A Knowledge Management Solution for Red Rules at Presbyterian Hospital

1. A Knowledge Management Solution for Red Rules at Presbyterian Hospital Prepared by Myra HerrmannKathleen Maxfield &Leslie Rettinger

2. Introduction • Every organization has a few rules that are well understood by all should never be broken, under any circumstance, by anybody in the organization. • This Red Rules project will design a learning system for a healthcare organization to support their “Red Rules”.

3. Definition of Red Rules • Red Rules cannot be broken. • few in number, • easy to remember, and • associated only with processes that can cause serious harm to employees, customers, or the product line. • must be followed exactly as specified except in rare or urgent situations. • possible and desirable for everyone to follow

4. Definition, cont. • Every worker is expected to stop the work if the red rule is violated. • Empowers workers to speak up regardless of rank or seniority.

5. Criteria for Red Rules It must be possible and desirable for everyone to follow a red rule every time Anyone who notices that the Red Rule violation has the authority and responsibility to stop further progress.

6. Criteria, cont. • All violations of a Red Rule are mediated through a Just Culture approach • Workers' actions are evaluated based on process in which it occurred. • Just Culture is used regardless of staff member's rank, popularity, and importance to the company.

7. Problem Statement • Current: • Both hand hygiene and the surgical “time-out” are protocols at Presbyterian Hospital. • Not consistently observed. • Potential harm to patients • Desired: • 100% compliance hand hygiene and the surgical “time-out” procedure.

8. Symptoms of the Problem Surgical Time-Out • Quality Control Compliance Assessment • Wrong site, Wrong side, Wrong patient • wrong site 2000-2003 • wrong patient 2000-2003 • Average of 10 operations per year • perioperative infections 2007 • medication reactions 2007 Hand Hygiene • Quality Control Compliance Assessment • Average 70% compliance • Average 57% physician compliance • C. difficile in 6 patients

9. Root Causes of Violations

10. Goals • To design a scalable learning system with reusable learning objects (RLOs) • These RLOs will be integrated into the existing repository system. • To create a RLO strategy to accommodate Red Rules in the existing online employee training system. • This initial project will develop a framework into which historical RLOs will be adaptable.

11. Strategies to Address Root Causes

12. Learning and Performance Architecture Training InstructionalSolutions Workplace Learning (Knowledge and Support Solutions) E-Learning Information Repositories All Employee Online Training Perform-ance Support Mentoring & Coaching Classroom Training Networks & Communities Experts Formal Learning Settings Informal Workplace Settings Traditional Blended Learning

13. KM System & Learning Environment • The knowledge management system at PHS is designed for the creation, archiving and sharing of expectations and expertise across the entire organization. • Red Rules online training is required for all employees and is targeted to clinical, non-clinical, administrative and management audiences. • All employee training is mandatory and will be taken between January 1 and March 31, 2009. • Training will be repeated annually to ensure continued reinforcement of red rules

14. Target Audiences • Target audience includes • Decision Makers • Managers • Healthcare Practitioners • Administrative Staff Media will be designed to meet the needs of these groups.

15. The Work Setting • Resources and constraints • Funding • Personnel • Technology/tools, time • Prevalent philosophy and culture • PHS values and vision • Strategy to continuously improve processes The implementation of Red Rules is integral to the vision of National Excellence.

17. Task Analysis - Hand Hygiene • How is hand hygiene performed? • Alcohol hand disinfection (AHD) technique: • Cover both hands thoroughly • Rub until hands are dry • Use a CHW every 5-6 AHDs to get rid of emollient residue • Conventional handwash (CHW) technique: • Wet hands, apply 5cc of antimicrobial soap • Rub hand surfaces under warm running water for 15-30 seconds. • Other aspects of hand hygiene: • Avoid skin dryness or irritation • Use hospital-supplied lotions

18. Task analysis – Surgical “Time-Out” • How is Time out performed? • Where the procedure will be done • Before starting the procedure. • Entire operative team involved. • Use active communication • Checklist documented: • Correct patient identity. • Correct side and site. • Agreement on the procedure to be done. • Patient Allergies • If perioperative antibiotics are to be given. • Correct patient position

19. Topics Identified From Content Analysis Topic #1. Why Red Rules? 1. Definition 2. Criteria 3. “Just Culture” approach

20. Topics Identified From Content Analysis Topic #2. Why hand hygiene? 1.facts about hand washing 2. procedure for hand- washing i. Steps involved ii. when to perform “time-out”

21. Topics Identified From Content Analysis Topic #3. Why surgical “time-out”? 1. Facts about “time-out” 2. Procedure for “time-out” i. steps involved ii. when to perform “time-out”

22. Topics Identified From Content Analysis Topic #4. Identifying noncompliance 1. Principle about speaking out! 2. Team members 3. Enforce Process Agreements i. Accept / Legitimize

23. Learner Analysis • Training should take into consideration • Background & experience of learners • Learning styles • Goals of learners • Group characteristics • Level of comfort entering the system • Build upon what is known • Make it engaging & motivating • Diversity (culture, language, etc.)

