dealt with more fully, with sustained high performance. • Reliability is a dynamic event and gets compromised by distraction and ignorance. • Mindfulness is about staying attuned to what is happening and about a deepening grasp of what those events mean.

50. Mindful Culture • To be mindful is to become susceptible to learning anxiety. And anxious people need what Edgar Schein calls “psychological safety.” • Mindfulness requires continuous, ongoing activity. • Mindfulness preserves the capability to see the significant meaning of weak signals and to give strong responses to weak signals.