Transcript Levels of Reliability

Reliability Principles
CQN Asthma Project
January 14, 2010
“I have no relevant financial relationships with
the manufacturers(s) of any commercial
products(s) and/or provider of commercial
services discussed in this CME activity.”
Outline
• Definition and purpose of high reliability systems
• Measuring reliability - some simple math
• Reliability principles and chronic illness care
changes
– How much improvement can we expect from each?
Version 2.0
CQN Asthma Project Practice Key Driver Diagram
Key Drivers
GLOBAL CQN AIM
We will build a sustainable quality
improvement infrastructure within our practice
to achieve measurable improvements in
asthma outcomes
Specific Aim
From fall 2009 to fall 2010, we will achieve
measurable improvements in asthma
outcomes by implementing the NHLBI
guidelines and making CQN’s key practice
changes
Measures/Goals
Outcome Measures:
 >90% of patients well controlled
Process Measures
 >90% of patients have “optimal” asthma care (all
of the following)
 assessment of asthma control using a
validated instrument
 stepwise approach to identify treatment
options and adjust therapy
 written asthma action plan
 patients >6 mos. Of age with flu shot
(or flu shot recommendation)
 >90% of practice’s asthma patients have at least
an annual assessment using a structured encounter
form
Engaging Your QI Team and
Your Practice
*The QI team and practice is active and
engaged in improving practice processes
and patient outcomes
Using a Registry to Manage
Your Asthma Population
*Identify each asthma patient at every visit
*Identify needed services for each patient
*Recall patients for follow-up
Using a Planned Care
Approach to Ensure Reliable
Asthma Care in the Office
* CQN Encounter Form
* Care team is aware of patient needs and
work together to ensure all needed
services are completed
Developing an Approach to
Employing Protocols
* Standardize Care Processes
* Practice wide asthma guidelines
implemented
Providing Self management
Support
* Realized patient and care team
relationship
Interventions
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Form a 3-5 person interdisciplinary QI Team
Formally communicate to entire practice the importance and goal of this
project
Meet regularly to work on improvement
All physicians and team members complete QI Basics on EQIPP
Collect and enter baseline data
Generate performance data monthly
Communicate with the state chapter and leaders within the organization
Turn in all necessary data and forms
Attend all necessary meetings and phone conferences
Select and install a registry tool
Determine staff workflow to support registry use
Populate registry with patient data
Routinely maintain registry data
Use registry to manage patient care & support population management
Select template tool from registry or create a flow sheet
Determine workflow to support use of encounter form at time of visit
Use encounter form with all asthma patients
Ensure registry updated each time encounter form used
Monitor use of encounter form
Select & customize evidence-based protocols for your office
Determine staff workflow to support protocol, including standing orders
Use protocols with all patients
Monitor use of protocols
Obtain patient education materials
Determine staff workflow to support SMS
Provide training to staff in SMS
Assess and set patient goals and degree of control collaboratively
Document & Monitor patient progress toward goals
Link with community resources
Health System Perspective: Quantifying “Reliability”
 “Reliability” = Number of actions that achieve the
intended result ÷ Total number of actions taken
 “Unreliability” = 1 minus “Reliability”
 It is convenient to use “Unreliability” as an index,
expressed as an order of magnitude (e.g. 10-2 means
that the action fails to achieve its intended result 1 time
in 100)
White Paper, p. 3
Slide 5
Associates in Process Improvement, 2009
Un-Reliability?
Slide 6
Associates in Process Improvement, 2009
What changes in the process of care
delivery will change the outcome?
Assessment of
asthma control
Appropriate
Treatment
Improved
Outcomes
Definition Of “Reliability”
Reliability is failure free
operation over time.
Can reliability principles
be applied effectively to
improve the consistent
delivery of high-quality
health care?
Reliability most connected to the IOM’s dimensions for the health care system of
• effectiveness (where failure can result from not applying evidence),
• timeliness (where failure results from not taking action in the required time)
• patient-centeredness (where failure results from not complying with patients’
values and preferences).
