Dr Paul Barach
Paul Barach, MD, MPH, is a double boarded anesthesiologist and critical care physician-scientist, Clinical Professor at Wayne State University School of Medicine, and Children’s Hospital of Michigan. He is Lecturer and senior advisor to Dean, Jefferson College of Population Health, Professor, Sigmund Freud University, Austria; Honorary Professor, University of Queensland, Australia, and Visiting Professor at the National Cancer Center in Seoul Korea. He is Chief Medical Officer of Pegwin and Chief of Population Health, Play it Health. He trained at the Massachusetts General Hospital affiliated with Harvard Medical School. Paul is an elected member of the lead honorary society the Association of University Anesthesiologists.
Dr. Barach is deeply committed to translating research into strategies for systems strengthening, health protection and disease prevention. Paul has more than 25 years of experience as a practicing physician and physician executive in the military and in academic medical centers and integrated delivery systems. He is a formally trained health services researcher, with advanced post graduate training in advanced medical education and assessment methods from the Harvard Medical School Josiah Macy Program medical education, lean six sigma, quality improvement and lean techniques at Intermountain Healthcare. He has had additional training in epidemiology and statistics including both methodological as well as applied HTA research. Prior to that he spent 5 years in the military and was involved in team training, leadership and simulation work.
Paul has market eminence an experienced health sector consultant with an extensive track record of improving interprofessional training, health service and medical education delivery in Australia, US, GCC and Europe. He has done this work as board member of the NMBE, advisor to the ABMS, ACGME and as associate dean at lead academic medical center. His experience includes health service policy, funding, accreditation, and planning, program development, monitoring performance and improving operational service delivery. He led the Patient Safety Commission for the World Society of Intravenous Anesthesia, and a board member of the International Academy of Health and Design, and has advised the UK CQC, Canada Accreditation Canada, Australian Clinical Excellence Commission, Norwegian UKOM, Singapore MOHH agency, Jordan Hakim agency, Pakistani Punjab HealthCare Commission, Bahamas Ministry of Health, Oman Medical Speciality Board, WHO and many US Patient Safety agencies in Florida, Massachusetts, Illinois and more.
Theories and ideas he has helped shape and provided research findings for, are now in common use as a result of his work: TeamSTEPPS, surgical team training, human factors tools, multi-method, triangulated approaches to research, governance of health systems, and interprofessional learning and culture change to achieve safe and reliable outcomes. His work has led to over $14,000,000 in federal competitive grant funding from the US NIH/AHRQ, EC FP-7, Australian NHMRC and Norwegian Federal Agencies.
He served as Editor of the British Medical Journal Safety and Quality and is Associate Editor of Pediatric Cardiology. He has published more than 300 scientific papers and 5 books. He has presented at or chaired international and national conferences, workshops, symposia and meetings on more than 500 occasions, including over 60 keynote addresses.
His books include
Surgical Patient Care Improving Safety, Quality and Value, Case Studies in Patient Safety Foundations for Core Competencies,
Pediatric and Congenital Cardiac Care Outcomes Analysis, and
Pediatric and Congenital Cardiac Care: Quality Improvement and Patient Safety.
Phone: 773 612 7039
Dr. Barach is deeply committed to translating research into strategies for systems strengthening, health protection and disease prevention. Paul has more than 25 years of experience as a practicing physician and physician executive in the military and in academic medical centers and integrated delivery systems. He is a formally trained health services researcher, with advanced post graduate training in advanced medical education and assessment methods from the Harvard Medical School Josiah Macy Program medical education, lean six sigma, quality improvement and lean techniques at Intermountain Healthcare. He has had additional training in epidemiology and statistics including both methodological as well as applied HTA research. Prior to that he spent 5 years in the military and was involved in team training, leadership and simulation work.
Paul has market eminence an experienced health sector consultant with an extensive track record of improving interprofessional training, health service and medical education delivery in Australia, US, GCC and Europe. He has done this work as board member of the NMBE, advisor to the ABMS, ACGME and as associate dean at lead academic medical center. His experience includes health service policy, funding, accreditation, and planning, program development, monitoring performance and improving operational service delivery. He led the Patient Safety Commission for the World Society of Intravenous Anesthesia, and a board member of the International Academy of Health and Design, and has advised the UK CQC, Canada Accreditation Canada, Australian Clinical Excellence Commission, Norwegian UKOM, Singapore MOHH agency, Jordan Hakim agency, Pakistani Punjab HealthCare Commission, Bahamas Ministry of Health, Oman Medical Speciality Board, WHO and many US Patient Safety agencies in Florida, Massachusetts, Illinois and more.
Theories and ideas he has helped shape and provided research findings for, are now in common use as a result of his work: TeamSTEPPS, surgical team training, human factors tools, multi-method, triangulated approaches to research, governance of health systems, and interprofessional learning and culture change to achieve safe and reliable outcomes. His work has led to over $14,000,000 in federal competitive grant funding from the US NIH/AHRQ, EC FP-7, Australian NHMRC and Norwegian Federal Agencies.
He served as Editor of the British Medical Journal Safety and Quality and is Associate Editor of Pediatric Cardiology. He has published more than 300 scientific papers and 5 books. He has presented at or chaired international and national conferences, workshops, symposia and meetings on more than 500 occasions, including over 60 keynote addresses.
His books include
Surgical Patient Care Improving Safety, Quality and Value, Case Studies in Patient Safety Foundations for Core Competencies,
Pediatric and Congenital Cardiac Care Outcomes Analysis, and
Pediatric and Congenital Cardiac Care: Quality Improvement and Patient Safety.
Phone: 773 612 7039
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Papers by Dr Paul Barach
Moscow May 15-17, 2018
.18th Ottawa Conference in the United Arab Emirates.
Evaluating policy and service interventions: framework to guide selection and interpretation of study end points
Management interventions may be divided into two categories; targeted service interventions with narrow effects, and generic service interventions that (like policy interventions) have diffuse effects
Measurement of clinical processes rather than patient outcomes may be more cost effective in evaluations of targeted service interventions. Clinical processes are not usually suitable primary end points for policy and generic service interventions because the effects at this level are too diffuse. Multiple clinical processes are consolidated on a small number of outcomes, which are the default primary end point for policy and generic service interventions.
