High Reliability Organizational (HRO) Culture using Standardized Patient Simulation and TeamSTEPPS

1. High Reliability Organizational (HRO) Culture using Standardized Patient Simulation and TeamSTEPPS March 8, 2017

2. Rules of Engagement • Audio for the webinar can be accessed in two ways: • Through the phone (*Please mute your computer speakers) • Through your computer • A Q&A session will be held at the end of the presentation • Written questions are encouraged throughout the presentation and will be answered during the Q&A session • To submit a question, type it into the Chat Area and send it at any time during the presentation

3. Upcoming TeamSTEPPS Events • Master Training Courses • Registration for courses through June 2017 now open • Registration opening on March 15 for courses in July-September 2017 • National Conference • June 14-16, 2017 • Downtown Hilton, Cleveland, OH • Registration open and almost to capacity!

4. Help Line (312) 422-2609 Or email: AHRQTeamSTEPPS@aha.org

5. Today’s Presenter(s) • Brent Ibata, PhD JD MPH FACHE Research Compliance Officer - Sentara Healthcare Adjunct Assistant Professor - Eastern Virginia Medical School TeamSTEPPS Master Trainer • Patric Lundberg, PhD Associate Professor - Eastern Virginia Medical School Director of Bioinformatics Analytics - Eastern Virginia Medical School TeamSTEPPS Master Trainer

6. Objectives • Understand the value of high reliability organizational culture in the design, development and execution of quality and performance improvement initiatives. • Demonstrate how to create and sustain a culture of creative inquiry to encourage healthcare innovation and achieve a high reliability organizational culture. • Describe how the use of TeamSTEPPS with simulated patients can help to create and sustain a high reliability culture.

7. Experiential Learning • For the things we have to learn before we can do them, we learn by doing them. – Aristotle • Give the pupils something to do, not something to learn; and the doing is of such a nature as to demand thinking; learning naturally results. - John Dewey • See one, do one, teach one.

8. Agenda Evolution on Healthcare Innovation Fundamentals of High Reliability Organizations Rapid Cycle Innovation (Design Thinking) Our patient simulation experience

9. Evolution of the Hospital

10. Evolution of Reimbursement

11. Evolution of Patient Safety

12. Hospitals of the Future Highly reliable healthcare organizations share common core characteristics: • Encourage and support continuous change • Invest in staff development and staff self-efficacy • Transparent patient safety metrics • Patient centric focus

13. Hospitals of the Past Struggling healthcare organizations share common core characteristics: • Deference to the status quo • Limited staff development dollars • Blame-game accountability • Provider centric focus

14. To Err is Human Institute of Medicine (1999) • At least 44,000 Americans die each year as a result of a medical error (may be as high as 98,000). • Total cost between $17 and $29 billion (lost income, lost productivity, disability and healthcare costs).

15. To Err is Human • Establish a national focus to create leadership, research, tools and protocols to enhance knowledge of patient safety. • Identify and learn from errors through mandatory reporting. • Raise standards and expectationsfor improvements in patient safety through oversight organizations, purchasers, and professional groups. • Create safety systems through the implementation of safe practices at the patient level. Recommendations (1999)

16. Crossing the Quality Chasm • Institute of Medicine (2001) • Establish a New Environment for Care • Focus and align the environment toward the six aims for improvement. • Safe, effective, patient-centered, timely, efficient, equitable • Provide, where possible, assets and encouragement for positive change. • Align Payment Policies with Quality Improvement

17. Timeline of Healthcare Reform • Medicare Prescription Drug Improvement and Modernization Act of 2003 (Pub. L. 108-173) • Origin of Hospital Inpatient Quality Reporting Program • Reduced annual payment update by 0.4% to non-participating hospitals or hospitals that failed to meet criteria for reporting. • Deficit Reduction Act of 2005 (Pub. L. 109-171) • Increased reduction to 2% • Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148) • Authorized 1st national Hospital Value Based Purchasing Pay-for-Performance program. • Effective FY2013 for discharges on or after October 1, 2012.

18. Quality Improvement - CoP • § 482.21 Condition of participation: Quality assessment and performance improvement program. • The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital's governing body must ensure that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.

