A presentation given by international keynote speaker Dr. Stephen Muething from Cincinnati Children's Hospital, USA at the CHA conference The Journey, in October 2012.

1. The Journey Towards
Zero Harm
A Report from One Journeyman
Stephen E. Muething, MD
Vice President for Patient Safety
James M. Anderson Center
October 23, 2012

2. It Truly Is A Journey
Thank you to CHA, the CEO’s and
the Children’s Hospital’s
for sharing and learning together.

5. 523 Bed Medical Center
32,000 Admissions/Year
1,000,000 outpatient visits
$143 million externally funded research
12,000+ employees
31,000 Surgical Procedures (20% Inpt)
17% average annual growth over past decade
National /International partnerships

6. Today’s Discussion
 Using Reliability as the Guidebook:
 Process Reliability
 High Reliability Culture
 Employee Safety
 HRO Techniques
 Learning Together to accelerate the journey
 Next Steps on the Journey

7. Reliability: more than Safety
 No needless deaths
 No needless pain
 No helplessness
 No unwanted waiting
 No waste
Don Berwick, Institute for Healthcare Improvement
Our Safety Strategy:
Eliminate all serious harm for patients
and employees by June 30th, 2015

8. Pyramid of Harm
(Patient and Employee)
Strategy: SSE’s &
Focus on the top Lost-time
of the pyramid and Injuries
progressively move down
Serious Harm Index &
OSHA Recordable Injuries
Events of Minimal to Moderate Harm &
All Employee Injuries
Near-Miss Events
Patient and Employee

11. Reliable Key Processes
 Dozens across organization
 Standardization
 Sustainability built into the system
 Real-time failure awareness
 Data feedback to the microsystems
 Making the right thing, the easy thing

12. Key Processes
 VAP Bundle
 CLA-BSI Bundle
 Pressure Ulcer Bundle
 Safe Medication Practices
 CA-UTI Bundle
 Etc, etc, etc………..

13. CONFIDENTIAL
Real Time Failure Awareness
Patient Safety Sept. 9- Sept. 15 Employee Safety Sept 14 – Sept 20
Events of Harm ISSUE PAST FY 13 FY12
CA-BSI WEEK YTD YTD
9/10 A5N
9/10 A5S Total OSHA Recordable cases: 4 48 59
9/11 B6HI
- Lost-Time 1 7 2
VAP
- Blood Borne Pathogen Exposures 1 15 18
9/2 B6HI (disease progressed
to classify this week – effective - Slips, Trips, Falls 0 4 6
date 9.2)
- Patient Interaction 1 4 8
SSI
9/1 (upon review – met criteria Late Incident Reports 2 28 N/A
for SSI) (These are incidents called in to 803- Until
OUCH beyond the day of injury) 2/23/13

14. Data Feedback To Microsystems

15. Data Feedback To Microsystems

16. Making The Right Thing, The Easy Thing

22. No aviation fatalities…
No crashes…
No nuclear leaks…
No Serious Harm

23. Characteristics of
High Reliability Organizations
1. Preoccupation with failure
Regarding small, inconsequential errors as a symptom that
something is wrong; finding the half-event
2. Sensitivity to operations
Paying attention to what’s happening on the front-line
3. Reluctance to simplify
Encouraging diversity in experience, perspective, and opinion
4. Commitment to resilience
Developing capabilities to detect, contain, and bounce-back from
events that do occur
5. Deference to expertise
Pushing decision making down and around to the person with the
most related knowledge and expertise

24. Senior Leadership “Owns” Safety

25. Transparency

26. Development of a
High Reliability Culture
Leadership Developing Mindfulness
• High functioning
• Aware of all harm –
microsystems
EVERYDAY
• Executive reinforcement to • Aware of all risk –
front line. CONTINUOUSLY
• Daily and shift huddles; • Harm reduction owned by
Organizational Daily Brief front line leaders
• Multiple improvements going • Learning to find the cause
on simultaneously • Alignment of the strategic
• Just culture plan with the front line
• Managing by Prediction rather
than Reaction

