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 Q6
Certified Professional
in Patient Safety
Review Course

December 10, 2018

8:30am – 4:00pm EST

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 P3

Nothing to Disclose
 The presenters, John Hertig, Maureen Frye, Dot Snow, and Kristin
Cronin, have no relevant financial or nonfinancial relationship(s)
within the services described, reviewed, evaluated, or compared in
this presentation.
 Review Course Faculty

John B. Hertig, PharmD, MS, CPPS

Associate Professor
Butler University College of Pharmacy and Health Sciences

Maureen Ann Frye, MSN, CRNP, ANP-BC, CPHQ, CPPS Dot Snow, MPH, CPPS
Senior Director, The Center for Patient Safety Director, National Risk Management &
and Healthcare Quality Patient Safety
Abington Jefferson Health Kaiser Permanente

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 Course Overview

This course is being offered to experienced patient safety professionals who

plan to take the Certified Professional in Patient Safety (CPPS) examination.
This course can help participants prepare for the exam by reviewing domain
content areas and test-taking strategies.

Learning Objectives
At the conclusion of this activity, participants should be able to:
 Review the five patient safety domains, following the exam content
outline
 Discuss patient safety scenario examples similar to actual exam questions
 Assess their own level of preparedness for the exam and address
additional areas for self study
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 Culture
Maureen Ann Frye, MSN, CRNP, ANP-BC, CPHQ, CPPS
Senior Director, The Center for Patient Safety and Healthcare Quality
Abington Jefferson Health

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 Focus
 The importance of defining and identifying a culture of safety within a
healthcare organization

 Content Outline for this domain includes:

– Assessment of Patient Safety Culture
– Raising Awareness
– Promoting a Culture of Safety

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 Objectives (7)
 Discuss management of safety culture survey results (A)
 Discuss methods for raising awareness of patient safety tools,
methods and culture (B)
 Describe response to adverse events and unexpected outcomes (B)
 Describe impact of organizational change on culture of safety (B)
 Explain how understanding and applying “Just Culture” principles
supports accountability (C)
 Outline considerations for driving culture change (C)
 Describe patient and family involvement in a culture of safety (C)

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Definition of Culture

 Driver of how each team works

 All culture is local, varies from work
system to work system
 Culture can
– create high performance
– can also result in collective blindness to
important issues
 “What actually happens when no one is looking”

 Collective mindset can sometimes blind a group of people to the

deviations they are taking from normal processes

 Normalized deviance Can create and

 Political correctness impact the culture of
 Excessive professional courtesy a work group
Human Drift Systemic Migration to the Unsafe Practice: Speeding

‘
Driving
85 mph – the Life Pressures
‘Illegal-Illegal’
space Driving
70 mph-
the
‘Illegal-Normal’ The speed limit
space is Perceived
65 mph- Vulnerability
Very unsafe the ‘Legal’ space (loss of risk
place: awareness)
Accident
Occurs
Belief Systems
(Perceived value)

Rene Amalberti
 “Culture eats process for lunch”
“How things get done around here”

(Man-Made Disasters, Barry A. Turner, Nick F. Pidgeon; Butterworth-Heinemann Limited, 1997 - Social Science; prior publication in 1978)

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 5 Major Requirements of an Ideal Safety Culture
From James Reason: Managing Risks of Organizational Accidents
1. All parties informed. Collect, analyze, share safety
information. e.g. briefings, debriefings. Ability to
proactively & reactively understand the risks/hazards.

2. Error reporting and feedback loops (front line engaged);

sensitivity to errors

3. Fair and just response to errors (no punishment for

human errors/system errors; fair consequence for unsafe
behavioral choices)

4. Flexibility to restructure when necessary, defer to

expertise when appropriate (reduce hierarchy)

5. Willingness to learn from errors

Sustainable over time through leadership commitment
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 Culture: Local or Organizational?
 Sexton et al., point to value of local (unit level) culture as focus of
evaluation and action
– “more variability among work units within the same hospital than among
hospitals”
 Also, variability at role level
– Physicians rate collaboration and communication with nurses very differently
than nurses’ rate it. Frontline staff and leadership have wide differences as well
– Contribution of teamwork and communication in sentinel events (TJC) suggests
then that this should be high focus area when interpreting and responding to
safety culture survey data
“A Safety Culture Primer for the Critical Care Clinician”, Daniel Hudson, Bryan
Sexton, Eric Thomas, Sean Berenholtz; Contemporary Critical Care, Vol 7, #5,
Oct 2009

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 Responding to Survey Results
 Response rates – aim for reliability of data
 Aim: 60%
 Leadership for response strategy
– How will results be disseminated across all areas?
– How will expert support be allocated for interpreting results?
– What is expected of each clinical area participating in the survey?
– Targeting low performing domains for improvement?
– Whole organization vs. clinical area focus?
– Analytics
 Identifying and disseminating best practices from
high-performing work units
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 Surrogates for
Patient Safety Culture Assessments
 Voluntary Reporting, Near-Miss reporting
– High levels of reporting may suggest culture is advanced enough that front-
line understand what constitutes a defect/system failure even if it doesn’t
reach the patient
– Consider # reported with identity of user included
– What % are near miss/good catch reports?

 Favorable trends suggest just culture in place, reports met with

appropriate support/response
 Patient Safety as Core Value or Driving for ZERO harm: patient
safety prioritized & messaged? If yes, suggests strong culture
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 Raising Awareness through
Engagement and Education
 Common definition of safety with numerous strategies
 Engaging team in specific patient safety initiatives
 Principles and science of patient safety
– Standardization, Checklists
– Human factors
– Teamwork training
 Error reporting, near misses
 Disclosure and apology

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 Education starts with active involvement in
Patient Safety Initiatives
 Leadership involvement in identifying, participating in various
activities
 Multidisciplinary engagement
– Broad, organizational activities
– Local, ongoing activities
 Patient/Family involvement
– Patient Advisory Councils
– Community forums

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 Educating Team Members
Principles & Practices in Patient Safety: Standardization
 Important in error reduction
 Requires buy-in from key stakeholders for success
– Within departments
– Across organizations
– Throughout the industry

 Example – color coded wristbands… the pros and cons

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 Managing the Unexpected
another key to creating RELIABLE performance in Patient Safety

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Principles & Practices in Patient Safety: Checklists
 List of actions that should be performed to optimize
patient outcomes
– Sound theoretical basis
– History of success in patient safety

 Examples
– Keystone ICU project
– Surgical safety checklist
– Handoffs

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Limited Short Term Memory
– Can only hold 5-7 pieces of information

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 Principles & Practices in Patient Safety :
Error Reporting and Near Misses

 Staff education
– Provide clear expectation of what and how to report
– Review routinely with staff
– Most importantly provide the ‘why’s’
– Give examples of important near misses
– Storytelling, Lessons Learned

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 Principles & Practices in Patient Safety :
Learning from Errors
 Errors are opportunities
– Intermediate vs. root causes
– Using aggregate data on common causes
– Structures and resources to support resolution/improvement
efforts when causes demonstrate trends
– Sharing learnings to prevent continued occurrence of similar
errors, reduce risks

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Root Cause Analysis and Actions

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 Principles & Practices in Patient Safety :
Human Factors
 The science of “human factors” is the study of “the
interrelationship between humans, the tools and equipment
they use in the workplace, and the environment in which they
work”
 Different than human error
 More in future module

World Alliance for Patient Safety. (2009). WHO Patient Safety Guide for Medical Schools. Retrieved May 5, 2015, from World Health
Organization: http://www.who.int/patientsafety/information_centre/documents/who_ps_curriculum_summary.pdf

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 Humans Factors
 The study of how people
interact with equipment,
technologies, and the
environment and the impact
safety and quality

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Principles & Practices
in Patient Safety :
Teamwork Training

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 Principles & Practices in Patient Safety :
Disclosure/Unexpected Outcomes

 Identify what needs to be disclosed

 Goal is to inform patient/family so they can make appropriate care
decisions
 Barriers to disclosure
– Lack of culture of safety
– Psychological barriers
– Legal barriers

 Models for disclosure and apology (AHRQ-CANDOR)

 Policy and infrastructure driven
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 Process Steps for the Conversation

 Designated personnel roles

 Conversation outlines
 Accommodations for special communication needs
 Support services available (patient/family and health care team)
 Steps for follow-up conversations
 Documentation of the conversation
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 CANDOR Process
Communication and Optimal Resolution

 AHRQ 2016 online toolkit

 Helps providers communicate accurately and
openly with patients and their families after an
untoward event
 Provides guidance on establishing candid,
empathetic communication and timely
resolution between patients and caregivers.

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 Effective Disclosure

 Effective disclosure provides the patient/family with all

the information needed for appropriate care decisions

 Successful disclosure cannot be measured solely on

the basis of whether malpractice litigation was avoided

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 Principles & Practices in Patient Safety :
Health Literacy
 Lack of health literacy leads to:
– Readmissions
– Inability to navigate the health care spectrum
– Increased health costs
– Limited preventative medicine
– Self report “poor health”

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Principles and Practices:
Proactive Risk Assessment and Mitigation

 Retrospective: Cause Analysis / RCA

 Proactive : Risk and Hazard Assessments
– Aggregate sources of knowledge of potential or actual risks

 Includes tools such as:

– FMEA: Failure Mode and Effect Analysis
– Probabilistic Risk Assessments
– Others
Managing Change: Anticipation, Balancing Measures

 Patient safety implications

 Proactive identification
 Countermeasures
 Post-change monitoring

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Just Culture and Accountability

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Creating Psychological Safety
 Psychological safety is a belief that one will not be punished or
humiliated for speaking up with ideas, questions, concerns, or
mistakes
 Building psychological safety requires softening of authority
gradients
 It is critical to a learning environment and enables individuals to
willingly contribute to collective work on a team
 Traditional punitive healthcare cultures impede creation of
psychological safety by blaming people for errors
• Edmondson, A. 1998. Psychological safety and learning behavior in work teams. Harvard Business School: Cambridge MA.
• Karl Weick and Kathleen Sutcliffe, Managing the Unexpected, John Wiley and Sons, 2007.

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 Human Error

The single greatest impediment to

error prevention in the medical industry is
“that we punish people for
making mistakes.”

Dr. Lucian Leape

Professor, Harvard School of Public Health
Testimony before Congress on
Health Care Quality Improvement

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 Mitigating Impact of Human Error
 Human Error
– Cannot be eradicated
– Error is part of the human condition
– Learn from errors
– Consequences of errors can be mitigated
– Anticipate predictable errors; build safe
processes;
enhance communication skills and teamwork
– We can’t prevent all errors, but we can reduce the
risks that can lead to harm
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 Accountability for Errors
 Differentiate “at-risk behavior” from
“reckless behavior”
– Managing at-risk behaviors requires
feedback, coaching
– Reckless behaviors require
administrative consequence
 Professionalism and Accountability
Models

(More in Systems Thinking module)

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 Challenges in Accountability

 Demanding Perfection vs. “No Harm, No Foul”

– People cannot be expected to work without errors
– People must be held accountable for their decisions, with
the same consequences, regardless of the outcome

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 A Culture of Accountability

“Just Culture”: safety-supportive system of

shared accountability where:
– The organization is accountable for safe systems design and for
encouraging, supporting safe choices of clinicians and staff (clear
expectations, set tone to create environment of mutual respect)
– Clinicians and staff, in turn, are accountable for the quality of their
choices – knowing that, as humans, we cannot will our selves to
be perfect, but we can strive to make the best possible choices.

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 Just Culture
Don’t simply punish people because of their actions,
but always hold them accountable for their
decisions.

