June National Content Call

1. June National Content Call A Closer Look at Learning from Defects June 11, 2013

2. Today’s Presenters Chris Goeschel ScD MPA MPS RN FAAN Assistant Professor, Johns Hopkins School of Medicine Director, Strategic Development for Research Initiatives, Armstrong Institute for Patient Safety and Quality Barbara Edson MBA MHA RN Vice President, Clinical Quality Health Research & Educational Trust American Hospital Association

3. Learning Objectives • Describe the Learn from Defects (LFD) tool and process • Discuss ways to apply the tool to your existing work • Understand how learning from defects can help you leverage other safety or error reporting tools • Describe how behavioral choices and corresponding actions influence safety

4. Problem Solving* First Order Recovers for that patient yet does not reduce risks for future patients Examples: You do get the supply or you make due Second Order Problem Solving Reduces risks for future patients by improving work processes Example: you create a process to make sure line cart is stocked *Anita Tucker

5. Learning from Defects Through Sensemaking http://www.ahrq.gov/cusptoolkit/identify.htm

6. What is a Defect? Anything you do not want to have happen again

7. Sources of Defects Adverse event reporting systems Sentinel events Claims data Infection rates Complications Where is the next patient going to be harmed?

8. Sensemaking • A systematic approach to event reporting. • Sensemaking can be applied to the analysis of individual events or specific systems.

9. Learning from Defects (LFD) Tool

10. Learning from Defects: Four Questions

11. What Happened? Reconstruct the timeline and explain what happened Put yourself in the place of those involved, in the middle of the event as it was unfolding Try to understand what they were thinking and the reasoning behind their actions/decisions Try to view the world as they did when the event occurred

12. “Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects….. Their part is that of adding the final garnish to a lethal brew that has been long in the cooking.” • James Reason, Human Error, 1990

13. Why Did It Happen? Develop lenses to see the system (latent) factors that lead to the event Often result from production pressures Damaging consequences may not be evident until a “triggering event” occurs

14. System Factors Impact Patient Safety

15. What will you do to reduce the risk of it happening again? Prioritize most important contributing factors and most beneficial interventions Safe design principles Standardize what we do Eliminate defect Create independent check Make it visible Safe design applies to technical and team work

16. Prioritizing Contributing Factors

17. What will you do to reduce risk? Develop list of interventions For each Intervention rate How well the intervention solves the problem or mitigates the contributing factors for the accident Rates the team belief that the intervention will be implemented and executed as intended Select top interventions (2 to 5) and develop intervention plan Assign person, task follow up date

18. Rank Order of Error Reduction Strategies Forcing functions and constraints Automation and computerization Standardization and protocols Checklists and double check systems Rules and policies Education / Information Be more careful, be vigilant

19. How Do You Know Risks Were Reduced? Did you create a policy or procedure (weak) Do staff know about policy or procedure Are staff using the procedure as intended Behavior observations, audits Do staff believe risks were reduced

20. Summarize & Share Findings Summarize finds 1 page summary of 4 questions Learning from defect figure Share within your organizations Share de-identified with others in collaborative (pending institutional approval)

21. System Failure Leading to Error: Reason’s Swiss Cheese Model Did not verify equipment availability Fatigue Hazards Bronch cart not stocked Patient suffers Communication between resident and nurse Hypoxic arrest

22. Examples of Where This was Applied CUSP program on ICUs Critical Care Fellowship Program Morbidity and Mortality Conferences

23. Critical Care Fellowship Program

24. CUSP and Sensemaking Tools

25. Example: Just Culture and LFD A system of shared accountability • Healthcare institutions are accountable for the systems they have designed and for supporting the safe choices of the patients, visitors and staff • Staff are accountable for the quality of their choices, knowing that they may not be perfect, but can strive to make the best possible choices available

26. Inputs and Outputs Two things we can do improve outcomes: Manage human behavior within the systems Design systems to accommodate human beings

27. Understanding Behaviors Human Error At-Risk Behavior Reckless Behavior

28. Managing Behaviors Human Error At-Risk Behavior Reckless Behavior Product of our current system design Unintentional Risk-Taking Intentional Risk-Taking • Manage through: • Removing incentives for At-Risk Behaviors • Creating incentives for healthy behaviors • Increasing situational awareness • Manage through changes in: • Processes • Procedures • Training • Design • Environment • Manage through: • Remedial action • Disciplinary action Console Coach Punish

29. JC - Basic Event Investigation What happened? What normally happens? Increasing value What does procedure require? Why did it happen? How were we managing it?

30. Leveraging Existing Tools • Assess current process • How does that fit with LFD tool? • LFD Questions • What happened? • Why did it happen? • What will you do to reduce the chance it will recur? • How do you know that you reduced the risk that it will happen again?

31. Key Lessons Focus on systems not people Prioritize Use Safe design principles Go mile deep and inch wide rather than mile wide and inch deep Pilot test Learn form one defect a quarter Answer the 4 questions

32. Next Steps: Action Plan Review the LFD tool with your team Review one defect in your unit Be prepared to share experience with using the tool on next coaching call Due Date: ____________ Work towards learning from one defect per month Post the stories of risks that were reduced Share with others

33. Questions?

34. Your Opinion Matters! We rely on your opinion to shape future content calls. At the end of today’s call, please complete our survey using this link: https://www.surveymonkey.com/s/CAUTI_Content

35. References Bagian JP, Lee C, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv 2001;27:522-32. Berenholtz SM, Hartsell TL, Pronovost PJ. Learning From Defects to Enhance Morbidity and Mortality Conferences. Am J Med Qual 2009;24(3):192-5. Griffith, S. Just Culture. Plano, TX: Outcome Engineering; 2011 Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf 2006;32(2):102-108.

36. References • Pronovost PJ, Wu AW, and Sexton JB. Acute Decompensation after Removing a Central Line: Practical Approaches to Increasing Safety in the Intensive Care Unit. Ann Intern Med 2004 June;140(12):1025-1033. • The CUSP Toolkit. December 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/index.html • Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316:1154–57. • Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008;299:685-87.