Hagstrom, J. Nathan, MD, MHCM

Hart, Rachael

O\u27Brien, Brittany

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksResearch Scholars Poster PresentationAssessing High Reliability in Inpatient PediatricUnitsRachael HartDeSales UniversityBrittany O'BrienKutztown University of PennsylvaniaJ. Nathan Hagstrom MD, MHCMLehigh Valley Health Network, j_nathan.hagstrom@lvhn.orgFollow this and additional works at: http://scholarlyworks.lvhn.org/research-scholars-postersThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtHart, R., O'Brien, B., Hagstrom, N., (2016, July, 29) Assessing High Reliability in Inpatient Pediatric Units. Poster presented at LVHNResearch Scholar Program Poster Session, Lehigh Valley Health Network, Allentown, PA.© 2016 Lehigh Valley Health NetworkLehigh Valley Health Network, Allentown, PennsylvaniaAssessing High Reliability in Inpatient Pediatric Units• As a children’s hospital we feel it is imperative that we strive for perfection and zero unnecessary harm. Health care is highly complex; risks are high and the pace fast-moving. Despite improvements in technology, errors continue to occur.  • Many have suggested that applying high-reliability principles to health care improves patient safety and other outcomes. High-reliability is achieved when the team or system 1) is preoccupied with failure, 2) is sensitive to operations, 3) defers to front-line experts, 4) is able to contain and bounce back from unexpected events and errors, and 5) is reluctant to oversimplify. It is achieved when the team or system achieves a high level of mindfulness about what has happened, what is happening, and what might happen.• Our main objective was to assess behaviors and practices that are common in high reliability organizations within inpatient pediatric units at Lehigh Valley Children’s Hospital.Staff Survey• All three units had a culture of high-reliability according to published standards. • The Pediatrics unit had the highest score of high-reliability, followed by the PICU and then the NICU.• The area with the lowest score for all units was “Reluctance to Simplify.”Service Line Huddle• There are a lot of discussions and sharing of ideas.• There were fewer concerns/risks reported than expected with some variability regarding what was considered a concern or risk (i.e. patients with central lines).• Daily metrics were not always reported because the person who had the information was not present or the information was not passed on. • Extent of condition was described typically only with a cause analysis, which was not always discussed the first day.  Action plans were not always stated. Unit Huddles• NICU would provide more detailed discussions about events that occurred and concerns for the day with countermeasures often listed on their huddle board. • PICU would list more concerns about patients likely due to the higher acuity.• Peds reviewed all issues that were listed on the huddle board each day whether they had changed or not, which allowed for more staff to be included.Family-Centered Rounds• Families were always invited to join in on the rounds and voice their questions, comments, and concerns.• When families received written reports of labs and written information, in general, they were appreciative.• Over the past year, the hospital has implemented key High-Reliability practices (figure 1) (ref 1) and Lean Daily Management methods and tools (figure 2) (ref 2) including standard work for huddles and rounds (see below). • In order to determine whether or not the hospital has achieved a culture of high-reliability, we did the following:– Staff Survey using validated questions from Weick and Sutcliffe (ref 1)– Structured observations of service line and unit huddles as well as family-centered rounds (collaborative rounding)– Staff Interviews• In high-risk, high complexity environments where the unexpected occurs not infrequently, high-reliability principles and practices are critical for ensuring minimal defects/errors in care and for not ignoring ambiguous threats that could result in significant adverse events.• By implementing a service line huddle, individual unit huddles, daily management visibility boards, and other standard work including bundles and clinical pathways, the Lehigh Valley Children’s Hospital has achieved a culture of high-reliability.Rachael Hart, Brittany O’Brien, Nathan Hagstrom MD, MHCM INTRODUCTIONMETHODSRESULTS DISCUSSIONCONCLUSIONSHigh‐ReliabilityJust CultureLearningThe 5 Attributes of an HROLean Daily ManagementRobust ImprovementSensemakingEliminating WasteMindfulnessFigure 1. Components of High Reliability.References:1. Weick, K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in an age of uncertainty (2nd ed.). San Francisco, CA: Jossey-Bass. 2. Mann, D. (2005). Creating a lean culture: Tools to sustain lean conversions. New York, NY: Productivity Press. 3. Nance, J. J. (2008). Why hospitals should fly: The ultimate flight plan to patient safety and quality care.Bozeman, MT: Second River Healthcare Press.Sustaining Improvement (Standard Work)Focusing on Processes (Visibility Boards)Empowering Accountability (Huddles)70%72%74%76%78%80%82%84%NICU PICU Peds All UnitsScored PercentageUnits SurveyedMindfulness Scores from SurveyInformation type % Reported Analysis & Action % DiscussedEvents in last 24 hours 49% Cause analysis 74%Concerns for today 54% Extent of condition 64%Daily metrics 83% Action plan 34%Lehigh Valley Children’s HospitalFigure 3: A view of the trends by unit in overall mindfulness. Table 1: Scores of the Principles of Mindfulness obtained from survey. (N=76)Table 2:  Service Line Huddle Report.N=13; Units included: Peri-operative, Outpatient Surgery, Labor and Delivery, Prenatal, Mom and Baby, Neonatal Intensive Care, Pediatric Intensive Care, Pediatrics, and the Children’s Emergency Room NICU PICU Peds All UnitsMindfulness 75.6% 79.5% 82.3% 78.4%Preoccupation with failure 67.3% 71.3% 73.6% 70.2%Reluctance to simplify 65.5% 65.7% 73.7% 69.4%Sensitivity to operations 69.1% 75.4% 79.2% 73.4%Resilience 72.7% 75.8% 78.8% 75.9%Deference to expertise 73.1% 76.9% 79.7% 76.4%Below Standards (<67%)           Met Standards (>67%)         Above Standards (>82%)0%10%20%30%40%50%60%Not at all To Some extent A greal dealPercent AnsweredSurvey ResponseWhen errors or health care acquired conditions happen, we discuss how we could have prevented them0%10%20%30%40%50%60%Not at all To Some extent A greal dealPercent AnsweredSurvey ResponsePeople report significant mistakes even if others do not notice that a mistake is madeStandard Work for HuddlesInformation Presented:• Each Unit:• Events in last 24 hours• Concerns for Today• Daily Metrics• Whole Group:• Follow-ups• AnnouncementsStandard Work for Family-Centered Rounds• Medical Team and Nursing Participation• Family and Patient Participation• Patient Information Presented in SBAR format• Goals for the Day Discussed• Discharge Criteria Discussed• Concerns and Risks AddressedHigh‐Reliability Element for Family‐Centered Rounds % PresentNurse Participation <20%*Team and Family Learns and Makes Sense of the Information Provided on Rounds 45%Discussion of What Could Go Wrong 45%Discharge Criteria 76%*Difficult to determine level of participation [a nurse was present for part of rounds >80% of the time]© 2016 Lehigh Valley Health NetworkFigure 2. Lean Daily Management.0%10%20%30%40%50%60%NICU PedsPercent AnsweredChildcare UnitManagers and directors readily pitch in whenever necessaryFigure 4: Staff survey responses for selected survey questions.Staff SurveyService Line HuddleUnit HuddlesFamily-Centered RoundsFigure 5: Unit huddle boards that are used to relay information to staff at shift changes (in order from left to right: PICU, NICU, Peds).Table 3: Reported Items from Family-Centered Rounds. (N=51)

Assessing High Reliability in Inpatient Pediatric Units

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Assessing High Reliability in Inpatient Pediatric Units

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