High Reliability Bob Spillane MD Interventional Radiology Department of Radiology Medical Director of Quality Hartford Hospital
High Reliability Organizations (HROs) Bob Spillane MD Interventional Radiology Department of Radiology Medical Director of Quality Hartford Hospital
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HROs
High Reliability Bob Spillane MD Interventional Radiology Department of Radiology Medical Director of Quality Hartford Hospital
High Reliability We re all in this together. Bob Spillane MD Interventional Radiology Department of Radiology Medical Director of Quality Hartford Hospital
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High Reliability Financial Disclosures 1. I have no financial disclosures. Spillane ARIN ATL 2015 MARCH 1, 2015 11
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High Reliability- Agenda Hartford Hospital and Why Me? Medical Errors The Swiss Cheese Model The Complex IR Environment High Reliability Organizations Characteristics of HROs High Reliability in IR Crew Resource Management (CRM) Take Aways Hartford Hospital implementation Spillane ARIN ATL 2015 MARCH 1, 2015 13
High Reliability Hartford Hospital Hartford, CT -800 beds Established 1854 Acute, tertiary care hospital 4500 transfers per year Level 1 Trauma Center Transplant LifeStar Helicopter program Celebrated #3000 in 2014 1600 doctors 7000 employees Spillane ARIN ATL 2015 MARCH 1, 2015 14
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High Reliability Acknowledgements CT High Reliability Initiated 2012 Dr. Mary Cooper 25 of 28 hospitals 10, 000 staff trained CHAMP Card Spillane ARIN ATL 2015 MARCH 1, 2015 17
Institute of Medicine 1999 44, 000 98, 000 each year A 727 each day Spillane ARIN ATL 2015 MARCH 1, 2015 18
High Reliability Medical Disclosures 1. I have been involved with, or present for, medical errors. Spillane ARIN ATL 2015 MARCH 1, 2015 19
High Reliability Medical Disclosures 1. I have been involved with, or present for, medical errors. Allow me an exercise Spillane ARIN ATL 2015 MARCH 1, 2015 20
If you have been the victim of a medical error, Spillane ARIN ATL 2015 MARCH 1, 2015 21
If a loved one, or someone you know, has been the victim of a medical error, Spillane ARIN ATL 2015 MARCH 1, 2015 22
If, through work, you ve been party to, or present for, a medical error, Spillane ARIN ATL 2015 MARCH 1, 2015 23
Raise your hand, please Spillane ARIN ATL 2015 MARCH 1, 2015 24
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Swiss Cheese Model Layered protections for failure prevention Spillane ARIN ATL 2015 MARCH 1, 2015 33
Swiss Cheese Model Layered protections for failure prevention J. Reason Human Error Cambridge University Press 1990 Spillane ARIN ATL 2015 MARCH 1, 2015 34
Institute of Medicine 1999 44, 000 98, 000 each year A 727 each day Spillane ARIN ATL 2015 MARCH 1, 2015 35
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High Reliability- Were all in this together James J Patient Safety 2013;9:122-128 Estimate based on data extrapolated from 4 data mining studies Contemporary data IOM To Err is Human ca. 1984 Estimates error rate (Preventable Adverse Event, PAE) Extrapolates a LETHAL error rate Spillane ARIN ATL 2015 MARCH 1, 2015 37
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High Reliability- Were all in this together James J Patient Safety 2013;9:122-128 Estimate based on data extrapolated from 4 data mining studies Contemporary data IOM To Err is Human ca. 1984 Estimates error rate (Preventable Adverse Event, PAE) Extrapolates a LETHAL error rate 200 000-400 000 per year Spillane ARIN ATL 2015 MARCH 1, 2015 39