19. Serious Safety Events (Never Events) • Retained foreign objects • Wrong patient • Wrong side • Wrong procedure • Falls • Suicides • Dialysis-related events • Procedural events • Delay in treatment • Criminal events • Perinatal death/injury • Medication errors • Fire-related events Source: Becker’s Hospital Review (2014-2015)

20. AHRQ Becoming a High Reliability Organization (2008) Sensitivity to Operations (Situational Awareness) Reluctance to Simplify (Multiple Failure RCA/ACA) (Healthy) Preoccupation with Failure (Situationally Appropriate) Deference to Expertise Resilience (Members of the Team)

21. Stages of Change: • The data are wrong; • The data are correct but it’s not a problem; • The data are correct and it’s a problem, but it’s not my problem; • The data are correct and I own the responsibility to fix the problem.

22. Foundation of an HRO Culture 5Ps We improve health everyday. BBEs Hourly Rounding Bedside Shift Report Safety Huddle SBAR Situational Leadership RED RULE

23. Sentara Commitments • Always keep you safe • Always treat you with dignity, respect & compassion. • Always listen & respond to you. • Always keep you informed & involved. • Always work together as a team to provide you quality healthcare. I commit to:

24. Sentara Behavior Based Expectations • Pay attention to detail • Communicate clearly • Have a questioning attitude • Hand off effectively • Never leave my wingman I commit to alwayskeep you safe:

25. Collaborative Grant Program • 501(c)(3) hospital – Sentara – Brent Ibata • Medical school – EVMS – Patric Lundberg • Liberal arts college – College of William & Mary – Jim Olver Rapid Cycle Innovation Training Grant in Healthcare Delivery Science and Health Services Research $20,000 multi-institution grant:

26. Grant Timeline Develop Training Program (Plan) Cohort #1 (Do-Study-Act) Cohort #2 (Plan-Do-Study-Act) Cohort #3 (Plan-Do-Study) Final Presentation(s)

27. Planning Stanford d.school Florida Hospital Innovation Lab Mayo Clinic Center for Innovation TeamSTEPPS Master Trainer at Duke

28. AHRQ Using Rapid-Cycle Research to Reach Goals (2015) Preparation Problem Exploration Knowledge Exploration Solution Development Solution Testing Implementation & Dissemination

29. Innovation Cycles Source: d.school and IDEO

30. d.school Innovation Cycle Source: d.school and IDEO

31. Empathy (human-centered design) Empathy is the ability to be aware of, understand, and be sensitive to another person’s feelings and thoughts without having had the same experience. Empathetic design is a process that involves interviews, observations, and iterative rapid cycle prototyping. Empathy is key to design thinking.

32. Cultures of Innovation Built environment (social and spatial) Permission to fail (fail fast, fail cheap) Innovation space (multidisciplinary) Culture (plan to sustain momentum) Source: Brown, Tim. Change by Design

33. Sentara Heart Culture of Innovation Sentara Heart Operations Committee Sentara Heart Joint Operations Committee Sentara Cardiovascular Research Institute Cardiac Grand Rounds Cardiac Journal Club Rapid Cycle Innovation Boot Camp

34. Basic HRO Materials (pop-up workshops) Marshmallow ($25) • Spaghetti, roll-of string, tape, tape measure. Wallet & prototyping ($3,000) • Prototyping cart (cardboard, crayons, Play Doh, etc.) Brainstorming Z-Rack Whiteboard ($500) • Z-Rack Post-Its (Priceless) Source: d.school.stanford.edu

35. Rapid Cycle Innovation Projects

36. Rapid Cycle Innovation Boot Camp

37. FINAL Agenda – Day #1 • 0800 – Icebreakers • 0930 – Marshmallow Exercise • 1000 – d.school Wallet Exercise • 1100 – How might we design the ideal office visit? • 1200 – LUNCH • 1230 – Post-It brainstorm Q’s HRO Culture • 1330 – Empathy Hunt • 1500 - Debrief

38. FINAL Agenda – Day #2 • 0800 – Icebreakers • 0830 – HRO TeamSTEPPS • 0930 – Post-It brainstorm “dig deeper” • 1000 – Empathy Hunt #2 • 1100 – Debrief • 1200 – LUNCH • 1230 – Fail fast, fail cheap – Build prototype(s) • 1300 – Test Prototype(s) • 1500 - Debrief

