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4/4/2018
1
Journey to Excellence: Leadership for Quality and Safety
Angela Green, PhD, RN, CPHQ, FAHA, FAAN
2018 NICU Leadership Forum
• Describe high reliability principles as a
framework for excellence and leadership
methods that promote a culture of safety and
high reliability.
• Discuss strategies to engage multi-disciplinary
teams in quality and safety work.
• Describe strategies for planning, implementing,
and sustaining improvements.
Objectives
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• I have nothing to disclose.
Disclosures
5
• What is your biggest safety or quality
challenge?
– Reflect to identify yours.
– Find a partner – share your challenges.
– Form a foursome – share your challenges.
– Large group sharing
• What challenges do we have in common?
• Any unique challenges?
• Big a-has?
Safety Story: 1 - 2 - 4 all
6
Johns Hopkins All Children’s
Hospital
4/4/2018
3
• Of the 259 beds:– 97 NICU
– 28 PICU
– 22 CVICU
– 56 General Medical
– 28 Post op surgical
– 28 Hematology/Oncology, Bone
Marrow Transplant
• Over 400 Pediatric Physicians
• 29 Pediatric Specialties
8
• 1999 IOM Report – To Err is Human: Building a Safer
Health System
– Houston, we have a problem….
• ~50,000-100,000 annual US deaths due to medical errors
• Medical error 3rd leading cause of death in the US
– 440,000 annual US deaths Makary & Daniel, 2016)
The Long Sad Story……
9
• Evidence-based bundles
• Registries
• National collaboratives
– Children’s Hospitals Solutions for Patient
Safety
• Culture
• Team member-wellbeing
• Safety II
Solution Evolution
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About Culture….
Culture eats strategy for breakfastPeter Drucker
11
Culture
Behavior
Culture
12
• Originated in high risk industries
• “Operate under vary trying conditions all
the time and yet manage to have fewer
than their share of accidents”
Weick & Sutcliffe, 2001
High Reliability – the Back Story
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13
• Preoccupation with failure
• Reluctance to simplify
• Sensitivity to operations
• Deference to expertise
• Commitment to resilience
Weick & Sutcliffe, 2001
Chassin & Loeb, 2013
High Reliability Principles
14
• Safety as a core value
• Blame-free environment
• Collaboration
– 200% accountability
– Non-hierarchical
• Communication
– Speaking up for safety
– Questioning and welcoming questioning
Culture of Safety – Key feature of
HRO
15
• Health risks of stress and burnout
• Cognitive impact of stress
• Trickle down effect
• Practices
– Healthy diet, physical exercise, adequate
sleep
– Self-awareness
– Recharge strategies
– Network of support
– Mindfulness
Self-Care
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16
• Managing demands on time, resources
and energy
• Managing physical and emotional health
• Improving joy in work
Perlo, Balik, Swensen, et al., 2017
Team Well-Being
Burnout
Low engagement
High turnover
Higher risk of accidents
Low safety
Low quality
17
Perlo et al., 2017
18
Brainstorm
Strategies for improving joy and meaning in
work for ourselves and our teams
Think Big & Bold
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• Safety I
– Focus on ensuring as
few things as possible
go wrong
– People are a hazard
as a source of
variability
– Reactive
• Safety II
– Focus on ensuring as
many things as
possible go right
– System ability to
succeed under varying
conditions
– People are necessary
for system flexibility
and resilience
– Proactive
19
Safety II
Hollnagel, Wears & Brathwaite, 2015
20
• Builds resilience
• Nurtures positivity
• Supports system adaptability
Safety II
Nemeth, Wears, Woods, et al. 2008, Hollnagel, 2018
21
• Teamwork and Communication
– Speaking up for safety
• Proactive and reactive
• No blame and shame
• Systems approach
• Continuous learning
• Leading by example
Essential Ingredients: Culture of
Safety and High Reliability
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• Safety stories
• Organizational safety huddle
• Unit based huddles
• Feedback rich environment
• Rounding
• Top 10 List
• Transparency
Studer Group, 2010
Healthcare Performance Improvement, 2011
Leadership Methods for High
Reliability
23
• Begin each meeting with a safety story
– Examples
• Event of harm in your organization
• Near miss in your organization
• Strategies for speaking up for safety
• Importance of reporting
• Safety success story from your organization
• Concerns/patterns, etc.
Healthcare Performance Improvement, 2011
Safety Stories
24
• Daily, same time, same place
• Short, “stand up” meeting
• Data based
• Multi-disciplinary
• Focus – standard script
– Current status
– Retrospective review of safety or quality issues
– Look ahead – concerns in the next 24 hours
– Follow up on issues identified previously
Healthcare Performance Improvement, 2011
Organizational Safety Huddle
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• Daily or (even better) each shift
• Same principles, same script as org huddle
– Focus – unit level
Unit-based huddles
26
• Balance of positive feedback and
constructive/need to improve feedback
– 5:1 or 3:1 depending on source
– Seek opportunities to catch someone doing it right
• No sandwiching
• Situation, Behavior, Impact
– Timely
– Observations, facts
Feedback Rich Environment
Healthcare Performance Improvement, 2011;
Studer, 2010; Wetzel, 2000
• Weekly, 30-60 minutes
• Supports sensitivity to
operations
• Reinforces your
commitment to your team
and to safety
• Opportunity to
– Share information
– Promote preoccupation
with failure
– Provide reinforcement
• Focus -
– What’s working well
– Who should I recognize?
