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The Journey to High Reliability….Your Flight Plan for Success

Patrick M. O’Shaughnessy, DO, MBA, FACEP, CHCQM

Senior Vice President & Chief Medical Officer

Catholic Health Services of Long Island

High Reliability Workshop

December 9th, 2013

Session Objectives

Discuss High Reliability concepts from aviation and other HRO’s and applicability to healthcare.

Who’s your Pilot in charge and who are your crew (People)?

What’s your flight plan (process)?

Have you mastered & integrated your avionics and air traffic control (technology and communication)?

Share lessons learned from our organization.

Articulate specific actions you can take to make progress toward high reliability.

Dr. Patrick M. O’Shaughnessy has nothing to discloseNo financial interests or affiliations with any materials presented or distributed at this lecture

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Catholic Health Services of Long Island

Healthcare system based out of Rockville Centre, Long Island New York with 1,928 total acute care beds and 790 continuing care beds.

Six Acute Care FacilitiesSaint Francis Hospital; The Heart Center

Mercy Medical Center

Saint Josephs Hospital

Good Samaritan Medical Center

Saint Catherine of Siena Medical Center

Saint Charles Hospital

Collectively the campuses provide clinical services across ALL major surgical and medical service lines, two campuses with OHS programs.

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Catholic Health Services of Long Island

Continuing Care Division

Our Lady of Consolation Nursing and Rehabilitative Center

Saint Catherine of Siena Nursing and Rehabilitative Center

Good Samaritan Nursing and Rehabilitative Center

Home Care Division

Care link and Care link plus telemedicine

Clinical Navigator programs

Hospice Division

Maryhaven Center of Hope

Inpatient residence’s for those with developmental disabilities

Outpatient residence’s and day programs

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Catholic Health Services of Long Island as a ministry of the Catholic Church, continues Christ’s healing mission,

promotes excellence in care, and commits itself to those in need.

CHS affirms the sanctity of life, advocates for the poor and underserved, and serves the common good. It

conducts its healthcare practice, business, education and innovation with justice, integrity and respect for the

dignity of each person.

CATHOLIC HEALTH SERVICESof Long Island

• Our Reason For BeingMission

• Our Place In The WorldVision

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An innovative and fully-integrated organization recognized for excellence…

♦ in person-centered compassionate care and community health

♦ as the preferred partner of physicians

♦ by providing exceptional quality while making efficient use of resources

♦ through the dedicated efforts of an engaged, high-performing workforce

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My Personal Background

Practicing Board Certified Emergency Physician.3 years in Academics

Areas of interest-> Simulation MedicineDisaster Medicine

Prior ED Department Director

3 years as facility Chief Medical OfficerSt. Catherine of Siena Medical Center

CHSLI System CMO, June 2013.

But…… I also like to fly planes!Career began at Embry-Riddle Aeronautical UniversityUpon migration into career of Medicine; was completely shocked to see how complex high risk systems were operated.

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Engineering RedundancyP8

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Pre flight CheckP9

Computerized ChecklistP10

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Computerized ChecklistP12

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When all else fails…CAPSP13

High Reliability Aviation: USN

Naval Aircraft Carrier Operations:

Carrier Commanding Officer quotes:“ A hundred things I have no control over could go wrong and wreck my career…..but wherever I go from here, I’ll have no better job than this….This is the best job in the world.”

So you want to understand an aircraft carrier? Well just imagine that it is a busy day, and you shrink SF airport to one short runway. Make planes take off and land at the same time, at half the present time interval, rock the runway from side to side, and require that everyone who leaves in the morning return that same day. Then turn off the radar to avoid detection, impose strict controls on communications, fuel the aircrafts with their engines running, put enemy in the air, and scatter live bombs and rockets around the deck. Now wet the whole thing down with salt water and oil, and man it with 20 year olds, half of whom have never seen an aircraft close up, power the ship with a nuclear reactor; oh and by the way…try to not kill anyone!

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USN Aircraft Carrier OperationsP15

http://www.youtube.com/watch?v=1c0lfwxRpj

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http://www.youtube.com/watch?v=gXTYQqr2i

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CHSLI Journey to High Reliability

2009: Beginning of focused Quality restructure

System PI Dashboard with system based quality goals

Sig Sigma black belt recruited; CHSLI system Six

Sigma and Lean program training initiated.

