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High Reliability Health Care

High Reliability Health Care. Primum Non Nocere. HRO. Current State of Medical Care: Highly trained, intelligent professionals Compassionate and motivated Without exception, want what is best for their patients. HRO. Current State of Medical Care (IOM):

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High Reliability Health Care

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  1. High Reliability Health Care Primum Non Nocere

  2. HRO Current State of Medical Care: Highly trained, intelligent professionals Compassionate and motivated Without exception, want what is best for their patients

  3. HRO Current State of Medical Care (IOM): Medical errors are 8th leading cause of death >110,000 preventable deaths = 747 crash/day >1,000,00 preventable injuries >$30,000,000,000 cost 55% adults receive recommended evidence based care

  4. HRO Error Attribution: 80 - 85% System 15 - 20% Human

  5. HRO How do system errors occur? Health Care is the most complex business in world Systems do not allow consistent delivery to the patients Systems have not been built to support the provider Operates 24/7/365 Resistance to standardization Providers -- culture of individualism Rapid rate of technological change w/o adequate IT support Communication failures

  6. HRO To err is human… …but to persevere in error is only the act of a fool Cicero

  7. HRO Sources of Human Error: Perception we see and hear what we expect Assumption we believe that things are a certain way Communication we say what we mean, but others hear what they percieve

  8. HRO A highly reliable organization consistently achieves the correct outcome by creating systems that support humans, reducing the variability and likelihood of errors.

  9. HRO Imagine a world without adverse events reaching your patient

  10. HRO Examples of HROs Nuclear industry Airline industry Process Improvement Tools they used: Lean Six Sigma Change Management

  11. HRO Creating a Collective Mindfulness to prevent unsafe conditions before harm occurs HROs are preoccupied with failure. Recognition by members threats to safety are complex. Recognition and obligation to report any deviation from approved operations. Resilience - errors occur, recognize and contain them. Deference to those with expertise

  12. HRO High Reliability is a Culture Transformation Leadership must commit to goal of Zero Patient Harm Principles and Practices of a Safety Culture are incorporated throughout the entire organization Process Improvement tools and methods are widely adopted

  13. HRO To understand the steps we must take to achieve High Reliability and Zero Patient Harm, we must first discover and acknowledge what are current culture is and create a Performance Improvement Plan to achieve a culture change

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