Just Culture Patient Safety: A Comprehensive Overview of Key Principles

$1,695.00

Hosted by Dr. Robert Turbow, M.D., J.D.

The course takes place on Wednesdays from 1pm to 5pm Eastern Time.

Following the purchase of this product, expect an email from us with pertinent registration information.

$1,695.00
$1,695.00

Description

At the conclusion of the course, the participants will be able to describe/discuss:

  • Contributing factors to preventable harm in healthcare
  • The role of High Reliability Theory in improving patient safety
  • The general principles of Human Factors Engineering
  • Examples of techniques to manage cognitive errors and distractions
  • How system design influences the likelihood of catastrophic failure
  • Contemporary strategies to make healthcare safer, including failure modes effects analysis, socio-technical probabilistic risk assessment, After Action Reviews, Walk Rounds, Safety Huddles, Safety Coach programs, and Clinical Decision Support

Learners receive 16 hours of instruction and exercises over 4-days (4 hours per week for 4 weeks). This e-learning solution uses live interaction with Dr. Robert Turbow, M.D., J.D. to enable learners to work in a collegial environment.

  • Managers/directors/supervisors
  • Hospital C-suite
  • Bedside providers
  • Physician leaders
  • Safety, Quality, Risk Management officers
  • Workers in high-consequence industries

Attend 4 4-hour sessions on sequential Wednesdays (1pm to 5pm Eastern Time) with a small cohort of e-Learners facilitated by Dr. Robert Turbow, M.D., J.D.

INTRODUCTION
Overview and brief review of course topics
Opportunities for attendees
How did we get here? – culture, complexity, competing values, and cognitive error
History, data, challenges, and controversies
How the healthcare industry has responded
The path towards improvement
Suggested reading and video- Still Not Safe, Chernobyl (Part 1)

SCIENCE OF SAFETY
Rigorous approach to complex industries
Evaluation of socio-technical systems
Understanding system design
Integrating the information
Improvement science
Suggested reading and video- Advancing the Science of Safety (AHRQ),

CULTURE OF SAFETY
Introduction to team dynamics- culture, history, hierarchy, environment
Evolving culture in high-consequence industries
Behavioral choices- Hand hygiene, medication processes, procedural pauses
Tragedy at Vanderbilt
Suggested reading and video- Team of Teams (McChrystal), Darker Shades of Blue (Kern)

HIGH RELIABILITY
Evolution of safety theory- Normal Accident, High Reliability, System Design (MIT)
History of HRO, methodologies and vocabulary
Principles- decrease likelihood of catastrophic failure
The role of “defenses” (Perrow)
Anticipate, contain, recover (Sutcliffe)
Resilience
Lessons from other high-consequence industries
Aviation- beyond checklists, IMSAFE, CIGARS, crew resource management
Nuclear- parallel processes, accountability, preparation/precursors
Applications in healthcare- emergency medicine, operating rooms, ICU’s
Suggested Reading and video- The mythical man month, Downfall (HBO)

HUMAN FACTORS ENGINEERING (HFE)
Definitions, background, and principles-
Systems designed to support human decision-making
Intersection of psychology and engineering
System safety and human factors (Rasmussen, Hollnagel)
How we learn- auditory, visual, tactile, or combination
Signifiers, affordances, mapping, feedback, constraints, standardization
Forcing functions
HFE in aviation and the automotive industry
Bringing Human Factors Engineering to the bedside
Suggested reading- The Design of Everyday Things (Norman), Human Factors in Patient
Safety (Dekker), FDA perspective on usability

COMPLEX AND COMPLICATED
Chaos theory
Moore’s law
Complexity in healthcare
Complexity theory- tight coupling, non-linear interactions, series vs parallel processes
Failure rate in multi-step processes
IT systems, infusion pumps, TAVR- trans catheter aortic valve replacement
Suggested reading and video- Chaos (Gleick), Butterfly Effect

COGNITIVE ERROR, DISTRACTION, AND BIAS
Principles and historical perspective
Scientific background
Types of biases- explanation and examples
Fallacies of thinking
Sentinel work- Kahneman, Tversky, Thaler, Croskerry
Implications and study in healthcare
Minimizing impact
Suggested reading and video- Behave (Sapolsky), Noise (Kahneman), Undoing Project
(Lewis), Patient Safety in Emergency Medicine (Croskerry)