System-wide Six Sigma initiatives began in 2010 with green belt training

Initiatives streamlined to facility-specific projects in 2012

To date, 77 employees have become certified green belts

To date, 22 system sponsored Six sigma quality programs across all

campuses

To date, 18 system sponsored Lean initiatives across all campuses

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CHSLI Journey to High Reliability

2010-2011: NO Harm Campaign -> NYS Partnership for Patients • Reduce hospital-acquired conditions by 40%• Reduce preventable readmissions by 20%

NYSPFP FOCUS AREAS NURSING CENTERED INITIATIVES

• Pressure ulcers• Injuries from falls and immobility• Venous thromboembolism• Adverse drug events

INFECTION PREVENTION INITIATIVES• Catheter-associated urinary tract infections• Central line–associated bloodstream infections• Surgical site infections• Ventilator-associated pneumonia

BUILDING CULTURE AND LEADERSHIP PREVENTABLE READMISSIONS INITIATIVE OBSTETRICAL SAFETY INITIATIVE

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PEOPLE

High Reliability Healthcare ResourcesCHSLI Resources & Work plan

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CHSLI Journey to High Reliability

2010- 2012

The Ongoing Quality Improvement Journey: Next Stop, High Reliability

Incorporated into PI structure locally and from system perspective.

Participation in NYS Partnership for Patients with goal of reducing all Harm and reducing readmissions

Soon realized we needed to take more formal approach and completely reorganized system PI->Quality Program with strategic plan and vision statement for taking active steps toward High Reliability.

Began finalization, roll out and implementation of CHS-e health EMR installation across all facilities (Epic Systems)

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High Reliability Healthcare/Aviation

THREE PILLARS TO SUCCESS

People (Our Pilots and Crew ->impacting our Patients/passengers)

Culture of Safety

Through NYSPFP all campuses participated with annual Culture of Safety Survey

12% improvement in participation across the system

Reward transparency and celebrate errors and near misses as opportunities

Leadership at All Levels

Patrick Scollard Award; CHSLI System annual award for leadership

HANYS Healthcare Leadership Academy

Good catch award program instituted in various forms across all campuses

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High Reliability Healthcare/ Aviation

People

Our most important resource

Ongoing training and education

Expansion of simulation center

Leadership training (MBA programs, partnership with Adelphi University)

Physician and Nursing leaders

CMO’s/ CNO’s and Departmental leaders exposed to High Reliability concepts and training

BOT/CEO/CAO’s Support and educated on HRO concepts

CAO’s from all campuses part of process

C Suite performance incentives aligned with quality indicators

Good catch and quality awards structured for employees

Physician contracts (Hospitalists and ED) restructured with Quality and HCAHPS based incentives….not just RVU’s!!

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High Reliability Healthcare/Aviation

Process - > Robust Process Improvement (Your Flight Plan)

System InitiativesLean/ Six sigma training expansion

Facility specific workflows and processes

Change Acceleration Process trainingGE/ Harvard Business Review

2013 introductory training CHSLI PI leadership team2014 Partnership TJC Center for Transforming Healthcare

Strategic training collaboration

Development of Quality Councils (QC) (PI=Retrospective/QC=Prospective)

IHI Trigger Tools to quantify and reduce harm events

System Board PI – Quality Management Committee of the BoardClinical Excellence (Priority Focus Areas)No Harm Campaign (Priority Focus Areas)System Priority Focus Projects/ Computerized Decisional Support

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IHI Trigger ToolsP23

Process->REDUCE HARM

IHI Global Trigger Tool

Department specific tools

Pharmacy – Medication management safety

OR – Procedural safety

ED – High Risk/ returns

OB/ Mother- Baby – delivery safety

IHI Expedition to start off- > Solo

Goals

Get upstream from harm

Move from RCA -> FMEA (Reactive –> Proactive)

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Get Up-Stream from HarmP25

HRO..It all starts with a vision……

“Vision without action is a daydream;

action without vision is a

nightmare”…..Japanese proverb

This requires a plan….

Structure ->function

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CHSLI Quality & Safety Vision Statement

and Goal

“To consistently deliver superior patient clinical outcomes

across the full continuum of care through creation of a

high-reliability culture and through embracing patient

safety as our core value.”

CHSLI’s goal:

Perform in the top 10% nationally in key quality and service indicators by 2017 through adherence of its system quality and safety plan.