When the policy or generic service intervention is inexpensive, cost effective and plausible outcomes may be undetectable at the patient level.
In such cases the effects of the intervention can still be studied at process levels further to the left (upstream) in an extended version of Donabedian’s causal chain.
inadequate culture-shift planning,
lack of employee involvement,
awed communication and leadership strategies.
Imagine a physical environment in Korea that helps reduce harm, infections, errors, falls, noise, confusion, anxiety and workforce injuries, while improving provider joy at work! Better environments transform the culture, improve patient safety and satisfaction and save money.
The framework of health care delivery is shifting rapidly across the world. Capital budgets and operational efficiency are critical in this time of shrinking reimbursement, increasing share of risk, and evolving models of care delivery. Getting the best value for your capital expenditures is key to your success. Capital projects that are informed by high-reliability organizational (HRO) initiatives can help your clients respond effectively to current pressures to reduce cost and improve quality. Creating a strategy for the future with experimenting with new methodologies and thinking processes that will be essential in the design of future healthcare facilities.
Facility design in Korea can affect how people work, and what processes, systems and technologies they will require to support the functioning of their work environments. Different ways of working and different configurations of clinical teams will emerge to ensure appropriate acquisition and use of new skills and competencies to produce quality outcomes. Higher reliability comes from authentic conversations, bold leadership and an organizational culture that enables staff to be fully present and honest in their feedback on better design, harm prevention and process improvement.
Reliability principles — methods of evaluating, calculating, and improving the overall reliability of a complex system — have been used effectively in industries such as manufacturing to improve both safety and the rate at which a system consistently produces appropriate outcomes. Even the most advanced healthcare organizations acknowledge that they are on a journey to achieving high reliability and need to address four essential building blocks: (1) a culture devoted to quality; (2) responsibility and accountability of staff; (3) optimizing and standardizing processes and (4) measurement of performance.
The talk will review the concepts of evidence-based quality, safety and population heath and review the forces and governments are facing in designing hospitals for the future. Engaging clinicians and patients in the design and operational process remains the biggest obstacle in addressing the growing implementation gap in providing cost effective and reliable care.
The majority of adverse patient events are preceded by predictable data patterns. Data mining methods, baysien networks and prediction models are emerging as methods for discovering patterns from large datasets, deducing knowledge from these patterns. They represent the uncertainties underlying clinical decision making. The knowledge of these patterns apriori may help mitigate and help prevent the intra and post-operatively clinical outcomes.
Methods
We analyzed a clinical anesthesia information management system (AIMS) at a tertiary academic hospital. The database query was used to identify adverse events (AEs) and their precursor patterns. A decision tree generator. C4.5, was used to induce a model from available data. We generated data files from the AIMS database. The data was pre-processed as input into a C4.5 generator. The output was in the form of a decision tree that was used to predict the occurrence of AEs.
Results
The database included data from more than 21,000 patients treated during a twelve month period. Each patient file included 20 vital sign parameters, that were automatically measured in the operating room by PICIS EMR software and recorded every 1-5 minutes in the AIMS. Among the 21,000 patients, 500 patients had vital sign fluctuations that met the criteria of an AE. We used refined definitions for four types of patient complications to improve the prediction ability of our analysis: hypertension, hypotension, hyperthermia and hypothermia. The four AEs were chosen due to their ease of measurement and less ambiguous definitions. We introduced two concepts: leading time (T1), and window size (T2), which denote the times in advance we can make the predictions and data we need to complete these predictions, respectively. We tested different pairs of (T1, T2) for each of the four AEs and then chose optimal pairs that result in the highest prediction accuracy.
Conclusions
We present an innovative data-mining based AE prediction model that has potential for making intra-operative care safer. We achieved a 70% accuracy for predicting AEs from the dataset a priori. We also found that voluntarily submitted quality assurance documentation greatly under-reported the incidence of many AEs among the 21,000 patients. The model we propose has the potential to alert clinicians to AE precursor conditions that might help prevent these events from progressing to patient harm.
The majority of adverse patient events are preceded by predictable data patterns. Data mining methods, baysien networks and prediction models are emerging as methods for discovering patterns from large datasets, deducing knowledge from these patterns. They represent the uncertainties underlying clinical decision making. The knowledge of these patterns apriori may help mitigate and help prevent the intra and post-operatively clinical outcomes.
Methods
We analyzed a clinical anesthesia information management system (AIMS) at a tertiary academic hospital. The database query was used to identify adverse events (AEs) and their precursor patterns. A decision tree generator. C4.5, was used to induce a model from available data. We generated data files from the AIMS database. The data was pre-processed as input into a C4.5 generator. The output was in the form of a decision tree that was used to predict the occurrence of AEs.
Results
The database included data from more than 21,000 patients treated during a twelve month period. Each patient file included 20 vital sign parameters, that were automatically measured in the operating room by PICIS EMR software and recorded every 1-5 minutes in the AIMS. Among the 21,000 patients, 500 patients had vital sign fluctuations that met the criteria of an AE. We used refined definitions for four types of patient complications to improve the prediction ability of our analysis: hypertension, hypotension, hyperthermia and hypothermia. The four AEs were chosen due to their ease of measurement and less ambiguous definitions. We introduced two concepts: leading time (T1), and window size (T2), which denote the times in advance we can make the predictions and data we need to complete these predictions, respectively. We tested different pairs of (T1, T2) for each of the four AEs and then chose optimal pairs that result in the highest prediction accuracy.
Conclusions
We present an innovative data-mining based AE prediction model that has potential for making intra-operative care safer. We achieved a 70% accuracy for predicting AEs from the dataset a priori. We also found that voluntarily submitted quality assurance documentation greatly under-reported the incidence of many AEs among the 21,000 patients. The model we propose has the potential to alert clinicians to AE precursor conditions that might help prevent these events from progressing to patient harm.
Major changes are needed in the delivery model to address these challenges. Given the pressures on healthcare, the systems that will thrive will focus on quality of care (including cost efficiency), through innovative healthcare delivery that results from the alignment of incentives with payers, patients and other participants in the healthcare equation.
