Human factors & error An HQCC perspective

1. Human factors & errorAn HQCC perspective Background Responses to regulated standards Learning from complaints Measuring and managing risks

2. Origins of HQCC • Local • Part of a Queensland Government response to findings of inquiries into events at Bundaberg and other public hospitals • Global • Dissatisfaction with effectiveness of internal / self regulation to resolve persistent problems of healthcare safety and quality

3. The nature of the taskAn unusual if not unique combination- 2 key sections (of 241) of the HQCC Act • Section 3 (1) : “ The main objects of this Act are to provide for : • … oversight and review of, and improvement in, the quality of health services; and • …. independent review and management of health complaints.” • Section 23(1&2) “ The Commission may make standards….. (that) may relate to any aspect of the quality of health services, including matters relating to: • …. safety, clinical and cost effectiveness, patient focus, access and responsiveness, public health, facilities and governance; and • …. the review of deaths in hospitals.”

4. Regulated standards • Rationale for choice • Significant burden of disease • Evidence-based best practice is known • Significant gaps between best and current practice • Significant variation in these gaps from place to place • Requirements – initial self assessment: • Do you have a documented process ? • Do you review its effectiveness ? • Do you have relevant improvement initiatives ?

5. Review of Hospital Related Deaths Credentialing Surgical safety Correct surgery Thrombo-embolism prophylaxis Antibiotic Prophylaxis Hand hygiene Complaints Management Management of AMI Following Discharge Providers’ Duty to Improve the Quality of Health Services Current regulated standards http://www.hqcc.qld.gov.au ‘Standards Manual’

6. Increasing compliance with standards

7. Improvements in standard 7 ‘duty to improve’ n=226 (all Qld public and Private facilities)

8. Standards – hospitals with most documented processes of care are also those with most improvement initiatives r=0.85

9. Is compliance with one standard a marker of other unmeasured good practice ? Werner et al 2007

10. Complaints and Investigations • Approx 2500 complaints per year • 35% related to doctor activities, 10% dentists • Approx 50 investigations at any one time • Usually triggered by major failure / public concern • Focus on systemic issues • Report may be tabled in Parliament • All complaints and investigations reveal a complex combination of risk factors : • Staff /clinician • Environment • Organisational culture

11. 3 types of staff (clinician) risk - skills and change capacity • Uncommon : Poor skills & low ability to change • Inadequately qualified for scope of practice • Limited insight due to personality or other incapacity • Commoner : Good skills but low willingness to change • ‘Ultra-orthodox’ professional / occupational identity • Inappropriately located complex /innovative practice • Commonest : Good skills & willing but constrained by: • Excess workloads / lack of resources • High task complexity

12. Task complexity risks

13. Management / organisational culture risks- characterised by response to “anomalies” Modified from Westrum R 2004

14. Measuring and managing risks- looking for ‘anomalies’ • HQCC data • Standards compliance • Complaints & Investigations • Root cause analysis summaries • Provider data • Internal complaints • Internal operations – eg time in theatre, I/H transfers • Mortality and morbidity • Organisational climate surveys • Staff development and appraisal practices • Technique • Statistical process control / cumulative time series analysis

15. The importance of staff and team development 61 acute hospitals in UK: 2000-7,500 employees Case severity adjusted (West et al 2002)

16. Showing that anomalies are significantStatistical process control–outcomesPaediatric cardiac surgery mortality Bristol Significantly different from peer group surgeons Cumulative Mortality 1985 1995 Spiegelhalter 2003

17. Showing that anomalies are significantStatistical process control–processesTime to complete a thyroidectomy Different and not improving Peer benchmark & stable Lim et al 2003

18. SPC :data feedback changes behaviour Qld variable life adjusted display - Stroke Mortality Boundary crossed Deterioration vs peer group Changed practices - back in control

19. Putting it all together - a measurable risk map High Low risk space ‘Environmental Factors Index’ = Resources Task Load X Complexity Low High High risk space ‘Management / Culture Index’ = Anomalies Fixed Total Anomalies Low ‘Staff Factors Index’ = Skills x % effective teams x % performance reviews

20. Risk driven responsive regulation HQCC model modified from Walshe 2003 / Ayres & Braithwaite Performance Scrutiny Regulation costs Low High High REFER Risk thresholds INVESTIGATE OVERSEE DEVOLVE Low High Low

21. Key points • Regulating standards increases process compliance but does it improve outcomes ? • Valuable but under-utilised : • complaints & other local ‘anomalies’ as risk indicators • statistical process control for analysis of these measurements • 3 key dimensions of safety and quality risk : • environmental capacity for case load and complexity • staff skills + personal and team development • managerial response to anomalies • New developments • methods of data integration and analysis to measure and complex interactions in these dimensions • responsive regulation to minimise health workplace disruption by matching level of intrusion with measured level of risk