You will find elaboration about some important concepts related to patient safety science

1. The Science of Patient Safety
Dr. Mohamed Mosaad Hasan
MD, MPH, CPHQ, CPPS, GBSS

2. Objectives
• Outline major principles for systems
thinking and reliable design
• Describe human error categories and
explain ways in which human factors
engineering impacts safe process design
• Differentiate improvement models that
have been utilized outside and inside of
the healthcare industry

3. CASE #1
• 35 year old male
• Seeking opthamology referral
• Lab results for a different patient were
reviewed

4. CASE #2
• 52 year old patient
• History of GI bleeds
and ulcers
• Prescribed an
NSAID

5. System

6. Hazards
• Hazard activities
(i.e., behaviors)
or conditions
that pose threat
of harm
• Sometimes
hazards lie
hidden in the
system, and
sometimes they
are quite
obvious

7. 44,000- 98,0000

8. Healthcare World before 1999-
2000
• Quality/safety assumed to be excellent.
• No business case to improve
safety/quality.
• No local expertise, research or best
practices.
• Little concerted effort by board, C-suite or
physicians to improve quality/safety
• Combination of wrong mental model and
no incentive leads to predictable results

9. Healthcare World Now
• Growing business case for safety/quality
• Steady progression from relatively weak pressures
(social pressure, accreditation w/ low chance to fail,
transparency), eventually settling on “all of the above”
plus payment changes
• Capacity building: people, tools, measures and IT
• Transition from quality/safety to value
• Recognition of need to remake delivery system to
survive/succeed in new healthcare world

10. Why Is This So Hard?
• Medicine is complex
• High degree of
uncertainty
• Care across the
continuum is challenging
• Diversity of workforce
and
complexity of patients

11. Definition of Insanity
• Insanity: doing the same thing over and over again and
expecting different results.
Albert Einstein

12. Error Causation and Prevention
• Most preventable harm to patients
receiving healthcare today is caused by
the unsafe acts of the various Practitioners
who are trying to help them.

13. Human Error – James Reason

15. Systems Thinking
 Refers to thinking in terms of:
 Interdependencies
 Interactions
 Sequences

16. Systems Thinking
 Provides a conceptual framework to help
see and understand relationships
 Helps to avoid simplistic solutions to
complex problems
 Focus on interdependencies

17. Reliability Science
Definition of Reliability:
“the extent to which an experiment, test, or
measuring procedure yields the same
results on repeated trials”
By Institute for Healthcare Improvement
“Failure free operation over time”
Relation to IOM’s aims: effectiveness,
timeliness, and patient-centeredness.

18. High Reliability Organization (HRO)
• Organizations despite functioning in
complex, hazardous environments,
have very low error rates
• Examples: airline industry, nuclear
power, chemical plants, aircraft carriers.
One small error can lead to catastrophic
consequences for not only the
employees but also for the general
public.

19. PRINCIPLES OF RELIABILITY
SCIENCE
• Anticipation: used to detect an error
before it occur.
• Containment: control the consequences
of errors

20. Checklists and other Systems
Let me read your
order Back to you.

21. The Culture of Low
Expectations
“We suspect that these physicians and nurses had
become accustomed to poor communication and
teamwork. A ‘culture of low expectations’
developed in which participants came to expect a
norm of faulty and incomplete exchange of
information [which led them to conclude] that
these red flags signified not unusual, worrisome
harbingers but rather mundane repetitions of the
poor communication to which they had become
inured.”
Drs. Mark Chassin and Elise Becher
Annals of Internal Medicine, 2002

22. Human Factors
• Human factors engineering focuses on
human beings and their interaction with
each other, products, equipment,
procedures, and the environment.
• Human factors leverages what we know
about human behavior, abilities,
limitations, and other characteristics to
ensure safer, more reliable outcomes.

23. Sleep Deprivation

24. Interruptions

25. Memory Issues

26. Forcing Functions
• Be more
careful,
or….
• Redesign
the breaks

27. Error Proofing
1. Simplification
2. Standardization
3. Reduce reliance on memory
4. Improve access to information
5. Use forcing functions and constraints

28. Error Proofing
6. Use visual controls
7. Leverage high-performance teams
8. Deploy redundancies
9. Eliminate environmental factors
10. Make errors more visible

29. PI approaches
Common Characters
Planned
Systematic
Collaborative
Organization-wide

30. Planned
ORGANIZED
DOCUMENTED

31. Systematic
PLANNING
PRIORITIZATION
ASSESSMENT
IMPLEMENTING
MAINTENANCE

32. ORGANIZATION WIDE
ALL LEADERS
ENTIRE ORGANIZATION
IMPORTANT FUNCTIONS

33. COLLABORATIVE
DEPARTMENTS
SETTINGS
DISCIPLINES

34. Model for Improvement
Three Questions
1) What is the aim?
2) How will we know a change is an
improvement?
3) What changes can we make that will
result in
an improvement?

