DB 2 543

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L e a r n i n g O b j e c t i v e s

C H A P T E R 9

A C H I E V I N G R E L I A B L E Q U A L I T Y A N D S A F E T Y

After reading this chapter, you will be able to

➤ explain the role of reliability science in the improvement of healthcare services,

➤ recognize how process reliability is measured and managed,

➤ identify strategies to increase the reliability of healthcare processes by improving

the effectiveness of people and the systems in which they work, and

➤ discuss how to measure the effectiveness of improvement actions and sustain

the gains.

➤ Catastrophic processes

➤ Human factors

➤ Noncatastrophic processes

➤ Reliability science

K e y w o r d S

Spath, Patrice. Introduction to Healthcare Quality Management, Third Edition : Third Edition, Health Administration Press, 2018. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/westernkentucky/detail.action?docID=5517319. Created from westernkentucky on 2021-02-15 13:07:15.

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E very year, healthcare organizations throughout the United States conduct hundreds of improvement projects following the models and using the tools you studied in the preceding chapters. With all of this activity, you might think the quality of healthcare

services is exemplary, with few inefficiencies and mistakes. Yet studies of healthcare perfor- mance continue to report high rates of error, overuse of services, and costly wastefulness (Agency for Healthcare Research and Quality 2016).

Why are many of the expected improvements not materializing? Does the fault lie with the improvement project models or tools? Do we need to conduct twice as many proj- ects and involve more frontline workers? Although a lack of significant progress is caused by many factors, one element that greatly contributes to quality problems is the design of work systems. As noted by Paul Batalden, MD, director of healthcare improvement leadership development at Dartmouth Medical School in Hanover, New Hampshire, “every system is perfectly designed to get the results it gets” (McInnis 2006, 32). If we want fundamentally different results in healthcare, we must use fundamentally different improvement strategies.

Regardless of which improvement model is used for a project, at some point actions or risk reduction strategies are designed. Often these interventions focus on creating new procedures and training people to do their job correctly. Too little attention is given to the work systems that give rise to inefficiencies and human errors. Bohmer (2010) proposes that the only realistic hope for substantially improving healthcare delivery is for the core processes to be revamped.

In this chapter, we introduce the systems approach to achieving safe and reliable healthcare. These techniques are based on reliability science, sometimes called human factors engineering, which originated in the US military during World War II (Wickens et al. 2012). The concepts are commonplace in other industries and should be applied when healthcare improvement teams reach the action planning phase of a project. By thinking differently about the changes needed to improve performance, project teams can have a significant and sustainable positive impact.

re l i a b l e pe r f o r m a n C e Performance reliability can be measured in various ways. The simplest way is to measure process output or outcomes. The number of actions that achieve the intended results are divided by the total number of actions taken. For instance, when you see your doctor, you expect her to have access to the results of your recently completed laboratory tests. The reliability of that process can be measured by gathering data on the occurrences of missing lab test results. If a clinic finds that 15 percent of outpatient appointments are affected by missing lab information, the process is said to have a failure rate of 15 percent and a reliability rate of 85 percent.

Reliability science

A discipline that

applies scientific

know-how to a process,

procedure, or health

service activity so

that it will perform its

intended function for

the required time under

commonly occurring

conditions.

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You may not clearly understand the concept of reliability; however, when your automobile will not start, you clearly understand the concept of failure. You also learn the cost of failure when you have to pay a mechanic to restore your automobile to a reliable condition.

Human factors scientists and engineers have studied the interactions of people, technology, and policy across multiple industries for years. Knowledge gained from these studies allows us to predict the rate of failures based on the reliability rating of the process. For instance, if the clinic’s process of reporting lab results has an 85 percent reliability rating, the clinic physicians should expect miss- ing results for one or two of every ten patients who underwent recent laboratory tests. Exhibit 9.1 shows the expected failure rates for each level of reliability (Resar 2006).

The reliability of healthcare processes var- ies. Studies suggest that most US healthcare orga- nizations currently perform at the 90 percent level of reliability, meaning they have a failure rate of 1 in 10 (Nolan et al. 2004). Some hospital processes (e.g., hand hygiene, hand-off communications) fail 40 to 60 percent of the time (Bodenheimer 2008; Erasmus et al. 2010). One of the most reliable healthcare processes is giving patients compatible blood for a transfusion. Failures of this process are rare, with the reliability rate estimated to be 99.999 percent (Amalberti et al. 2005).