24. Learner Analysis, cont. Online training is primary forum Spanish and English versions provided Paper versions available upon request Some classroom training is available

25. Evaluation Quarterly Reviews by the Quality Control Department include the following measurements: # that passed online training Incidents of peri-operative infections Incidents of wrong site, wrong side, or wrong patient surgery Incidents of medication reactions Self Evaluation surveys # of lawsuits

26. Reusable Learning Objects StrategyMission Statement Create an architecture/framework to support RLO's, as well as legacy content, that are searchable and accessible in multiple formats to meet the needs of a demographically diverse and changing workforce.

27. RLO Strategy Goals • Set the framework for new patient initiatives • Establish components in RLOs • Create a scalable approach to allow for growth of RLOs • Create format-free RLOs to support multiple methods of delivery (i.e. print, on-line, searchable/exploratory, PDA, etc) • Reduce redundant information and efforts

29. Storage Learning ObjectDevelopment Author Delivery Learner • Online training • Print • Instructor led • Elements • Content • Metadata • Objectives • Search • Learning Approach • Interactivity • Architecture • Context Patient Safety Council Clinical Education and Quality Staff PEL Learning Center Staff All Staff The PHS Red Rules Learning Object Process

30. The PHS Red Rules Learning Object Process Restrictions on use Changes to business processes Showing return on investment (ROI)

31. PHS Existing Learning Object Diagram

32. PHS RLO Strategy Diagram

33. PHS RLO Hierarchical Structure • RLO Delivery • Types of Media Supported • PowerPoint presentations • video clips • supporting documents • job aids • Static Delivery of Content

34. PHS System for Collecting Metadata

35. PHS RLO Knowledge Product

36. Environment for Learning and Performance Improvement Non-Learning Approaches to Performance Posters on every floor Alcohol-based hand wash and lotion at every patient room Pop-up reminders on electronic record Targeted role models Checklists

37. Change Management and Communications Patient Safety is one of two initiatives Red Rules is the vehicle to communicate the Patient Safety expectations “Just Culture” sets the cultural expectations Standards are set for 90% compliance Compliance is measured RLOs will be used as needed Workforce commitment will be sustained through management oversight Communication and training will be tied

38. Learning & Performance Leadership Leadership supports Red Rules Common vision & value will be developed through: All employee training Refresher training for managers Communication of benefits & best practices Strategy is to demonstrate use of RLOs and Sharepoint as a Proof of Concept Wins will be shared on the Sharepoint site Governance is managed by Patient Safety Council

39. Environment for Learning and Performance Improvement Hand Hygiene - Barriers To Learning

40. Environment for Learning and Performance Improvement Evaluation of Performance Incidents of peri-operative infections Incidents of wrong site, wrong side, or wrong patient surgery Incidents of medication reactions Self Evaluation surveys # of lawsuits Monitor volume of alcohol based rub per 1,000 patient-days

41. Reuse and Repurpose Knowledge(Process Diagram)

42. Reuse and Repurpose Knowledge(Metadata) • Levels of Metadata • RIOs, RLOs, legacy content  • Consistency • Tags • Standards

43. Reuse and Repurpose Knowledge(Metadata Standards) • Title • Content Type • Values (Audit, Bylaws, Clinical Procedure, etc) • Content Subtype • Values (Member, Patient, Staff, etc) • Functional Category • Values (Environmental, Marketing, Clinical/Amb Svc, etc) • Release Date • Facility • Values (Dr Office, Hospital, ER, etc) • Full-Text Search Words

44. Red Rules Knowledge Center Objective The objective of the SharePoint portal is to provide a single-source, collaborative, interactive resource for the development of reusable objects (Red Rules) and their implementation at Presbyterian.

45. Red Rules Knowledge Center • Features/Resources • Blog/threaded discussion • Third party resources/links • Identification of experts • Announcements • RLO objects/documents (in progress and published) • Survey for feedback/assessment • Calendar (and work/meeting spaces)

46. Red Rules Knowledge Center Red Rules Knowledge Center

47. Questions?