– Safety concerns or
systems/processes that
need improvement
– Do you have what you
need to do your job?
– Anything I can help you
with right now?
27
Rounding on Staff
Healthcare Performance Improvement, 2011;
Studer, 2010
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• Identify and prioritize
problems/focus areas
• Name an owner with
a due date
• Always 10
• Sample –
– Error Prevention Training
Implementation Plan
– Roll wave 2 CUSP teams
– Transition complaints to Service
Excellence
– Implement CAUTI K cards
– Plan for Overexertion work group
bundle measurement
– Risky Unit Analysis next steps
– Routine productive integrated
safety meeting
– Structure and process to support
Outpatient Care Centers
– PSQ/IP team member attending
each M&M
– Complete Armstrong Institute
Patient Safety Certificate
28
Top 10 List
Healthcare Performance Improvement, 2011
29
• Data, problems, your own mistakes
• Role models behavior for team at all levels
• Mitigates blame and shame
• Can’t fix it if we don’t know it’s broken
Transparency
30
• Reporting events and near miss events
• Speaking up for safety
– Stop the line
• Bedside report
• Hourly checks/rounding
Frontline Strategies
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Engaging Multidisciplinary teams
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• Be you – authenticity matters
• Share your vision
– Engage hearts and minds
• Character, competence, caring
• Help others shine
• Recognize others, express gratitude
Are They Following You?
33
• Relationship
• Communication
• Influence
Foundation: Getting to Yes
Oh yes, I’d lOve tO wOrk On that!!!
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• Listen
• Consider other’s perspectives and
acknowledge their truth
• Question, welcome being questioned
• Clear, concise
– Word : unit of meaning ratio
• Many times, many ways
Communication Concepts
35
• Rationalizing
• Asserting
• Negotiating
• Inspiring
• Bridging
Influence Styles
Discovery Learning Inc., 2011
36
• Engage the heart
– Tell the stories, give the examples
– Make it personal, real and meaningful
• Engage the head
– Data!
Start with Why
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• Inclusive, non-hierarchical
• Empowerment
• Recognition and gratitude
– Thank you notes
• Food helps
Other Strategies for Success
38
• Councils/committees
• Dept/staff meetings
• Rounding
• Huddles
Leverage Structure
39
• Developmental opportunity
• Succession planning
• Clinical ladder, promotion & tenure, etc.
Create Wins
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40
• Huddles
• Rounding
• Communication boards
• Newsletters
• Meetings
• Etc., etc., etc.
Communication Strategies
41
• Time
• Access to data
• Engage experts/key stakeholders
A Word About Resources
42
• Charter
• Leader and co-leader
• Sponsor
• Goal oriented, data-based
• Meeting structure
• Accountability structure
– Deliverables with timelines
– Plan for manage barriers
Structure and Process: Doing the
Work
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• Leverage
– Desire for excellent care
• If that doesn’t work
– Leverage relationships
– Create win-win situations – maintenance of
certification and/or promotion & tenure
– I’ll help you, if you’ll help me….
Engaging Physicians
44
• Inclusive, non-hierarchical approach
• Empowerment & deference to expertise
• Creating wins
• Structure and process for doing the work
• Share progress
• Celebrate accomplishments and
milestones
• Acknowledge leaders and key contributors
Essential Ingredients: Engaging the
Team
45
Improvement Strategies
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46
• Focus on event reporting as a learning tool
• Encourage (and recognize) reporting of
events and near miss events
• Close the loop on events
– Including with staff who reported/submitted
• Tell the stories
– Impact of reporting
More Culture: Reporting Culture
47
• Individual, team, department, organization,
and system issues
• We fail our patients and teams when the
only response is – discussed with
individuals involved.
– Other options?
Event Follow Up
48
• You’ve noticed an increased frequency of
event reports identifying that central line
tubing was not labelled according to policy.
– What questions do you have?
– How might you get more information?
– What are some possible reasons for this
occurring? (think individual, department,
organization)
– How can you close the loop?
Case Study
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49
IHI Model for Improvement
IHI, 2018
50
• Healthy preoccupation with failure
• Routine sources of data
– Dashboards
– Event reporting system
– Collaboratives and registries
• Sensitivity to operations
– Concerns expressed by staff
– Improvement teams
• Other sources?
Knowing What’s Broken
51
• Associated risk
• Frequency
• System defects make repeat events likely
• Provocative and plausible challenges
• External motivators
Prioritization
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• Form the team
• Set aims/goals
• Establish measures
• Select change
• Test change Implement change
• Spread changeIHI, 2018
Houston….we have a problem
53
• We’ve talked about that….
• Ownership and empowerment matters!
Form the team
54
• Specific
• Measurable
• Actionable
• Relevant
• Timebound
Set SMART Goals
Improve CLABSI bundle reliability
Improve CLABSI bundle reliability from a baseline of 70% to greater than or equal to 90% by December 2019.
