“Teaching, Learning and Keeping Everyone Safe: All at the Same Time”

1. “Teaching, Learning and Keeping Everyone Safe: All at the Same Time” Stephen E. Muething, MD ECT Faculty Recognition Dinner Keynote September 21, 2011

4. UNITED STATES 60,000 – 100,000 deaths per year from adverse events in hospitals

5. OHIO • 60,000 Experience adverse events annually • 50,000 years of potential life lost • 1 Billion dollars in direct healthcare expense • 5% of nosocomial infections lead to death: 7,500 deaths each year • 6.5% of patient admissions results in a adverse drug event

6. CHILDREN • 1 Billion dollars annually secondary to patient safety issues • Surgical Site Infections: increase stay of 10 days • Blood Stream Infections: increase costs of $33,000 each • Ventilator-associated Pneumonias: increase stay of 8 days

8. Check Lists “Be Safe” Speak Up Time Outs Culture of Safety Leadership Accountability Protocols “Wash Your Hands”

9. RELIABILITY

12. CONTROVERSIAL STATEMENT #1 STANDARDIZATION Helps our Learners Learn

15. “STANDARDIZATION IMPARES LEARNING” • “I LEARNED FROM OBSERVING” • “IT’S A COOKBOOK”

16. RELIABILITY CULTURE HIGH RELIABILITY ORGANIZATIONS Others have been Implementing, Learning and Improving for decades

18. MINDFULNESS

19. COMMONALITIES of HRO’s • Unforgiving social and political environment • Environment rich with potential for error • Scale of consequences precludes learning through experimentation • Complex processes • Complex technology -Rochlin, 1993

21. CORE CHARACTERISTICS • Preoccupation with Failure - Encourage reporting of even small errors and convene quickly to address • Reluctance to Simplify Interpretations - Encouraging diversity in experience, perspective, and opinion • Commitment to Resilience - “errors don’t disable” • Deference to Expertise - Decision making deferred to workers with the most knowledge and expertise not the highest rank • Sensitivity to Operations - Find loopholes in system’s defenses, barriers and safeguards on the frontline. Maintain Situation Awareness

22. HROs and Hospitals • Preoccupation with Failure • Near misses are viewed as invitations to improve, not successes • Chronic unease/wariness instead of complacency • “No Blame” culture • Everyone discusses every day what “almost happened”

23. HROs and Hospitals • Reluctance to Simplify Interpretations • Don’t assume failures are the results of a single, simple cause • Understand all the ways the system may fail • Look to others who may do things better • Usecause analysis to plan improvements

24. HROs and Hospitals • Commitment to Resilience • Assume errors will occur • Lookout for the unexpected and the unusual • All should be aware when the system is in a stressed situation • Practice, practice for the “unexpected” • Simulation training

25. HROs and Hospitals • Deference to Expertise - Front-line leaders are empowered to solve problems everyday and escalate more complex issues right away • Staff at every level are comfortable sharing information and concerns and finding solutions • Includes the patient as well as the family

27. HROs and Hospitals • Sensitivity to Operations • Organization designed around the front-line not the other way around. • Safety behaviors are clear • Daily and Shift Huddles • 200% accountability • Situation Awareness

28. CONTROVERSIAL STATEMENT #2 If you’re not building situation awareness you’re setting learners up for failure

29. WHAT IS SITUATION AWARENESS?

32. Situation Awareness Model Bedside Team Microsystem Team OrganizationTeam Family concerns MRT High risk therapies WatchstanderSenior Resident Intern PEWS>5 WatchstanderPCF/Manager Safety Team (MPS and SOD) at 800, 1600 & 100 Bedside nurse Watcher Reliable escalation of risk Communication concern Rapid assessment and communication with primary team Attending 32

33. Are we an HRO Yet?

34. Not Yet!

35. CONTROVERSIAL STATEMENT #3 We CAN eliminate preventable serious harm from teaching hospitals

39. HUMAN FACTORS • Designing technology that makes it difficult to make errors • Understanding decision making and designing health record to facilitate decisions • Learn what makes a high performance team and replicate

41. QUESTIONS? • COMMENTS? • CONTROVERSIAL STATEMENTS • WELCOME!

42. Thank you