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 Human Error
Failure of a planned sequence of mental or
physical activities to achieve its intended
outcome
James Reason

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 “Furious Pattern Matchers”
Why Humans Make Errors

 Predominant method for

humans to process
information, signals
 Quick
 “Grabs” salient elements,
leaves out what is
considered non-essential
 Survival
Example of Pattern Recognition

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2 Main Cognitive Processes
 Automatic Processing leads to Slips/Lapses -
Errors of Execution
• Right plan/intention, but do it wrong
• Interruptions, Fatigue, Time Pressure, Anger,
Anxiety, Fear, Boredom

 Conscious Processing (problem solving) leads

to Mistakes - Errors of Planning
• Intended action/plan not the correct one
• Assessment of situation faulty (wrong rule applied)
• Lack of knowledge (no rule exists)
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 “At-Risk Behavior” Defined
 “Behavioral choice that increases risk where risk is not recognized
or is mistakenly believed to be justified”

 Adjustments made to manage the variability of the situation

encountered in a complex, fast-paced, tightly coupled environment.
Choosing to do something other what is defined in policy, protocol,
law, or accepted safety norms to try to meet objective of the work at
hand.
“normalized deviance” “work-around” “drift”
David Marx in “Just Culture Training for Healthcare Managers”, Outcomes Engineering LLC, 2008
Derik Hollnagel, Robert Wears, Jeffrey Braithwaite; “From Safety I to Safety II: White Paper”; 2015
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 Strength of Behavioral Incentives
 I will consider deviating if:
 Consequences are weaker than the rules or other preconditions.
 The consequences are uncertain
 The consequences are delayed or not apparent

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 “Reckless Behavior”
 Conscious behavioral choice to disregard
a substantial and unjustifiable risk
 No intention to cause harm

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Systemic Migration of Boundaries:
Deviation is Normal
100%
Agreement:
Non-
HIGH

acceptable
Usual Space of
VERY UNSAFE SPACE

Action
Individual Benefits

“Illegal normal”;
Real life
standards 60- 100% expected safe
90% space of action as
defined by
professional
standards such as
safety regs,
accreditation
LOW

standards
ACCIDENT

HIGH Production Performance LOW

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 Behavioral Choices – “Drift”
• Need to adjust/adapt to highly variable conditions.
• Develop comfort with inherent risks/threats.
• Underestimate risk of “drifting” from safety procedures; believe likelihood of
harm is minimal.
• Continual reinforcement of underestimated risk supports continued drifting
behavior.
Unconscious
No intention Conscious
Intent,
Intent
(human error) adaptation
(recklessness)
(drift)

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Patient Advocacy Reporting System: PARS®
Process
Pyramid for Promoting Reliability and Professional Accountability

One sample model for

driving accountability

References
• Ray, Schaffner, Federspiel.
1985.
• Hickson, Pichert et al, 2007.
• Pichert et al, 2008.
• Mukherjee et al, 2010.
• Stimson et al, 2010.
• Pichert et al, 2011. Adapted from Hickson, Pichert,
Webb, Gabbe. Acad Med. 2007.
• Hickson et al, 2012. ©2012 VUMC

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ARS Question

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 POLL OPEN
The graph shows the teamwork climate results (SAQ) for
your organization. Your response would be to:

A Initiate teamwork development in all the departments

below the 50th %ile

B Initiate teamwork development in all the departments

below the 25th %ile

C Do nothing, more than 75% of departments scored above

the desired threshold of 60%

D Consider the other domains of the survey before defining

actions
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 POLL OPEN
You are educating clinical managers in your healthcare facility on how to
identify appropriate events for conducting a Root Cause Analysis (RCA).
Which event provides the best opportunity for an RCA?

A A post-operative patient removes his own IV causing a skin tear

from the tape.

B A patient with no known allergies experiences an anaphylactic

reaction to an antibiotic requiring transfer to ICU.

C The biopsy samples from a colonoscopy are never received by

pathology after the procedure.

D There have been 3 occurrences of depressed respirations in the

same department in the last 4 months related to sedation.

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Vote Trigger
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The instrument count is incorrect at the conclusion of a surgical POLL OPEN
procedure. The hospital policy does not stipulate that the surgeon remain on the
premises until an x-ray is obtained. The surgeon leaves the hospital to catch a
flight. The x-ray reveals a retained instrument. Another surgeon is contacted to
remove the retained instrument. What should leadership do next?
A Create a process map of how instruments are managed during
surgery looking for latent flaws

B Revise the hospital policy to make it clear that surgeons must

stay in the OR until instrument count issues are resolved

C Counsel the surgeon about customary clinical standards for a

surgeon using appropriate accountability system

D Reeducate the OR nursing staff on keeping track of instruments

on the sterile field
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A nurse on a medical-surgical unit does not comply with POLL OPEN
barcode medication administration (BCMA) while caring for one of
her patients. What should her supervisor do?
A Ask staff if there are adequate scanners to meet their
needs

B Counsel the nurse on the importance of following

policy

C Request that the pharmacy run a report of the BCMA

compliance rates of the unit

D Ask the nurse what was occurring at the time, and

why she chose to bypass the policy
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 References
 Gawande, A. The Checklist Manifesto: How to Get Things Right
 Patient Safety Primer: Checklists, US Department of Health and Human Services, Agency for
Healthcare Research and Quality, Patient Safety Network
http://psnet.ahrq.gov/primer.aspx?primerID=14
 The science of improving patient safety by Johns Hopkins Medicine
http://www.youtube.com/watch?v=jxxkz-WeV_w
 Patient Safety Primer: Human Factors Engineering, US Department of Health and Human
Services, Agency for Healthcare Research and Quality, Patient Safety Network
http://psnet.ahrq.gov/primer.aspx?primerID=20
 Patient Safety Primer: Teamwork Training, US Department of Health and Human Services,
Agency for Healthcare Research and Quality, Patient Safety Network
http://psnet.ahrq.gov/primer.aspx?primerID=8
 Marella, W. (2007) Patient Safety and Quality Healthcare. Why Worry About Near Misses?
http://www.psqh.com/sepoct07/nearmisses.html
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 References

 http://teamstepps.ahrq.gov/
 http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/wristbands/Document
s/wristband_manual.pdf
 Understanding Patient Safety, Robert Wachter, McGraw-Hill Medical, 2012
 Managing the Unexpected, Karl Weick and Kathleen Sutcliffe, John Wiley and Sons, 2007
 Managing the Risks of Organizational Accidents, James Reason, Ashgate, 1997
 Organizational Culture and Leadership, Edgar H. Schein, Josey-Bass, 1985
 “A Safety Culture Primer for the Critical Care Clinician”, Daniel Hudson, Bryan Sexton,
Eric Thomas, Sean Berenholtz; Contemporary Critical Care, Vol 7, #5, Oct 2009.

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Measuring and Improving
Performance

Dot Snow, MPH, CPPS

Director, National Risk Management &
Patient Safety
Kaiser Permanente

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Measuring and Improving Performance
A. Measurement
1) Identify valid patient safety data sources
a) Qualitative and Quantitative
2) Collect and aggregate patient safety data
3) Analyze patient safety data using statistical techniques
4) Interpret patient safety data
5) Develop credible and understandable reports
6) Present results of data analyses to decision makers

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Measuring and Improving Performance
B. Improving Performance
1) Select an appropriate improvement methodology for an
initiative
2) Apply improvement methodologies
3) Use process, outcome and balancing measures to improve
performance
4) Employ project management skills
5) Employ facilitation skills to promote teamwork

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 Objectives
1. Interpret data graphs and draw conclusions
2. Understand the variety of sources of patient
safety data
3. Understand how data displays facilitate decision
making
4. Identify and understand how to apply various
improvement methodologies
5. Compare and contrast various project
management skills including team facilitation

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Measurement

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 Data sources for patient safety are
plentiful…

They may not be formal organizations; they

may your family member or your neighbor
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Examples of United States National Data
Sources for Patient Safety
 Agency for Healthcare Research & Quality (AHRQ)
 Veterans Affairs National Center for Patient Safety (NCPS)
 CMS Hospital Compare (Patient Safety Indicators, HCAHPS)
 Occupational Health Safety Administration (OSHA)
 The Joint Commission Sentinel Events
 MEDMARX Adverse Drug Events
 NDNQI, MDS (Falls and Pressure Ulcers)
 Food & Drug Administration
 NIOSH
 NHSH
 National Inpatient Sample
 Patient Safety Organizations
 Other: Leapfrog, Castlight, Consumer Reports, ’deadbymistake.org’

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 International Sources of Patient Safety
Information
 World Health Organization (WHO) World Alliance for Patient Safety website (www.who.int) includes:
– International Classification for Patient Safety (ICPS)
– Patient Safety Journal Library

 Australian Institute of Health and Welfare (www.aihw.gov.au)

 New Zealand Ministry of Health (www.health.govt.nz)

 United Kingdom National Patient Safety Agency (NPSA) (www.npsa.nhs.uk)

 Canadian Institute for Health Information (CIHI) (www.cihi.ca)

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Examples of Internal Hospital Data Sources
for Patient Safety
– Safety Event Data
– Survey results (Patient Safety, Engagement)
– Medication Safety events
– Sentinel Event trends
– Complaints & Grievances, Compliments
– Claims Loss Runs
– Financial Losses
– Dashboards/Scorecards
– Safety Huddles, Walk-Rounds
– Standard Operating Procedures
– Safety Attitude Questionnaires
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 Benefits & Opportunities
of Data Repositories
 Benefits:  Opportunities:
– Provides structure of – Lack of standardized national
reporting requirements taxonomy
– Provides baseline for – Lack of standardized
identified trends collection systems
– Precursor to improve safety – Inconsistency of data
efforts interpretation & required
– Comparison across reporting elements
healthcare organizations – Lack of transparency*
– Promotes transparency* – Lack of validation
– Drives leadership – Local coding ambiguity
involvement/change
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 Data Repositories
Questions about data management:

 Who oversees?
 Central vs. decentralized?
 Is there an internal data integrity or validation processes?
 Is data ‘locked’ after a period of time once validated?
 How to manage qualitative vs. quantitative information

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Qualitative vs. Quantitative
 Quantitative Data:  Qualitative Data:
– Anything that can be – Categorical measurement
expressed in a number not expressed in numbers
(quantified) but in natural language
– Can be analyzed – Can be categorized to
statistically increase ordering
– Associated with a – Categories may be
measurement scale ordered and are called
– Example ordinal variables
– 6 ft 7 inch. – Example:
– Very Tall

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Sample Leadership Rounding Reports

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 Leadership Rounding Data
Total Issues Trend
140

120

100

80

60

40

20

0
Q1 Q2 Q3 Q4

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Categories by questions
12

10
4
8 6 6
0 8 8
6
6
4 2
7 7 Patient Feedback
2 5 5
3 3 3 Caregiver Feedback
2
0

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Top 5 Category Trend by Quarter
50
45
40
35
Food
30
Equipment & Supplies
25
Hospital Environment
20 Communication
15 Response/Delay
10
5
0
Q1 Q2 Q3 Q4
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Descriptive Statistics

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 Standard Deviations
 Which line represents the mean?
 Which represents the 1st standard deviation?
 Which represents the 2nd standard deviation?

C B A B C
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Descriptive Stats Data Display

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Inferential Statistics

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 Inferential Tests
 Test of significance – Definition
 Many complicated definitions
– Simplest level – probability that a relationship exists between two
variables
– The likelihood that something is due to random chance versus a true
relationship
– P values generally accepted at p < 0.05 as being statistically significant

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Which of the following chart types would be best used
demonstrate non-random process variation over time?

