Reliability Theory in Action

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8 Νοε 2013 (πριν από 3 χρόνια και 7 μήνες)

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Reliability Theory in Action



Jane Murkin

Regional Manager Improvement and
Support Team

SEHD

Why reliability?


Implementing reliability concepts has been found to reduce
defects in care, increase the consistency with which
appropriate care is delivered and improve patient
outcomes.



( IHI 2004)




Reliability means keeping a promise”




(Don Berwick)




Session Aims:











An introduction to reliability theory and concepts



Learning from Highly reliable organisations



The application of reliability principles to healthcare



A practical example of using reliability theory to improve
Patient Safety
-

Case study




Introductions


Hugh Rogers


Associate for Service transformation

NHS Institute for Innovation & Improvement, Consultant Urologist, West
Middlesex Hospital






John Pickles


Consultant ENT Head and Neck Surgeon and
Associate Medical Director, Luton & Dunstable Hospital NHS
Foundation Trust


Safety



Effectiveness



Patient Centred



Timeliness



Efficiency



Equity

Dimensions of Quality

(
Crossing the Quality Chasm, IOM, 2001)

Reliability


Hugh Rogers
FRCS

Associate, Service Transformation

NHS Institute for Innovation & Improvement

Variation in outcomes

Care is not safe


Institute of Medicine report

“Between the care we have

and the care we could have,

lies not a gap, but a chasm


Exercise

What experiences have you, your family or
friends had of errors in healthcare that
caused pain, harm or helplessness?

A framework for quality in healthcare


Crossing the Quality Chasm: Institute of Medicine 2001


Timeliness



No needless delay


‘Treat me quickly and appropriately


Efficiency and productivity



No waste


‘Use the resources we give you to greatest effect’


Patient centredness



No feelings of helplessness


‘Treat me with respect and empower me’


Reliability



No needless suffering


‘Give me effective treatments and relieve my pain’


Safety


No needless deaths


‘Protect me and heal me’


Equity



No inequity


‘Treat me fairly’



Safety & reliability =


Reducing avoidable
harm

What is reliability?


The capacity to perform a given function under given conditions
for a specified period of time
(Juran)



A reliable health care system is one that is designed to ensure
that every patient consistently receives evidence
-
based,
effective care every time he or she needs it.
(IHI white paper)




“Reliability means keeping a promise”

(
Don Berwick
)

Compare Reliability and Safety


Safety


Errors of commission


Special cause strategies


Reactive


Focused projects



Reliability


Errors of omission


Common cause strategies


Proactive


Design of reliable systems


High frequency low impact Low frequency high impact

Overlap

Failure has high impact

© NHS Institute for Innovation and Improvement

Reliability

What this means in terms of
systems

Less than 10
-
1

(<80%, out of control)

Chaotic, ad hoc, no system

10
-
1

(80


95%

success)

Intent, vigilance, hard work

10
-
2

(95


99.5%
success)

Design informed by reliability science and
human factors

10
-
3
or more

(<5 per 1000
failures)

Design of ‘High Reliability Organisations’

(Nolan, after Weick)

Safety & Reliability


Good people working hard will not be able to overcome the
complexities of today’s systems of care to prevent errors.
Human beings make errors:


Misreading errors 3 in 1000


Omission in the absence of reminders 1 in 100





(BMJ March 18 2005 Tom Nolan)



Consensus that approx 10% of patients suffer harm through errors


Cost 3 million bed days in UK, £1billion pa


50% preventable



‘In the airline industry, we assume that mistakes are inevitable’


Martin Bromiley, Pilot, BMI (Widower)




Vulnerable


system

Average


system


Resilient


system

Prof James Reason

Commitment to resilience (or intrinsic safety)

Reliability rates in Healthcare

A

large

study

in

US

health

care

using

detailed

case

notes

review

concluded

that

the

“defect

rate”

in

the

technical

quality

of

American

healthcare

is

approximately

-

45%

(McGlynn, et al
The quality of healthcare delivered
to adults in the United States

NEJM 2003; 348)

Sensitivity of routine system for reporting patient safety incidents in an
NHS hospital
Sari AB et al: BMJ 2007; 334:79
-
81

Case notes review using a trigger tool

Only 5% of adverse incidents that led to harm were reported

Editorial

Vincent C: BMJ 2007; 334:51

“We need systematic assessment of error and harm … from a wider range of sources.