Human factors

“The environmental,

organizational and job

factors, and individual

characteristics which

influence behavior at

work” (Clinical Human

Factors Group 2016).

Reliability Level (%) Expected Failure Rate

Less than 80 Unpredictable, chaotic performance

80–90 1–2 failures out of 10 opportunities

95 Up to 5 failures per 100 opportunities

99.5 Up to 5 failures per 1,000 opportunities

99.99 Up to 5 failures per 10,000 opportunities

99.999 Up to 5 failures per 100,000 opportunities

99.9999 Up to 5 failures per 1,000,000 opportunities

exhibit 9.1 Process Reliability Levels and Expected Failure Rates

DID YOU KNOW??

• You have a 1 to 2 percent chance of dying accidentally for

every 10 mountains you climb in the Himalayas. The reliabil-

ity rating for this high-risk activity is 80 to 90 percent. Bun-

gee jumping has a similar risk of death.

• Automobile travel is fairly safe, with a reliability rating of

99.99 percent. The risk of a fatal accident is low—up to 5 for

every 10,000 times you ride in a car.

• The reliability of commercial aviation is better than 99.9999

percent, with an extremely low risk of a complete engine fail-

ure leading to loss of aircraft.

Source: Amalberti et al. (2005).

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i m p r o v i n g Q u a l i t y

Reliability ratings are important for healthcare quality improvement purposes. Reliability science has demonstrated that certain process improvements are more likely to create consistent quality. When improvement actions rely mostly on people’s vigilance and hard work to get things done correctly, the best level of reliability that can be achieved is 80 to 90 percent (Luria et al. 2006). On occasion, higher levels of reliability can be achieved, but they are not possible to sustain over time.

People often work in complex healthcare environments without carefully designed mistake-proofing infrastructures. For instance, hospital nurses are constantly interrupted as they carry out important patient care duties. In a review of several studies of nurse activities, the reported interruptions per hour ranged from 0.3 to 13.9 (Hopkinson and Jennings 2013). Healthcare professionals are able to cope with these situations and, most often, performance is not affected. However, people cannot be vigilant 100 percent of the time, and mistakes happen.

Exhibit 9.2 summarizes the types of actions necessary to achieve sustained reliable quality at different percentages (Amalberti et al. 2005). These actions, based on human factors and reliability science principles, should be considered in the design of actions intended to improve quality.

Not every healthcare process can be made highly reliable. Resources are insufficient, and not every process requires a high (99.5 percent or greater) level of reliability. For noncatastrophic processes, good outcomes depend on having at least 95 percent process reliability. For catastrophic processes, good outcomes depend on having 99.5 percent or better reliability. Improvement project teams should agree on the desired level of reliability and then implement actions that will achieve this level. For some healthcare processes, 80 to 90 percent reliability may be sufficient. Organizations might achieve better patient outcomes by bringing several chaotic processes to 90 percent reliability rather than concentrating on improving the reliability of just a few to 99.5 percent. This thinking coincides with the risk management concept of ALARP, which stands for “as low as reasonably practicable.” Deter- mining the extent to which workplace risks are controlled “involves weighing a risk against the trouble, time and money needed to control it” (Health and Safety Executive 2014).

The US Department of Veterans Affairs (VA) National Center for Patient Safety (2016) created an action categorization system on the basis of human factors science. These action categories are used by teams involved in root cause analyses and other patient safety improvement projects. Rather than divide improvement actions into levels of reliability, the actions are labeled as weak, intermediate, and strong. Studies at the VA have shown that when a strong action is developed and implemented, it is 2.5 times more likely to be effective at improving performance than are weak or intermediate actions (DeRosier, Taylor, and Bagian 2007). The types of actions that fall into the weak, intermediate, and strong categories are listed in exhibit 9.3.

Noncatastrophic

processes

Processes that do

not generally lead

to patient death or

severe injury within

hours of a failure

(e.g., hand hygiene,

administration of low-

risk medications).

Catastrophic processes

Processes with a high

likelihood of patient

death or severe injury

immediately or within

hours of a failure

(e.g., identification of

correct surgery site,

administration of

compatible blood for a

transfusion).

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Reliability Level (%) Actions

Less than 80 Primarily rely on qualified people doing what they believe is the right thing

80–90 Implement basic failure prevention strategies, such as the following: • Standard protocols/procedures/order sheets • Personal checklists • Common equipment • Feedback on compliance • Awareness and training

95 Implement sophisticated failure prevention and basic failure identification and mitigation strategies, such as the following: • Build decision aids and reminders into the system. • Set the desired action as the default (based on scientific

evidence). • Account for and take advantage of habits and patterns in the

process design. • Specify process risks, and articulate actions for reducing risks. • Take advantage of scheduling. • Use redundant processes. • Operate independent backups. • Measure and provide feedback on compliance with process

specifications.