High Reliability- Were all in this together Serious Harm is 10X-20X more common than LETHAL Harm Spillane ARIN ATL 2015 MARCH 1, 2015 40
High Reliability- Were all in this together Serious Harm is 10X-20X more common than LETHAL Harm Spillane ARIN ATL 2015 MARCH 1, 2015 41
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www.jointcommission.org Spillane ARIN ATL 2015 MARCH 1, 2015 44
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Why does this happen? Spillane ARIN ATL 2015 MARCH 1, 2015 47
We work in a COMPLEX environment Spillane ARIN ATL 2015 MARCH 1, 2015 48
We work in a COMPLEX environment Various resources IR Suites Staff needs Patient needs Transport Equipment needs IT issues downtime Spillane ARIN ATL 2015 MARCH 1, 2015 49
We work in a COMPLEX environment Various resources IR Suites Staff needs Variable acuity Spillane ARIN ATL 2015 MARCH 1, 2015 50
We work in a COMPLEX environment Various resources IR Suites Staff needs Variable acuity Spillane ARIN ATL 2015 MARCH 1, 2015 51
We work in a COMPLEX environment Various resources IR Suites Staff needs Variable acuity Emergent add-ons calls Equipment issues, phone Spillane ARIN ATL 2015 MARCH 1, 2015 52
We work in a COMPLEX environment Various resources IR Suites Staff needs Variable acuity Emergent add-ons calls Equipment issues, phone Spillane ARIN ATL 2015 MARCH 1, 2015 53
We work in a COMPLEX environment Various resources IR Suites Staff needs Variable acuity Emergent add-ons calls Equipment issues, phone Spillane ARIN ATL 2015 MARCH 1, 2015 54
Why does this happen? Complex Systems are intrinsically hazardous systems Spillane ARIN ATL 2015 MARCH 1, 2015 55
Why does this happen? Complex Systems contain changing mixtures of latent failures within them Spillane ARIN ATL 2015 MARCH 1, 2015 56
Why does this happen? Complex Systems run in degraded mode Spillane ARIN ATL 2015 MARCH 1, 2015 57
Why does this happen? Catastrophe is always just around the corner Spillane ARIN ATL 2015 MARCH 1, 2015 58
Why don t these things happen more often? Spillane ARIN ATL 2015 MARCH 1, 2015 59
Why don t these things happen more often? Spillane ARIN ATL 2015 MARCH 1, 2015 60
Why don t these things happen more often? Complex Systems are heavily and successfully defended against failure Spillane ARIN ATL 2015 MARCH 1, 2015 61
Human Operators have dual roles: as Producers of and Defenders against failure Spillane ARIN ATL 2015 MARCH 1, 2015 62
Catastrophe requires multiple failures single point failure is not enough Spillane ARIN ATL 2015 MARCH 1, 2015 63
Human practitioners are the adaptable element of complex systems Spillane ARIN ATL 2015 MARCH 1, 2015 64
High Reliability Organizations (HROs) Concept developed based on complex systems that successfully avoid accidents and catastrophic failures Examples studied: Aircraft Carrier operations Nuclear Power generation Commercial aviation Spillane ARIN ATL 2015 MARCH 1, 2015 65
High Reliability Organizations (HROs) Concept developed based on complex systems that successfully avoid accidents and catastrophic failures Examples studied: Aircraft Carrier operations Nuclear Power generation Commercial aviation Recommendations put forth: 1. Seek to know what you don t know Spillane ARIN ATL 2015 MARCH 1, 2015 66
High Reliability Organizations (HROs) Concept developed based on complex systems that successfully avoid accidents and catastrophic failures Examples studied: Aircraft Carrier operations Nuclear Power generation Commercial aviation Recommendations put forth: 1. Seek to know what you don t know 2. Recognize the cost of failure and the benefits of reliability Spillane ARIN ATL 2015 MARCH 1, 2015 67