Human factors and design thinking are approaches that can affect the design of how people work, and what processes, systems and technologies they will require to support the functioning of the work environment. Our work is about the people, the organization of work, and the spaces that support quality and resilience Innovation is best designed by listening to those on the front lines of healthcare delivery—patients and clinicians—and incorporating relevant knowledge from other scientific disciplines such as operations, research, organizational behavior, social sciences, industrial and biomedical engineering and human factors psychology. Effectively engaging clinical staff and particularly physicians is critical to this change in the design and delivery of effective health- care systems.
A human factors analysis addresses an organization as a complex socio-technical system; it identifies the stress points in the system and redesigns it to prevent errors from occurring, traps them while they are inconsequential, or mitigates their effects. And while technical skills are fundamental to good outcomes, the non-technical skills—coordination, cooperation, listening, negotiating, and so on— also can markedly influence the performance of individuals and teams and the outcomes of treatment. More positively, redesign of systems helps providers and patients do the right thing with less cost and effort.
High reliability—or consistent performance at high levels of safety over prolonged periods— is a hallmark for non-health-related, high-risk industries, such as aviation and nuclear power generation. High reliability is centered on supporting and building a culture of trust, transparency, and psychological safety. The ultimate goal of higher reliability of care comes from authentic conversations, bold leadership and an organizational culture that enables staff to be fully present, secure, and honest in their feedback on better design, harm prevention and process improvement.
Major changes are needed in the delivery model to address these challenges. Given the pressures on healthcare, the systems that will thrive will focus on quality of care (including cost efficiency), through innovative healthcare delivery that results from the alignment of incentives with payers, patients and other participants in the healthcare equation.
Human factors and design thinking are approaches that can affect the design of how people work, and what processes, systems and technologies they will require to support the functioning of the work environment. Our work is about the people, the organization of work, and the spaces that support quality and resilience Innovation is best designed by listening to those on the front lines of healthcare delivery—patients and clinicians—and incorporating relevant knowledge from other scientific disciplines such as operations, research, organizational behavior, social sciences, industrial and biomedical engineering and human factors psychology. Effectively engaging clinical staff and particularly physicians is critical to this change in the design and delivery of effective health- care systems.
A human factors analysis addresses an organization as a complex socio-technical system; it identifies the stress points in the system and redesigns it to prevent errors from occurring, traps them while they are inconsequential, or mitigates their effects. And while technical skills are fundamental to good outcomes, the non-technical skills—coordination, cooperation, listening, negotiating, and so on— also can markedly influence the performance of individuals and teams and the outcomes of treatment. More positively, redesign of systems helps providers and patients do the right thing with less cost and effort.
High reliability—or consistent performance at high levels of safety over prolonged periods— is a hallmark for non-health-related, high-risk industries, such as aviation and nuclear power generation. High reliability is centered on supporting and building a culture of trust, transparency, and psychological safety. The ultimate goal of higher reliability of care comes from authentic conversations, bold leadership and an organizational culture that enables staff to be fully present, secure, and honest in their feedback on better design, harm prevention and process improvement.
Imagine a physical environment in Russia that helps reduce harm, infections, errors, falls, noise, confusion, anxiety and workforce injuries, while improving provider joy at work! Better environments transform the culture, improve patient safety and satisfaction and save money.
The framework of health care delivery is shifting rapidly across the world. Capital budgets and operational efficiency are critical in this time of shrinking reimbursement, increasing share of risk, and evolving models of care delivery. Getting the best value for your capital expenditures is key to your success. Capital projects that are informed by high-reliability organizational (HRO) initiatives can help your clients respond effectively to current pressures to reduce cost and improve quality. Creating a strategy for the future with experimenting with new methodologies and thinking processes that will be essential in the design of future healthcare facilities.
Facility design in Russia can affect how people work, and what processes, systems and technologies they will require to support the functioning of their work environments. Different ways of working and different configurations of clinical teams will emerge to ensure appropriate acquisition and use of new skills and competencies to produce quality outcomes. Higher reliability comes from authentic conversations, bold leadership and an organizational culture that enables staff to be fully present and honest in their feedback on better design, harm prevention and process improvement.
Reliability principles — methods of evaluating, calculating, and improving the overall reliability of a complex system — have been used effectively in industries such as manufacturing to improve both safety and the rate at which a system consistently produces appropriate outcomes. Even the most advanced healthcare organizations acknowledge that they are on a journey to achieving high reliability and need to address four essential building blocks: (1) a culture devoted to quality; (2) responsibility and accountability of staff; (3) optimizing and standardizing processes and (4) measurement of performance.
The talk will review the concepts of evidence-based quality, safety and population heath and review the forces and governments are facing in designing hospitals for the future. Engaging clinicians and patients in the design and operational process remains the biggest obstacle in addressing the growing implementation gap in providing cost effective and reliable care.
At the core of high reliability organizations (HROs) are five key concepts, which we believe are essential for any improvement initiative to succeed:
• Sensitivity to operations. Preserving constant awareness by leaders and staff of the state of the systems and processes that affect patient care. This awareness is key to noting risks and preventing them.
• Reluctance to simplify. Simple processes are good, but simplistic explanations for why things work or fail are risky. Avoiding overly simple explanations of failure (unqualified staff, inadequate training, communication failure, etc.) is essential in order to understand the true reasons patients are placed at risk.
• Preoccupation with failure. When near-misses occur, these are viewed as evidence of systems that should be improved to reduce potential harm to patients. Rather than viewing near-misses as proof that the system has effective safeguards, they are viewed as symptomatic of areas in need of more attention.
• Deference to expertise. If leaders and supervisors are not willing to listen and respond to the insights of staff who know how processes really work and the risks patients really face, you will not have a culture in which high reliability is possible.
• Resilience. Leaders and staff need to be trained and prepared to know
how to respond when system failures do occur.
This talk shows how hospital leaders have taken these basic concepts and used them to develop and implement initiatives that are key to enhanced reliability.
The talk will review how the concepts have been used to:
• Change and respond to the external and internal environment
• Plan and implement improvement initiatives
• Adjust how staff members do their work
• Implement improvement initiatives across a range of service types and
clinical areas
• Spread improvements to other units and facilities
Applying high reliability concepts in your organization does not require a huge campaign or a major resource investment. It begins with leaders at all levels beginning to talk honestly about the challenges, sharing day transparently, and thinking deeply about how the care they provide could become more reliable.