4/4/2018
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• Labelling all lines for central administration
is part of your CLABSI prevention bundle.
Your organization has a goal of achieving
greater than 90% compliance with all
bundle elements. Upon review, your
team’s compliance is 73%.
Case Study – Adding on
56
• Outcome
– Peripheral IV infiltration rate
• Process
– Adherence to the prevention bundle
• Balancing
– Changes that may occur in response to
intended change, but are not the focus of the
change
– Number of central line days
Establish Measures
57
• Weakest and most frequently employed–
education and policy change
• Reminders, visual or auditory cues
• Make it easy to do the right thing
– Package tubing label with infusion when
dispensed
• Make it hard or impossible to do the wrong
thing
– Digoxin ordering option – micrograms only
Select/Plan Changes
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Tool: Cause & Effect Diagram
IHI, 2017
59
• As you contemplate possible tests of
change to improve compliance with tube
labelling, you construct a cause and effect
diagram. Identify possible interventions by
category -
– People
– Environment
– Materials
– Methods
– Equipment
Case Study – Adding On
60I
Tool: Driver Diagram
IHI, 2017
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• Plan, Do, Study, Act
• Rapid Cycle Tests of Change
• Start small, scale up
• Engage key stakeholders (deference to
expertise)
• Listen and use feedback (sensitivity to
operations)
Test, Implement and Spread Change
- PDSA
62
In God we trust, all others must bring data.
W. Edwards Deming
You can’t manage what you can’t measure.
Peter Drucker
63
• Pareto charts
• Track progress over time
– Run charts
– Statistical control charts
Displaying Data
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Tool: Pareto Chart
IHI, 2017
65
Tools: Bar Graphs and Run Charts
66
Tool: Statistical Control Chart
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• Transparency
• Dashboards
• Money shot for improvement - track data
over time
– run charts and statistical control charts
– trend requires 5 or more consecutive points in
the same direction
– centerline shift requires 6 or more points
above or below the median
IHI, 2018
Displaying Data
68
• Long-term ownership
• Maintain preoccupation with failure
• Follow the data
– Respond trends, significant changes
• Display data publicly
• Report outcomes to committees/councils
Sustain
69
• Use huddles and rounds to reinforce,
discuss progress and celebrate success
• Recognize key contributors
Sustain
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70
• Strong reporting culture
• Goal oriented, data based
• Small tests of change, then scale up
• Accountability structure
Essential Ingredients – Improvement
Strategies
71
What will you
Stop?
Start?
Continue?
Back Home Story
Questions, Sharing…..
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73
• Chassin, MR., Loeb, JM. (2013). High-Reliability Health Care: Getting There from
Here. The Millbank Quarterly, 91(3), 459-490.
• Discovery Learning, Inc. (2011). Influence Style Indicator.
www.discoverylearning.com.
• Healthcare Performance Improvement. (2011). High Reliability Leadership Methods.
Adapted for SPS.
• Hollnagel, E. (2008). Safety-II in Practice. London and New York: Routledge.
• Hollnagel, E., Wears, RL, Brathwaite, J. (2015). From Safety-I to Safety-II: A White
Paper. The Resilient Health Care Net: University of Southern Denmark, University of
Florida, Macquarie University.
• Institute for Healthcare Improvement. (2018). Extranet Help: Tools for Data Analysis.
http://www.ihi.org/help/extranet/Pages/extHelpDataAnalysis.asp.
• Institute for Healthcare Improvement. (2018).
http://www.ihi.org/resources/Pages/HowtoImprove/default.asp.
• Institute for Healthcare Improvement. (2017). QI Essentials Toolkit.
References
74
• Kohn, LT., Corrigan, J., Donaldson, MS., (eds). 2000. To Err is Human: Building a
Safer Health System. Washington DC: National Academies Press.
• Makary, MA., Daniel., M. (2016). Medical Error – The Third Leading Cause of Death
in the US. British Medical Journal, 353, i2139.
• Nemeth, CP, Wears, RL, Woods, DD et al. (2008). Minding the Gaps: Creating
Resilience in Healthcare. In: Henriksen, K., Battles, JB., Keyes, MA et al. (Eds).
Advances in Patient Safety: New Directions and Alternative Approches (Vol3),
Performance and Tools. Rockville, MD: AHRQ.
• Perlo, J., Balik. B., Swensen, S., Kabcenell, A., Landsman, J., Feeley, D., (2017). IHI
Framework for Improving Joy in Work. IHI White Paper. Cambridge, MA: Institute for
Healthcare Improvement.
• The Studer Group (2010). The Nurse Leader Handbook: The Art and Science of
Leadership. Gulf Breeze, FL: Fire Starter Publishing.
• Weick, KE., Sutcliffe, KM. (2001). Managing the Unexpected: Assuring High
Performance in an Age of Complexity. San Francisco: Jossey-Bass.
• Wetzel, S., (2000). Feedback That Works: How to Build and Deliver Your Message.
Greensboro, NC: Center for Creative Leadership.
References