A C

B D

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Run + Control Charts
 Answer two questions

– Does the process contain non-random patterns aka special

causes?

– What effect did your plan have on the process performance?

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 Identifying a Run
 One or more consecutive data points on the
same side of the mean

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 Control Charts
 Same as run charts but with control limits

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 Setting Control Limits
 Accounts for natural variability
 Usually set at ± 3 SDs from mean
 Or can set them manually based on observed
variability

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In December 2012, Hospital A reports a clostridium difficile infection rate of
POLL OPEN
8% and begins a series of infection prevention measures to reduce hospital-acquired
infections in general, including the use of stronger anti-bacterial cleaners throughout
the hospital and a hand hygiene awareness campaign. In December 2013, this
hospital reports a clostridium difficile infection rate of 4%. What is the best
conclusion that can be drawn from these infection rates?

A Hospital A was successful in reducing their clostridium difficile

infection rate in 2013.

B Hospital A reduced their clostridium difficile infection rate, though one

cannot tell which intervention was most effective.

C Multiple infection prevention efforts are needed to drive down

clostridium difficile infections rates.

D No conclusions can be drawn.

Vote Trigger

IHI 2018
Understanding Variation

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 Understanding Variation
 How will we know that a change is an improvement?

 Two types of variation:

– common cause
– special cause

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Common and Special Cause Variation
Exercise
 Write your name 5 times with your dominant hand
 Now, write your name 5 times with your other hand
Common Cause
 Differences you see in your name written with your
dominant hand is common cause – normal expected
variation
Special Cause
 Differences you see in your name written with your other
hand is special cause variation – the variation that results
from the condition of using your non-dominant hand

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 Common Cause Variation
 Example of a run chart
 Horizontal line through the
data represents the central
tendency of the data
 Common cause variation is
normally expected variation
 It exists in all processes

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Special Cause Variation

 A shift in observed data

values
 Rule of thumb: at least 7
consecutive observations
 Indicative of impact to
specific conditions or
process changes

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 Special Cause Variation

TREND

PATTERN

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Developing Credible and Understandable
Reports
It’s all about the effective
visual communication of data…..

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 What are the Purposes of Reports?

 To address the information needs related to a particular objective

or set of objectives
– Organizational strategic planning
– Monitoring operations
– Analytical purposes

 Requires customization to the audience

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 Scorecards and Dashboards
Scorecards:
– A collection of key performance indicators together with their
associated performance targets

Dashboards:
– A container for a related group of items and reports,
sometimes including scorecards

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Scorecard Example

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Dashboard Example

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 A Few Words About Dashboards
 A commonly used format presented to decision-makers
 By design, they squeeze a great deal of useful and
sometimes disparate information into a small amount of
space
 Condense information via summarization and exception
 Keep media displays simple

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What Makes A Good Dashboard?

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 Other Ways of Presenting Written Results to
Decision-Makers
PowerPoint slides:
– use graphics to display data distributions
– include the take-away message in a text box on the slide
SBAR format:
– Situation: succinct statement of the present issue
– Background: pertinent historical information to provide context
– Assessment: data/analysis germane to issue at hand
– Recommendation: specific and precise actions

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The Board of Hospital A wants to know how Hospital A’s safety POLL OPEN
performance in central line associated blood stream infection (CLABSI)
compares to that of other hospitals in their region. Which data display would
best inform them for that decision?

A Control charts of overall infection rate by quarter for the past

two years for each hospital in the region

B A table indicating the CLABSI infection rates of all hospitals in

the region relative to National Healthcare Safety Network
benchmark for CLABSI infections for the past two years

C A written report summarizing the current CLABSI prevention

protocols of each hospital in the region

D A table showing the number of CLABSI infections in each

hospital in the region by quarter for the past two years

IHI 2018
Improving Performance

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 Common Improvement Methods
First and foremost:
 What problem are you trying to solve?
 What changes will you make?
 How will you know the changes will result
in improvement?
 Have you thought about unintended
consequences or potential failures of the
changes (FMEA)?
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 Key Components of Process
Improvement
Establish a team:
Executive sponsor, leader, subject matter experts, front
line staff

Clearly articulate goals or aims:

Goals are specific , measureable and achievable

Perform gap analysis between current and ideal state

Develop action plan for ideal state with identified
accountability fop action plans

Perform small tests of change until ideal state is

reached
PDSA/PDCA

Spread the changes

Develop communication plan, use success stories and
continue to monitor
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 Improvement Methodologies
 Six Sigma
– Disciplined, data-driven methodology to achieve system
control to 6 SD
– Goal to fine tune processes to be extremely precise and
highly reliable

 LEAN
– Systematically eliminates waste caused by non-value added
steps from the system
– Goal to streamline operations and gain customer loyalty be
eliminating waste

 Plan – Do – Study – Act (PDSA)

– Make small scale, testable changes; it is a quick test of change
– For those that seem to work, test the system further to see if
it will break in a controlled environment

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 Why do we measure?
 Improve Care and Service to Patients
– Identify opportunities for improvement
– Benchmark and compare performance
– Track progress to improvement
– Spread and sustain improvement

 Monitor and Inform System Performance

– Process, leading
– Outcome, lagging
– Balanced measures

 Accountability
– Identify and track progress against organizational goals
– Governance/fiduciary responsibility
– Align to financial incentives for leadership and staff
Patient Safety Curriculum Module 8: Methods for Measuring Performance and Clinical Outcomes;
Maulik Joshi, President, Health Research & Educational Trust Sr VP of Research, American Hospital
110 Association, 2011

© IHI 2018
 Project Management Tools
 Charter (Mission statement, scope, objectives,
participants, funding, authority)
 Stakeholder analysis
 Project Team formation
 Gantt/PERT chart for time/resource management
 Scheduled team meetings, minutes, reports
 Authority structure
 Measurements and reports
 Post-implementation tracking

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Example “Project Plan” in TeamSTEPPS® Curriculum
Specific Documented Plan for Successful Implementation

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 8 Steps of Change

Unfreeze the
status quo

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Whichever method…use one!

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Facilitation for Patient Safety Professionals

 Facilitation is a process used to add content,

process, and structure to meet the needs of an
individual, group or team.
– Facilitator leads groups to obtain knowledge
and information, work collaboratively, and
accomplish their objectives.

From: About.com, Human Resources

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 Facilitation for Patient Safety Professionals
 Facilitation for groups or teams is provided by internal or
external people who are skilled in:
– Presenting content and information
– Designing and formulating a process that helps a group
achieve its objectives
– Providing an appropriate structure to meetings, training
or other work event, so that the mission of the group is
accomplished
– Promoting shared responsibility for the outcome
– Drawing forth from participants the answers to their
questions, necessary decisions, and solutions to problems
From: About.com, Human Resources

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 Patient Safety Professionals:
Considerations for Facilitation Needs
 Consider the projects you support
– How do you support team leaders?
– What is the organizational support for team leaders
or facilitators of projects (let’s think FMEAs or
action plans from significant RCAs or deployment of
culture of safety survey findings for instance)?
– How do you build collaboration, coordination and
effective communication within the project team,
and then, to the target audience of the change?
From: About.com, Human Resources

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Team Training as an Improvement Tool or
Risk Mitigation Tool
 Various programs: Crew Resource Management,
TeamSTEPPS®
 Main thrust
– Team collaboration, communication and coordination
– Human mental processing deficits support the need for
strong teamwork
–Can help minimize slips, lapses, mistakes
 How to introduce these methods
– Simulation
– CRM/Aviation model
– Modeling
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Why We Should Consider Improving Teamwork
in Healthcare
Length of ICU Stay After Team Training
2.4

2.2
Avg. Length of Stay (days)

2 50
%
Re
1.8 du
cti
on
1.6

1.4

1.2

1 June July Augus t Se pt Oct Nov De c Jan Fe b M arch April M ay

OR Teamwork Climate and Postoperative Sepsis Rates
(per 1000 discharges)
(Pronovost, 2003) 18
Journal of Critical Care Medicine
16
14

12 Group Mean
AHRQ National Average
10
8 Low Teamwork
Climate
Mid Teamwork
6 Climate

4 High Teamwork
Climate
2
0
Teamw ork Climate Ba sed on Safety Attitudes Que stionnaire

Low  High
(Sexton, 2006)

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The Impact of Ineffective Communication
in Healthcare Teams
 The Joint Commission has cited communication failure as
number one contributing factor in reported sentinel events.
 VA National Center for Patient Safety has identified
communication failures in approximately 75% of more than
7,000 root cause analyses of adverse events and close calls.
 Closed malpractice claims from various clinical settings
showed that ineffective communication and teamwork
contributed to medical errors and patient harm in 43% to
70% of cases.

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The Impact of Ineffective Communication
in Healthcare Teams
 Resident physicians from surgery, internal medicine, and
OB/GYN training programs of a university teaching
hospital perceived communication failures as a factor in
91% of adverse events and near misses.
 Observations of surgical teams in the OR revealed 30%
communication failure rate, with 36% of these failures
leading to visible negative effects including procedural
error, team inefficiency, tension, resource waste, work-
arounds, patient inconvenience, and delay.

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 References
 Fausz, A. (2013). Understanding Variation in the Healthcare Industry: Using Data to Make Better
Decisions. http://www.leanhealthcareexchange.com/?p=3562

 Few, S. (2006). Information dashboard design: O'Reilly.

 Tufle, E. (1983). The visual display of quantitative information. CT Graphics, Cheshire.

 Lloyd, R. (2014). The Science of Improvement on a Whiteboard. Institute of Healthcare Improvement–

Open School.

 Lloyd, R. Using Run and Control Charts to Understand Variation.

from http://www.ihi.org/education/WebTraining/OnDemand/Run_ControlCharts/Pages/default.as
px

 Meyer-Massetti, C., Cheng, C. M., Schwappach, D. L., Paulsen, L., Ide, B., Meier, C. R., & Guglielmo, B.
J. (2011). Systematic review of medication safety assessment methods. American Journal of Health-
System Pharmacy, 68(3), 227-240.

 Thor, J., Lundberg, J., Ask, J., Olsson, J., Carli, C., Harenstam, K. P., & Brommels, M. (2007). Application
of statistical process control in healthcare improvement: systematic review. Qual Saf Health Care,
16(5), 387-399. doi: 10.1136/qshc.2006.022194

 Wu, A. W., Lipshutz, A. K., & Pronovost, P. J. (2008). Effectiveness and efficiency of root cause analysis
in medicine. JAMA, 299(6), 685-687.

