Implementing Standardised Clinical Practices - Clinical Human ...

Implementing Standardised Clinical Practices - Clinical Human ...

Standardisationfor Qualityin Clinical PracticeMatt Inada-KimAcute PhysicianHampshire HospitalsIHI & HarvardClinical Human Factors GroupOpen Seminar October 23 rd 2012Addenbrookes

Definitions Take one“The process of developing & implementingtechnical standards”Commerce / ManufacturingCommunication / ResearchWhat about Healthcare? And in what settings?“Doing the same thing in the same way”

Why?1. SafetyMultiple, dynamic unique teamsMigratory staff2. Quality Improvement“Variation harms quality” J Edwards Deming- Toyota3. The pursuit of High Reliability4. It’s what the population want

Team VariabilityF SpeyerThe workforce of my Medical Assessment Unit• 10 Consultants• 8x Sisters, 25x Staff Nurses & 15x HCA• 11x Registrars, 15x Senior House Officers, 16x House Officers1xConsultant, 1xSister, 5xSN, 3xHCAs, 1xSpR, SHO & HO per shiftNumber of potential teamsNursing 1.4 billion (UK)Medical 26,400

Myth 1- Clinicians like making heroic difficult decisionsNo !We are no longer test pilots, but airline ones.This is a culture shift..of Intuition evolving towards Empiricism & StandardisationClinicians seek it…through consensus, evidenceBy standardising, the easy decisions make themselves

Myth 2- All clinical problems are unique and differentNo, Only 5-10% of my acute intake follow an atypical pattern.These “outlier cases” require expertise, intuition and time (>90%)Happy Side Effect-Standardisation allows me more “thinking” time on outliers

Standardisation vs IntuitionStandardisation IntuitionEvidence Fundamental IndirectBrain Left RightMantra Facts Rational InsightStrengths In “Certainty” The “Grey”Champions Similarity InnovationAllows Rapid progress Allows “Leaps”Weaknesses Reduces Innovation Inhibits systemic learningVariation Reduces IncreasesHigh Reliability Enables ReducesHealthcare contextually needs bothThe difference is rarely clear cut

Myth 3- We do this already…Measure and Prove it !There is often wide, unconscious, variationfor the same problemMyth 4- Clinicians don’t like standardisationWe like doing our best for patients, and following bestpracticeWhy do our systems sometimes inhibit us?

Consistency is really hardWe are not computersWe are human beingsInfluenced by personal experienceScience tells us what to do, but not always when to do it.

IntermountainARDS survival 10% -> 40%CABG mortality 1.5%Readmission rates 1/3 rdPreterm CS 30 -> 2%+ 50 others“It’s more important that you do it the same waythan what you think is the right way.”Reducing variation to isolate aspects of treatmentsthat make the difference

Brent James“The trained expert mind of a physician isthe most valuable resource inmedicine.”“This needs to be focused on theproblems where it is most needed:those for which data does not have ananswer.”“In my experience …. In my measured experience”

But bear in mind…“the Human mind can do a better job of piecing togetheramorphous bits of information- diagnosing a diseasethaneven the most powerful computer.”You cannot write a protocol that perfectly fits everypatient, humans are just too variable.“If they are taught the ways in which their instincts can leadthem astray, and if they reflect on their previous mistakes,they can avoid some of the pitfalls of intuition. They canbecome more self-aware.”Groopman, Harvard


1. Environment• Inter / Intra Organisational Variation• Layout of wards / treatment rooms /theatres• Stationary• Equipment sets CVP/ LP


2. Interventions• Prescribing• Guidelines• SOPs• Evidence based

“Medical Care is too complex to be carried out from memory alone”Atul Gawande, Harvard1. Basics are often overlookedPete Pronovost, Johns Hopkins2. To ensure minimum expected steps3. Empower nurses to challenge

Pronovost ChecklistPreCVP infection -28,000 deaths per yearPostZERO rate at 108 hospitalsAn Exercise in Standardisation & Human Factorsengineering

Kaiser Multisite Sepsis improvementWhippy et al.21 Medical centres in Northern California 2009-2011“Playbook” using treatment bundlesStandardised managementHuge Leadership buy-in/ support / fundingResultsSeptic Diagnoses 35.7 ->119.4 / 1000 admissionsBlood Cultures and Lactate 27%->97%

3. Information• Handover• Documentation• Results interfaces• Contact numbers e.g. cardiac arrest


Blood results

Multiple incompatible systems

TrainingCrucial to embedding these principles• Embedding policy / SOPs• checklists• Simulation• Definition of Team roles

Simulation to Standardise

SystemsInformationInterventions1. The part that lags the mostEnvironment2. Structures are often intuitive historical models3. Inertia to change4. Greater Dynamic Flexibility

Bewildering choice

Let’s consider Handover

Handover Standardisation1. Process• Introductions, Leadership, Roles• Format, Ordering, Delegation• Escalation, Duration, Sterility2. Tools3. Language

Communication Templates

Telephony• Bleeps – how, what• Key numbers• Department names• Communication templates

BalanceBlind Standardisation is not the answerIntuition has a crucial situational roleIt must be dynamic and responsiveHuman Factors must be borne in mind“You can ignore a protocol if you can justify it”

BarriersIgnorance“Not invented here”Perceived reduction in InnovationMyth 3- all health care settings are differentInterpretation- they have similarities

Execution• The need for Improvement Science• There are ways and means of doing andmonitoring progress“The flame of idealism burns brightly within allphysicians… it defines us as a profession andthat’s your real leverage point” Brent James

Standardisation for QualityUniformity, Consistency and Reduced Variationin what and why we do thingsand where, when and how we do themLeading to measurable high reliability and qualityaddressing variationnationally, organisationally and individually

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