Organisations must move towards active measurement and improvement programmes”

Seeing the picture through “lean thinking”
Ben
-
Tovim D (letter) BMJ 207;334:169

“We have to take hospital safety out of the safety and quality ghetto and beyond
strategies such as clinical audit and feedback …”

Incident reporting is not enough

First understand your own issues:

Triangulation of 3 key methods


Case notes review using Global Trigger Tool


Incident reporting and investigation


Root cause analysis, Fault tree analysis, Human Factors etc


Executive safety walk
-
rounds

Level 1 Reliability

Personal Intent, Vigilance and
Hard Work:

10
-
1


Performance

(80% to 95 % success)


Feedback of information on
compliance


Awareness and training


Personal check lists


Common equipment, standard
order sheets

Level 2 Reliability

Reliability Science, System design
and Human Factors

10
-
2
Performance

(95% to 99.5% success)


Standardise processes


Make the desired action the default


“Opt
-
out”


The desired action = flow
of work


Build design aids into the system


Create redundancies and time lapses

Principles for increasing
reliability

What are we trying to

accomplish?

How will we know that a

change is an improvement?

What changes can we make that will

result in the improvements we seek ?

Act

Plan

Study

Do

A model for improvement...

Aims

Measurement

Ideas, evidence,
hunches,

other people etc
.

The

three

fundamental

questions for

improvement

The fourth

question:

how to make
changes

Langley, Nolan et al 1996

Succeed


Experts produce final
product


Takes 2 years


No changes allowed


Measure before and after


No new learning


Experts produce draft for
testing


Takes 2 hours


Changes are expected


Measurement over time


Learn and improve

Standardisation:

Fail


Human factors:


-

the power of team briefs & debriefs


Getting everyone on the same page


Helping everyone to speak up


Increasing resilience


Building a well
-
functioning team


Helping to understand what happened


Making sure we keep learning


Beyond 10
-
3
‘High Reliability Organisations’


They face an excess of unexpected events


They operate under very trying conditions and yet
have very few ‘accidents’


Nuclear power
-
generation plants


Naval aircraft carriers


Chemical production plants


Offshore drilling rigs


Air traffic control systems


Incident command teams



Where would you find them in healthcare?

Characteristics of HROs


Central goals are clear and widely shared


Consensus that failure would be disastrous


During times of peak loads emphasize collegial decision making


Formal decision analysis, based on standard operating procedures


Prize vigilance against lapses and flexibility towards rules


Key equipment available and well maintained


Short
-
term efficiency takes a back seat to very high reliability


Rely on professional judgment, regardless of position or rank


Remember this?

Reliability rates in Healthcare

A

large

study

in

US

health

care

using

detailed

case

notes

review

concluded

that

the

“defect

rate”

in

the

technical

quality

of

American

healthcare

is

approximately

-

45%

(McGlynn, et al
The quality of healthcare delivered
to adults in the United States

NEJM 2003; 348)


Reliable Care Lowers Mortality Rates

also reduces complications, length of stay and readmissions

What is the cost of poor quality?

Length of Stay and Mortality

West Middlesex Hospital

Weekly
average
LOS

Monthly
HSMR

Synergy for quality:

Quality
care

Reliability

Lean &
Flow

Safety &
Mortality

High quality error free care is the most cost
-
effective

Will


Ideas


Execution / Implementation

What does an organisation need to
do this?

Commitment of
senior leaders &
frontline managers

Publications

Case studies

Local Innovation

Advanced improvement
capability

X

Reliability Theory in Action


John Pickles

Luton & Dunstable Hospital

NHS Foundation Trust

It could never happen
here

UK Adverse Event Trigger Toolkit


1.

Early warning score triggering without
appropriate response

2.

Readmission

-

to hospital within 30 days or
to ICU/HDU

3.

Unplanned transfer to ICU/HDU

4.

Shock
or Cardiac arrest

5.

DVT/PE following admission evidenced by
imaging +/or
D dimers

6.

Medication

Vitamin K

Naloxone

Flumazenil

Glucagon or 50% glucose

7.

Nursing

Patient fall

Decubiti

8.

Surgical

Return to theatre

Change in planned procedure

9.

Lab
-

Haematology

High INR (>5)

Transfusion for abrupt drop in Hb not
immed postop

10.

Lab
-
Biochem
istry

Rising urea or creatinine

(>2x baseline)

Electrolyte abnormalities

Na
+
<120 or >160

K
+
<2.5 or >6.5

Hypoglycaemia (<3mmol/l)

Raised Troponin (>1.5 ng/ml)

11.

Lab
-
Microbiology

MRSA bacteraemia

C. difficile

VRE

Wound infection

Nosocomial pneumonia

Posi
tive blood culture


Case
-
note review


Key Findings


Avoidable deaths


Poor record keeping & communication


Incomplete observations &
“Failure to rescue”


Lack of response to results


Adverse drug events


Lack of standardisation, e.g thromboprophylaxis


Links with C Difficile and MRSA


Incomplete DNR policies


The Health Foundation’s

Safer Patients Initiative



Initially a £4.3 million initiative began in late 2004 following a national competitive
application process.



Phase 1
: Four acute hospital trusts:



-

Conwy and Denbighshire NHS Trust (Wales)



-

Down Lisburn Health and Social Services Trust (Northern Ireland)


-

Luton and Dunstable Hospital NHS Trust (England)



-

NHS Tayside (Scotland)




Phase 2
: 20 sites working in partnership, based across the UK.