99.5 Gather information to understand which failures are occurring, how often they occur, and why they occur. Then redesign the system to reduce these failures using sophisticated failure prevention, identification, and mitigation strategies: • Design the system to prevent the failure, making sure the

steps in the process act independently of each other so failures can be identified and corrected.

• Design procedures and relationships to make failures visible when they do occur so they may be intercepted before causing harm.

• Design procedures and build capabilities for fixing failures when they are identified or mitigating the harm caused by failures when they are not detected and intercepted.

Better than 99.5 Moving beyond 99.5% requires technology and advanced system design that require significant resource investments.

Source: Adapted from Nolan et al. (2004).

exhibit 9.2 Actions Necessary to Achieve Reliability Levels

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Improvement teams frequently favor weak interventions over higher-level actions because weak actions are lower risk and easier to create and implement. Staff training and distribution of memos telling everyone to follow procedures can be accomplished fairly easily. Unfortunately, such actions by themselves rarely have a lasting impact (Williams and Bagian 2014). Training can be made stronger by combining it with periodic competency assessments involving random observation by management. People newly trained in a procedure are more likely to follow it if they know they will be occasionally and randomly observed (Bernstein et al. 2016).

ap p ly i n g re l i a b i l i t y pr i n C i p l e S When actions based on reliability principles are not incorporated into the design of health- care improvement initiatives, the project goals are less likely to be achieved. Consider

Strength of Improvement Action Example of Action

Weak • Double-checks • Warnings and labels • New procedure/policy • Memos • Training • Additional study/analysis

Intermediate • Checklist/cognitive aid • Increase in staffing/decrease in workload • Redundancy • Enhanced communication (e.g., read back) • Software enhancements/modifications • Elimination of look-alikes and sound-alikes • Elimination/reduction of distractions (e.g., sterile

medical environment)

Strong • Architectural/physical plant changes • Tangible involvement and action by leadership in

support of patient safety • Simplified process, with unnecessary steps removed • Standardized equipment, process, or care map • New-device usability testing before purchasing • Engineering control or interlock (forcing functions)

Source: Reprinted from National Center for Patient Safety, US Department of Veterans Affairs, “Root Cause Analysis.” Retrieved from www.patientsafety.va.gov/professionals/onthejob/rca.asp. Copyright © 2016.

exhibit 9.3 Strength of Various

Improvement Actions

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what happened in the following case study. An improvement team met for several weeks to design and implement actions aimed at reducing the incidence of heel pressure ulcers (skin breakdowns) among hospitalized patients.

C a S e S t u d y

Many patients in the hospital were developing heel ulcerations. More than 13 percent of patients aged 18 or older developed a heel ulcer within four days of admission. This rate was higher than the national average, so an improvement team was formed with representatives from nursing, physical therapy, and wound care services to reduce the incidence of heel ulcers by 50 percent within one year. The team evaluated current practices and implemented the following stepwise actions to improve the process:

1. Nurses were trained to use an assessment scoring system to identify patients at risk of heel ulcerations. A poster board showing assessment instructions was made available for five days in each nursing unit.

2. After reviewing the training material, nurses took a test to determine their proficiency in assessing a patient’s heel ulcer risk. A score of 90 percent was required to pass the test.

3. Once all nurses had taken and passed the test, a new protocol was implemented that required use of the risk-assessment scoring system at the time of a patient’s admission, 48 hours after admission, and whenever a significant change was seen in a patient’s condition.

4. The hospital’s computerized health record system was modified so nurses could add the patient’s ulcer risk score into the patient’s record at the required intervals.

5. Patients at moderate or high risk of a heel ulcer were started on a protocol of ulcer prevention that included application of a thin dressing or heel protectors on reddened areas and elevation of the patient’s heels with pillows.

One year after the actions were completed, the incidence of hospital-acquired heel pressure ulcers had not significantly changed. An analysis of current practices found that staff nurses were not consistently completing the periodic risk assessments and that heel ulcer prevention interventions were not always employed. A lot of work had been done by the improvement team, the people who had created the training and post-training exam, and the people who had modified the computerized record system, yet no significant improvements occurred.

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Everyone involved in improvement projects wants performance to improve. But good intentions are not enough to ensure good outcomes. To achieve better performance that is reliable, human factors science must be taken into consideration when making changes.

