Slide Presentation from the AHRQ 2009 Annual Conference
On September 15, 2009, Anthony Slonim made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1,309 KB) (Plugin Software Help).
Risk Informed Evaluation
of Patient Safety Training
Anthony D. Slonim, MD, DrPH
Vice President Medical Affairs
Carilion Medical Center
Senior Staff, Departments of Medicine and Pediatrics
Professor, Medicine and Pediatrics
Virginia Tech-Carilion School of Medicine
- Decision-making science How do we normally make decisions?
- Picking up on Level 4.Can we train to improve our decision making results?
Decision Making Science
|P (A/B) =
||P(B/A) * P(A)
Square patterned image divided into four. Each segment is an alternating color of pink and green.
- How many squares do you see?
- Jumping to
conclusions too quickly.
- Is there flashing in the squares?
- Your mind will play tricks on you!
Medical Decision-Making Process
- Perception/Data gathering (training-H and P, Labs, Rads)
- Interpretation (training-pattern recognition and probability)
- "Amber light" means prepare to stop, maybe
- Decision making (based on probability + experience)
- Action taking (reflex/"gut level response"/programming)
- Hit the brake or accelerator
Marx D and Slonim AD: Assessing patient safety risk before the injury occurs: An Introduction to Socio-Technical Probabilistic Risk Assessment. Quality and Safety in Healthcare 2003; 12 Suppl 2: 33-38.
Image depicting a treatment process with Triage Nurse in the center of a square, with ED Nurse outside the Triage Nurse. Finally Physician is on the outside of the ED Nurse.
- Make a Dx and Treat
- Get Help: Cardiology
- Do more testing-which test?
Same image as above but with word written on top of it:
What are the results?
Did we get it right?
Expert Decision Making:
Practice, Practice, Practice
- Expert - pattern matching against large mental library, quick, accurate if confirm correct answer
- Novice - library is empty - slow, error prone process
- Certain Diagnoses are Favored- Frequent, Recent, Serious
- Heuristics - fixating on the wrong pattern
Picture of a triangle and 3 red circles at each point.
Picking up on Level 4:
Can we train for results?
- Level I Reactions
- How well trainees liked training
- Level II Learning
- The extent to which trainees understand and retain principles, facts, and techniques
- Level III Behavior
- The extent to which behavior changes as a result of training
- Level IV Results
- Impact of training on organizational criteria
Elements of Quality Programs
Flow chart of Quality Functions
- Program Identifcation and Prioritization
- Data Analytics
- Change Management
- Improved Outcomes
- Quality Functions
- Education / Training
Why is there a safety problem?
- Considerable variation in practice
- Based on opinion or consensus
- Evidence-based guidelines-unsupported
- Failure to create fail-safe processes
- Our providers may not know their work
- We're learning to work together
- We're not sure of the results we're looking for
- A series of sequential steps governing interactions
- Between patients and providers
- Between providers and providers
- Examples of process analysis techniques:
- Root cause analysis-retrospective
- HAACP (hazard analysis and crit control points)
- FMEA (failure mode effects)
- PI methodology
Low-frequency, High Impact Events
- Low frequency, high-impact events
- Variable processes and practices
- Wrong site surgery
- The abduction of children from hospitals
- Deaths or major harm
- Process analysis helps to identify risk and prioritize interventions
- Decision support helps to guide decision making
Probabilistic Risk Assessment
- A hybrid between process analysis and decision support
- Identifies risk points and directs to interventions
- Is hierarchical and probabilistic
- Allows disentanglement of patient level risks, provider level risks, and system level risks
- Assigns probabilities for prioritization of risk reduction strategies
- Includes sociotechnical components into the models
Probabilistic Risk Assessment identifing Qualitative methods
- The Institution
- The Providers
- The Patient
The Prospective Risk Model
Diagram showing the top three risks.
- The systematic collection of descriptive and judgmental information necessary to make decisions related to instructional activities
- Ensures training
- Meets its stated objectives
- Changes trainee attitudes
- Increases trainee knowledge
- Develops trainee skills
- Transfers results to the job
- Important variables to consider:
- Organizational Factors
- Individual Factors
- Trainee Knowledge, Skills, and Attitudes
- Training Transfer
- Organizational Outcomes
Merging Kirkpatrick and ST PRA
- Socio-Technical Probabilistic Risk Assessment
- Good for examining low base rate events (Six Sigma)
- Models contributing causes
- Procedural tasks
- Team tasks
- Identifies the impact of an intervention
- Evidence base
- Empirically based
- Adjust and test the model
- Monte Carlo
- Changes in the likelihood of outcomes
- Quick Wins
- Burn-out / Fatigue
- Difficult-to-Sustain, Short-Term Results
Quality Fusion Approach
Graph demonstrating fusion results of impact over time.
What is Escalation?
- Failure to rescue associated with
- Interpretation problems
- Throughput problems
- Put another way.
- When you do not realize the patient is in trouble OR you know the patient is in trouble, but you don't respond as needed.
Ideally, we track the illness. As the patient gets worse (line goes up), we respond. As the patient improves we adjust.
Going Off Course
The defect rate in our model
is caused by failures to properly track
the course of the illness.
Never On Course
Sometimes, we're off course right from the beginning and it's difficult to get back on course.
Image of a red and blue line with an arrow in between them to signify being off course.
The Prospective Risk Model
The Top Three Risks
- A focus on results helps providers and patients
- Training on risk points can improve performance
- Leads to better results
- Requires alterations in decision making
- Enhances empiric data for better understanding training
Current as of December 2009
Risk Informed Evaluation of Patient Safety Training. 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/slonim.htm