Safer Hospital Care: Strategies for Continuous Innovation
Features
- Describes world-class best practices for delivering high quality service
- Presents solutions with the potential for a high return on investment
- Explains how to reduce unsafe practices with proven tools and techniques adapted from the aerospace, nuclear, and chemical industries
Summary
From newborns switched in the nursery to medication mix-ups and hospital-acquired infections, we are all familiar with the horror stories about hospital safety, and unfortunately, the statistics say we aren’t exaggerating. The safety issue in U.S. hospitals has become so profound and embedded, that we cannot hope to fix it without a paradigm shift in our approach. After defining and demonstrating the true depth of this dangerous concern, Safer Hospital Care: Strategies for Continuous Innovation elaborates on the steps required to make that paradigm shift a reality.
A respected and sought out expert on hospital safety, author Dev Raheja draws on his 25 years of experience as a risk management and quality assurance consultant to provide hospital stakeholders with a systematic way to learn the science of safe care. Supported by case studies as well as input from such paradigm pioneers as Johns Hopkins and Seattle Children’s, he explains how to:
- Adapt evidence-based safety theories and tools taken from the aerospace, nuclear, and chemical industries
- Identify the combination of root causes that result in an adverse event
- Apply analytical tools that can effectively measure hospital efficiency
- Establish evidence between Lean strategies and patient satisfaction
- Make use of various types of innovation including accidental, incremental, strategic, and radical, and establish a culture conducive to innovation
This practical guide shows how to find solutions that are simple and comprehensive, and can produce a high ROI. To reform hospitals, we must recognize that they are highly dynamic systems that must be fixed systemically. Instead of thinking in terms of continuous improvement, we need to think in terms of continuous innovation. Safe hospital care is not just about doing things right; it is also about breaking old habits, finding new tools and doing the right things.
Table of Contents
The Etiologies of Unsafe Healthcare
Failure Is Not an Option
An Unconventional Way to Manage Risks
Defining Unsafe Work
How Unsafe Work Propagates Unknowingly
How Does Unsafe Work Originate?
So, Why Do We Unknowingly Sustain Unsafe Work?
Using Best Practices Is Insufficient
There Is Hope
The Lessons Learned
Sufficient Understanding Is a Prerequisite to Safe Care
Insufficient Understanding of System Vulnerability
Insufficient Understanding of What Is Preventable
Insufficient Understanding from Myopia
Insufficient Understanding of Oversights and Omissions
Insufficient Understanding of Variation
Some Remedies
Preventing "Indifferencity" to Enhance Patient Safety
Performance without Passion
Not Learning from Mistakes
Inattention to the Voice of the Patient
Making Premature Judgments without Critical Thinking
Lack of Teamwork
Lack of Feedback and Follow-Up
Performance without Due Concern
Lack of Accountability
Encouraging Substandard Work
Reacting to Unsafe Incidences Instead of Proactively Seeking Them
Inattention to Clinical Systems
Difference in Mindset between Management and Employees
Poor Risk Management
Performance Diligently Done in a Substandard Manner
Continuing to Do Substandard Work, Knowing It Is
Substandard
Ignoring Bad Behavior
Inattention to Quality
Continuous Innovation Is Better Than Continuous Improvement
Why Continuous Innovation?
Types of Innovations
Marginal Innovation
Incremental Innovation
Radical Innovation
Disruptive Innovation
Accidental Innovation
Strategic Innovation
Diffusion Innovation
Translocation Innovation
The Foundation for the Innovation Culture
Choice of Innovation
Encouraging Creativity
Structure for Sustaining Innovation
Innovations Should Start with Incidence Reports
The Purpose and Scope of Incidence Reports
What to Do with Incidence Reports?
A Sample Incidence Reporting Procedure
A Sample Incidence Report Form
Ideas for Innovative Solutions
Doing More with Less Is Innovation
Be Lean, Don’t Be Mean
Eliminate Waste, Don’t Eliminate Value
Do It Right the First Time—Excellence Does Matter
Add More Right Work to Save Time and Money
Attack Complacency
Create a Sense of Urgency
Establish Evidence between Lean Strategies and Patient Satisfaction
Ideas for Lean Innovation
Reinvent Quality Management
A Recipe for Success
Redefine Quality
Conduct Negative Requirements Analysis
Develop Strategic Plan Based on SWOT Analysis
Consciously Manage Quality at All the Levels of an Organization
Quality at Conformance Level
Quality at Process Level
Quality of Kind at Organization Level
Architect a Patient-Centric Quality System
Validate Interactions and Dependencies Frequently
Incorporate Feedback Loops
Reinvent Risk Management
Identify Risks
Failure Mode and Effects Analysis (FMEA)
Fault Tree Analysis (FTA)
Operations and Support Hazard Analysis
More Safety Analysis Techniques
Mitigate Risks
Orchestrate Risks
Create a Sound Structure
Integrate the Support Staff
Conduct Risk Management Rehearsals
Aim at High Return on Investment without Compromising Safety
Human Errors May Be Unpreventable; Preventing Harm Is an Innovation
Principles of Human Factors Engineering
Principles of Human Factors Engineering (HFE)
Harm Prevention Methodologies
Crew Resource Management (CRM)
Management Oversight and Risk Tree (MORT)
Change Analysis
Swiss Cheese Model for Error Trapping
Mistake Proofing
Managing Safety: Lessons from Aerospace
Where Does US Healthcare Stand on System Safety?
System Safety Theory of Accidents
System Safety in Emergency Medicine
Aerospace Hazard Analysis Techniques
The Paradigm Pioneers
Johns Hopkins Hospital
Allegheny General Hospital
Geisinger Health System
VA Hospitals
Seattle Children’s Hospital
Ideas for Future Paradigm Pioneers
Protect Patients from Dangers in Medical Devices
The Nature of Dangers
Hazard Mitigation for Existing Devices
Potential Dangers in New Devices and Technologies
Hazard Mitigation for New Devices and Technologies
Can We Use This Knowledge in Bedside Intelligence?
Heuristics for Continuous Innovation
Heuristics for Medicine
Other Heuristics for Medicine
Heuristics for Frontline Processes
Stop Working on Wrong Things, and You Will Automatically
Work on Right Things
Learn to Say "No" to Yes Men
"No Action" Is an Action
No Control Is the Best Control
Heuristics for Management
If You Don’t Know Where You Are Going, Any Road Will Get You There
Convert Bad News into Good News
As Quality Goes up, the Costs Go Down
That Which Gets Measured, Is What Gets Done
% of Causes Are Responsible For % of Effects
Aequanimitas—The Best-Known Strategy for Safe Care
Aequanimitas Explained
Why Aequanimitas Is the Best-Known Strategy for Safe Care?
The Practice of Aequanimitas
Modern Variations of Aequanimitas
Emotional Intelligence (EI)
The Beginner’s Mind
Ray Brown’s Senses
Appendix A: Swiss Cheese Model for Error Trapping
Index
Each chapter includes an Introduction, Summary, & References