C o n S i d e r t h e h u m a n f a C t o r S

Often, improvement initiatives fail because we expect people to perfectly execute their job responsibilities. Competence is important to an individual’s ability to do her job—you wouldn’t expect someone untrained in automobile repair to fix your car. But humans are not perfect, and there are no guarantees that mistakes will not be made. Interventions to improve performance are most successful when they address both the individuals doing the work and the way in which work gets done. For instance, the automobile mechanic must be adequately trained, have the right tools, and be provided a tolerable work environment. When healthcare improvement teams reach the action-planning phase, they must consider the human aspects that cause inconsistent performance and design systems that promote reliable quality.

Strong and effective systems make people more effective than they might be without such systems. Changes in procedures, rules, workflow, and automation; the introduction of new technology and equipment; and other system changes help to make people effective. In addition, strong and effective people make systems more effective. Rather than blaming and shaming people for not doing their job, seek to develop and enhance the competencies and skills of people in the system and ensure their needs are met. When introducing workflow changes, automation, new roles, and other interventions designed to improve performance, consider the needs of the people involved and how they will be affected. Organizations often fail in this regard by making the following mistakes (Spath 2015):

◆ Creating additional work for fewer people

◆ Removing people from roles in which they were comfortable

◆ Placing people in unfamiliar new roles as if they were interchangeable parts

◆ Not involving or consulting with the people affected by decisions but instead making assumptions about what is “good for them”

When working in complex and sometimes fast-moving healthcare environments, people can become overwhelmed with tasks, potentially causing cognitive overload—a situ- ation in which the demands of the job exceed the individual’s ability to mentally process all the information encountered regarding a situation (Ternov 2011). To ensure people are as effective as possible in their job, cognitive overload must be minimized. Critical concept 9.1 shows how to do this.

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t e S t r e d e S i g n e d p r o C e S S e S

Changes to processes are often implemented without a clear understanding of how the change affects other parts of the system—the people, other processes, and services. Testing the impact of redesigned processes on performance is a crucial step in all the improvement models described in chapter 5. One way to assess improvements is to test process changes, before they are implemented, on a small subset of activities or patients (usually five to ten individuals). If the changes achieve the intended goals, they can be applied to all activities or patients. Quantitative and qualitative data should be collected during the pilot phase of a process change. This information helps the project team see the impact changes will

CRITICAL CONCEPT 9.1 Steps to Reduce Cognitive Overload on People!

• Limit or discourage people from working when they are physically ill or under psy-

chological duress.

• Be sure people are physically and psychologically fit for the tasks that need to be

completed.

• Provide people with adequate breaks away from their job; breaks should not be op-

tional.

• Add technologies that reduce reliance on memory, and insist that the technology

be used as designed (e.g., barcoded patient identification systems, monitoring

systems).

• Rotate tasks in a department when possible; when people do the same task all the

time, they can become complacent and experience the effects of mental underload.

• Monitor people for excessive fatigue; a lack of adequate rest reduces productivity

and efficiency.

• Place limitations on employee overtime, and provide adequate off-work intervals

between shifts.

• Provide team training, including the use of simulation methods.

Source: Adapted from Kochar and Connelly (2013); Patel and Buchman (2016); Vincent and Amalberti (2016).

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have on the people doing the work as well as on related activities and systems. It also can convince others of the value of adopting the changes organization-wide.

Testing does not end at the pilot phase. After changes have been implemented for a short time, the team must determine how well they are working.

a C h i e v e 80 t o 90 p e r C e n t r e l i a b i l i t y

To consistently reach 80 to 90 percent work system reliability, the improvement team must create a specific process and use staff education and vigilance to achieve standardization. The attempt at reducing heel pressure ulcers described in the case study earlier in this chapter lacked an important component: vigilance. Specific processes were designed to assess a patient’s risk of a heel ulcer and to prevent one from developing, and staff was educated in these processes. But management exercised no ongoing oversight to determine if nurses were following the processes, and no actions were taken for noncompliance. Without vigilance, compliance slid, and the failure rate often exceeded 20 percent.

Standardization and vigilance are necessary to reach sustained 80 to 90 percent reliability. These contributors to quality can be instituted by creating defined protocols, requiring the use of common equipment or supplies, creating checklists that remind people what needs to be done, and following other methods for reducing process variation. Many of these techniques are the same strategies used during a Lean project to eliminate waste and improve process efficiencies (Zidel 2012).