White Paper, p. 2, 3
Slide 8
Associates in Process Improvement, 2009
Levels of Reliability
Level
Slide 9
Reliability
Failures in
10,000 actions
Success Rate
1
10-1
80%-95%
1500-2000
2
10-2
96%-99.5%
50-1499
3
10-3
99.6% - 99.95%
5-49
4
10-4
99.96%-99.995
0.5-4
10-5
99.996 – 99.9995
0.1-0.4
10-6
>99.9996
<.1
White Paper, p. 4
Associates in Process Improvement, 2009
Human Factors Engineering
René Amalberti: Premises
• “Unconstrained” human performance (guided by
personal discretion, only) is worse than 10-2
• “Constrained” human performance can reach 10-2
to 10-3
Amalberti’s Reliability Framework
René Amalberti
Increasing safety margins
No limit on discretion
Excessive autonomy of actors
Becoming team player
Agreeing to become
« equivalent actors »
Accepting the residual
Ego-centered safety protections, vertical conflicts risk
Accepting that
Loss of visibility of risk, freezing actions changes can be
destructive
Craftmanship attitude
Blood transfusion
Cardiac Surgery
Patient ASA 3-5
Anesthesiology
ASA1
Medical risk (total)
Himalaya
mountaineering
Chartered Flight
Microlight or
helicopters spreading
activity
10-2
10-3
Railways (France)
Road Safety
Chemical Industry (total)
10-4
10-5
Nucleur Industry
10-6
Ultra safe
Very unsafe
Slide 11
Civil Aviation
No system beyond
this point
Fatal Iatrogenic
adverse events
White Paper, p. 3-4
Fatal
risk
Associates in Process Improvement, 2009
Exercise
1. Review the goals on your improvement
project.
2. What Level of reliability are you
targeting on your project?
10-1
10-2
10-3
Slide 12
Associates in Process Improvement, 2009
How reliable is the
collaborative?
Alabama Data
What can we learn from variation across states?
Alabama
Oregon
Ohio
Level 2 Reliability at CCCH
Asthma Action Plan
How are they doing it?
Optimal Care at CCCH
Components of a Process
Have Known Failure Rates
Level 1 (80-90%) Reliability
• Team focus on the outcome goal
• Working harder
• Feedback of information on performance
• Awareness and training
• Standardize decision-making (e.g., guidelines)
Level 1 Reliability Concepts in CQN
• Team focus on the outcome goal:
– Team aim and goals.
• Working harder:
– Collaborative participation
• Feedback of information on performance:
– Monthly measurement and feedback of results
• Awareness and training:
– Training of practice physicians and staff
• Standardize decision-making:
– Algorithms for severity classification, control, medications
% of children screened
Level 1 Reliability
Level 2 (95%) Reliability
• Real time identification of failures (“identify
and mitigate”)
• Checklists and observation
• Redundancy
• Making the “right thing” the “easy thing”
• Standardization of process
Level 2 (95%) Reliability Embedded in
CQN Key Drivers
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Real time identification of failures
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Checklists and observation
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Redundancy
•
Making the “right thing” the “easy thing”
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Auditing and daily review of failures
Templates (structured encounter form)
Planned care (e.g., pre-clinic huddle involving nurses)
Monthly population review using registry for care management
Patients empowered to participate in pre-visit planning
Protocols
Default to the appropriate option: Patients get asthma encounter form whether
physician orders or not.
Standing “flu shot” orders
Standardization of process
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Protocols and defined roles for template use (e.g., front desk, nurse)
Defined staff roles (includes hiring, training, performance evaluation)
Desired Outcome
Level 2 Reliability
Level 3 (99%) Reliability
• Preoccupation with failure:
– Real time awareness of failures
– “Process Owner” for patient education
– Measure days between serious events (e.g., ED visits)
• Reluctance to simplify interpretations:
– Learning from each failure and from those doing better.
• Sensitivity to operations:
– Support the front line (e.g., practice coaches)
• Deference to expertise:
– Avoid a strict “Top-Down” Culture
Desired Outcome:
Level 3 Reliability
“Robust Design”
Process/control factors
• Level 1 Components
• Level 2 Components
• Level 3: Mindfulness
Situational factors
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Severity of problem
Values/habits/lifestyle
Preferences
Support system
Resource availability
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Outcomes
• Optimal care
• QOL
• Admissions
THANK YOU
QUESTIONS?