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Patient Safety Risks & Solutions

John B. Hertig, PharmD, MS, CPPS

Associate Professor
Butler University College of Pharmacy and Health Sciences

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 Objectives
 Define a systematic approach to identifying and reporting
risks, using a variety of methods (A)
 Describe specific methods for proactive and reactive risk
analysis (FMEA, RCA) (A)
 Discuss benefits and drawbacks of well-known patient
safety solutions (B)
 Consider the impact of technology on patient safety (B)
 Identify considerations in sharing best practices and
learnings from risk analyses in your organization (A, B)

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 Identifying and Reporting
Patient Safety Concerns and Risks
 Importance of capturing concerns
– Provide internal data set that identifies priorities in patient
safety improvement needs
– When managed in a just fashion, support psychological safety
and strong safety culture
– If strong feedback loops exist, with recognition of reporters,
robust reporting is enhanced (including near miss reporting)

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 Aggregating, Analyzing and
Sharing Safety Concerns and Risks
 Importance of analyzing and sharing concerns
– Identify common risks and defects, concerning trends to
create data-driven improvement strategies
– Share trends and lessons learned at staff meetings, unit
safety team meetings, etc.
– Provide quarterly summary of “solutions” to safety
reports to celebrate progress, encourage ongoing
reporting
– Use various newsletters to present patient safety
information
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Methods to Collect Safety Concerns
 Voluntary Reporting Systems
– Computerized/paper
– Optional anonymity
 Learning Boards
 Patient Safety Leadership Rounds
 Patient complaints and concerns
 Product recalls and vendor alerts
 FMEA, RCA, other process analyses

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 Voluntary Reporting Systems
 Generally electronic but may have some paper
elements

 Infrastructure for access, analysis, aggregation,

improvement

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 Safety Event and
Near-Miss Reporting

 What % of your safety reports are considered

“near misses”?
– A. 0- 24%
– B. 25- 49%
– C. 50- 74%
– D. 75- 100%

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Importance of Near Miss Reporting

 Provides opportunity to examine

failure points of systems in which
individuals operate
 Proactive opportunity to improve
before significant event occurs
 “Holes in the Swiss cheese” caused by process defects and
system failures can be identified through near misses
 Addressing these defects provides an opportunity to
strengthen defenses and prevent future harm

 Signal of safety culture

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 Safety Reporting and
Patient Safety Organizations (PSOs)
 The Patient Safety and Quality
Improvement Act of 2005
 Designed to improve patient safety
through analysis of reported events and
reduction or elimination of the risks and
hazards associated with the delivery of
patient care
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Value of Patient Safety Organizations
 Independent, external experts
 Can collect, analyze, and aggregate safety
reports locally, regionally, and nationally to
develop insights into the underlying causes of
patient safety events
 Develop more reliable information on how best
to improve patient safety

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 Additional Approaches to
Identify Risks
 Learning Boards
 Patient Safety Leadership Rounds
 Eliciting concerns from patients and
families
– Through safety reporting systems
– During Safety Rounds
– Through patient advisory/advocacy councils

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The Role of Learning Boards
 Provide space for frontline workers, including
physicians, to share defects
 Promote visibility of specific threats &
missteps (transparency)
 Show resolution of defects
 Promote threat awareness
and reporting behaviors
to enhance a culture of
safety

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 Learning Boards
Identified Active Resolved

Clinical > 30 days

Visual Operational

Behavioral

# of defects # of defects without action # of defects resolved in

surfaced/month > 30 days past 30 days

Measures Data collection: Data collection: Count

Data collection: Count Monitor and move often on the first day of each
on the first day of each month
month
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Leader Patient Safety Walkrounds
 Dr. Allan Frankel, HealthPartners,
Boston
 Now also featured by Institute for
Healthcare Improvement
– Increasing the in-basket of patient safety information
– Changing the culture of safety by increasing
transparency
– Engaging senior leadership with frontline staff
around patient safety issues
– Opportunity to collect data about defects, staff
concerns

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 Implementing Safety Rounds
 Preparation for hospital executives
 Preparation for unit participants
– Leaders, staff and employees, PSO, pharmacist,
physicians
 Facilitating the process
– Provide sample questions in advance; begin with
introductions and purpose; elicit examples of
safety concerns; include Board member; elicit
concerns from patients and families
– Collect data/findings, aggregate for broader
analysis
– Determine method for followup, feedback
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Evolving Evidence about LWR
“units with ≥60% of caregivers reporting exposure to
at least 1 WR had significantly higher safety climate,
greater patient safety risk reduction, and better
feedback on actions taken as a result of WRs
compared with those units with <60% of caregivers
reporting exposure to WRs”

Schwendimann R, Milne J, Frush K, et al.. Am J Med Qual. 2013 Sep-

Oct;28(5):414-21. doi: 10.1177/1062860612473635. Epub 2013 Jan 25.

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 Product Risks
Recalls and Vendor Alerts
 Variety of agencies issue product recalls relevant to healthcare
 Vendor alerts and recalls
 Consumer Product Safety Commission
 ECRI, OSHA, ISO considerations

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Product Recalls and Vendor Alerts
 Organizational Responsibility
– Manage the incoming information
– RASMAS: software to assist in managing alerts
– Identify risks for the organization, i.e. pertinent alerts or recalls
for your organization
– Perform gap analysis
– Action Planning
– Broad communication of needed changes, impacts
– Patient notification if implants involved
– Follow-up evaluation to assure safe resolution

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Risks of vulnerable patient populations
 Emergency Department
 Behavioral Health Diagnoses
 Patients with multiple co-morbidities
 Pediatric populations: ‘Lack of voice’
 Elderly
 Publically insured
 Low health literacy
 Non-English speaking

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 Proactive Risk Assessment
Failure Modes and Effects Analysis
 Proactive analysis technique used to
prevent problems before they occur
– Designed to analyze potential failures of
systems, components of the system and
the effects of the failures
– The focus is what could go wrong versus
what did go wrong

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 Components of an FMEA
 Identify a high risk process and assemble a team
 Diagram the process in high level steps
 Brainstorm potential failures and what affects the failures may bring
 Prioritize the failures in terms of criticality
 Identify the root causes of the failures
 Redesign the process
 Analyze and test the new process
 Implement and monitor the redesigned process

143
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FMEA Matrix – the Tool

Frequency of Potential Cause

Detection of Potential Cause
Severity of Effect of Failure

Mitigation Value of Control

Potential Effect
Potential
of Failure Current Controls in
Failure Mode Potential Cause of

RPN
(worst case Place (for each
(what could go Failure
scenario for failure mode)
wrong)
patient)

1. Patient assessed pre-op

1a. Decision needs

1a1-a Process not defined
to be made related
1a1. Patient may enough to be consistent. 1a1-a1 Pre-screening by
to where patient will
come to suite and (Entry: admitted after MRI, phone by POSU (NP
be screened and
not be MRI eligible. POSU with MRI, direct Triage)
will all patients be
admit w/ MRI)
screened

1a1-b1 In radiology based

1a1-b Screening was done
MRI suites only (screen
too far in advance of the
immediately prior to
surgery
procedure)
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Rating scales for RPN
Severity: What would be the worst possible
Frequency: How often might this occur?
outcome?
1- Noticeable to the patient; would not affect the
1-Little or no safety, highly unlikely
process
2- May affect the patient; would affect the process 2-Possible, but problem occurs in isolated cases
3- Minor physical or psychological injury to the 3- Documented, but infrequent; problem has
patient; would affect the process reasonable chance to occur
4- Dangerous; would result in major injury to the
4-Documented, frequent; problem occurs regularly
patient (e.g., loss of limb, loss of function); would
or within a short time period
affect the process
5- Very dangerous; would result in potential death;
5- Documented, almost inevitable.
would affect the process

Detectability: How likely is it to be detected before Controls (Mitigation): Are preventive controls in
reaching the patient? place and do they work?
1-Almost always detected immediately 5-Little or no preventive measures
3-Moderate prevention measures in place but not
2-Likely to be detected
fail-proofed
3-Moderately likely to be detected 1- Risk eliminated
4-Unlikely to be detected
5-Detection not possible
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 Root Cause Analysis
 Triggered by serious patient safety events or
trends that represent risks/hazards that could
cause harm

 Process for identifying the causal factors that

underlie risks, and deploying actions to
eliminate or reduce those risk factors

 Retrospective, reactive analysis, initiated in

response to an adverse event or condition

RCA2:Improving Root Cause Analyses and Actions to Prevent Harm; NPSF, 2015.

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 Different Methodologies for RCA
 Traditional (e.g. accrediting agencies such as TJC )
 Common Cause Analysis
 Fishbone Diagramming
 Cause and Effect Trees
 RCA Squared (RCA2): National Patient Safety
Foundation: prevention of future harm

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 RCA2: Root Cause Analysis and
Action
 Goal to improve effectiveness and utility of RCA
– Methodologies to lead to more effective RCAs
– Identify significant flaws to be remediated to
achieve improvements in patient safety.
– Prevent future harm through action
 Emphasis on defining strong actions for the
underlying causes
 Supports risk-based prioritization of qualifying
events
RCA2:Improving Root Cause Analyses and Actions to Prevent Harm; NPSF, 2015.

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 Hierarchy of Actions
 National Center for Patient Safety’s “Hierarchy of
Actions” classifies corrective actions as:
– Weaker: actions that depend on caregivers to
remember training or what is written in policy
– Intermediate: actions are somewhat dependent on
staff remembering to do the right thing, but provide
tools to help staff remember what to do of to facilitate a
process to completion or enhance communication
– Strong: the action may not totally eliminate the
vulnerability but provide very strong controls/guard rails

Dept of Veterans Affairs National Center for Patient Safety,

http://www.patientsafety.gov/CogAids/RCA/index.html

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Phases of the RCA Process

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What determines a “Thorough/Credible”
Root Cause Analysis?
 “Thorough”
– Human and other factors
– Analysis of underlying systems
– Address all areas identified in the RCA Matrix
– Identify risk points
– Potential improvements
 “Credible”
– Varied participants
– Internally consistent
– Explanation of “Not Applicable” or “No Problem”

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 Getting to the root and
sharing the lessons
 Drilling beneath the surface:
– The 5 Whys?
– Answering all the matrix elements
based on the type of event
– Cause and Effect Trees
 Sharing of Lessons Learned:
– Dissemination across the hospital,
health system
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Ishikawa (fishbone) Diagram

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Cause and Effect Tree

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 Action Planning Expectations

 For each of the findings identified in the analysis as

needing an action, indicate the planned action
expected, implementation date and associated
measure of effectiveness. OR.…
 If after consideration of such a finding, a decision is
made not to implement an associated risk reduction
strategy, indicate the rationale for not taking action at
this time.

The Joint Commission

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Measuring Effectiveness of Actions

 Assure that measures will provide data that will truly

assess the effectiveness of the action
 Consider whether pilot testing of a planned improvement
should be conducted
 Improvements to reduce risk should be implemented in all
areas where applicable, not just where the event occurred

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Measurement Considerations

 What is  How is data used?

measured?  Is it reliable?
 Why measured?  Is it a one time or
 What is gained? periodic audit?
 Who will  What resources
measure? are available?
 How frequent?

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 Follow-up
 Recognize employee efforts/contributions
 Listen to employees when they share impact
 Share data that show impact
 Adapt plan if it’s not having intended effect
 Ensure accountability and follow-through of
action plan items
 Mark your calendar for 3 and 6 month follow-
up (or more)
 Keep leadership informed of progress/barriers
 Share Lessons Learned
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 Important RCA Pitfalls
 Lack of leadership support
 Skipping the chronology
 Consideration of systems contributors not broad
enough
 Consideration of at-risk behaviors insufficient
 External sources of knowledge not reviewed
 Not linking causation to the actions
 Weak actions
 Failure to carry out the action plan & measure
success
 Focus too narrow or too broad
 Unjust punitive action Adapted from ISMP, April 22, 2012

159
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Patient Safety Solutions and Evidence
Based Safety Practices

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 Using Evidence to Support
Improvement
 Patient safety programs and initiatives
should be supported by evidence where
feasible
 Best-practices should
be evaluated
 Use a variety of
sources

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 Bundles
 IHI defines a bundle:
“a structured way of improving the processes of
care and patient outcomes: a small,
straightforward set of evidence-based
practices — generally three to five — that,
when performed collectively and reliably, have
been proven to improve patient outcomes.”

162
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 Examples of Bundles
 Central line bundle to reduce HAIs
– Hand hygiene and sterile contact barriers;
– Properly cleaning the patient’s skin;
– Finding the best vein possible;
– Checking every day for infection; and
– Removing or changing the line only when needed.

