Building High-Reliability Patient Care Teams

2. Building High-Reliability Patient Care Teams JMO Forum 10th August 2012 Dr Charles Pain, Director, Health Systems Improvement Clinical Excellence Commission

3. Argument • We have a quality problem in healthcare • Current improvement strategies have their limits • We must learn from them and build new approaches • A microsystems approach has the potential to be transformative

4. HEALTHCARE IN FOCUS 2011: At a glance November 2011 www.bhi.nsw.gov.au

5. HEALTHCARE IN FOCUS 2011: At a glance November 2011 www.bhi.nsw.gov.au (Ω) The Commonwealth Fund’s 2011 International Survey of Sicker Adults in Eleven Countries

6. Safety in human activities Professional Fishing Blood transfusion No system beyond this point Fatal Iatrogenic adverse events Anesthesiology Cardiac Surgery Patients Medical risk (total) Hymalaya mountaineering Chartered Flight Civil Aviation Microlight spreading activity Railways (France) Road Safety Chemical Industry (total) Nuclear Industry Fatal risk 10-2 10-3 10-4 10-5 10-6 Very unsafe Unsafe Safe Ultra safe Source: Professor Rene Amalberti

7. Is healthcare getting safer? • The United States Agency for Healthcare Research and Quality has made important advances by adding safety indicators. • In UK, rates are actually increasing in all but two of the nine indicators so far translated. • “Deaths in Healthcare Resource Groups” (HRGs) appear to be decreasing significantly. • “Foreign Body Left during Procedure” is also decreasing slightly, but this indicator has been found to include many cases which are not related to patient safety. • The remaining indicators appear to suggest that care is getting steadily less safe 2009 2005 2008 Prof. Rene Amalberti

8. Challenges • Demand • Resource constraints • Technical complexity • Public expectations • Newsworthiness • Political risk

9. So we have a challengeLet’s start by focussing on what we are trying to achieve.......... which is excellent care

10. What does excellent care look like?(What we are aiming for) • right choice of care (appropriate) • which addresses clinical needs (effective) • good patient experience (acceptable) • no unnecessary harm (safe) • optimal resource use (efficient) • consistent care standards (reliable)

11. How would we deliver excellence? • Good care decisions • Good execution of care decisions • Compassionate and respectful care • Early recognition of mistakes • Good coordination & no duplication of effort • Good systems & commitment of staff

12. Agreed. But.....How would we actually deliver excellent care?In other words, what strategies or systems of care will deliver these elements of excellence?

13. A decade of improvement in NSW.....

14. December 2003

15. Improving care in NSW • Walker Inquiry • Structural and governance changes (area health services, boards, chief executives) • Patient Safety and Clinical Quality Program • Clinical Excellence Commission • Clinical Governance • Incident reporting • Improvement programmes

16. November 2005 Vanessa Anderson dies • Minor head injury in a 16 year old (golf ball) • Coroner found she died from over-sedation • “I have never seen a case such as Vanessa’s in which almost every conceivable error or omission.....continued to build one on top of the other.”

18. An attempt to summarise our problems.....Universal Root Causes

19. Universal Root Causes • Culture –punitive blaming system culture, which is tribal, and disengages crucial groups, particularly the clinicians • Clinical governance – ambiguities about who is responsible for what in healthcare, and lack of clear lines of accountability for safety and quality

20. Universal Root Causes • Communication – poor communication of essential information among healthcare providers and with patients and their families • Teamwork and coordination of care – poor teamwork, care planning and delivery in a fragmented system of care

21. Universal Root Causes • Capacityand capability - human resource and skills mal-distribution, both geographically, and over time (daily, weekly and seasonally). • Appropriateness of care – failure to deliver appropriate care when it is needed or failure to escalate care to a service that can meet needs.

22. Root causes manifest as: • Poor diagnostic precision • Failure to set objectives of care • Failure to rescue • Poor teamwork and coordination, including poor communication • Fragmentation of care • Inadequate and inappropriate treatment

23. November 2008 In NSW Garling found.... • A good system and high standards • and • A Great Schism • Lack of continuity • Fragmented care • A need for better teamwork http://www.lawlink.nsw.gov.au/Lawlink/Corporate/ll_corporate.nsf/vwFiles/E_Overview.pdf/$file/E_Overview.pdf

24. What do other inquiries show? (Travaglia JF, Braithwaite J, et al MJA 2008) • failures of clinical governance, • deficiencies in teamwork and • failure to include patients as informed members of the team.