Working in partnership with a world leader in patient safety, the Institute for
Healthcare Improvement.

The change package to reduce adverse events by 50%


The SPI change package addresses five clinical areas:




-


Critical care



-

Care on general wards


-

Infection prevention and control


-

Medicines management



-


Peri
-
operative care


Work Area

Change Package Element

Critical Care

Establish infrastructure


Daily goal sheets


Daily multi
-
disciplinary rounds

Infection Prevention


Ventilator bundle


Central line bundle


MRSA


Glucose control (ITU then to HDU)

General Ward

Risk Identification and Response


Rapid response (Outreach) teams


Early warning system

Infection Prevention


MRSA

Communication and Teamwork


Safety briefings


Communication tools (e.g. SBAR)

Leadership

Infrastructure to support safety

Strategic placement

WalkRounds

Medicines Management

Reconciliation

Anticoagulation

Conduct an FMEA on a high risk medication process

Perioperative

DVT Prophylaxis

Beta Blocker (known BB patients first)

SSI bundle

Culture of safety

Determinants of Safety


System: environment, procedures and rules within which
we practice



Human factors: ability to perform well, individually and as a
team



Culture: shared values and beliefs which influence
behaviour

Reliable systems


Care bundles:
Central line


Ventilator



Standardisation:
DVT prophylaxis


Antibiotic prophylaxis



Monitoring:
Early warning system


Critical care outreach



Medication:

Reconciliation


Warfarin induction schedule


FMEA

Measuring Results



Direct measurement



Observational audit



Random case
-
note reviews



Run Charts



HSMR


System changes




Reliability

Antibiotic prophylaxis at the L & D 2001



1. Single dose


2. Give within 60 minutes before


incision


3. Antibiotic choice as per guideline



90% received pre
-
op antibiotic


40% received antibiotic as above


Antibiotic prophylaxis
-

system

1.
Standardisation of antibiotic regime


2.
Anaesthetist to administer with induction by default


3.
Times of admin. & knife to skin recorded


4.
Stop
-
check on table


5.
Antibiotics given on table if missed


On
-
time antibiotics

Increasing Reliability of Clinical Observations

Mortality Project Improvement All observations 'complete'
0
2
4
6
8
10
12
14
16
18
20
Month
Jan-04
Feb-04
Mar-04
Apr-04
May-04
Jun-04
Jul-04
Aug-04
Sep-04
Oct-04
Nov-04
Dec-04
Jan-05
Feb-05
Mar-05
Apr-05
May-05
Jun-05
Jul-05
Aug-05
Sep-05
Oct-05
Nov-05
Dec-05
Jan-06
20 sets of notes reviewed each month
Calls to Outreach Team

0
20
40
60
80
100
120
140
160
4/20/2005
5/16/2005
6/17/2005
7/16/2005
8/16/2005
9/14/2005
10/14/2005
11.13/2005
12/16/2005
1/14/2006
2/20/2006
3/16/2006
4/16/2005
5/16/2005
6/16/2006
7/16/2006
8/16/2006
9/16/2006
10/16/2006
11/16/2006
12/16/2005
01/12/2007
2/16/2007
3/16/2007
Month
Calls Per month
Cardiac Arrest Call Rate


per 1000 Discharges

0
2
4
6
8
10
12
02/28/2005
3/20/2005
4/20/2005
5/16/2005
6/17/2005
7/16/2005
9/14/2005
10/14/2005
11.13/2005
12/16/2005
1/14/2006
2/20/2006
3/16/2006
4/16/2005
5/16/2005
6/16/2006
7/16/2006
8/16/2006
9/16/2006
10/16/2006
11/16/2006
12/16/2005
01/12/2007
2/16/2007
3/16/2007
Month
C. Arrest per 1000 discharges
Cardiac arrests outside A&E

Weekly Cardiac Arrests Outside A/E Department
-5
0
5
10
15
11th Jan 2004
22nd Feb
4th April
16th May
27th June
8th August
19th sept
31st Oct
12th Dec
22nd Jan
5th March
17th April
29th May
10th July
21st Aug
2nd Oct
14th Nov
25th Dec
5th Feb
19th Mar
30th Apr
11th June
23rd July
3rd Sep
15th Oct
26th Nov
7th Jan 2007
18th Feb
1st Apr
Period
Individual Value
F
B
Special Cause Flag
Adverse events
-50
0
50
100
150
2/28/2005
3/20/2005
4/20/2005
5/20/2005
6/30/2005
7/30/2005
8/23/2005
9/29/2005
10/20/2005
11/20/2005
12/20/2005
1/20/2006
2/16/2006
3/16/2006
4/16/2006
5/16/2006
6/16/2006
7/16/2006
8/16/2006
9/16/2006
10/16/2006
11/16/2006
12/16/2006
1/16/2007
Period
Individual Value
A
G
Special Cause Flag