Research into surgical outcomes has primarily focused on the role of patient pathophysiological risk factors, and on the skills of the individual surgeon. The outcome of surgery is, however, also dependent on the quality of care received throughout the patient’s stay in hospital and the performance of a considerable number of health professionals, all of whom are influenced by how they learn, and the environment in which they work. Drawing on the wider literature on safety and quality, risk management in healthcare, and recent papers on surgery and human factors, this talk argues for a much wider assessment of factors that may be relevant to surgical outcome. In particular, we suggest the development of an “operation profile” to capture all the salient features of a surgical operation. The aims of this initiative are: to expand operative assessment beyond patient factors and the technical skills of the surgeon; to extend assessment of surgical skills beyond bench models to the operating theater; to provide a basis for assessing interventions and to provide a deeper understanding of surgical outcomes, staff welfare and patient wellness.
Hospitals and OR design affects the design of how people work, and what processes, systems and technologies they will require to support the functioning of the work environment. Different ways of working and different configurations of clinical teams will emerge to ensure appropriate acquisition and use of new skills and competencies to produce quality outcomes. Higher reliability comes from authentic conversations, bold leadership and an organizational culture that enables staff to be fully present and honest in their feedback on better design, harm prevention and process improvement.
Reliability principles — methods of evaluating, calculating, and improving the overall reliability of a complex surgical system — have been used effectively in industries such as manufacturing to improve both safety and the rate at which a system consistently produces appropriate outcomes. Even the most advanced healthcare organizations acknowledge that they are on a journey to achieving high reliability and need to address four essential building blocks: (1) a culture devoted to quality; (2) responsibility and accountability of staff; (3) optimizing and standardizing processes, and (4) measurement of surgical performance.
The presentation will review the foundational concepts of evidence-based surgical quality and safety and develop a better appreciation for the forces and pressures surgeons and surgical leaders are facing. Engaging surgical clinicians in the design and operational process remains the biggest obstacle in addressing the growing implementation gap in providing cost effective and reliable surgical care.
Hospital administrators, clinical leads and the experts planning, designing and constructing healthcare facilities need to work differently to meet the challenge. New ways are being established of collaborating, integrating services, systems and programs to constantly improve care, and in Ontario, meeting the new requirements of health funding reforms.
Join us for a very informative day to learn about these cutting-edge technologies, approaches for integration and how they are transforming healthcare facilities.
At this event, the audience plays an important role in advancing the discussion and understanding. Our audience is comprised of healthcare leaders and multi-disciplinary experts that provide expertise to the healthcare facility sector. Please join us for our Toronto winter session!
Canadian Centre for Healthcare Facilities (CCHF) is a national, not-for-profit association. CCHF’s goal is to help the healthcare facility sector achieve the highest quality healthcare facilities, responsive to patient care needs, through the planning, design, construction, and operation phases. CCHF will do this by:
• Connecting: Bringing together cross-disciplinary stakeholders (hospital administrators, clinical experts, researchers, engineers, architects, designers, construction managers)
• Sharing: Approaches to improving the design of healthcare facilities, including: design for innovations, evidence-based design, lean, patient centred design, design and facilities standards, post-occupancy evaluations
• Learning: Building knowledge networks through research, case studies and expert input
• Inspiring: Bringing together innovative thinkers and leaders to share their expertise as
speakers, sponsors, attendees and program advisors.
Healthcare executives and design professionals will learn how Design Thinking was applied in actual case studies and how projects transitioned beyond theory to practice. Hear from design practitioners at every level of the system who have successfully employed design thinking methodologies in healthcare to go beyond good and create meaningful patient experiences.
Learning Objectives:
1.Identify the transitional care outcomes and components that matter most to patients and caregivers using human factors and adverse event analysis methods.
2. Develop a standard process to optimize patient transitions using a process mapping methodology from the patient/care giver perspectives.
3. Discuss barriers and facilitators for successful interventions and local implementation
4. Discuss recommendations for dissemination and implementation of effective transitions of care.
approaches are not producing the pace, breadth, or magnitude of improvement that patients demand and providers expect. Proscriptive rules, guidelines and checklists are helping to raise awareness and present some harm but are falling short from helping to provide an ultrasafe system (Amalberti et al. 2005). A new system centered around the patient and their clinical microsystem that renders clinical care processes more predictable, effective, efficient and humane is needed
(Mohr et al. 2004).
The focus on the actions of individuals, without addressing the underlying microsystem, as the sole cause of adverse events inevitably results in continued system failures and the resultant injuries and deaths of children.
Strategies to make sedation care more reliable and even safer might include: adoption of reliability engineering principles, setting up robust near miss reporting systems, applying critical event analysis tools, wide adoption of simulation and sedation team training, adopting checklists, standardizing medication protocols, implementing robust hand off protocols and patient identification checklists, and adherence to the ASA Sedation practice parameters.
The surgical space, by nature, is a high-risk hypercomplex environment where hazards lurk around every corner and for every patient. Health care institutions continue to face challenges in providing safe patient care in increasingly complex and demanding technical, organizational, and regulatory environments. Real, sustainable change comes from the organizations and hardworking staff that deliver care to patients. It is odd that something so important and personal as health care does not have widely acknowledged or adopted “industry standards” of inspection, reporting, and improvement.
Both high reliability theory and systems theory provide conceptual and practical frameworks for supporting accreditation driven approaches towards delivering safe and reliable care. Although many ambiguities and conflicts arise from the implementation of these theoretic constructs, they should guide the development of work processes and stimulate innovation in designing ways to provide safe and effective care within health care systems. Organizing surgical care around the pursuit of safety and reliability as an overarching priority is a professional obligation for all members of the health care team. This goal can be accomplished by organizing around and shaping a culture focused on reliable performance but requires substantial investments in human capital.
Surgical Patient Care: Improving Safety, Quality and Value targets an international audience which includes all hospital, ambulatory and clinic-based operating room personnel as well as healthcare administrators and managers, directors of risk management and patient safety, health services researchers, and individuals in higher education in the health professions.
http://www.springer.com/us/book/9783319440088
faces such rapid growth in demand with the simultaneous need to realign its health-care systems to be able to treat the disorders of affluence. These countries have seen considerable socioeconomic and health development in the region over the past decades.