IT SYSTEMS
History
Implementation schism
Acceptance and rejection
Opportunities, challenges, and tragedies
Clinical decision support, order sets, tailoring alerts
Real-time alerts/pop-ups to enhance safety
Bar code scanning, smart pumps, smart ventilators, medication dispensing systems
Meaningful use
Documentation and patients’ access to their charts
Suggested Reading and video- The Digital Doctor (Wachter), The Glass Cage,

SYSTEM DESIGN (DESIGNING SAFE SYSTEMS)
What is valued in healthcare?
Historical tolerance of necessary work-arounds
Safe design principles (Hopkins)
Common features in catastrophic failure
Modeling and managing risk
Understanding healthcare as a complex system
Complex adaptive systems
Resiliency
Organizational Theory (Sutcliffe)
Reading- Bureaucratization of Safety (Dekker), Still Not Safe (Wears and Sutcliffe)

QUALITY AND SAFETY
History of quality tracking
Donabedian- structure, process, outcome
Automotive lessons- Toyota Production System
Metrics in healthcare
Dealing with Big Data- what to track, what is meaningful
Lessons about algorithms
Grading agencies
The science of improvement
Suggested Reading- Transforming Healthcare (Kenney)

IMPLEMENTATION SCIENCE
History
Five approaches
Contemporary interpretation
Suggested Reading- Qualitative Inquiry and Research Design (Creswell and Poth),
Knowledge Translation in Health (Wensing and Grol)

OUTPATIENT SAFETY
History and prior national focus primarily on inpatient indicators
Metrics in ambulatory medicine- growing appreciation of human and financial costs
Chronic conditions- hypertension, diabetes, cholesterol
Cancer screening- cervical cancer, mammograms, prostate screening
Common themes- inpatient and ambulatory
Types of errors
Strategies
Challenges and opportunities
Determining causation
Lack of resources- fundamental focus on hospital medicine
Inpatient metrics often more amenable to measurement
Determining safety vs quality
The role of family members

CONTEMPORARY APPROACHES
Limited impact of substantial historical efforts
Safety climate scores
Collecting information- event reporting, walk rounds, case reviews
Disclosure to families
Rapid response teams
National patient safety goals
Organizations- ECRI, Leapfrog, IHI, TJC, ISMP, etc…
Coach programs
Huddles and learning boards
Patient Safety Organizations
Simulation labs
Experiential learning
Clinical pathways
Peer review, Quality Committees, disciplinary bodies

COURSE SUMMARY AND WRAP-UP
Review and integration of class content
Ongoing Challenges
The Path Forward

Course Objective

At the conclusion of the course, the participants will be able to describe/discuss:

  • Contributing factors to preventable harm in healthcare
  • The role of High Reliability Theory in improving patient safety
  • The general principles of Human Factors Engineering
  • Examples of techniques to manage cognitive errors and distractions
  • How system design influences the likelihood of catastrophic failure
  • Contemporary strategies to make healthcare safer, including failure modes effects analysis, socio-technical probabilistic risk assessment, After Action Reviews, Walk Rounds, Safety Huddles, Safety Coach programs, and Clinical Decision Support
General Details

Learners receive 16 hours of instruction and exercises over 4-days (4 hours per week for 4 weeks). This e-learning solution uses live interaction with Dr. Robert Turbow, M.D., J.D. to enable learners to work in a collegial environment.

Who Should Attend
  • Managers/directors/supervisors
  • Hospital C-suite
  • Bedside providers
  • Physician leaders
  • Safety, Quality, Risk Management officers
  • Workers in high-consequence industries
``4-Days Over 4-Weeks`` Intensive Format

Attend 4 4-hour sessions on sequential Wednesdays (1pm to 5pm Eastern Time) with a small cohort of e-Learners facilitated by Dr. Robert Turbow, M.D., J.D.

Curriculum

INTRODUCTION
Overview and brief review of course topics
Opportunities for attendees
How did we get here? – culture, complexity, competing values, and cognitive error
History, data, challenges, and controversies
How the healthcare industry has responded
The path towards improvement
Suggested reading and video- Still Not Safe, Chernobyl (Part 1)

SCIENCE OF SAFETY
Rigorous approach to complex industries
Evaluation of socio-technical systems
Understanding system design
Integrating the information
Improvement science
Suggested reading and video- Advancing the Science of Safety (AHRQ),

CULTURE OF SAFETY
Introduction to team dynamics- culture, history, hierarchy, environment
Evolving culture in high-consequence industries
Behavioral choices- Hand hygiene, medication processes, procedural pauses
Tragedy at Vanderbilt
Suggested reading and video- Team of Teams (McChrystal), Darker Shades of Blue (Kern)

