Slide Presentation from the AHRQ 2009 Annual Conference
On September 14, 2009, Brion Hurley made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1.31 MB) (Plugin Software Help).
Risk Reduction in Healthcare
Healthcare System Solutions
Lean Six Sigma Black Belt
Mr. Pareto Head courtesy of Quality Progress magazine.
Image: Cartoon showing that most people are not interested in seminars on prevention, rather they want to attend seminars on reaction, since that is where the savings and improvements are more evident.
How do you manage risks today?
- Option 1: "We don't have any risks".
- Option 2: "Hopefully, nothing bad happens today" (hopeful thinking, knock on wood).
- Option 3: "Everybody needs to be careful all the time!"
- Option 4: "If you make a mistake, we'll fine/discipline/fire you!"
- Option 5: "We had a meeting and discussed the chance that could happen, so go communicate to everyone."
- Option 6: "We brainstormed what could happen, and we took some actions to minimize the chance."
- Option 7: "We developed a risk assessment of our process, and have an ongoing action plan and cadence to address the highest prioritized risks."
Common Risk Tools
- Here are some more formal ways of determining risk in your processes
- 5 Why's.
- Fault Tree Analysis.
- Data Analysis.
Gather data to determine where to start
- Group ideas into categories
- Use Fishbone diagram format (Personnel, Processes, Machine, Environment, Measurement, Supplies, etc).
Image: Displaying a fishbone diagram, with the problem at the head, and the categories as the bones of the fish.
A comment is added stating "gather data to determine where to start."
- Ask why AT LEAST 5 times, keep going until root cause (process error) identified
Patient dose changes excessive WHY?
- Patient INR higher at preferred lab than clinic WHY?
- Lab and clinic results vary by 0.20 - 0.40 WHY?
- Lab MNPT values are different WHY?
- Labs used different normal population groups WHY?
- Definition of "normal" population not well-defined (Process).
Process Change: All labs will pool data together for a community MNPT value.
Fault Tree Analysis
An image of a Fault Tree Analysis is shown.
- Failure Mode and Effects Analysis
- Failure mode = the way in which the failure occurs.
- Implanted device runs out of batteries, wrong prescription given to patient, patient falls down, patient given wrong dose amount, illegible handwriting.
- Effects = potential consequence or final outcome of the failure mode
- Adverse or sentinel event, ER visit, surgery, litigation.
- Slight pain, redness, patient would not know.
- Various names associated with it
- Healthcare (HFMEA), Process (PFMEA), Design (DFMEA), Safety/System (SFMEA), etc.
- Process Step.
- Failure Mode.
- Effect of Failure.
- Severity Score.
- Cause of Failure.
- Occurrence Score.
- Prevention & Detection Controls.
- Detection Score.
An FMEA example which shows an example of risks from an anticoagulation patient management process.
Risk Priority Number
- Severity x Occurrence x Detection = RPN.
- Higher the number, higher the risk to the customer (patient).
- Scoring is relative and somewhat subjective, key is consistency with team.
- Difficult to compare across processes, organizations, facilities unless teams are the same.
||Process FMEA Severity
||may endanger machine or operator without warning
||Hazardous- w/ warning
||may endanger machine or operator with warning
||major disruption in operations (100% scrap)
||minor disruption in operations (may require sorting and some scrap)
||minor disruption in operations (no sorting but some scrap)
||minor disruption in operations (portion may require rework)
||minor disruption in operations (some sorting and portion may require rework)
||minor disruption (some rework but little affect on production rate)
||minor disruption (minimal affect on production rate)
||> 1 in 2
||Cpk < 0.33
||1 in 3
||Cpk ~ 0.5
||1 in 8
||Cpk ~ 0.75
||1 in 20
||1 in 100
||1 in 400
||Cpk ~ 1
||1 in 2000
||1 in 15,000
||Cpk > 1.33
||1 in 150,000
||Cpk > 1.5
||< 1 in 1,500,000
||Cpk > 1.67
||Process FMEA Detection
||No known process control to detect cause mechanism and subsequent failure.
||Remote chance that process control to detect cause mechanism and subsequent failure.
||Low chance that process control to detect cause mechanism and subsequent failure.
||High chance that process control to detect cause mechanism and subsequent failure.
||Current control almost certain to detect cause mechanism and failure mode.
Image: Same FMEA example as before, except highlighting the top 2 risks by RPN, where the highest RPNs equate to the highest risks.
Provide standard questions to all nurses near phone, include in patient education material process changed so copy of all dose changes should be mailed to patients as confirmation.
- Choose top 2-3 items to improve
- Too many will be overwhelming and seem endless (no more than 1 action per person).
- If risk reduced, work on next highest (continuous improvement).
- List investigation plan, unless solution is obvious to all
- More detailed data collection plan.
- Test out potential solutions (experiment).
- Further team brainstorming and investigation.
- Sometimes data will tell you there is a risk, or will validate how much risk exists.
- Are labs in Cedar Rapids consistent with one another when measuring INR values?
- Overall opinions said "YES" - low risk?
- Develop an experiment to prove it
- Already exists a tool, called Gage Repeatabiliy & Reproducibility (R&R).
Summary of Gage R&R Study
Graphic shows 10 patients, with one circled, which points to 6 blood dials, then separates out the vials into 2 groups (labs A and B), with 3 vials in each group. The INR results from each of the 3 vials is listed next to them.
Comparison of Labs - INR
||Average INR at Lab A
||Average INR at Lab B
Significant Difference in Averages (p-value = 0.000)
Results Exceeded Gage R&R Acceptance Criteria
Are you doing enough?
- JCAHO Standard LD.5.2 requires facilities to select at least one high-risk process for proactive risk assessment each year.
- Such selection to be based, in part, on information published periodically by the Joint Commission that identifies the most frequently occurring types of sentinel events and patient safety risk factors (adverse events).
- New DNV ISO-9000 hospital accreditation will require prevention activity.
- Never too late to start risk reduction.
- Risk assessment has a wide spectrum of implementation
- The more critical the problem, the more structure (tools) and detail required.
- Prevention requires formal methods and evidence of analysis and action.
- Most problems are not new, they have been solved or mitigated already
- Look nationwide, and outside healthcare.
- Use actual data whenever possible
- However, not all risks can be quantified.
- Start simple, then evolve to more complex methods
- Doesn't have to be complicated, just get started.
Healthcare System Solutions
Current as of December 2009
Risk Reduction in Healthcare. Slide Presentation from the AHRQ 2009 Annual Conference (Text Version). December 2009.
Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualconf09/hurley.htm