Surgical Patient Care: Improving Safety, Quality and Value, Springer, 2017, http://www.springer.com/us/book/9783319440088
The three greatest barriers to organisational change are most often the following:
�� inadequate culture-shift planning,
�� lack of employee involvement,
�� flawed communication and leadership strategies.
Organisations also need a clear system in place to support ongoing measurement, implementation, and assessment, and effective ways to address the normalised deviance. This chapter aims to provide practical advice to intensive care providers and administrators on how to encourage and support healthcare professionals and managers to change their clinical practices
Barach P. Addressing barriers for change in clinical practice. In Quality Management in Intensive Care: A Practical Guide. (Eds) Bertrand Guidet, Andreas Valentin and Hans Flaatten, Cambridge University Press, 2016.
978-1-107-50386-1.
Health professional students including medicine, nursing, pharmacy, health administration, public health, as well as practicing professionals such as patient safety officers, chief quality officers, risk managers, and health service researchers will gain valuable insight into the real-world of medical errors and a better understanding of how they can be prevented through practical, actionable methods.
Patients’ rights have been formulated in a number of documents and guidelines from various international bodies. Laws and declarations on patients’ rights do not automatically make health care safer, but can help to empower patients. Empowered patients are in a better position to manage their own health and health care and to participate in efforts to improve safety. "e report presents an overview of legal aspects influencing
patient safety and describes examples of patient involvement. It highlights the need to strengthen a continuum of information between various levels of care, including patient experiences, health literacy and engagement. "e work is expected to contribute to the wider process of evidence collation aimed at finding
effeceint ways to build realistic and informed expectations of health care, while encouraging patients to be vigilant and knowledgeable to ensure maximum safety standards. Recommendations are formulated with respect to the macro, meso and micro levels of health service delivery.
outcomes. This book concentrates on implementation science in terms of continuous quality improvements and safety science and systems.
Pediatric and Congenital Cardiac Care: Volume 2 - Quality Improvement and Patient Safety reveals the remarkable developments that have been seen in the fields of pediatric
cardiology and cardiac surgery. This unique collaboration between four Editors from disparate medical disciplines (cardiac surgery, cardiology, anesthesia, and critical care) incorporates an international community of scholarship with articles by luminaries
and cutting edge thinkers on the current and future status of pediatric and congenital cardiac care. The goal of this and its companion volume is to understand and advance the profession and its activities, to use common terms, and to improve the management of risk and safety in order to enhance pediatric and congenital cardiac care.
and methodologies to analyze outcomes. This book concentrates on implementation science in terms of continuous quality improvements and safety science and systems.
Pediatric and Congenital Cardiac Care: Volume 1 – Outcomes Analysis reveals the remarkable developments that have been seen in the fields of pediatric cardiology and cardiac surgery. This unique collaboration between four Editors from disparate medical disciplines (cardiac surgery, cardiology, anesthesia, and critical care) incorporates an international community of scholarship with articles by luminaries and cutting edge thinkers on the current and future status of pediatric and congenital cardiac care. The goal of this and its companion volume is to understand and advance the profession and its activities, to use
common terms, and to improve the management of risk and safety in order to enhance pediatric and congenital cardiac care.
The goals of the project were to:
• Identify the role of the patient at SIVF using process mapping and analysis of available sources of data
• Consult with patients about their experience and inform SIVF of strengths and areas in need of improvement
• Examine staff attitudes, organizational policies and HR documents towards work practices, safety, communication and staff welfare using survey and interview tools
• Identify the learning culture at SIVF around reporting of non-routine events and patient harm.
• Develop and deliver a training program that focuses on recognizing the patient as the center of the IVF process
The goals will be accomplished in three phases:
Phase I: Pre-intervention assessment and data collection Phase II: Intervention design based on Phase I
Phase III: Re-evaluation after the interventions.
Phase I is complete and this report summarizes the results from Phase I and sets the stage for Phases II, the training phase. The data indicate that there are many positive aspects of Sydney IVF which include:
• A strong reputation for the highest quality IVF treatment
• An internationally recognized track record for innovation and pioneering IVF techniques
• High levels of staff loyalty and pride in the company’s achievements
• A strong culture of continuous improvement and change readiness
• A commitment to personalized patient centred care.
The results from Phase I of the project indicate there is vibrant strategic plan but that at times execution lags. There is scope for improvement helping Sydney IVF maintain their strong brand and manage their risks more astutely. Sydney IVF needs to protect it’s free thinking and creative behaviors that launched them on their journey to market leadership. Combining innovation and scale is a pressing challenge and will require hiring creatively throughout the organization while adopting more integrated ways to manage risk not just collect risk information.
For SIVF’s growth a structured process is critical for innovation to scale through all departments in the company. Innovation has to be sponsored and strongly supported by management. The recommendations provide a platform for future efforts to improve the resilience and enhance the brand and safety of care provided by Sydney IVF.
This report shows that a relentless focus on accurately reported outcomes of care is the critical glue that can bring together patients, professionals,
providers and those paying for and regulating care.
The provision of effective, safe and reliable neurotrauma services requires a diverse range of health professionals, services and external agencies. These need co-ordination and collaboration to help overcome a myriad of system challenges such as separate funding, administration, different governance and reporting structures.
There exists the opportunity to reshape service delivery, patient outcomes, efficiencies and enhance collaboration with health care providers through the establishment of a single dedicated Neurotrauma Precinct founded on best practice principles and innovation.
The Neurotrauma precinct would be dedicated to end-to-end treatment from time of injury to well being at home. This continuum includes: retrieval, acute care, rehabilitation, community transition, and re-socialization focusing on social and economic participation of people who have sustained a major traumatic brain injury or spinal cord injury (“neurotrauma”).
In the face of health reform and increased devolution of responsibilities, specialist statewide services in particular low incidence areas such as neurotrauma can deliver excellent outcomes, which are not financially feasible without a carefully designed system based around specialist capabilities. The Lifetime Care and Support Authority (LTSCA) has the required infrastructure and governance to ensure that efforts to improve the system support each and every person who sustains a major traumatic brain injury or spinal cord injury, his or her families and care givers at home.
People who sustain neurotrauma currently have suboptimal outcomes in NSW. The Spinal Cord Injury and Brain Injury Directorates both suffer from a lack of strategic support and a service delivery framework which has been the victim of funding constraints and a lack of a focus on the entire injury-recovery continuum in recent years.