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 Bundle Pitfalls
 Bundles are not checklists, despite the temptation to call
checklists bundles
 Must be “all or none” to be effective. Picking and choosing
which elements to follow limits the clinical value

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 Checklists

 A memory tool for complex processes

 Effective in industries that have a hardwired culture of safety,
such as aviation
 Recent literature has demonstrated that checklist efficacy in
healthcare organizations has been variable
 Compliance with, and benefits of checklists are heavily affected
by organizational culture

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 Reasons for Checklist Failure

 Lack of ownership by physicians and other leaders

 Checklist is illogical or inappropriate for a particular clinical
setting
 Perception that the process wastes time and resources

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 Simulation
 High fidelity simulation is helpful in training for resuscitation,
but “low fidelity” simulation may be equally useful in a
variety of settings
– Prior to implementing new equipment, processes or procedures
– As part of Failure Modes & Effects Analysis (FMEA)
– Role play practice before critical conversations with staff, patients,
and families

167
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Advancing Information Technology (IT)
in Healthcare:

What are the benefits and risks to

patient safety?

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 Benefits of Health IT
 Reduce medication errors
 Eliminate illegible writing
 Enable computerized order entry
 Achieve best practices with Clinical Decision Support
 Reminders for preventative care recommendations
 Track immunizations, testing, and referrals
 Centralize patient records
 Allow access across all settings
 Allow patient access to record

169
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 Error Recognition in HIT
 2008 and 2015: Joint Commission issues
Sentinel Event Alert: 25% of medication errors
have an HIT component

 2009: UPMC Children’s Hospital reports a

significant decrease in mortality after
implementation of a Computerized Physician
Order Entry (CPOE) system.
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 Medication Delivery and HIT
 Bar coding of medications can improve medication errors when
the underlying processes are safe. It provides another safety net
for human error, but doesn’t fix a broken system.
 IV Pump libraries and guardrails improve safety but like all
improvements are subject to:
– work-arounds
– alert fatigue
– require constant auditing and updating

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Unintended Consequences of HIT
What unintended consequences have you
experienced?

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 Unintended Consequences of HIT
 More/new work for clinicians
 Unfavorable workflow issues
 Never-ending demands for system changes
 Problems related to paper persistence
 Untoward changes in communication patterns and practice
 Negative emotions
 Generation of new kinds of errors
 Unexpected and unintended changes in institutional power structure
 Overdependence on technology

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 Socio-technical Model for Analysis
of HIT
1. Hardware and software
2. Clinical content
3. Human-computer interface
4. People
5. Workflow
6. Internal organizational policies, procedures,
environment, and culture
7. External rules, regulations, and pressures
8. System measurement and monitoring
Sittig, D and Singh, H. “A New Socio-technical Model for Studying Health Information Technology in
Complex Adaptive Healthcare Systems. Qual Safe Health Care. 2010 October.
174
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 Examples of Error Categories
 Hardware/Software: band-width for communication, power
outages, updates, sufficient hardware deployment for users

 Clinical Content: Order sets, Clinical Decision Support,

Patient Education materials

 Human Computer Interface: Geographic location of devices,

alert fatigue, patient engagement, patient pick lists

 People: Human bias, copy/forward, new ways to think of

work/workflows

 Workflow and Communication: Hospital and office

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 HIT Risk Analysis
 When introducing HIT must look at impact on safety – pre and
post implementation
 HIT is a tool and doesn’t improve workflow.
 Need to redesign unsafe workflows and adapt the HIT to the
new safer ones – not the opposite
 Constant surveillance

176
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 Lessons Learned from Risk
Identification and Analysis
 Methods:
– Story- telling: Patient &/or family presentations
– Letters from the Board or CEO
– E-mailed Safety Alerts
– Video Clips
 Forum Ideas (live):
– Town Hall Meetings: front line staff
– Various committees, unit-based practice councils
– Physician/ Resident Forums
– In person with subject matter expert- upon request

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 Lessons Learned:
Sharing the Wealth
 Some events may need multiple venues of
distribution.
– Patient Story
– Video clip of patient story (future learnings)
– Safety Alert cascaded to front line (protected email)
– ‘Catchy’ title to draw interest
 Timing:
– As soon after all details of event are known (timely so its
impactful)
– Scheduled quarterly RCA sharing meetings
– Other forums over time
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Your organization utilizes a “home grown” electronic safety event POLL OPEN
reporting system that is no longer meeting the needs of the
organization. Hospital administration is asking for your opinion for next
steps. What next steps would you take to identify a replacement
system?
Ask Information Systems to either fix the old one or build a
A new one

Identify key stakeholders and perform a gap analysis of

B current state to ideal state

C Poll colleagues and purchase what they use

D Purchase the least expensive software and grow with it

IHI 2018
 POLL OPEN
Your organization is preparing to change to a new
electronic health record. Many departments have been
involved with the planning of this huge effort. What would you
suggest as part of the preparation strategy?

A Conduct a root cause analysis

B Conduct a failure modes and effects analysis

C Offer a “plan, do, study, act” session

D Offer to do a claims analysis for any related

errors

IHI 2018
A new Cath Lab is under construction in your hospital, and the medical POLL OPEN
director contact you to express concerns related to the transport of
patients from the Cath lab to the ICU. You agree to assist in the design of
an FMEA. Components of the FMEA will include:

A Assembling a multidisciplinary team whose members will

brainstorm potential failures

B Conducting the “5 whys” to figure out what could go wrong

C Listing potential root causes of adverse events in the

current Cath lab

D Asking the medical director to participate in leadership

rounds in the current Cath lab to identify potential safety
risks
IHI 2018
A new medication administration safety process was implemented in a hospital. A POLL OPEN
team convened to perform a failure mode effects analysis and calculate a risk
priority number (RPN). After a targeted medication safety program on the new
process was delivered to nurses, the same team was convened to perform another
FMEA. The team would be happy to see:

A The detectability increased and RPNs were lower

B The detectability decreased and RPNs were lower

C The frequency numbers decreased and RPNS were

higher

D The frequency numbers increased and RPNs were lower

IHI 2018
 POLL OPEN
Sharing of lessons learned from RCA’s does
what?
A Exposes the fallibility of the involved clinician(s)

B Allows others to introduce work-arounds to avoid the

same situation

C Allows co-workers to learn the rationale for why an

event occurred and incorporate new lessons learned
into practice

D Sharing these events allows for exposure from litigation

perspective and should not be encouraged

IHI 2018
 References
 Frankel, A., Grillo, S. P., Baker, E. G., Huber, C. N., Abookire, S.,
Grenham, M., . . . Gandhi, T. K. (2005). Patient safety leadership
WalkRounds™ at Partners HealthCare: Learning from
implementation. Joint Commission Journal on Quality and Patient
Safety, 31(8), 423-437.
 Joint Commission Resources 2005, Tools and Techniques, Third
Edition.
 NPSF. RCA2: Improving Root Cause Analyses and Actions to
Prevent Harm. 2015.
 Schwendimann, R., Milne, J., Frush, K., Ausserhofer, D., Frankel,
A., & Sexton, J. B. (2013). A closer look at associations between
hospital leadership walkrounds and patient safety climate and risk
reduction: a cross-sectional study. Am J Med Qual, 28(5), 414-421.
doi: 10.1177/1062860612473635
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 Systems Thinking & Design
and Human Factors Analysis

Dot Snow, MPH, CPPS

Director, National Risk Management &
Patient Safety
Kaiser Permanente

185
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 Objectives
• Systematically identify, define, and address patient
safety issues
• Apply systems theory and thinking to improve
processes, including principles of high reliability
• Understand drift and rules violations as indicators of
performance and/or system design flaws
• Differentiate among human error, behavioral
choices, and system failures
• Recognize how key components of systems interact
to determine safety
186
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 First, Some Definitions
 Systems Thinking
An approach to
analysis that focuses
on the way the
system’s constituent
parts interrelate and
influence one another
within a whole
187
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 First, Some Definitions
 Human Factors Analysis
Represents science at
the intersection of
psychology and
engineering

Looks at all aspects of

a work system to
support human
performance and
safety 188
© IHI 2018
 Patient Story
As you hear this story,
think about:

The cascade of
situations that led to the
adverse outcome

The instances where

better system design
might have caught the
errors
189
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 Human Factors Engineering

 Addresses problems by modifying system design to better aid

people

“We can’t change the human condition,

but we can change the conditions under
which humans work”
--James Reason

190
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 What Impacts Human
Performance?
 We tend to overestimate our abilities and
underestimate our limitations

191
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 Quickly, Say The Color Not
The Word

Pink green Blue

Yellow Purple Red
blue Yellow Purple
Orange red Black
Black Orange Yellow
Red black
192
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What Impacts Human Performance?

 External factors:  Internal factors:

– Noise – Fatigue
– Distractions – Stress
– Interruptions – Anxiety
– Task design – Depression
– Environmental
conditions
193
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 The Role of Key Components of
Systems That Determine Safety
People
– Health literacy of staff
– Practice norms (alarm fatigue/alert overrides)
– Physical limitations
Tasks
– Complexity of action(s)
– Sequencing

194
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 The Role of Key Components of
Systems That Determine Safety
Tools, technology, and techniques
– Complexity of equipment
– Ergonomic considerations of operating equipment
– Sufficient training, particularly when newly
introduced
Environment
– Noise
– Distractions and interruptions
– Clutter, proximity of needed tools
195
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The Role of Key Components of
Systems That Determine Safety

Organization
– Safety culture
– Financial decisions
– Operational decisions
– Policies and procedures

196
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An Example: “In Search of the Lost Cord”
• Experienced but fatigued pediatric nurse (person)
• Double shifts; per diem staff (organization)
• Patient had electrodes on her chest, an IV pump with a
detachable cable to recharge the battery, and a heart monitor
(technology/tools)
• Nurse needed to reconnect EKG lead cable to the monitor (task)
• Two interruptions while tracing the cable (environment)
• Battery cable and EKG lead cable had similar 6-prong connection
(technology/tools)
• With some force, the nurse pushed the cables together (person)
• A lethal current of electricity streamed through the cord of the IV
pump through the EKG lead (outcome)
Planning for Unintended
Consequences

198
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Planning for Possible Unintended
Consequences
 Analysis of current error reports
 Benchmarking
 Review of external literature
 FMEA
 Workflow analysis
 Simulation
 Pilots, small tests of change

199
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Systems Errors: Complicated

200
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Complex Systems and Latent Failure
Distractions Deferred
Latent Failures
Unit Culture Variation maintenance
Inadequate
training

Trigger

“Normal” Undesired
Technical Individuals Outcome
operations Defenses
Professional Team
Adapted from: Reason J. Human Error. Cambridge UK; Cambridge University Press; 1990: 208.
201
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 Workflow Analysis
 Workflow needs to lead providers to do the right thing and
protect the patient

 Many workflows are legacy processes – “This is the way we

always did it.”

 Make no assumptions

202
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 Workflow Analysis Process
 Include all members of the team: All caregivers, unit clerks,
transporters, environmental workers, etc.
 Map out the current workflow
 Redesign with a blank page – don’t make assumptions
 Constant feedback

203
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 Workflow Analysis: Caveats

 Look for real and perceived barriers

 What will be the unintended consequences?

 Always do a small test of change – PDSA

 Did we solve the problem that prompted the event analysis?

204
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 Workflow Analysis Redux

 Standardize wherever possible and logical

 Measure, measure, measure!
 Did we obtain the outcomes we wanted
 Sustainability: Audit the new processes overtime –
have staff developed new work-arounds that negate
the corrective action?

