Measuring Whole System and Whole Person Harm
CarolHaraden,PhDVicePresident,IHI
Safety is system
property
2015: NPSF Expert Panel 15 Years Post To Err Is Human
“…the expectation at the time was that expanded data sharing and implementing interventions to solve specific concerns would result in substantial, permanent improvement. In the intervening decade and a half, it has become increasingly clear that safety issues are far more complex—and pervasive—than initially appreciated.”
A “Project”…
Source: J. Reinertsen, 2005
Improving Surgical Safety!June 6, 1944
Source: J. Reinertsen, 2005
What’s the Difference?
A Project Improving Surgical Outcomes!
Source: J. Reinertsen, 2005
The Differences Are…
Level of ambitionCommitment: hearts poundingCore strategy: staying aliveClear measure of daily success: stay alive and territoryClear overarching goal: win the war
This is still ONE battle only- not the
war!
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The Theatres of World War IIEuropean TheatreMediterranean, African and Middle Eastern Theatres Pacific Asian Theatres
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European Theatre Alone 10
WesternFront•InvasionofDenmarkandNorway (April–June1940)•BattleofFrance (withBenelux countries/FallGelb)(May–June1940)•BattleofBritain (+OperationSeaLion )(July–October1940)•WesternFront(1944–1945)
• BattleofNormandy (June–August1944)• NorthernFranceCampaign (July–September1944)• SouthernFranceCampaign(OperationDragoon)(August–September1944)• BattleoftheSiegfriedLine (RhinelandCampaign,Ardennes-AlsaceCampaign)(August–December1944)
•PhonyWar• CentralEuropeCampaign (March–May1945)
EasternFront•BattleofPoland (OperationFallWeiss)(1939)•EasternFront (initiallyOperationBarbarossa)(June1941toMay1945)•Finland (June1941-September1944)
Leading the Whole System to Highly Safe, Reliable and Effective Results is even BIGGER than this!
The Big Picture View (Management)
The Ground Level View (Staff)
James Reason
Safety as a battle we can fight and winOR
Safety as guerilla warfare
What’s the difference?
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Some differences:
Conventional-Larger, more unwieldy force with much central control-Prepared for certain amount of time-Often seen as invaders-Often in unfamiliar terrain-Clear cut victory is aim-Fight, win, negotiate
Non-Conventional-Small, highly mobile and motivated bands of people, decentralized -Prepared for the long struggle-Depends on support of locals-Know the terrain well-Clear cut victory is rare-Exhaust, force invader to withdraw
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How Will You Know If….
You are winning the battle and losing the war?
All of your projects to improve quality and safety are adding up to system safety?
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Start to Think About Moving Beyond Project Measures
Process MeasuresAMI Care
Time to stintBeta Blockers on arrival
Pneumonia CareAntibiotic timing
Immunization RatesInfluenza vaccination
Medication reconciliationCAUTI rates
Whole System Outcome Measures– Mortality rate– Adverse event rate– Days lost to work
Let’s Start With a Couple System Level Aims…
Reduce MortalityReduce Harm
What would the measures of these be for an office practice, the ED, ICU, Pediatrics? What would the projects need to be?
An Example: Reduce Mortality
Mortality Reduction Tier 1: Big Dot
Tier 2:Portfolio
Tier 3:Projects
Reducing Patient Mortality
What besides great projects needs to be in place to achieve this large system aim?
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NHSScotlandSurgicalMortality
Safety is a System PropertyIt can not be understood using a number of disparate metricsEven good individual reliabilities do not equal reliability of the whole
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Framework for Safe, Reliable and Effective Care
Transparency
Leadership
PsychologicalSafety
Negotiation
Teamwork&Communication
Accountability
ReliabilityImprovement
&
Measurement
ContinuousLearning
EngagementofPatients&Family
LearningSystem
Culture
©IHIandSafeandReliableHealthcare
© 2010 Pascal Metrics Inc.© 2010 Pascal Metrics Inc.
A Familiar Framework
1. Risk Factors2. Exercise3. Nutrition4. Health Literacy5. Etc
1. Cardiovascular2. Pulmonary3. Gastrointestinal4. Musculoskeletal5. Etc
Personal Habits Physical Exam
Transparency
Leadership
PsychologicalSafety
Negotiation
Teamwork&Communication
Accountability
ReliabilityImprovement
&
Measurement
ContinuousLearning
EngagementofPatients&Family
Framework for Safe, Reliable and Effective Care
Facilitatingandmentoringteamwork,improvement,
respectandpsychologicalsafety.
Creatinganenvironmentwherepeoplefeelcomfortableandhave
opportunitiestoraiseconcernsoraskquestions.
Beingheldtoactinasafeandrespectfulmannergiventhetrainingandsupporttodoso.
Developingasharedunderstanding,anticipationofneedsandproblems,agreedmethodstomanagetheseas
wellasconflictsituations
Gaininggenuineagreementonmattersofimportancetoteammembers,patientsandfamilies.
Regularlycollectingandlearningfromdefectsandsuccesses.
Improvingworkprocessesandpatientoutcomesusingstandardimprovementtools
includingmeasurementsovertime.
Applyingbestevidenceandminimizingnon-patientspecificvariationwiththegoaloffailure
freeoperationovertime.
Openlysharingdataandotherinformationconcerningsafe,respectfulandreliablecarewithstaffandpartners
andfamilies.
©IHIandSafeandReliableHealthcare
Framework for Safe, Reliable and Effective Care
LearningSystem
Culture
Psycho
logical
Safety
Accoun
tability
Team
workand
Commun
ication
Negotiatio
n
Leadership
ContinuousLearning
ImprovementandMeasurement
Reliability
Transparency
©IHIandSafeandReliableHealthcare
Enduring Issues That Can Not Be Managed by Project Thinking• Best outcomes and safe care for off-service patients• Collaboration between professions, care units, office practices, home care
and care homes• Professionalism
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Insert Don video clipP27
In Summary• We need to think about drivers of safety as a system • Think in metaphors, if it helps • A framework can help us on the journey - white paper• Think about large system aims and drive projects to reach them
AND enduring issues that can not be solved by singular projects • And don’t forget spread….that’s another talk!• All the very best and we are here to help.
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