Best practice outcomes for people who have sustained neurotrauma are achieved by dedicated, specialist centres that combine fast retrieval, acute care and sustained, coordinated rehabilitation care. These centres may include surgery and intensive care where required, linked to inpatient and outpatient rehabilitation and lifetime care and support programs aimed at re-socialisation and re-integration into society.
Remaining patient-centric during major reform while making bold steps towards accountability and transparency will ensure NSW remains a leader in overseeing delivery of care in the nation.
The provision of effective, safe and reliable neurotrauma services requires a diverse range of health professionals, services and external agencies. These need co-ordination and collaboration to help overcome a myriad of system challenges such as separate funding, administration, different governance and reporting structures.
There exists the opportunity to reshape service delivery, patient outcomes, efficiencies and enhance collaboration with health care providers through the establishment of a single dedicated Neurotrauma Precinct founded on best practice principles and innovation.
The Neurotrauma precinct would be dedicated to end-to-end treatment from time of injury to well being at home. This continuum includes: retrieval, acute care, rehabilitation, community transition, and re-socialization focusing on social and economic participation of people who have sustained a major traumatic brain injury or spinal cord injury (“neurotrauma”).
In the face of health reform and increased devolution of responsibilities, specialist statewide services in particular low incidence areas such as neurotrauma can deliver excellent outcomes, which are not financially feasible without a carefully designed system based around specialist capabilities. The Lifetime Care and Support Authority (LTSCA) has the required infrastructure and governance to ensure that efforts to improve the system support each and every person who sustains a major traumatic brain injury or spinal cord injury, his or her families and care givers at home.
People who sustain neurotrauma currently have suboptimal outcomes in NSW. The Spinal Cord Injury and Brain Injury Directorates both suffer from a lack of strategic support and a service delivery framework which has been the victim of funding constraints and a lack of a focus on the entire injury-recovery continuum in recent years.
Best practice outcomes for people who have sustained neurotrauma are achieved by dedicated, specialist centres that combine fast retrieval, acute care and sustained, coordinated rehabilitation care. These centres may include surgery and intensive care where required, linked to inpatient and outpatient rehabilitation and lifetime care and support programs aimed at re-socialisation and re-integration into society.
Remaining patient-centric during major reform while making bold steps towards accountability and transparency will ensure NSW remains a leader in overseeing delivery of care in the nation.
People eligible for the Scheme will have suffered a spinal cord injury, moderate to severe brain injury, multiple amputations, severe burns, or will be blind as a result of the accident. The majority of the participants to the scheme have catastrophic neurological injury (ie. Severe spinal cord or brain injury).
Catastrophic neurological injury represents a major cost in respect to healthcare, equipment and environment modifications, long term care costs, and in terms of productivity losses.
Key Issues and Challenges
Key issues and challenges with the current system include:
1. Funding, Governance & Service Arrangements
a) Services are fragmented across the continuum of care. They are episodic and segregated by organisational boundaries. Aligning this system to delivering high quality life long outcomes requires substantial navigation and negotiation by both participants and those delivering care and support.
b) There is a lack of clarity/accountability concerning how funds are used.
c) There are limited agreed standards and performance measures
concerning delivery of a service and the effectiveness of the service.
2. Organisation Arrangements
a) Delivery of acute services is arranged across several major trauma centres. This arrangement impedes learning and improvement and creates difficulties in achieving minimal service volumes.
b) Care tends to be organised around a narrowly focused episode rather than the end to end journey. This means there is lack of continuity as the patient moves across the continuum of care.
c) Services in the community are fragmented and often inadequate. This is causing blockages within the inpatient facilities and limiting access to patients needing care.
d) The specialist trauma workforce is currently limited, and specialised trauma training is not as expansive as other jurisdictions and specialties.
3. Processes
a) There is variability and differences in services and practices.
b) Where protocols and standards do exist, there is lack of robust process to monitor compliance and to systematically revise protocols and standards.
c) The system is linear and applies a “one size fits all” paradigm of care. It tends to lose focus on lifetime outcomes, and doesn’t easily permit entry and access according to the needs of different patients.
4. Data & Outcomes
a) Lack of evidence and information relating to the optimal methods to provide care and services to neurologically injured patients.
b) Data that does exist tends to be limited to a particular organisation, administratively focused, and is insufficient for understanding system performance and outcomes.
c) Inadequate process and governance arrangements for seeing the findings from research implemented into practice.
5) Key Opportunities
Changes are required to the current system in order to deliver improved life time out comes for patients with catastrophic neurological injury. This needs to occur within the context of health reform, industry trends, and broader technology and management changes and practices.
Of particular relevance are:
a) National efficient pricing and performance measures tied to funding is expected to be developed as part of National Health Reform. Over time it is expected that this mechanism will move to a more outcome based funding model.
b) Proposed National Injury Insurance Scheme will increase the scale and make it more economically feasible to orient services to improve lifetime outcomes for patients with catastrophic neurological injury.
c) NSW Health policy has recommended further concentration of trauma services, development of specialist skills and workforce, and embedding continuous quality and safety improvement in the health system.
d) Technology, industry changes, and clinical innovations enable care and services to be delivered in a more accessible and cost effective way.
healthcare reform. The framework of health care delivery is shifting rapidly across Australia given growing calls for radical change and cost containment. Things have changed since early days; safety and quality benchmarks are often integrated into strategic goals and there is more focus on patient-centered care. Patients, however, still experience needless harm and often struggle to have their voices heard, processes are not as efficient as they could be, and costs continue to rise at alarming rates while quality flat lines. The systems that will thrive will focus on cost efficiency, quality of care, innovative health care delivery, and alignment of incentives with payers, patients, and other participants in the health care equation.
Australia is undergoing the largest single period of new healthcare facility procurement in its history.
The combined force of the NSW Health/Australian reforms and workforce and financial pressures against a backdrop of rising demand, increasing complexity and changes in demographics, means the delivery of health care in the current configuration cannot be sustained. NSW is being ''overwhelmed'' by rising healthcare costs with nearly 30% of the state budget expended in the delivery of healthcare. NSW Treasury estimates that total spending over the next 20 years will exceed 55 per cent of the state budget.