25. Garling’s view • Garling emphasises the need for, “A new model of teamwork… to replace the old individual and independent ‘silos’ of professional care.” [Overview, para 1.25]. He also talked of “…strengthening the training of new clinicians in better, safer treatments based on a patient-centred team approach; [Overview, para 1.34].

28. Staff teamwork matters most to patients • “Among patients who offered excellent ratings, how well the doctors and nurses worked together was the main factor that influenced their rating.” Bureau of Health Information Insights into Care: Patients’ Perspectives on NSW Public Hospitals, May 2010

29. Summing up the problem with healthcare • Healthcare systems have low reliability, high cost, poor patient satisfaction (sometimes) and often do not meet patient needs • Efforts to improve quality have had successes, but sustainability and scalability is a challenge • Healthcare providers are under increasing pressure to improve (and so are governments)

30. Towards solutions.....

31. Nature of solutions • Effective • Sustainable • Scalable • Affordable

32. How would we deliver excellence?(let’s remind ourselves) • Good care decisions • Good execution of care decisions • Compassionate and respectful care • Early recognition of mistakes • Good coordination & no duplication of effort • Good systems & commitment of staff

33. Principles for a solution • Health systems are frogs not bicycles (A. Mant) – complex adaptive systems • Multidisciplinary teams are our basic production units (cells). They deliver care to patients • Patients are part of the team • We should start re-designing the system at the microsystem level but also recognise the importance of the macrosystem (organism) • A multivalent approach is needed to be sustainable

34. A microsystems approach.....

35. What is a clinical microsystem? • A group of clinicians and non-clinicians that care for a group of patients • A geographic entity • United by a common purpose • In which roles are clear • Characterised by core functions • Dependent on essential standards, tools, resources and skills

37. Vertical Teams Horizontal Team Patient Journey WARD

38. The Healthcare Unit Teammembers Family Patient Clinicians Non-clinicians CHP 2008

39. Patient Care Team Functions • Leadership and Governance • Team Structure and Dynamics • Care Planning, Coordination and Delivery • Standard Protocols and Procedures • Patient Safety and Quality Systems • Patient Experience • Education, Training and Supervision • Workforce Management and Development • Information Access • Support Services and Equipment

41. Patient Care Team Functions examples of supporting Standards, Tools, Skills and Resources Values-based, Interdisciplinary leadership, Authority to lead Leadership & Governance Structured ward rounds, Team decision-making structures, Teamwork skills Care planning with objectives, Care navigation Team Structure & Dynamics Care Planning Co-ordination & Delivery Excellent Care Handover checklists, Standard observation charts, Core safety standards Standard Protocols & Procedures Patient Experience Asking, listening and responding to concerns, AIDET Tool, Patient activated rapid response Incident reporting and review, Risk register, Prioritisation EMR, Decision support Patient Safety & Quality Systems Information Access Core skills training (eg. DETECT, Team Health) Supplies management, Equipment procurement Human factors design Education, Training & Supervision Support Services & Equipment Workforce Management Rostering for seniority, Skill balance, Succession planning Source: C Pain & S Whitby

42. Examples of Programmes Leadership & Governance TeamSTEPPS Team Structure & Dynamics Care Planning Co-ordination & Delivery Excellent Care Standard Protocols & Procedures Patient Experience IPSE Program Patient Safety & Quality Systems Information Access Education, Training & Supervision Support Services & Equipment Workforce Management Team Health

43. Our solutions must operate at the microsystem or unit level

44. ....and will deliver: • Good care decisions • Good execution of care decisions • Compassionate and respectful care • Early recognition of mistakes • Good coordination & no duplication of effort • Good systems & commitment of staff

45. Way Forward • Adopt functions as a basis for operationalising a microsystems approach • Adopt or develop necessary standards, tools, resources and skills for teams to perform key functions.

46. Way Forward (cont.) • Reinforce foundations for healthcare unit teams, by focussing on unit leadership, role clarity of members, and establishment of key team structures and processes. • Build teams through coaching and communities of practice, and provision of standards, tools, resources and skills.

47. Questions?