40. How might we communicate HRO to front-line staff?

41. How might we communicate HRO to front-line staff?

42. AHRQ TeamSTEPPS

45. The EVMS Sentara Center for Simulation and Learning is a 25,000 square foot facility with over 12,000 students attending 2,718 classes in 2016 • Standardized Patients • Physical Exam Teaching Associates • Genitourinary Teaching Associates • High Technology Mannequins • Part Task Trainers • High tech virtual reality trainers • Low tech for less complex skills (ex. IV catheter insertion) Sentara Center for Simulation & Immersive Learning

46. Sentara Center for Simulation & Immersive Learning

47. Empathy-based rapid cycle innovation can produce dozens of prototypes in a short period of time. • Front-line staff can be quickly taught design thinking tools to prototype innovative solutions to everyday healthcare problems. • Standardized patients in ‘real’ simulated clinical environments makes role-based scenarios easy, fun, without creating ‘stage-fright’ since the standardized patient is the focus. • Standardized patient scenarios bring alive TeamSTEPPS skills. Lessons Learned – Standardized Patients & TeamSTEPPS

48. Presenter Biography & Contact Info Brent Ibata, PhD JD MPH FACHE Research Compliance Officer for Sentara Healthcare Dr. Ibata has over twenty-five years of progressive healthcare leadership experience starting as an ER tech on the West Side of Chicago, moving through a decade at an academic teaching hospital in St. Louis, followed by three years as a director of a multidisciplinary clinic. Dr. Ibata is a Mensan and TeamSTEPPS Master Trainer who has spent most of his career building and sustaining environments that inspire and reward innovation and quality. The seeds for his career in healthcare innovation were planted in Chicago as a graduate of Lane Technical High School and The Second City Training Center. Dr. Ibata has a PhD with an emphasis in health services research, a JD with a certificate in health law, and a Master in Public Health. He is the author of numerous journal articles in addition to dozens of presentations at regional, national, and international conferences related to innovation in healthcare. Email: baibata@sentara.com Phone: (757) 252-9401

49. Presenter Biography & Contact Info Patric Lundberg, PhD Dr. Lundberg is an Associate Professor of Microbiology and Molecular Cell Biology, Virology Section Leader, Course Director of Bioinformatics & Biostatistics and Director of Bioinformatics Analytics at the Eastern Virginia Medical School in Norfolk, VA. He is a TeamSTEPPS Master Trainer and co-investigator for the 2013-14 multi-center collaborative grant titled Rapid Cycle Innovation Training Grant in Healthcare Delivery Science and Health Services Research with Sentara Heart Hospital, the College of William & Mary, and the Eastern Virginia Medical School. Email: LundbePS@evms.edu Phone: (757) 446-5174

50. Bibliography/References • Brown, T. (2009). Change by design. Harper Business. • Cleveland Clinic. A Lesson in Empathy. Available at: https://youtu.be/cDDWvj_q-o8 • dschool.stanford.edu • Hines S, Luna, K, Lofthus J, et al. (2008). Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. AHRQ Publication No. 08-0022. Agency for Healthcare Research & Quality. • Ibata, B. (2009). Public Health Law & the Built Environment in American Public Schools: Detailed History with Policy Analysis. VDM Publishing. • Institute of Medicine (US) (2001). Crossing the quality chasm: a new health system for the 21st century. National Academy Press. • Institute of Medicine (US) (2000). To Err is Human: Building a safer health system. Institute of Medicine. National Academy Press. • Kelley, T. (2007). The art of innovation: Lessons in creativity from IDEO, America's leading design firm. Crown Business. • Kelley, T., & Kelley, D. (2013). Creative confidence: Unleashing the creative potential within us all. Crown Business. • Lanser May, E. (2013). The Power of Zero: Steps Toward High Reliability Healthcare. Healthcare Executive. • Wujec, Tom (2010). The Marshmallow Challenge. Ted Talk. Available at: https://www.ted.com/talks/tom_wujec_build_a_tower