A radical re-think is required to devise new ways of procuring healthcare facilities. Despite unprecedented levels of capital spending on health infrastructure, the facilities planning process and its design outcomes continue to frustrate patients, providers and communities. Without reform, NSW's ability to maintain the high level of service currently provided will be compromised.
There is a window of opportunity to change the face of NSW health care very significantly, opened by the National Health & Hospitals Reform, the Special Commission of Inquiry into Acute Care in NSW Public Hospitals (Garling Commission) and the system-wide response: Caring Together - the Health Action Plan for NSW, and strategies to address the variation in clinical services and outcomes across NSW. However, engaging and partnering with clinicians remains one of the biggest obstacles in addressing the growing implementation gap in providing cost-effective and quality care in NSW.
JBara Innovations was contracted by NSW Health Infrastructure (HI) to develop a quality improvement project that would provide coherent, evidence-based clinical input into the planning and development of healthcare facilities in NSW and inform Health Infrastructure of apparent strengths and opportunities for improvement..
The goals of the project were to:
• Identify evidence-based best practice in mental health facility design, in regard to fitness-for-purpose and effectiveness in delivering care.
• Identify the perceived role and impact of Health Infrastructure (HI) on the efficiency and effectiveness of mental healthcare facilities procurement in NSW.
• Consult with Mental Health Units in New South Wales, the NSW Ministry of Health (MOH), and planning & design professionals about their experience with Health Infrastructure.
• Examine staff attitudes and organizational policies in regard to the current planning and procurement process in NSW.
• Prepare an environmental scan of current practices to identify issues and gaps in the planning process, deficiencies in current roles and responsibilities, and options for improvement and change.
Since 2007, Health Infrastructure has been responsible for health facility project planning, direction, management and commissioning. Historically, the procurement process has not always been smooth with a growing trust gap between stakeholders and the former NSW Department of Health. HI’s efforts to build trust and credibility have been complicated by the cautious attitudes held by clinicians, contractors and communities toward the Department1,2. The restructure announced by the new Director General of Health, Dr Mary Foley, on 24th August 2011 acknowledged HI’s core role in the planning of health facilities in the state and emphasized the need for
1 Despite the devolution of Area Health Services into Local Health District, Area names are generally retained in this Report, as all sites visited were commissioned under the Area framework. The organizational structure of the delivery system does not alter the recommendations of the Report, although it may make responsiveness to those recommendations more feasible. Local Health Districts are referred to in the recommendations.
Poor communication between stakeholders led to a twelve week closure of the Hornsby Mental Health Intensive Care Unit for retrofitting, at a cost of half a million dollars and negative local media:Hornsby and Upper North Shore Advocate: May 13, 20 2010; October 13, 14, 16 2008.
Health Infrastructure Quality Improvement Project HI to “address concerns about stakeholder management, particularly clinical engagement, responsiveness and cost and budgetary transparency.”
The challenge was to devise and implement the change. HI had been aware of the challenges, and prior to the release of the Director General’s report had commissioned JBara Innovations to identify opportunities to improve the process and engagement of stakeholders. Implementation of the ten recommendations that arise from this study will support a collegiate and productive process in the procurement of high value, safe, functional and therapeutic healthcare facilities in NSW.
This Report includes an extensive literature review, key informant interviews, site visits, a review of project documentation and reports focused on the process of mental health facility procurement in NSW. The literature suggests that the built and natural environments exert a range of impacts on patients and staff.
The data indicates that change should target both the systemic and cultural levels, with a particular emphasis on improving professional and business alignments that lead to project delays, budget overruns and political remonstrations. Effective redesign and improvement of the HI service model will involve bringing the voices of the many stakeholders into a shared dialogue with HI.
The data indicate that Health Infrastructure’s work and leadership is perceived in a positive manner, and it is particularly noted for:
• being a learning organization, actively changing procedures and methods on the basis of experience and reflection
• a strong reputation for leadership
• a recognized track record for innovation and pioneering health facility
procurement techniques
• high levels of staff loyalty and pride in achievements
• a strong culture of continuous improvement and change readiness
The data also indicate some scope for HI to more effectively refine its governance model, manage its risks, and appreciate the impact of its decisions on the level and NSW Government. Future arrangements for type of clinical risks in the system.4 Upstream ‘latent factors’ enable, condition, or exacerbate the potential for ‘active errors’ and patient harm.
Understanding the characteristics of a safe, resilient and high performing system requires research to optimize the relationship between people, tasks and dynamic environments. The socio-technical perspective incorporates the concept of latent conditions whereby the cascading nature of human error is understood as beginning with the decisions and actions of management; including decisions made during planning, design and procurement of health facilities. Identified risks were particularly associated with: the rapid churn in the formal membership of decision making bodies; frequently disrupted communication processes; an overly lengthy time horizon between development of the Clinical Services Plan (CSP) and Procurement Implementation (PI); fast tracking of service planning processes to meet dominant stakeholder agendas; limited health facility planning expertise inside the organization; and use of negotiated guidelines as project control tools, instead of tools to engage users and providers in a structured dialogue during planning and design.
The Report sets out the key initiatives of an integrated quality improvement strategy that HI should consider incorporating into the scheduled program of capital works, currently valued in excess of one billion dollars. Although the study focuses on mental healthcare facilities, the findings we believe are applicable to all healthcare settings in NSW.
The project recommendations provide a platform to enhance the adaptability of the process of planning to particular circumstances, and to improve the design and procurement of NSW health facilities.