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Quality Management Committee of the Board

Three System Pillars

I) Clinical Excellence

> Selected CMS / Joint Commission quality and safety measures (Priority Focus Areas or PFA’s)

• Core Measures

• PSI 90 measures

II) No Harm Campaign (Priority Focus Areas or PFA’s)

> NYSPFP select measures

• CAUTI/CLABSI/ SSI

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Quality Management Committee of the Board

Three Pillars

III a) System Priority Focus Projects (Operational)

* projects tied to measures in other two pillars with

alignment of incentives

* quarterly updates to System QMC grid

- Surgical Safety Checklist Initiative (WHO toolkit/Life wings)

- Hand Hygiene Campaign (Joint Commission CFTH TST)

- HF Readmission Reduction(Joint Commission CFTH TST)

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Quality Management Committee of the

Board

III b) CHS- e Health Decisional Support and Forced Functionality(Operational)

•Hand Off Communication

•Medication Safety

•Fall Reduction

•CPOE

•Documentation improvement

•Triggers!!

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SIGN-IN TIME-OUT SIGN-OUT

Brief Prior to: STOP Prior to: Debrief Prior to:

Sedation/Induction Procedure/Incision Leaving the Procedure Room/OR

KNOW ME

Nurse:

� I would like to introduce (Patient’s Name).

� The patient’s medical record number is:

� Please tell us what surgery you are having

today.

� Please point to the area.

� I can see the site is marked.

� The consent is complete, accurate and signed.

� The patient is allergic to (medication)

Anesthesia:

� EBL (minimal or >500ml and preparation

confirmed) (adequate IV access, blood

products, fluids available).

� Airway status is (adequate or enhanced and

preparation confirmed) (equipment/assistance

available).

� Anesthesia assessment ,equipment and safety

checks complete

� Beta-Blockers (have been given or are not

needed)

� Consideration has been given for VTE

prophylaxis, Glycemic control and

Normothermia measures.

CARE FOR ME

RN/ST:

� Is everyone ready for the timeout?

� Can the Team Members please identify

themselves by name and role?

Surgeon:

� This is (patient's name)

� I am performing (proposed procedure).

� The correct site is marked and visible to me.

� Positioning is correct

� Images are (available/correctly labeled and

oriented/site &side confirmed with radiologist*)

* Confirmation with radiologist required for high

risk procedures including, but not limited to:

craniotomy, endarterectomy, pneumonectomy,

adrenalectomy, nephrectomy, amputation.

� Needed implants, devices and equipment are

available.

� I (do/do not) expect to need blood products.

� I have no special concerns at this time.

Anesthesia:

� The appropriate antibiotic(s) has (have) been

given and properly timed. Redosing plan is:

� Risk for fire is: (low or high and preparation

confirmed).

� I have no special concerns at this time.

Nurse:

� Baseline counts have been completed

� Sterilization indicators have been confirmed

� Does anyone have any questions?

� Since we are all in agreement then the “time-out”

is complete and we can proceed.

EASE MY WAY

Nurse:

� The sponge, sharps and instrument counts

(are/are not) complete and correct.

� The wound class is (wound class).

� There are (#) specimens labeled as (read

label)

� What are the key concerns for recovery and

management?

Surgeon:

� We performed a (name of procedure).

� I have no concerns at this time.

(postoperative ventilation, pain management,

nausea/vomiting, glucose control, temperature,

et al)

Anesthesia:

� The disposition for this patient is

(disposition).

� I have no concerns at this time.

(postoperative ventilation, pain management,

nausea/vomiting, glucose control, temperature,

et al)

CHSLI Surgical Safety Checklist Initiative

Checklists

Save lives!

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Clinical ExcellenceP33

No HarmP34

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Weighted indicator scoringP35

CHS Performance vs. Targets

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Detail

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Significant Event Trending

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CHS E-Health Examples (ATC and Avionics)

Triage Triggers and Best Practice Advisories39

Safety First Best Practice Advisories

WHAT IS YOUR PERSONAL MINIMUM? 40

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Sepsis Evidence-Based Order Set

AUTOMATICALLY PRE-SELECTED 41

CHS E Health ExamplesVTE ASSESSMENT 42

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VTE assessment hyperlinks to

references

DVT/VTE PROPHYLAXIS ORDER SET

ISAUTOMATICALLY SUGGESTED ON ALL ADULT

PATIENTS

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High Risk Medication Hard StopMEDICATION MANAGEMENT SAFETY 45

Titration Soft Stop Guidance

Parameters46

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Medication Safety - Dual Verification by Pharmacists for Neonatal, Pediatrics and Chemotherapy

Medication Safety - Dual Verification (continued)

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High Risk Medication Safety

Forced Functionality

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Barcode Medication Administration Warnings

Return to Table of Contents

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SBAR Handoff Report

SBAR Handoff Report

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Morse Fall Risk Assessment

IHI Fall Risk for Injury

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The Journey of 1000 miles………starts first with

PEOPLE…then Process…then Technology ……

The CHSLI RPI Team

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