Process standardization also improves patient safety. According to Bagian and colleagues (2011), local patient safety managers in VA facilities rated process standard- ization as one of the best interventions for achieving good results. Other actions rated as leading to much better results included those that improve the communication process between clinicians and those that enhance the computerized medical record through software upgrades.

If an improvement team has determined that 80 to 90 percent reliability is suffi- cient, it need not take further action other than periodic monitoring to ensure the failure rate does not increase. Exhibit 9.4 describes the steps that a rehabilitation facility took to reach 80 to 90 percent sustained compliance with hand-hygiene requirements. This level of reliability was the goal, so no further interventions were needed.

Additional improvement actions are necessary if a higher level of reliability is desired. They should not be taken, however, until a sustained level of 80 to 90 percent reliability has been achieved for at least six months (Baker, Crowe, and Lewis 2009). Adding improve- ment actions when a process is still unstable could further degrade reliability. The adverse effect of tampering was discussed in chapter 4.

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a C h i e v e 95 p e r C e n t r e l i a b i l i t y

Moving a work system from 80 to 90 percent reliability to 95 percent requires stronger interventions than have been adopted thus far. Some actions, such as building decision aids into the system, may be as straightforward as creating paper checklist reminders for people to use. Decision aids can also take the form of more sophisticated computerized feedback that alerts people to unusual clinical situations requiring attention.

Intermediate and strong actions needed to improve the reliability of a process to 95 percent are listed in exhibits 9.2 and 9.3. Often, a number of advanced failure prevention and failure identification and mitigation strategies are needed. For instance, the inpatient psychiatric unit at Sinai Hospital of Baltimore (2017) reduced the incidence of patient elopements (unauthorized absence without permission) from four attempted and actual elopements in 2013 to none in 2016. To achieve this improvement, the unit implemented several interventions throughout 2015 and 2016:

◆ Provide staff education to improve awareness and increase staff vigilance

◆ Add more security cameras in the unit

Improvement Action Measurement Results

1. Mandatory hand-hygiene and infection-control training for all patient care staff

40% compliance

2. “Clean Your Hands” posters displayed in units; weekly observation reviews by infection control team, with immediate feedback for noncompliance

Up to 60% compliance

3. Hand-hygiene process standardized using “Five Key Moments for Hand Hygiene” and staff educated in process; data gathered to better understand the causes of noncompliance so that process can be changed to prevent these failures

Up to 70% compliance

4. “Five Key Moments” posters displayed in units and patient rooms; hand-hygiene reminders included in shift change discussions and during patient bed rounds; ongoing weekly observation reviews by hand- hygiene champions, with nonconfrontational feedback for noncompliance; continued evaluation of causes of noncompliance and changes made to prevent failures

Sustained 80–90% compliance

exhibit 9.4 Rehabilitation Facility Hand- Hygiene Improvement Project

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◆ Keep patients in hospital garments for 24 hours after arrival in the unit

◆ Limit the number of outside staff with access to the locked unit

◆ Escort ancillary hospital staff pushing carts (food and linen) to the unit exit door

◆ Dress patients at risk for elopement in green gowns and green socks

◆ Place black-out tape over the five-second flashing green light on the exit door badge scanner

◆ Install safety signs to direct patients to the day area and away from high-risk elopement areas

◆ Add a “panic button” to the staff communication devices to allow for immediate and simultaneous elopement alerts

Exhibit 9.5 shows intermediate and strong actions taken by a hospital to improve the reliability of the intravenous (IV) medication and solution administration process. These actions resulted in sustained 95 percent reliability for many of the process steps. Of course, the interventions differ in their power to effect changes. Some, such as automated functions that prevent IV pumps from being incorrectly programmed, are very strong in preventing failures. Other interventions, such as labels on the IV bags, are less likely to reduce failures. An important step in any improvement project is to closely monitor the effectiveness and impact of action plans and make adjustments as needed.

a C h i e v e 99.5 p e r C e n t o r b e t t e r r e l i a b i l i t y

Some healthcare processes should function at 99.5 percent reliability or better because failures within them are likely catastrophic for patients. To achieve 99.5 percent performance or greater requires identifying failures, determining how often they occur, and understanding why they occur.