35. SHEWHART (PDCA) AND DEMING
MODEL (PDSA)
 P = PLAN
 D = DO (PILOT)
 CHECK OR STUDY
 ACT

36. 36
Shewhart Cycle
Plan
Do
Check
Act
1. Identify customer
needs/expectations
2. Describe the
current process
3. Measure and
analyze data
4. Identify improvement
opportunities
5. Identify root causes
of problems
6. Generate and choose
solutions
7. Plan and implement
a pilot of the solutions
8. Evaluate results of pilot9. Draw conclusions
10. Standardize the change
11. Monitor the change
and hold the gains
The Tradiotnal PDCA Model

38. FOCUS – PDCA MODEL
 F = FIND A PROBLEM
 O = ORGANIZE TEAM
 C = CLARIFY YOUR KNOWLEDGE ABOUT THE PROCESS
 U = UNDERSTAND SOURCES OF VARIATION
 S = SELECT THE PROCESS IMPROVEMENT
 PLAN THE NECESSARY STEPS
 DO ALL NECESSARY TO IMPLEMENT
 CHECK THE RESULT OF ACTION
 ACT FULLY IMPLEMENT
(Useful for REDESIGN of a new process or QI)

39. F.O.C.U.S.
→Find an improvement project
(initiative):
– Review related standards & documents
– Analysis of collected data
– Identify problems & desired outcomes
39

40. F. O .C.U.S.
→Organize ad hoc (task force) team:
– Identify & involve stakeholders (e.g.
physicians, nurses, administrative …etc)
– Cover all related departments to the
improvement initiative
– Select team members who best do or know
the process to be improved
40
O

41. F.O.C.U.S.
→ Clarify current process & desired
outcomes:
– Fully understand the current process by
all team member
– Draw flow chart to clarify the process
variation/problem
– Collect data from all affected areas
relevant to process & desired outcomes
41
C

42. F.O.C.U.S.
Understand Process Variation, Root
Causes & Desired Outcomes

43. F.O.C.U.S.
→Select the best practice procedure:
– Analyze alternative solutions related to
process improvement
– Choose the best solution that will achieve
desired outcome
– Develop approval with a summary of
required information about expected
outcomes, resources needed, time-frame,
responsibilities ..etc
43
S

44. P.D.C.A.
Plan the improvement project:

45. P.D.C.A.
Do the improvement project:

46. P.D.C.A.
Check the results:

47. P.D.C.A.
Act to hold gains or re-adjust
FOCUS_PDCA

48. Lean Methodology
• LEAN: An effective
approach for
improving patient
safety by process
design that improves
reliability through
standard work,
mitigation, and
continuous
improvement

49. Focus Area of Lean
Lean:
 Lean pioneered by Toyota, focuses on the
efficient operation of the entire value chain.
 Focus areas:
– Remove non-value added steps to:
 Reduce cycle time
 Improve quality
– Align production with demand
– Reduce inventory
– Improve process safety and efficiency

50. Six Sigma

51. Core Attributes for Safe, Reliable
Systems
• Well-defined workflows
• Mistake-proofing principles
• Measurement strategy
• Team members who share responsibility
to provide safe, reliable care

52. The Science of Patient Safety
• New concepts: science of error
causation (“systems thinking”), complex
systems, human factors, cognitive
psychology, applied informatics…
• New attitudes: teamwork, discipline,
professionalism, balancing “no blame”
with accountability, disclosure…
• New skills: error analysis, leadership,
change management...

53. “We think that the anxiety, demoralization, and
sense of loss of control that afflict too many
healthcare professionals today directly come not
from finding themselves to be participants in
systems of care, but rather from finding
themselves lacking the skills and knowledge to
thrive as effective, proud, and well-oriented
agents of change in those systems…. A physician
equipped to help improve healthcare will be not
demoralized, but optimistic; not helpless in the
face of complexity, but empowered; not frightened
by measurement, but made curious and more
interested; not forced by culture to wear the mask
of the lonely hero, but armed with confidence to
make a better contribution to the whole.”
Berwick and Finkelstein, Acad Med, 2010