205
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Safety Assessment Matrix
Prioritizing Efforts

206
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 Normalized Deviance
 What is it?
– Drift
– Shortcuts
– Continuum of intent
 Why does it happen?
– Fluctuations in situations within a complex environment
– Rules violations as early signals of system design flaws
or performance flaws are ignored
– Competency
– Personal motivations
 How can it be identified?
– Proactive observation of processes
– Error reporting and review
– Performance improvement efforts
– Complaints
207
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Accepting Deviance in Healthcare

208
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The Social Element in Healthcare –
People and Hierarchies

Broken Rules

Mistakes

Lack of support

Incompetence

Poor Teamwork

Disrespect

Micromanagement

209
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Hierarchy of Controls

210
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 Success of Risk Reduction
Strategies
 Risk Reduction- reduction of uncertainty present
in a situation
– Forcing functions
– Automated alerts and decision trees
– Checklists
– Rules, policies
– Education

211
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 Highly Reliable Organizations
 Standardize
 Simplify
 Avoid reliance on memory or vigilance
 Create redundancies as double checks
 Learn from failure
 Learn from the expertise of frontline workers
 Use forcing functions/constraints judicially

212
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Three-Step Design Strategy
 Step 1: Simplification and
standardization are used to
help minimize the chance of
● ● process failure.
●●
●  Step 2: “Controls” are applied
● to help prevent error from
occurring in the simplified
process.
●  Step 3: Errors that
● nevertheless occur are
identified and interrupted
before they cause harm.
213
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 Step 1: Standardize and Simplify
Simplification:
 Eliminating unnecessary steps (waste) in your
workflow
Standardization:
 Creating predictability and consistency in your
workflow
 Aids to standardization include things like:
– Common equipment
– Standard orders sheets
– Checklists
– Feedback of information on compliance
– Lots of education…and some training
214
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 Step 2: Application of Controls
 Recognizes the limits of human performance
 Lowers the risk of failure even with simplification and
standardization
 Minimizes the risk of “drift”
Examples
– Building decision aids / reminders into the system
– Leveraging teamwork and communication
– Making the desired action the default action
– Scheduling practices
– Taking advantage of habits and patterns
215
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 Step 3: Catching Errors
and Mitigating Harm
 Often accomplished through the use of
redundancy tools
 Characteristics of redundancy tools:
– Require careful consideration since they do
represent a form of “waste”
– Need to be truly independent
– Must follow with a mitigation strategy
– If redundancy is catching a lot of errors
getting through, a system component
redesign may be indicated
216
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Designing Process Improvement:
Incorporating Regulatory and Accreditation
Requirements

“Can’t live with

them, can’t live
without them”

 Standard consideration when changing process

 Stay on top of upcoming regulatory/accreditation
changes
 Benchmark with peer organizations

217
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Best Practice Resources
Regulatory and Accreditation Agencies
as Source of Information

218
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 Final Thought

“So long as it involves humans,

health care will never be free of
errors…but it can be free of
injury.”
--Donald Berwick

219
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 POLL OPEN
Which of the following descriptions best
reflects principles of safe system design?
A Hospital A routinely reviews and updates policies
and procedures every two years.

B Hospital B routinely studies close calls.

C Hospital C routinely provides trainings on the use

of newly introduced medical equipment.

D Hospital D routinely utilizes control charting to

report safety performance.

IHI 2018
 POLL OPEN
Which of the following descriptions is true
about human factors?
A Human factors science represents the intersection of
medicine and engineering.

B Human factors science consists of a set of principles

that can be learned during training.

C Human factors science addresses problems by

modifying the design of the system to better aid people.

D Human factors science is about eliminating human

error.

IHI 2018
A known barrier to patient safety is staff not speaking up POLL OPEN
when they are concerned or if they see safety violations.
You would help foster a culture that supports speaking up by:

Putting up posters around the organization that reinforce

A speaking up as a safety strategy

Using culture of safety data to assist low performing

B departments with defining strategies for improvement

Using trends in event reporting to identify staff who don’t speak

C up

Re-educating management on the use of Just Culture principles

D

IHI 2018
 POLL OPEN
Regulatory and Accreditation standards/requirements
can help guide improvements by:

A Fining people who don’t participate

B Outlining specific targets for performance

C Defining required topics of performance

D Providing language for metrics defined in the

improvement project

IHI 2018
The patient safety team reviewed a sample of patients who had been POLL OPEN
readmitted within 48 hours of discharge and noticed that the
patient’s discharge medication lists had not been accurately
reconciled. The appropriate next steps for the team to take include:

A Reprimand the discharging provider

B Ask nursing to be responsible for all medication reconciliation

C Gather a team of key stakeholders to flow map the medication

reconciliation process

D Gather data on the accuracy and timeliness of medication

reconciliation

IHI 2018
 References
 Certified Professional in Healthcare Management 2013 Study Guide:
Chapter 3 (Impact of Government, Legislation, and Accreditation
Processes); McKesson Health Solutions LLC.
 Carayon, P., & Wood, K. E. (2010). Patient safety - the role of human factors
and systems engineering. Stud Health Technol Inform, 153, 23-46.
 Maxfield, D. (2005). Silence kills: The seven crucial conversations for
healthcare: VitalSmarts.
 National Partnership for Reinventing Government. (1999). Balancing
Measures: Best Practices in Performance Management.
from https://www.opm.gov/policy-data-oversight/performance-
management/measuring/balancing-measures/
 Neily, J., Mills, P. D., Young-Xu, Y., Carney, B. T., West, P., Berger, D. H., . . .
Bagian, J. P. (2010). Association between implementation of a medical team
training program and surgical mortality. JAMA, 304(15), 1693-1700.
 Russ, A. L., Fairbanks, R. J., Karsh, B.-T., Militello, L. G., Saleem, J. J., &
Wears, R. L. (2013). The science of human factors: separating fact from
fiction. BMJ quality & safety, bmjqs-2012-001450.
 Westcott, R. T. (2013). The certified manager of quality/organizational
excellence handbook: ASQ Quality Press.
 Weick, K. E., & Sutcliffe, K. M. (2011). Managing the Unexpected: Resilient
Performance in an Age of Uncertainty: Wiley.
225
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 Leadership

Maureen Ann Frye, MSN, CRNP, ANP-BC, CPPS, CPHQ

Senior Director, Center for Patient Safety and Health Care Quality
Abington Jefferson Health

226
© IHI 2017
 Leadership: Exam Content Outline
A. Align patient safety strategy with organizational
mission, vision, values, and goals
A. Advocate for patient safety as a top priority
B. Collaborate with key stakeholders to prioritize patient safety
efforts
C. Identify key stakeholders for distinct patient safety initiatives
D. Develop operational plan to improve patient safety
E. Advocate for resources required to support operational plan
F. Foster transparent communication throughout the organization
G. Foster transparent communication with patients and their
caregivers
H. Create opportunities for interdisciplinary patient safety
conversations and problem solving
227
© IHI 2018
Leadership: Exam Content Outline cont.
J. Advocate for integration of patient safety responsibilities into job descriptions
and performance evaluation tools
K. Embed accountability into investigation and system improvement
L. Promote the application of principles of high reliability at all levels of the
organization
M. Demonstrate ability to influence decision makers and frontline staff to
participate in patient safety initiatives
N. Use storytelling as a mechanism to engage stakeholders and drive change
O. Work within the organization to accomplish process improvement, effectively
engage leaders, and influence stakeholders and frontline staff
P. Provide patient safety content expertise for purposes of maintaining continuous
survey readiness as defined by regulatory bodies
Q. Promote compliance with requirements related to reporting serious
occurrences and reportable events to appropriate organizations
R. Maintain ongoing working relationships with: clinicians, managers, executives,
governing body, external agencies, patients, staff, regulatory agencies

228
© IHI 2018
Objectives
I. Discuss the integration of patient safety into the
organization’s overall strategy as it relates to its
mission. (A, B and C)
II. Examine several strategies to operationalize patient
safety at the facility level (D and H)
III. Discuss how the patient safety professional can
advocate successfully for patient safety resources (E)
IV. Describe ways to influence key stakeholders and
engage them in patient safety at an organization wide
level (F, G, I and J)
229
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Strategy Safety Leadership

You as leader in
Patient Safety
operations

You as influencer
of others to
mobilize and
engage

230
© IHI 2018
Safety as Part of the Mission, Vision, Values and Goals
“Leadership is the critical element in a
successful patient safety program and is non-
delegable.” Leaders must demonstrate the core value of
patient safety in their actions, words and decisions.

“If safety is to be seen as a strategic priority for Board/

Governance

all staff, then leadership must make it a key

Senior,
Operational and
Medical
Staff Leadership

focus of their attention.” Microsystem- to everyday work at

the ‘sharp end’

Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series white paper. 2006
231
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Safety as Part of the Vision and Mission
NPSF Vision Statement
 Creating a world where patients and those who care
for them are free from harm.

NPSF Mission
 NPSF partners with patients and families, the health
care community, and key stakeholders to advance
patient safety and health care workforce safety and
disseminate strategies to prevent harm.
232
© IHI 2018
 What is your Organization’s MISSION and VISION
 Mission:
– Your organization’s overall function. The mission statement attempts to answer
“What is your organization attempting to accomplish?”
– Inspires the organization and guides its values

 Vision:
– Your organization’s desired future state.
– Where your organization is headed, what it intends to be and how it wishes to
be perceived in the future. 2017-2018 Baldrige Excellence Framework Healthcare Criteria

233
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Safety as Part of the Mission, Vision, Values and Goals

 35 Hospital Mission Vision and Value statements

randomly selected online
– Key words and phrases used most frequently
– High Quality
– Cost Effective
– Compassionate
– Teamwork
– Patient centered
– Only 7 explicitly specifically included the words “safe” or
“safety”

234
© IHI 2018
Safety as Part of the Mission, Vision, Values and Goals

 “…to restore health as swiftly, safely, and

humanely as it can be done”
 “…to excel in patient quality and safety”
 “…we value safety as a guiding principle”
 “…to deliver the very best healthcare in a safe,
compassionate environment”

235
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Safety as Part of the Mission, Vision, Values and Goals
 “…to provide the safest, highest quality health
care and the best experience possible for our
community”
 “We believe that maintaining the highest safety
standards is critical to delivering high-quality
care and that a safe workplace protects us all.”
 “…to be a national leader for excellence and
innovation in the delivery of health care and
patient safety…”
236
© IHI 2018
 SSE Rate
 Do you have one?

0
1

0.2
0.4
0.6
0.8
1.2
1.4
1.6
1.8
July-07
October-07
January-08
April-08
July-08
October-08
January-09
April-09
Jul-09
Oct-09
Jan-10
Apr-10
Jul-10
Oct-10
Jan-11
Apr-11
Jul-11

237
Oct-11

© IHI 2018
Jan-12
Apr-12
Jul-12
Oct-12
Jan-13
Apr-13
Jul-13
Oct-13
July 2007 – April 2007

Jan-14
Apr-14
Jul-14
Oct-14
Big Dot Measures for Patient Safety

Serious Safety Event Rate at Hospital X

Jan-15
Apr-15
Jul-15
Oct-15
Jan-16
Apr-16
July-16
Oct-16
Jan-17
Apr-17
95% decrease in serious safety events since 2007

Jul-17
Oct-17
Jan-18
Apr-18
0
1
2
3
4
5

# of Events
Assessing the Current Quality and
Safety Activities in your Organization
 What are teams currently doing?
 What are the conversations at meetings?
 What are the conversations within the teams?
 Where is the focus?
 Improvement for whom?
 Voice of the patient present?

 Look for the hidden pockets of excellence

 Reward and recognize the excellence and spread/share
 Time to start setting your quality/safety priorities…. More
than just VBP and publically reported metrics!

238
© IHI 2018
Setting Quality and Safety Priorities
No ‘one’ way to go about it!