Specifically, getting to 99.5 percent reliability requires three essential steps. First, process failures must be closely monitored. Second, targeted interventions must be designed and tested until the desired level of reliability is achieved and maintained. For example, a large ambulatory health center in the South implemented several process changes to ensure patients with diabetes have regular body mass index (BMI) measurements (Baker, Crowe, and Lewis 2009). In addition to educating staff on the importance of obtaining a BMI at every patient visit, BMI was made a data element on the clinic’s standardized flow sheet that serves as the front page of the record. A care manager reviews patient records the day before a visit to determine if BMI is entered into the electronic record, and job descriptions for all patient care staff were updated to include the task of ensuring BMI documentation

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Type of Action Intervention

Standardization is pervasive

• Reduce the variety of IV solutions available as floor stock to those most frequently used

• Use only standard concentrations of IV solutions • Make only one kind of IV medication pump in each class

available in the hospital • Develop and implement standard IV physician orders

Decision aids and reminders are built into the system

• Label all IV solutions that do not come from the pharmacy with a tag displaying the nurse’s name, date, name of solution, and rate of administration

• Place on each IV bag a drug-specific label containing flow rate calculations

• Program standard IV orders into the computerized order entry system

The desired action is the default

• Use IV pumps with forcing functions to prevent programming errors

Habits and patterns are studied and used in the design

• Change the arrangement of the medication access control device so only one injection is available per drawer

Process risks are specified, and actions for reducing risks are articulated

• Include discussion of risks and interventions in the annual staff competency assessment process to reduce these risks

Scheduling is used to advantage

• At change of shift, double-check all potentially hazardous IVs (medications, pump settings, and IV tubing) for failure

Redundant processes are in place

• Place on each IV bag a drug-specific label containing flow rate calculations

Independent backup is in place

• Have two nurses independently double-check all IV medications, pump settings, and IV tubing before administration and before patient transfer to another location

Compliance is measured and results are shared

• Gather data on compliance with the new process and the number of incidents involving IV medication and IV solutions; regularly evaluate results and share with everyone involved in the process

exhibit 9.5 Examples of Interventions That Improved Reliability of Administration of IV Medications and Solutions

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at every visit. After experiencing negative reactions from some patients when asked to be weighed, the clinic revised its diabetic education materials with input from patients. The percentage of patients with diabetes with a completed BMI improved from less than 20 percent to 100 percent.

Third, once sustained reliability (99.5 percent or better) is achieved, performance must be regularly reviewed and feedback provided to the people doing the work. Every

failure should be examined, and the information obtained should be used to redesign the process or create ways for staff to better identify and cor- rect failures quickly or to lessen the effects of the failures.

In some situations, the healthcare organiza- tion may seek to improve reliability to 99.9 percent or better. Achieving such a high level of reliability requires more than human labor. Technology and possibly architectural changes are needed. Anesthe- sia administration, once thought to cause 1 to 2 deaths in every 10,000 patients receiving anesthe- sia, is now considered to be one of the most reliable processes occurring in healthcare delivery (Stoelt- ing 2017). A host of changes to anesthesia admin- istration, based on an understanding of human factors principles, were initiated throughout the United States in the 1970s. Reaching the current high level of reliability required the adoption of

important safety technology (pulse oximetry, capnography, audible physiologic alarms, electronic health records) as well as improvements in the culture of safety. Overall, the combined effect of all the initiatives has been a 10- to 20-fold reduction in mortality and catastrophic morbidity for healthy patients undergoing routine anesthesia (Stoelting 2017).

mo n i t o r i n g pe r f o r m a n C e Designing process changes on the basis of reliability science is the starting point to achieving consistently high quality. The next step is to make the changes. Once the improvement team has developed action plans, leadership oversight will ensure the actions are implemented as intended. Researchers studying the implementation of corrective measures following root cause analyses found that healthcare organizations never fully implemented up to 55 percent of the proposed actions (Peerally et al. 2016).

The organization’s progress in implementing action plans must be tracked and leaders kept informed of outstanding and completed action items. Exhibit 9.6 is an excerpt from a monthly report on the status of improvement actions provided to hospital leaders. When

LEARNING POINT Reaching 95 Percent or Better Process Reliability*

Reaching 95 percent or better process reliability involves four

main steps:

1. Agree on a measure for assessing reliability.

2. Measure how often accuracy is achieved according to the

agreed-on measure, thereby establishing a baseline against

which to compare results of the initiative.

3. Establish reliability goals for the measure.

4. Make stepwise improvements and measure success.

Source: Dlugacz and Spath (2011).