High Reliability Organizations (HROs) Concept developed based on complex systems that successfully avoid accidents and catastrophic failures Examples studied: Aircraft Carrier operations Nuclear Power generation Commercial aviation Recommendations put forth: 1. Seek to know what you don t know 2. Recognize the cost of failure and the benefits of reliability 3. Keep everybody in the loop Spillane ARIN ATL 2015 MARCH 1, 2015 68
1.High Consequence Industries 1. Healthcare 2. Nuclear Power 3. Military Command and Control 4. Commercial aviation 5. Space Exploration 6. Wildfire firefighting 7. Chemical process control 8. Deep Sea Oil/Gas exploration 9. Deep ground mining 10.Mass transit systems 11. Big Science projects Spillane ARIN ATL 2015 MARCH 1, 2015 69
The healthcare industry may be the largest and most expensive endeavor in the developed world, with the United States at the top of the list of per capita expenditure. A decentralized and massive undertaking 4000-6000 hospitals (Same number of surgicenters) Owned by 1000-2000 firms 200 000 physician offices 20 million surgical procedures with Anesthesia 1 billion prescriptions written per year Risk and Reliability in HealthCare and Nuclear Power: Learning from Each Other. AAMI Monograph 2013. Eds: Weinger MB Halbert BD Logan MK Spillane ARIN ATL 2015 MARCH 1, 2015 70
In contrast, Nuclear Power. About 100 Nuclear power plants in the United States Owned by 30-40 firms Regulated and scrutinized by the NRC Highly-trained individuals Extensive use of simulation and team work Spillane ARIN ATL 2015 MARCH 1, 2015 71
High Consequence events: Health Care v. Nuclear Power Scale of catastrophe Publicity Operator risk Facility Risk D Gaba MD. AAMI Monograph. Page 22 Spillane ARIN ATL 2015 MARCH 1, 2015 72
In contrast, Nuclear Power. About 100 Nuclear power plants in the United States Owned by 30-40 firms Regulated and scrutinized by the NRC Highly-trained individuals Extensive use of simulation and team If you ve seen one hospital. you ve seen one hospital Spillane ARIN ATL 2015 MARCH 1, 2015 73
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Medical Errors OR Fires happen maybe 600 times per year Wrong patient or wrong side surgery happen maybe 50 times per week in the U.S. Chasen MR Loeb JB Milbank Quarterly 2013;91(3):459-490. Spillane ARIN ATL 2015 MARCH 1, 2015 76
Managing the Unexpected Spillane ARIN ATL 2015 MARCH 1, 2015 77
Managing the Unexpected Characteristics of HROs 1. Preoccupation with failure. 2. Reluctance to simplify. 3. Sensitivity to Operations 4. Commitment to Resilience 5. Deference to Expertise Spillane ARIN ATL 2015 MARCH 1, 2015 78
Managing the Unexpected Characteristics of HROs 1. Preoccupation with failure. 2. Reluctance to simplify. 3. Sensitivity to Operations 4. Commitment to Resilience 5. Deference to Expertise Spillane ARIN ATL 2015 MARCH 1, 2015 79
Mindfulness Spillane ARIN ATL 2015 MARCH 1, 2015 80
Mindfulness History: L elbow pain Spillane ARIN ATL 2015 MARCH 1, 2015 81
Mindfulness Spillane ARIN ATL 2015 MARCH 1, 2015 82
Highly Reliable Organizations (HROs) Spillane ARIN ATL 2015 MARCH 1, 2015 83
Highly Reliable Organizations (HROs) Teamwork is Innovation Spillane ARIN ATL 2015 MARCH 1, 2015 84
Highly Reliable Organizations (HROs) Teamwork is Innovation Spillane ARIN ATL 2015 MARCH 1, 2015 85
1.Crew Resource Management (CRM) 1.Cockpit Resource Management 1.IR SUITE RESOURCE MANAGEMENT 2. Coined by John Lauber 1. NASA 3. NTSB analysis of United Airlines flight 173 in 1979 1. Crew was focused on a landing gear problem and the plane ran out of fuel Wikipedia, Crew Resource Management Spillane ARIN ATL 2015 MARCH 1, 2015 86