VANCOUVER, BC, CANADA MAY 28-31, 2007
Prepared by Jan Visser in collaboration with Paul Barach, John van Breda and Yusra Laila Visser Eyragues, France : August 13, 2007
VANCOUVER, BC, CANADA MAY 28-31, 2007
Prepared by Jan Visser in collaboration with Paul Barach, John van Breda and Yusra Laila Visser Eyragues, France : August 13, 2007
§ As part of the establishment of the integrated transport authority (TfNSW), it was determined that the CRS (excluding Crashlab) would move from RMS to TfNSW given the preponderance of strategy and policy type functions within CRS
§ A Review has been undertaken subsequent to the decision to move CRS to determine whether all existing functions should remain in an integrated unit within the Policy & Regulation Division (PRD), or whether some other structural model would be more appropriate
§ The Review has determined that there is a strong case for change, specifically:
– With the realignment of responsibilities, accountabilities and capabilities between TfNSW and RMS, there is a case to separate “strategy, policy &
R&D” functions from “program management & delivery” functions
– The benefits expected from the 2008 CRS restructure have not been fully realised – in particular, there are opportunities to improve strategic focus, community acceptance of policy innovations and the Centre’s influence and collaboration
– Internal and external transport stakeholders indicated a decline in the level of confidence in CRS, and are concerned about its method of operation
– While NSW has achieved improvements in road safety outcomes in line with other States, they lag international leaders by a considerable margin
§ The Steering Committee has endorsed a future model for road safety that has a lean strategy, policy and R&D unit in PRD, and that has a greater
focus on community consultation and engagement. Remaining functions should be distributed to more appropriate divisions within TfNSW and RMS
§ The proposed structure for the road safety branch in PRD has 53 permanent positions – some of the positions would be considered “new” or “major change” from the current CRS structure. Under the proposed structure it is estimated that:
– 20 positions are potential surplus – 9 of these are vacant, 4 are administrative roles, 7 others – 10 positions are performing functions that are more aligned to TSD or PPD
– 5 positions are performing functions that are more aligned to RMS
§ Key next steps include (i) endorse functional model and organisation structure for PRD, (ii) agree location of residual functions, (iii) agree governance model with clear statement of accountabilities, (iv) commence people transition process
Healthcare is in a crisis that is fuelling dramatic reform in North Carolina while the framework of health care delivery is shifting rapidly across the US. The systems that will thrive will focus on cost efficiency, quality of care, innovative health care delivery and sustained clinician engagement.
In December 2013, AccessCare requested a proposal to identify opportunities to increase its efficiency and effectiveness in delivering healthcare services along with prioritizing next steps. Cirra (teaming up with Sterling Enterprises International and J Bara Innovation) propoed using a multi-phased approach consisting of Assessment – Discovery – Action – Manage – Sustain (ADAMS). AccessCare agreed to fund the Assessment and Discovery portions of the ADAMS approach as Phase 1 of ADAMS. AccessCare agreeing with the proposal requested that Cirra include Community Care of Wake and Johnston Counties (Wake-Johnston) along with Community Care of the Sandhills (Sandhills) as participants in Phase 1.
Phase 1 was launched on February 10 with a joint meeting held at AC offices. On May 29 an all day Discovery Workshop with AC, Wake-Johnston, and Sandhills clinical leaders, participating at AccessCare offices was held to conclude Phase 1.
The outcomes of the Discovery Workshop included:
1. Identification of strengths and weaknesses for each of the 3 networks.
2. Identification of near term (i.e., 6 months or less) actions, mid term (i.e., 18 months or less), and long term (i.e., 1 – 3 years) actions for each of the 3 networks.
3. Identification of near term, mid term, and long term actions common to all 3 networks.
Accompanying this Executive Summary is an Appendix. The Appendix summarizes the activities leading up to the Discovery Workshop and the outcomes from that Workshop which provide a foundation for launching Phase 2 of ADAMS. Phase 2 emphasizes capitalizing on the strengths identified, mitigating the weaknesses, prioritizing resourcing, and insuring a process that will deliver the Action, Manage, and Sustain portion of ADAMS.
An outcome of the Discovery Workshop was the determination that there are 6 primary initiatives that are common across the 3 networks participating that we recommend should be target areas for addressing in Phase 2 (Action-Manage-Sustain).
The 5 initiatives are:
1. Strategic Planning
2. Brand Management
3. Integrated Communications Plan
4. Performance Improvement, Monitoring, and Reporting
5. Information Services
In November 1999, the Institute of Medicine (IOM) published a landmark report entitled “To Err is Human: Building a Safer Health System.” Produced by the IOM’s Committee on Quality of Health Care in America, the report estimated that 44,000 to 98,000 Americans die in hospitals each year as a result of medical errors. Nonfatal “adverse events” (injuries caused by medical management rather than by the underlying condition of the patient) are ten- hundredfold more numerous than deaths due to errors. The IOM Report estimated that total national costs for adverse events (lost income, lost household production, disability, health care costs) are between $38 billion and $50 billion annually. Based on the IOM Report and assuming similar care, in Massachusetts we can expect between 1000 and 2000 preventable deaths a year.
Release of the IOM Report generated enormous coverage in the media, and intense focus on this issue has continued unabated. There is substantial evidence that the majority of health care errors are preventable, and are the result of systemic problems rather than poor performance by individual providers. Proposals have surfaced in Congress and from the White House to
implement the IOM’s recommendations, and several bipartisan-supported Congressional hearings have fueled discussion and debate on the subject.
In Massachusetts, where much of the work in patient safety has been pioneered, there is proposed legislation which includes a near miss reporting system, changes in mandated reporting systems and the creation of a new state agency to coordinate and support patient safety efforts and research. It also calls for confidentiality protection to encourage sharing of sensitive data. It is vital that all stakeholders, government, the professions, healthcare administrators, industry and consumers be involved at all stages and that mechanisms for ongoing, effective consultation and communication be provided at local and state levels.
There are ethical, humanitarian, and financial imperatives to find out what is going wrong, to collate, and analyze the information, and to devise and implement strategies to better detect, manage, and prevent these problems. Despite clear policy guidance and compelling ethical rationale, which support disclosure of adverse events, there are legal, regulatory and cultural barriers that perpetuate the current situation. Patients and families sometimes are not being told about adverse events that have led to bad outcomes or injuries.
This report concludes with a set of recommendations that encourages open debate on patient safety initiatives in Massachusetts. The Commonwealth can help create a culture of safety. If the fear of litigation continues to countervail the efforts to improve patient safety, transformation from the present unsatisfactory situation into a culture promoting safety for our patients may never be fully realized.
The following discussion is intended to provide background from a number of perspectives on the impact of the role of the state on patient safety. Several options for state level action in Massachusetts are presented. These include:
• Recommendation 1: Create and endow a Patient Safety Center for the Commonwealth
• Recommendation 2: Structure a leadership vehicle for the future development of patient safety programs
• Recommendation 3: Mandatory adoption of error prevention strategies
• Recommendation 4: Implement Incident Reporting
Recommendation 5: Provide and ensure appropriate confidentiality protection
• Recommendation 6: Study alternatives to the current medical liability and accountability systems