 Set One Big Hairy Audacious Goal

 Advertise Big Events
 Focus on Troublesome Trends
 Sorting of Signals
(capture risks/hazards to prioritize actions)

239
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 240
© IHI 2017
Setting Quality and Safety Priorities Great
Saves/Good
Catches

Iterative process and a balancing process!

Quality
– Establish a data hub for quality and safety signals Reviews

– Integrate all sources of knowledge into one repository

– Identify themes through qualitative data review Data

– Draft goals Event

– Apply filters to help prioritize goals

reports

Patient
Feedback

– Vet goals across the institution (strategic planning process) Rounding

– Articulate key tactics for each goal

– Approve goals and performance metrics Patient Safety
Knowledge
– Plan implementation and track progress
241
© IHI 2018
 Creating a Sense of Urgency
 Set realistic goals – SMART: Specific, Measurable,
Actionable, Realistic and Time-Bound (Short & Long Term)
 Show the numbers but tell the compelling stories, too
 The cost of harm is widespread
– The human cost
• The patient
• The family
• The care team
– The financial cost – potential savings, ROI etc.
– The cost to reputation 242
© IHI 2018
 IHI’s 6 Activities for Boards to
Focus on to Promote Patient Safety
1. Setting aims
2. Getting data and hearing stories
3. Establishing and monitoring system-level
measures
4. Changing the environment, policies and culture
5. Learning – starting with the board
6. Establishing executive accountability

Conway, J (2008) Getting Boards on Board

243
© IHI 2018
 Engaging the Board

“It is (also) crucial that each board meeting

include at least one story of an actual patient
harmed or killed while receiving care in the
system. It is the drama and poignancy of the
individual case – a person with a name, face
and family who was seriously injured by an
error – that provides the energy needed to
inspire real action in safety.”
Wachter 2012 Understanding Patient Safety p.401

244
© IHI 2018
 Engaging the Whole Organization
Share the good and the ‘troubling’
 Leadership engagement is crucial
 Recruiting and involving the frontline- In what ways do you engage them?
– Gather information trust
– Be fair and just in your search for answers
– Understand causal factors
– Set priorities
– Follow through and make improvements
report improve
• Frontline as part of the solution
– Follow up
– Everyone is responsible for sustaining the gains
 Transparent sharing of the stories on the intranet page?
245
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 System Complexity and
the Impact to the Human
 80% of medical errors are system derived1

 Good people working harder will be insufficient to

overcome the complexities in healthcare

 “Our systems are too complex to expect merely

extraordinary people to perform perfectly 100%
of the time. We, as leaders, have a responsibility
to put in place systems to support safe practice.”
James Conway

246
1 “Safe and Reliable Healthcare” Frankel, A, Leonard, M et al
© IHI 2018
Quality and Safety on Every Agenda
 Make it okay to talk about concerns, share near miss
or actual events, even your own.

 Don’t just tell the story!

 Foster understanding of complexity and reliability
 Connect it to the error prevention behaviors or processes that could
have prevented the error or harm
 Include the impact on the patient, their experience, and the employee
involved

 Highlight actions to prevent reoccurrence

 The spirit of Fair and Just Culture must be a component

247
© IHI 2018
 The Role of the Regulators
 Regulators fill our need for public oversight of health care
entities and providers. Without them, health care would be
a messy free for all.
 There is an endless alphabet soup of health care regulators.
They come in all shapes and sizes.
 They are significant stakeholders in our patient and quality
efforts. EMBRACE them to move the agenda forward!
 All regulators have a defined authority to oversee aspects of
our operations and practices, including access to our
facilities, people, and records.
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 The Regulators
 The Centers for Medicare and Medicaid Services
(CMS) sets and enforces minimum standards as a
prerequisite to payment.
 State Departments of Public Health often do the work
of CMS by enforcing the Conditions of Participation
through on-site surveys. Most interested in patient
safety systems.
 The Joint Commission routinely accredits most U.S.
hospitals as being in compliance (or not) with the CMS
Conditions of Participation. Derives its authority from
CMS. There are other “deemed” organizations.
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 Continual Readiness
Boards of Trustees

Quality of Care Committee of the

Boards of Trustees General Executive
Committee (GEC)

Quality & Patient Safety Committee Quality Oversight Committee

Excellence Every Day

Safety Committee
Coordinating Committee

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 POLL OPEN
You have been asked to present an overview of
safety events to the board of trustees. In order to best
represent safety issues, you should:
A Highlight system-wide improvements that have been
implemented in the past year

Present cases of harm with contributing root causes and

B actions taken

Display a graph of the numbers and types of safety events

C reported in the past year

Lead an open discussion of board members’ safety concerns

D and recommendations

IHI 2018
 POLL OPEN
When setting organizational safety priorities,
it is best for you to:
Determine priorities based on pay for performance
A
measurements

B Focus primarily on accreditation standards and

requirements

C Develop a mechanism to gather input from a

variety of sources

Review the current literature to identify areas of

D
frequent concern

IHI 2018
Operations

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Developing the Operational Plan

Some examples might be:

 Transforming Care at the Bedside (TCAB)
 Leadership rounding
 Safety briefings
 Process redesign to improve reliability
 Senior executive adopt-a-work unit

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 Transforming Care at the Bedside
 Created in 2003 by the Robert Wood Johnson Foundation and
Institute for Healthcare Improvement (IHI)
 Five themes
– Transformational leadership
– Safe and reliable care
– Vitality and teamwork
– Patient-centered care
– Value added care processes

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Transforming Care at the Bedside

 Examples of successes & spread

–Rapid Response Teams
–Communication models
–Professional support systems
Rutherford P, Lee B, Greiner A. Transforming Care at the Bedside. IHI Innovation Series white paper. Boston: Institute for
Healthcare Improvement; 2004. (http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/TCAB/Pages/default.aspx)

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 Leadership Rounding
 Who?
– Executive leadership (what about trustees?)
 How often?
– At least weekly
 Where?
– All patient care areas
 Why?
– Executive leadership Frontline staff
.

Leadership Series: Executive Patient Safety Walkrounds™: Patient Safety Advisory 2008
Jun;5(2)37-8
http://www.ihi.org/resources/Pages/Tools/PatientSafetyLeadershipWalkRounds.aspx

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Safety Briefings (Organizational)
 Embeds safety into the normal routine
 Not dependent on management
 Brief duration
 Non-punitive
 Structured
 Look back – Look ahead – Follow up

Joint Commission Resources, Hospital Engagement Network. Patient Safety Initiative: Hospital Executive and Physician Leadership Strategies.
Available at http://store.jcrinc.com/patient-safety-initiative-hospital-executive-and-physician-leadership-strategies/.
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Process Redesign to Improve Reliability
 Reliability in health care
– Patients getting the intended tests, medications,
information, and procedures
– At the appropriate time
– In accordance with their values and preferences
 Leaders support
– Standardization
– Redundancy
– Human factors engineering design
Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series white paper.
Cambridge, MA: Institute for Healthcare Improvement; 2006. (www.IHI.org)
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 Framework for a
Reliability Culture

Design of Design of
Design of Culture Policies &
The key is to Work Micro- vs. Macro-
system Shared Values Protocols
design care Processes and Beliefs Standard work
delivery systems How work is done documents, rules for
work Design /Redesign of
Design of
so that harm does Technology &
Structure
not reach the Workforce and Environment
Team Structures The equipment, environment
patient and human interfaces
w/technology that impact the
work

Leadership
Reinforce & Build Accountability
for performance expectations and
Find & Fix system problems

Technical skills / Behaviors Nontechnical skills of

competencies of Individuals & Groups individuals and team practice

GOAL: Zero Harm and an Defects  Cause

Exceptional Experience The Patient’s Experience analysis and Improvement
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Abington Health to reflect organizational goals and experience. Adapted by MAFrye
 Senior Executive Adopt-a-Work Unit

 Pairs a hospital executive with a work unit or microsystem

 Educates and improves awareness of safety issues
 Empowers staff to take accountability for safety issues
 Creates high trust partnerships
 Provides resources and tools

Joint Commission Resources, Hospital Engagement Network. Patient Safety Initiative: Hospital Executive and Physician
Leadership Strategies. http://store.jcrinc.com/patient-safety-initiative-hospital-executive-and-physician-leadership-strategies/.

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 Advocating for Resources
 Can be a challenge for a clinician/patient safety leader
 Alignment- make the human case for safety by
aligning the request to the:
– Mission
– Risks/Harm events
– Strategic plan
– Community needs assessment
 Who do you need to sell it to?
 KNOW your audience
 Gather some influencers / supporters
 Return on investment (ROI)
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 ROI Example when engaging Finance

eICU Investment:
 $10 million dollars in equipment, training, staffing
 Decreased mortality and ICU LOS: Savings of $12 million
 Savings: $2 million
 ROI = $2M/$10 M X 100 = 20%

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Embedding Accountability into
Investigation and System Improvement
 Setting the expectations
– Alignment to the mission, vision and values of
the organization
– Investigation of errors and near misses
– Executive involvement in investigations and
improvement activities
– Ensures priority of patient safety activities and
system improvement

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 Executive Dashboard

 Electronic display of key performance indicators

– Clinical indicators
• Patient safety and quality

– Financial indicators

– Balance of indicators

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You are meeting with the CFO to determine return on investment (ROI) POLL OPEN
for multiple patient safety initiatives. Which project is most likely to
receive approval based on the determined ROI:

A Procurement of new beds with built-in alarms to reduce

falls with an ROI of 0.9

B Implementation of evidence based guidelines to reduce the

rate of catheter associated urinary tract infections with an
ROI of 3.0

C Implementation of Computerized Provider Order Entry to

reduce the number of medication errors with an ROI of 1.0

D Implementation of a sitter program, which has been shown

to reduce falls and improve patient satisfaction with an ROI
of 0.5
IHI 2018
 POLL OPEN
Which of the following changes to operations
would best highlight leadership’s commitment to
patient safety?
Implementing quarterly town hall meetings to share
A organizational information

The hospital executive reporting on patient safety at every

B board meeting

Including an executive representative on all root cause

C analysis teams

Executive leadership regularly participating in leadership

D rounds and daily safety briefings

IHI 2018
Engagement

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Engaging Stakeholders

Definition of a Stakeholder
 One entrusted with the stakes of bettors (a
disinterested but trusted third party)
OR
 One who is involved or affected by a course of
action

http://www.merriam-webster.com/dictionary/stakeholder
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 Engaging Stakeholders
Gallup – State of the American Workplace 2013
 Studies conducted 2008, 2010 and 2012
 Measure the level of employee engagement
 350,000 survey responses over 3 year period
 Focus on “financial side” of engagement
– Better productivity=improved performance

http://www.gallup.com/strategicconsulting/163007/state-american-workplace.aspx

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Engaging Stakeholders

 In 2012, 18% of employees

in America were “actively
disengaged”

 In 2012, 30% of employees

in America were “engaged”

http://www.gallup.com/strategicconsulting/163007/state-american-workplace.aspx

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 Engaging Stakeholders Look at the
difference
between the top
25% and the
bottom 25% of
respondents and
note the
difference
between groups

Organizations with highly engaged employees have

fewer patient safety incidents
http://www.gallup.com/strategicconsulting/163007/state-american-workplace.aspx

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 Engaging Stakeholders

Organizations with highly engaged employees have

fewer patient safety incidents
http://www.gallup.com/strategicconsulting/163007/state-american-workplace.aspx

