29 April Production and Operations Management Conference Reno Nevada USA

1. Improving Patient Safety How to Use Service Modularity in Healthcare Processes to Manage Systemic Errors Dr Maria Kapsali 04/29/2011 POMS

2. Contents 1. Healthcare error 2. Systems approaches 3. HEPM: a complex adaptive approach 4. Modularity – complementing HCAS Appendix: The NHS

3. Health care error literature professional stream: law and litigations 2. human performance stream: psychology and engineering and includes research in ergonomics and human factors such as cognition Problems oversimplification as it does not capture the variability in human behaviour or the complexity in processes focused on individuals/groups overlook the systemic factors linking the environment to people’s actions

4. Systems approaches to error the environment shapes and institutionalizes action discriminate between individual errors which are inevitable and the majority which are systemic (active vs latent failures Control the systemic through controlling organizational processes) Advantages: enhances collective effort, addresses most mistakes happening in hospital operations Disadvantages:at this stage frameworks are still abstract so they are not widely operationalizable Focus on holes within the system but cannot distinguish which may be critical or not

5. Systems approaches to error Reason, J., 1995. Understanding adverse events: human factors. Qual. Saf. Health Care, 4;80-89.

6. Systems approaches to error Holzmueller, C., P. Pronovost, and R. Branson. 2004. How can we learn from incidents? Critical Connections. 3(1).

7. Complex Adaptive Systems HEPM: Healthcare Error Proliferation Model opertionalizes the Swiss Cheese Model to study the complex adaptive healthcare system in four multiple layers/discrete locations/interfaces populated with ‘holes’ where the causes of accidents are nested. 1) organizational leadership 2) risky supervision 3) situations for unsafe practices 4) unsafe performance Palmieri, PP.A., DeLucia, P.R., Peterson, L.T., Ott, T.E., Green, A., 2008. The anatomy and physiology of error in adverse health care events, Patient Safety and Health Care Management Advances in Health Care Management, 7: 33-68.

9. Observations in the wardsEPSRC Project: Design Out Medical Error The five processes are: handwashing, handover, vital signs monitoring, infection control and medication

10. Methods: Data analysis Find ‘hotspots’ = critical activities where most harmful errors happen Find which hotspots overlap amongst the five ward processes and are systemic Find ways to simplify or standardise these activities to eliminate erroneous actions Identification of hotspots through: processes maps; Combined FMEA results – Pareto Use Fishbone and HEPM through mind maps and causal chains from content analysis Identification of the critical interfaces in the adaptive complex ward processes Suggestions how to modularize the processes

11. Results (29 hotspots within all 5 processes)

12. Results: identifying the systemic causes

13. Results: HEPM Root Cause Analysis – the systemic causes Leadership Risky Supervision Emphasis on operational cost and time metrics Focus on satisfying the funders not the patients Lack of training Human resource is not invested upon Elaborate procedures Supervising low level - little on the job training Unsafe performance Lack of improvement culture Avoid personal responsibility information 'holes' The Built Environment - lack of equipment and inhibiting space Time Negligence Lack of effective visual directions Ignorance Unsafe conditions

14. Controls Negligence Performance control procedures Time Pressure Cost Errors Unsafe Performance Fear of blame Process Leadership-design Reliability holes of important Information Ignorance Lack of training Capacity Lack of Group Supervision Capability Lack of facilities Lack of Group Supervision Control holes Lack of feedback Information Results: FeedbackLoop model of the systemic causes

15. Risky Supervision 1 2 6 3 Leadership 3 7 1 1 2 Unsafe practices 4 6 5 2 Results: the activities amongst the processes overlap Modularize designing for common interfaces amongst overlapping processes Information block Training – routinizing Procedures Group leadership Resources Negligence Time Unsafe conditions 7 2 1 6 1 3 7 1 7 4

16. Suggestions Modular designs to enhance the implementation of systemic models of HC could use the identification of hotspots The NHS is already modular and needs to redesign its interfaces and especially the information and control holes which include the registration and passing on of data amongst the handover, vital signs monitoring and medication processes, instead of trying to create a totally holistic information and communication system.

17. Thank you Any Questions

18. The NHS Many structural reforms affecting quality management Tried to turn a rigid unitary organization with a clear chain of command from the Health Secretary to the unit manager into a looser more flexible one, by separating into purchasers and providers. The result was a quasi autonomous, multidivisional form (M-form) with operational responsibilities separated from strategic responsibilities The model of the ‘flexible firm’ pursued in these reforms and as advocated by Atkinson (1984) has an inherent contradiction, prescribing the combination of Taylorism and functional flexibility in the same job design

19. Advantages Disadvantages Managerial risks improved Staff interest and awareness improved Decline in individualism more teamwork Greater involvement in peer reviews and monitoring audits Efficiency savings Establishment of standards Quite cheap around 8% of GDP spent on NHS Focus on introducing concepts to managers less focus on how to implement them Lack of unified quality strategy which was delegated locally led to a fragmented system of various performance monitoring variations according to Trust – the system cannot be assessed holistically and the guidelines are usually vague Effects of reforms on quality management Morgan and Everett (2007)

20. Disadvantages 3. Dependence on control through performance measurements and not on cultural change and brokerage amongst professional silos 4. Scepticism amongst professionals towards the quality systems which are perceived as a tool for cost cutting and control over their individual performance – the system is based on individual blame 5. The implementation of additional performance criteria led to fatigue Morgan and Everett (2007)

21. Disadvantages Political controversy – demand and access vs efficiency control Care is too often delayed, long queues and rationing Community based care was not fully realized Relations between general practice, public health and hospital based acute are fragmented The system works in functional compartments that leave patients unhappy and providers frustrated Morgan and Everett (2007)