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delays are unacceptable, senior leaders often need to intervene to clear away implementa- tion barriers. In chapter 12, we discuss the leadership structure necessary to support quality management activities, including the role of the organization’s governing board and quality oversight groups in monitoring performance.

m e a S u r e e f f e C t i v e n e S S

Improvement goals are set at the start of an improvement project. Clearly documented goals help frame the improvement initiative. The project goals guide decisions about what needs to be changed in the process and how best to accomplish the changes. Once action plans

Date of Report: ____________________________________________

Current Status Project Description Actions Responsible Party Actions to Date

Needs attention

Reduce delays in start times for interventional radiology procedures

1. Revise the patient scheduling procedure

2. Publish an article about new policy in medical staff newsletter

3. Revise the scheduling software to accommodate new policy

4. Conduct monitoring by radiology department for compliance with new policy

1. Imaging director

2. Medical staff services office

3. Imaging director and software vendor

4. Imaging director

1. Done

2. Done

3. Vendor has repeatedly canceled on-site visit for software upgrade

4. Radiology department unable to start new procedure due to software upgrade delay

In progress Improve timeliness of electrocardiogram (EKG) interpretations

1. Standardize the EKG interpretation process

2. Modify transmission process at off-site locations

3. Obtain software upgrade to enable results tracking

1. Vice president of medical affairs

2. Diagnostic center managers

3. Managers of noninvasive cardiology and information technology departments

1. Done

2. Done

3. Funds for software in next year’s capital budget

exhibit 9.6 Improvement Action Tracking Log

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have been implemented, evaluate whether goals have been achieved. Regardless of what improve- ment model is used to execute the project, it will include a step in which the effectiveness of action plans is measured.

Action plan effectiveness can be determined using process or outcome measures. Recall from chapter 3 that process measures are data describing how services are delivered, and outcome measures are data describing the results of healthcare ser- vices. Exhibit 9.7 is a description of an improve- ment project undertaken in a multiclinic primary care organization to improve the use of preventive care screenings. Several actions were taken, and three measures were used to evaluate the success of the actions.

Chapter 3 discusses data collection sys- tems for gathering performance measurement information. Similar data collection systems must be enacted to measure the effectiveness of action plans. Useful and accurate performance information is needed to judge the success of action plans.

A question that often arises during discus- sions of how to measure the success of improve- ment actions is, How long must we continue to gather and report measurement data? Ideally, all of the following criteria should be met to con-

clude that successful corrective action plan implementation has been achieved (Minnesota Department of Health 2015):

◆ Data for the process measure were monitored over time.

◆ The goal was attained (process and outcome).

◆ You are confident that the change is permanent.

◆ The event is not repeated (if improvements were made to prevent another adverse event).

LEARNING POINT Measuring Action Plan Effectiveness*

Consider the following questions when developing measures to

evaluate the success of improvement actions:

1. How will you know the action has been effective in improving

performance?

2. What will you evaluate to determine if the process is more

reliable?

3. Do you have any data that can be used for before-and-after

comparisons?

4. How often will you measure performance (by shift, daily,

weekly, biweekly, monthly, other)?

5. How will data be gathered, and by whom?

6. How long will you continue to measure performance?

7. How often will performance results be reported, and to

whom?

8. Once measurement data substantiate that performance

goals are met, how often will you measure to ensure im-

proved performance is sustained?

Source: Adapted from Bagian et al. (2011).

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re a l i z i n g Su S ta i n e d im p r o v e m e n t S Once the desired level of reliable quality has been reached, the problems affecting undesir- able performance must stay fixed. “I thought we solved that problem already” is an utter- ance often heard in healthcare organizations. Financial and human resources are constantly expended on improvement projects and system redesign, yet familiar problems may creep back in to disrupt the performance of key processes. Managers trying to improve perfor- mance sometimes make mistakes that could have been avoided with forethought.

Improvement Project Goal: Increase rates of preventive care screening services Improvement Actions: 1. Telephone patients to remind them to come to the clinic for needed preventive care

screening. 2. Design a preventive care services summary in patient electronic records to

document needed preventive screening, date of patient contact, and date of completion.

3. Educate staff in preventive service requirements and how to use the summary in patient records.

4. Change the workflow to include having medical assistants or nurses prepare paperwork for preventive screenings before a patient’s visit and give to the provider at the time of the visit.