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 Engaging Stakeholders
Journal of Patient Safety
 Study conducted to determine relationship between
employee engagement and patient safety culture
– Loma Linda University Health Systems (AHRQ & Gallup)
– Assessed employee engagement and culture of safety
– Psychometrically valid survey tools
– > 70% response rate on surveys between 2007-2009
 Results
– Direct relationship between high levels of engagement
and strength of safety culture
– Fewer employee injuries with increase in engagement
Journal of Patient Safety. 2012; 8: 194-201

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Methods to Improve Engagement
 Communicating vision and mission
– Senior leader communication of safety vision and mission
 Connecting purpose and work
– Communicating through data and story
 Empowering people
– Listen
– Use staff recommendations for workflow
 Recognizing excellence
 Listening and Acting on issues
http://performanceexcellencenetwork.org/the-presidents-blog/workers-are-mad-as-hell-14-ways-to-increase-employee-engagement/
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Methods to Improve Engagement
Patients and Families as stakeholders
 AHRQ Guide to Patient and Family Engagement
in Hospital Quality and Safety
 Four strategies outlined IDEAL Discharge
– Patients and families as advisors I Include the Patient
D Discussing
– Communicating to improve quality E Educating
– Nurse bedside shift report A Assessing

– IDEAL Discharge planning L Listening

AHRQ Guide. http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/guide.html

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You are charged with identifying and recommending a new event POLL OPEN
reporting computer system for your organization to use. Which of the
following would be the best technique to use when evaluating new
software systems?
A Invite senior leaders of the organization to a workshop to ask
questions of the software vendor. Review leader evaluations following
workshop

B Conduct an open vendor fair for all staff to review various options.
Evaluate written and verbal feedback on the systems from participants

C Develop a “Request for Proposal” to submit to various software

vendors. Evaluate the best responses to make a recommendation

D Submit a national, electronic survey to your peers to determine the

vendor used most often. Recommend the most frequently referenced
vendor

IHI 2018
A medication error occurred at a nearby hospital which has received POLL OPEN
media attention. You find similar processes in place at your
organization and recognize there may be resistance to changing
them. What would be the best method to use to influence others as
to the need for change?
A Present the story in conjunction with your own facility’s data.

B Reference accreditation standards and hospital policy as the

need to make a change in process.

C Develop a staff recognition program for reporting actual events

that occur in your facility.

D Conduct a root cause analysis on a similar event that has

occurred at your own facility.

IHI 2018
 Influencing Others to Action
The Power of Story
“Stories capture the context, … the emotions… Stories
are important cognitive events, for they encapsulate, into
one compact package, information, knowledge, context,
and emotion.”
• Machines have become more effective
at large data sets and “crunching
numbers”
• Human empathy and storytelling has
become even more significant in this
age of big data
Norman D. Things That Make Us Smart

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 Influencing Others to Action
Narrative Medicine
 2001 JAMA piece by Dr. Rita Charon
 Calls for a new approach to medicine – narrative
medicine
 Transition from “tell me where it hurts” to “tell me
about your life”

“…physicians need the ability to listen to the narratives of the

patient, grasp and honor their meanings, and be moved to act
on the patient’s behalf.”
Charon R. JAMA. Oct 17, 2001.
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 References
 Bohmer, R. M., Bloom, J. D., Mort, E. A., Demehin, A. A., & Meyer, G. S. (2009).
Restructuring within an academic health center to support quality and safety: the
development of the center for quality and safety at the Massachusetts General
Hospital. Academic Medicine, 84(12), 1663-1671.
 Botwinick, L., Bisognano, M., & Haraden, C. Leadership guide to patient safety. IHI
Innovation Series white paper [monograph on the Internet]. Cambridge, MA: Institute for
Healthcare Improvement; 2006.
 Charon, R. (2001). Narrative medicine: a model for empathy, reflection, profession, and
trust. JAMA, 286(15), 1897-1902.
 Conway, M. (2008). Getting boards on board: engaging governing boards in quality and
safety. Joint Commission Journal on Quality and Patient Safety, 34(4), 214-220.
 Frankel, A. (2004). Patient Safety Leadership
WalkRounds™. http://www.ihi.org/resources/Pages/Tools/PatientSafetyLeadershipWalkR
ounds.aspx
 Joint Commission Resources, Hospital Engagement Network. Patient Safety Initiative:
Hospital Executive and Physician Leadership Strategies. Available
at http://store.jcrinc.com/patient-safety-initiative-hospital-executive-and-physician-
leadership-strategies/
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 References
 Lucian Leape Institute at the National Patient Safety Foundation. (2013). Through the eyes of the
workforce: Creating joy, meaning, and safer health care.
 Mort, E. A., Demehin, A. A., Marple, K. B., McCullough, K. Y., & Meyer, G. S. (2013). Setting quality
and safety priorities in a target-rich environment: An academic medical center’s
challenge. Academic Medicine, 88(8), 1099-1104.
 Norman, D. A. (1993). Things that make us smart: Defending human attributes in the age of the
machine: Basic Books.
 Rutherford, P., Lee, B., Greiner, A., & Gordon, A. B. (2004). Transforming care at the bedside:
Institute for Healthcare Improvement.
 Swenson S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the
Health of Populations and Reduce Costs. IHI White Paper. Cambridge, Massachusetts: Institute for
Healthcare Improvement; 2013.
 Thorp, J., Baqai, W., Witters, D., Harter, J., Agrawal, S., Kanitkar, K., & Pappas, J. (2012). Workplace
Engagement and Workers’ Compensation Claims as Predictors for Patient Safety Culture. Journal of
patient safety, 8(4), 194-201.
 Wachter, R. (2012). Understanding Patient Safety, Second Edition: McGraw-Hill Education.
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Question & Answer

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Preparing to take the
CPPS Exam

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Background / History of Exam
 The National Patient Safety Foundation* established and launched
the Certified Professional in Patient Safety (CPPS) designation for
three reasons:

– To define patient safety science

– To advance expert patient safety practice
– To measure favorable practitioner and
patient outcomes

* NPSF merged with the Institute for Healthcare Improvement (IHI) in 2017.
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Professional Advancement
 Rigorous and comprehensive credentialing process that attests to
patient safety competencies and expertise

 Evidence-based examination:

– Establishes core standards for the field of patient safety, benchmarks

requirements necessary for health care professionals, and sets an expected
proficiency level
– Gives those working in patient safety a means to demonstrate their proficiency
and skill in the discipline
– Provides a way for employers to validate a potential candidate’s patient safety
knowledge and skill base, critical competencies for today’s health care
environment
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 Testing Domains
DOMAINS COVERED ON EXAM

18% Culture
20%

Measuring & Improving

Performance
Risk ID & Patient Safety Strategies
20%
22%
Systems Thinking & Design /
Human Factors Analysis
20% Leadership

To view detailed content outline, click here:

http://www.ihi.org/education/cpps-certified-professional- 289
in-patient-safety/Pages/CPPS-Content-Outline.aspx © IHI 2018
Cost of the Exam
 The cost of the CPPS examination is:
– $295 for members of the American Society of Professionals in Patient Safety
(ASPPS)
– $400 for nonmembers
– International candidates, please add $100 US for international examination fee
 Exam may be rescheduled once free of charge (with appropriate
notice); must reschedule within 90 days of original exam date
 Additional requests to reschedule shall incur cost

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Exam Questions
 Categories of cognitive types of questions:
– Recall: the ability to recall or recognize specific information (14%)
– Application: the ability to comprehend, relate or apply knowledge to new or
changing situations (48%)
– Analysis: the ability to analyze and synthesize information, determine solutions
and/or evaluate the usefulness of a solution (38%)
 Must pass all five exam domains
 110 Questions
(10 = pre-test questions for future use)

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Eligibility Guidelines
 Individuals from across the health care spectrum may sit for the CPPS
examination providing they possess a baseline combination of education,
experience, and a commitment to improving the safety of patient care

 Candidates for the CPPS credential are those who include patient safety
practices as an integral component of current or future professional
responsibilities. In addition, candidates must possess academic and professional
experience at one of the following levels:
– Baccalaureate degree or higher plus 3 years of experience (includes time spent in clinical
rotations and residency programs) in a health care setting or with a provider of services to the
health care industry

– Associate degree or equivalent plus 5 years of experience (includes time spent in clinical
rotations) in a health care setting or with a provider of services to the health care industry

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What is the passing score?
 Because questions that address application and analysis (these are
the vast majority of questions) have different weighting scores as
compared with rote questions, the formula for passing does not allow
for us to post a singular passing grade on the exam
– On a scale-scored basis (as alluded to above), the passing score is typically in
the range of 70 percent
 First time pass rate generally ranges from 65-70%

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 Assessment & Application
 Complete the optional self-assessment test to see how you
score in each of the exam domains
 Complete the exam application
 www.GOAMP.com - schedule appointment at convenient
local testing center for you
 Morning and afternoon/some Saturday appointments
are available (location dependent)

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 Testing Day
(Testing locations are overseen & operated by AMP/PSI credentialing)

 Get a good night sleep before the scheduled

exam
 Arrive on time
 Check in with testing proctor
 2 government issued forms of identification
(drivers license, passport) and other form of
identification with name and signature
– Validate all information is correct
 Cannot bring in personal items (phone, food,
drinks, study materials, purse)
 Wallet/car keys are acceptable but will be
secured
 Will need to turn out pockets to validate no cell
phones on person
 Escort by proctor to testing location
 Proctor cannot answer questions about exam
 Testing Process
 Pencil, scratch paper provided
 Finger print image may be required (may be done on screen)
 Digital photo – on score form/on testing screen
 Help Screen to assist with navigation
 Two (2) hour timed exam
– Practice to test software before timer starts
– No scheduled breaks
– On screen clock (can be turned off)
– Ability to bookmark questions to return to later
 110 questions of which 100 are graded
 Check out with proctor
– Should provide immediate scored report
 Test Preparation/Available Materials
 CPPS Resource List
– Journal Articles
– Books, Monographs
– Guidelines, Recommendations
– Webinars
 Focus on areas of
weakness
 Find study buddies,
those in your organization
who may have the needed
knowledge
 Self-assessment Exam (SAE)
 CPPS Review Course
Maintaining your CPPS designation
 3-year recertification period

 Recertification may be achieved by:

– 45 credits of documented continuing
education
and/or other qualified activities
– Re-testing

 Continuing education courses and other

qualified activities must address at least
one of the tested domains

 Recertification Handbook at www.ihi.org/CPPS

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Test Taking Tips

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Test Taking Tips
 Answer questions you are comfortable with first; flag harder questions to
come back to later (bookmark feature allows you to return to skipped
questions)
 Read each question carefully, don’t jump to thinking you know what the
question is asking
 Read all answer options carefully, don’t just pick the first one you see that
makes sense
 Read and consider all options and select the best choice
– Look for words such as except, not, and least as key words to understand exactly
what the question is asking
– Beware of choices such as always and never
– Anticipate the answer and then look for it
– Consider all alternatives
– Exclude obviously wrong answers
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Test Taking Tips (continued)
 When preparing for the exam, train your mind to avoid mental
shortcuts; pay attention to what is really being asked
 It’s easy to make mistakes. A hasty question-reader will fall for a good
distractor (an option that could seem right but isn't the right answer for
that scenario)
 The exam is designed to test more than just knowledge; you also
need to demonstrate the analytical and critical thinking skills needed
in real-world situations (use your patient safety experience)

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Test Taking Tips (continued)
 Relate answer options back to the question
 Balance options against each other
 Use logical reasoning
 Choose answers that contain words you know
 Watch your time, pace yourself
 Don’t be distracted by other test takers
 Answer every question. After you’ve answered all the questions you
feel confident about and time is running out, there is no penalty for
guessing
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Good luck!

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Thank you for joining us!

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