1.IR SUITE RESOURCE MANAGEMENT a set of training procedures for use in environments where human error can have devastating effect. cockpit. focuses on interpersonal communication, leadership, and decision making in the leading to communication barriers are reduced and problems can be solved more efficiently, increased safety. Spillane ARIN ATL 2015 MARCH 1, 2015 87
Assertiveness Spillane ARIN ATL 2015 MARCH 1, 2015 88
Crew Resource Management The need to speak up: HIERARCHY and the POWER DISTANCE INDEX (PDI) IBM HR researcher Geert Hofstede, 1960s-1970s -Cross cultural psychology and its workplace impact -Questions about how people worked together, how they solved problems, how they felt about authority Spillane ARIN ATL 2015 MARCH 1, 2015 89
Crew Resource Management The need to speak up: HIERARCHY and the POWER DISTANCE INDEX (PDI) Cultures have different POWER DISTANCE INDICES or POWER GRADIENTS Moderate to Low in the United States Industries and Teams have different POWER GRADIENTS Anesthesiologists and Surgeons view it as LOW Nurses tend to view it as HIGH Spillane ARIN ATL 2015 MARCH 1, 2015 90
Crew Resource Management The need to speak up: HIERARCHY and the POWER DISTANCE INDEX (PDI) Cultures have different POWER DISTANCE INDICES or POWER GRADIENTS Moderate to Low in the United States Industries and Teams have different POWER GRADIENTS Anesthesiologists and Surgeons view it as LOW Nurses tend to view it as HIGH PERCEIVED POWER GRADIENTS LEAD TO AUTHORITY GRADIENTS Spillane ARIN ATL 2015 MARCH 1, 2015 91
Crew Resource Management is about Communication! Spillane ARIN ATL 2015 MARCH 1, 2015 92
Crew Resource Management is about Communication! Qual Saf Hlth Care 2002;11:355-357 Spillane ARIN ATL 2015 MARCH 1, 2015 93
Intimidating behavior Often ascribed to MDs, but it s not just the MDs Occurs with MDs, RNs, Techs, Pharmacists Includes loud or profane language, but also things like, -condescending language -not returning phone calls or pages -intimidating or belittling body language -impatient behaviors or language Spillane ARIN ATL 2015 MARCH 1, 2015 94
Intimidating behavior Not tolerated by HROs Why? Because they suppress reporting of safety concerns Spillane ARIN ATL 2015 MARCH 1, 2015 95
What are we doing with this at Hartford Hospital? Spillane ARIN ATL 2015 MARCH 1, 2015 96
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Crew Resource Management Improved Communication Structured interaction Spillane ARIN ATL 2015 MARCH 1, 2015 98
Crew Resource Management Spillane ARIN ATL 2015 MARCH 1, 2015 99
Crew Resource Management Expectations for interactions Spillane ARIN ATL 2015 MARCH 1, 2015 100
Multi-tasking is bad Spillane ARIN ATL 2015 MARCH 1, 2015 101
Multi-tasking is bad Spillane ARIN ATL 2015 MARCH 1, 2015 102
Focusing on the human interaction and the transfer of information Spillane ARIN ATL 2015 MARCH 1, 2015 103
Focusing on the human interaction and the transfer of information Spillane ARIN ATL 2015 MARCH 1, 2015 104
Crew Resource Management The expectation to speak up Spillane ARIN ATL 2015 MARCH 1, 2015 105
Staff training at Hartford HealthCare Spillane ARIN ATL 2015 MARCH 1, 2015 106
POLITE PERSISTENCE GRACIOUSNESS Spillane ARIN ATL 2015 MARCH 1, 2015 107
High Reliability We re all in this together. Human practitioners are the adaptable element of Complex Systems Richard I Cook MD
Human practitioners are the adaptable element of Complex Systems Richard I Cook MD Thank you for having me.