HIGH RELIABILITY
Evolution of safety theory- Normal Accident, High Reliability, System Design (MIT)
History of HRO, methodologies and vocabulary
Principles- decrease likelihood of catastrophic failure
The role of “defenses” (Perrow)
Anticipate, contain, recover (Sutcliffe)
Resilience
Lessons from other high-consequence industries
Aviation- beyond checklists, IMSAFE, CIGARS, crew resource management
Nuclear- parallel processes, accountability, preparation/precursors
Applications in healthcare- emergency medicine, operating rooms, ICU’s
Suggested Reading and video- The mythical man month, Downfall (HBO)

HUMAN FACTORS ENGINEERING (HFE)
Definitions, background, and principles-
Systems designed to support human decision-making
Intersection of psychology and engineering
System safety and human factors (Rasmussen, Hollnagel)
How we learn- auditory, visual, tactile, or combination
Signifiers, affordances, mapping, feedback, constraints, standardization
Forcing functions
HFE in aviation and the automotive industry
Bringing Human Factors Engineering to the bedside
Suggested reading- The Design of Everyday Things (Norman), Human Factors in Patient
Safety (Dekker), FDA perspective on usability

COMPLEX AND COMPLICATED
Chaos theory
Moore’s law
Complexity in healthcare
Complexity theory- tight coupling, non-linear interactions, series vs parallel processes
Failure rate in multi-step processes
IT systems, infusion pumps, TAVR- trans catheter aortic valve replacement
Suggested reading and video- Chaos (Gleick), Butterfly Effect

COGNITIVE ERROR, DISTRACTION, AND BIAS
Principles and historical perspective
Scientific background
Types of biases- explanation and examples
Fallacies of thinking
Sentinel work- Kahneman, Tversky, Thaler, Croskerry
Implications and study in healthcare
Minimizing impact
Suggested reading and video- Behave (Sapolsky), Noise (Kahneman), Undoing Project
(Lewis), Patient Safety in Emergency Medicine (Croskerry)

IT SYSTEMS
History
Implementation schism
Acceptance and rejection
Opportunities, challenges, and tragedies
Clinical decision support, order sets, tailoring alerts
Real-time alerts/pop-ups to enhance safety
Bar code scanning, smart pumps, smart ventilators, medication dispensing systems
Meaningful use
Documentation and patients’ access to their charts
Suggested Reading and video- The Digital Doctor (Wachter), The Glass Cage,

SYSTEM DESIGN (DESIGNING SAFE SYSTEMS)
What is valued in healthcare?
Historical tolerance of necessary work-arounds
Safe design principles (Hopkins)
Common features in catastrophic failure
Modeling and managing risk
Understanding healthcare as a complex system
Complex adaptive systems
Resiliency
Organizational Theory (Sutcliffe)
Reading- Bureaucratization of Safety (Dekker), Still Not Safe (Wears and Sutcliffe)

QUALITY AND SAFETY
History of quality tracking
Donabedian- structure, process, outcome
Automotive lessons- Toyota Production System
Metrics in healthcare
Dealing with Big Data- what to track, what is meaningful
Lessons about algorithms
Grading agencies
The science of improvement
Suggested Reading- Transforming Healthcare (Kenney)

IMPLEMENTATION SCIENCE
History
Five approaches
Contemporary interpretation
Suggested Reading- Qualitative Inquiry and Research Design (Creswell and Poth),
Knowledge Translation in Health (Wensing and Grol)

OUTPATIENT SAFETY
History and prior national focus primarily on inpatient indicators
Metrics in ambulatory medicine- growing appreciation of human and financial costs
Chronic conditions- hypertension, diabetes, cholesterol
Cancer screening- cervical cancer, mammograms, prostate screening
Common themes- inpatient and ambulatory
Types of errors
Strategies
Challenges and opportunities
Determining causation
Lack of resources- fundamental focus on hospital medicine
Inpatient metrics often more amenable to measurement
Determining safety vs quality
The role of family members

CONTEMPORARY APPROACHES
Limited impact of substantial historical efforts
Safety climate scores
Collecting information- event reporting, walk rounds, case reviews
Disclosure to families
Rapid response teams
National patient safety goals
Organizations- ECRI, Leapfrog, IHI, TJC, ISMP, etc…
Coach programs
Huddles and learning boards
Patient Safety Organizations
Simulation labs
Experiential learning
Clinical pathways
Peer review, Quality Committees, disciplinary bodies

COURSE SUMMARY AND WRAP-UP
Review and integration of class content
Ongoing Challenges
The Path Forward