Awareness of Quality of Care

4. Awareness of Quality of Care

5. 56 countries, 281 million operations, • 1 operation for every 25 human being alive per year. • Major complications: 3 – 16% • Death rate: 0.4 to 0.8% • Assuming 3% adverse events and 0.5 death rate: • 7 million suffered adverse event. • 1 million die during or after surgery. • More than halve of the events are known to be • preventable. • A major cause of death and disability worldwide.

6. Onbedoelde schade in Nederlandse ziekenhuizen • In 2004 42000 patients died in hospitals • 3% of admissions • 5.7% adverse events • 4.1% deaths related to adverse events • Estimated deaths 1735 • Life expectations of these patients were in one-third 1 – 5 years, in 18% more than 5 years • 54% of adverse events are surgery related EMGO Instituut and NIVEL, 2007 www.nivel.nl

7. “Good people are set up to fail in bad systems. Let’s figure out how to keep everyone safe”

8. We are in a strange place. Everyone knows there is a problem, but we don’t know how to fix it. Sir Ian Kennedy, Conference Everybody’s Business, 2006

9. Why high-risk processes in the OR are prone to process failure? • variable input • complicity • inconsistency • tight coupling • human interaction • time pressure • hierarchical culture

10. Factors responsible for error • Workload • Inadequate knowledge or experience • Poor human factor design • Inadequate supervision or instruction • Stressfull environment • Mental fatique or boredom • Rapid change

11. Event litigation relation to other specialities Achieve optimal patient’s safety Competition (market working) Limit costs New technology Shift to a day surgery maximized diagnosis New procedures/technique (NOTES) Increase production Conflicting goals influencing process in the OR

12. System behaviour - adverse event trajectory Fault quality control Communication Staff training Resources Facility Faulty action Active failure Latent failure Situational factors Adverse event Care provider Unlucky circumstances Technical staff Information system Management Safety barrier absolute or relative

13. Pathways to adverse event analysis, DEB and MTO. Perform team Select process DEB (proactive) Evaluate system effect of disturbance Map process Hypothetic disturbance Validate hypothesis Implement error containment actions Search for latent failures and barrier to be adjusted Develop preventive actions Safety improvement Identify options or insufficient barriers Identify latent failures View event mapping View cause analysis Barrier analysis Identify situational factors Investigation and …………… MTO (reactive) MTO = Man Technology Organisation = HEPS = Human performce Enhancement System DEP = Disturbance Effect Barrier Close analysis Map event

14. Exploration of gaps The role of gaps in the continuity of care processes and patient’s safety – challenging but promising • Catalogue gaps and map them • Find out how experts detect, anticipate and bridge gaps • How gaps are created by organisational and institutional changes Outcome of explorations can provide a coherent useful view on patients safety and be appleid to identify future safety problems, anticipate the impact of change and measure the progress.* * R.I. Cook (2008)

15. Hospital management Media Individual care provider Insurers Insurers Staff of department Advocacy groups Patient’s family Staff involved Others? Supporting technical staff Patient Attorneys Stakeholders with potentially conflicting goals Event reporting system does it work?

17. Reducing errors through work system improvements Standardised Reduced Reliance on memory Simplify process Design for errors Adjust work schedules Optimize information access and quality Optimize the environment Improve communication Improved Work System Adequate safety training Right people for the job

18. ANESTHESIOLOGIST ASSISTENT CIRCULATING NURSE ANESTHESIOLOGISTS Other specialists SURGICAL NURSES SURGEONS SUPPORT SERVICES PATIENT

19. Perform procedure as planned and manage workload Operational team actions Communicate with team Problem solving Fundamental requirements Team structure and climate Team work skills And expertise Team dimensions and their interrelationship.

20. Creating common mental model for surgical team in operating theatre • getting everyone on stage in the same play safe environment (feel free to speak up, if any safety concerns) • getting everyone on stage in the same play, and no plot changes OR-teams should be unitairy and cohesive in order to achieve high-level of performance

21. Situation Background Assessment Recommendation What is going on? What is clinical background/context? What I think the problem is? What would I do to correct it? SBAR Approaches and behaviour for improvement of communication

22. CUS Critical language approach. “I am concerned” “I am uncomfortable” “This is unsafe” “I am scared”

23. Safe performance of task How human solve problems Main rules Side rules Exception of rules Knowledge from experience: Scripts/schematas

24. Problem solving - Rasmussen • Skill-based Standardised task • Rule-based Novel situation with some likelihood • Knowledge-based Entirely new situation • Simulation Experience apprenticeship

31. Equipment  Time out  Black box  Debriefing