27. Development of a
High Reliability Culture
Error Prevention
• Behavior training
• Reinforce via Safety Coaches
• Reinforcement and accountability by supervisor
(5:1 feedback)
• Situation Awareness
– Identify - Mitigate – Escalate

28. Pyramid of Harm
(Patient and Employee)
SSE’s &
Lost-time
Injuries
Serious Harm Index &
OSHA Recordable Injuries
Events of Minimal to Moderate Harm &
All Employee Injuries
Near-Miss Events
Patient and Employee

30. Employee Safety

32. Top 3:
Blood Borne Pathogen Exposure
Patient Interaction
Slips/Trips/Falls

34. Structures & Techniques
From HRO’S

35. • Pre-Briefs/Debriefs
• Checklists
• Flattening Hierarchy
• Standardizing Communication
• Huddle
• Situation Awareness

36. James M. Anderson Center
for Health Systems Excellence
Managing By Prediction

37. James M. Anderson Center
for Health Systems Excellence
Organization Huddle
Adopted from the US Navy
The Admirals’ Huddle on a
Carrier Task Force
• Look Back
• Look Forward
• Identify and Solve Issues
Every Morning @ 9AM

38. James M. Anderson Center
for Health Systems Excellence
Cincinnati Daily Operations
Children’s Brief
Version 8:35 AM
Department
Huddles
8:00AM
Unit-Clinic-Team
Huddles
6:30-7:45AM

39. James M. Anderson Center
for Health Systems Excellence
Three Topics
• What Happened in the Previous
24 Hours?
• What’s Predicted for the Next 24
Hours?
• Issues Which Need Resolution.

40. James M. Anderson Center
for Health Systems Excellence
Departments Reporting Out on
Daily Operations Brief
Employee Safety Radiology
Inpatient & ICUs Family Relations
Surgery (Liberty too) Laboratory
Emergency Department Infection Control
(Liberty too) Supply Chain
Outpatient Information Systems
Psychiatry (A4C2 too) Protective Services
Home Health Care Facilities
Pharmacy Others
Respiratory

41. James M. Anderson Center
for Health Systems Excellence
Inpatient Huddles

42. SITUATION AWARENESS

43. Situation Awareness Model
Family Bedside Microsystem Organization
concerns Team
Team Team
High risk
therapies Intern
Watch Stander Rapid
Senior Resident Response
PEWS>5
Safety Team
Bedside Watch Stander
Watcher nurse (MPS and SOD)
PCF/Manager at 800, 1600 & 100
Reliable escalation of
Communication risk
concern Rapid assessment and
Attending communication with
primary team
43

44. Situation
Awareness project
go-live

45. Learning Together
Start With One State

46. Expanding Scope to Eliminate Harm
Across US Children’s Hospitals
(2012)
Spread
(2012)
Share network best
Create National practices with all (2012)
Children’s Network Disseminate at national
meetings (2012)
Expand network to include
26 leading children’s Develop strategies with
(2008-2011) hospitals outside Ohio national organizations
Develop Ohio Network (Phase I) (2012)
Active improvement work Add 50 hospitals (Phase II)
Initial HAC improvement work
on 10 HACs to data sharing and network
SSE reduction; efforts to learning opportunities (2013)
address organizational culture Efforts to address
organizational culture Establish other regional
Creation of pediatric patient collaboratives (2013)
harm index “All Teach, All Learn”
Develop mentor hospitals
8 33 83

48. Adopting Common Behaviors
48

49. Thank you
Questions?
stephen.muething@cchmc.org
Cincinnatichildrens.org/andersoncenter

51. Human Factors

52. SEIPS Model
Pascale Carayon et al.

54. Questions?
Thank You
stephen.muething@cchmc.org
http://cincinnatichildrens.org/andersoncenter
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