How Effectiveness of Actions Will Be Measured:

Measure Data Collection Method Goal

Percentage of patients needing preventive screenings who are contacted by phone

Quarterly query of database of patients needing screenings to determine if patient was contacted

Sustained 95 percent

Percentage of patients needing preventive screenings who receive them as required

Quarterly query of preventive care services summary database

Sustained 95 percent

Number of patients who refuse preventive screenings after discussion with provider

Quarterly query of preventive care services summary database

No more than 5 percent per quarter

exhibit 9.7 Improvement Project Measures of Action Plan Effectiveness

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C h a n g e b e h av i o r S

When process improvements come undone, the cause often can be traced back to the attitudes or behaviors of the people doing the work—behaviors that should have been modified but were not. Process improvement efforts tend to focus on standardizing and error-proofing work steps and sometimes overlook the human part of the process. For instance, nurses in a hospital that implemented a barcoded patient identification system to reduce medication errors found the process too cumbersome and began to take shortcuts (Koppel et al. 2008). The nurses made duplicate copies of patient wristbands so they could check the barcodes at the nursing station rather than in patient rooms. This shortcut sig- nificantly raised the potential for medication errors. Understanding what causes shortcuts is at the heart of knowing how to modify attitudes and behaviors. This is just as important as creating a more efficient process. Otherwise, people will lapse into the old way of doing things, and the new process will have no chance of becoming a habit.

Why don’t people adopt desired process changes? Five main factors that affect per- formance are listed in exhibit 9.8.

Performance Factor Possible Interventions

Expectations Do people know what they are supposed to do?

• Provide clear performance standards and job descriptions.

• Create channels to communicate job responsibilities.

Feedback Do people know how well they are doing?

• Offer timely information about people’s performance.

• Use mistakes as learning opportunities.

Physical environment Does the work environment help or hinder performance?

• Make sure people are able to see, hear, touch, and feel what is necessary to do the job.

• Correct problems causing environment, supply, or equipment complaints.

Motivation Do people have a reason to perform as they are asked to perform? Does anyone notice?

• Frequently provide reinforcement to people while they are learning new tasks.

• Apply consequences (positive or negative) to change behaviors toward the desired direction.

Required skills and knowledge Do people know how to do the task?

• Ensure people have the skills needed to perform the work.

• Provide access to learning opportunities.

exhibit 9.8 Performance Factors and

Possible Interventions

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Interventions to achieve compliance with process changes vary according to the performance issue, but the cause of failures must be understood before action is taken to correct them.

d o n ’ t o v e r l o o K e d u C at i o n

Knowledge, diligence, effort, focus, resources, and effective leadership are all essential to the achievement of performance improvement goals. Leaders would be unwise to announce improvement priorities and then expect the improvements to automatically materialize. This approach does not work. Just as cheerleading does not improve a football team’s chances of winning, announcements from leadership alone do not create reliable quality. Project teams need encouragement from leaders, but everyone involved in process improvement also must be able to use basic quality tools and techniques such as those covered in this text.

Only recently has more attention been given to securing reliable healthcare quality through the application of human factors principles and reliability science. Rather than tinker with work systems and hope for the best, some healthcare organizations are applying improvement strategies that have been used successfully for years in other industries. High-reliability industries, such as aviation, air traffic control, and nuclear power, have long recognized that relying on human perfection to prevent accidents is a fallacy. These industries conduct training, enforce rules, and expect their high standards to be met, but they do not rely on people being perfect to prevent accidents. They look to their systems, as should healthcare organizations (Ghaferi et al. 2016).

Human factors and reliability design concepts should be required for all healthcare improvement projects. To reach higher levels of reliable performance, systems and processes must be designed to be more resistant to failure. Situations or factors likely to give rise to human error must be identified and process changes made to reduce the occurrence of failure or to minimize the impact of any errors on health outcomes. Efforts to catch human errors before they occur or to block them from causing harm are ultimately more fruitful than those seeking to somehow create flawless people.

The application of human factors principles and reliability science is long overdue in healthcare. As noted by Deming (1986), one of the founders of the contemporary quality movement, “It is not enough to do your best; you must know what to do, and then do your best.”

C o n C l u S i o n

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1. What does reliability mean to you? In your experience, what healthcare process have you found to be reliable? What process have you found to be unreliable? Explain what is different about the reliable process versus the unreliable process.

2. Consider the failed improvement project in this chapter’s case study when answering the following questions:

a. What process changes could be implemented to achieve 80 to 90 percent reliability in preventing and managing heel ulcerations?

b. What process changes could be implemented to reach 95 percent reliability in preventing and managing heel ulcerations?

c. If process changes are made to achieve 80 to 90 percent reliability, how would you measure the effectiveness of these changes?

d. If process changes are made to achieve 95 percent reliability, how would you measure the effectiveness of these changes?

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