Kaiser Permanente A Journey in InSitu Medical Simulation

Kaiser Permanente: A Journey in In-Situ Medical Simulation Stanford University, 2008 Paul Preston, MD Permanente Medical Group Regional Safety Educator

Thanks for the Invitation! Without your leadership, we wouldn’t have a program g You keep sending us great people who ask for this g I hope we can deliver g Ever bring coals to Newcastle? g

Agenda Simulation - its role in safe, reliable care g Simulation outside of Kaiser Permanente g Adapting Simulation to Kaiser Permanente g How this is relating to our other systemic goals g How we may be able to measure this (Help!) g Our vision for the future g Have fun! g

The Start of a Journey g g “What you need here is a Doctor who thinks like an Engineer” “Sometimes I wonder if we’re training exotic fish then putting them into the same polluted pond”

Why is he wearing a tie?

Kaiser Permanente Program Founded: 1945 Largest non-profit HMO 8. 3 million members Headquarters Oakland, CA 30 hospitals 431 medical offices Northwest Region Northern California Southern California Colorado Region Ohio Mid. Region Atlantic Region Georgia Region Hawaii Region 141, 909 employees, 12, 012 physicians

Accident Causation Latent Failures Triggers te Incomple es Procedur gical o h c cts A Psy e f a s s Un sor tion a z i n Precur a Org Team Defenses Attention ns Distractio te erred f a e u q D e d a n I tenance n i a g n i M n i a Tr Clumsy gy Technolo ual Individ ical t n e d i c Ac Techn Modified from Reason, 1990

g g Core Mission- Prepaid, Non-Profit, Comprehensive Healthcare Great Health Maintenance, “World Class Hospitals” NOT Research, Teaching, Cutting Edge Interesting History- Why does Kaiser have hospitals?

Sim Champion Building Support. .

The Latest Crisis g Report criticizes Kaiser for lack of action • Federal inspectors fault its Fresno hospital's response to complaints about a doctor who allegedly fatally botched two deliveries. g CARMICHAEL, Calif. -- A Kaiser Permanente plastic surgeon remained in jail Wednesday accused of inappropriate sexual contact with his patients and keeping a cache of weapons at his Carmichael home, police reported. • Sacramento County Sheriff's Department officials went to the home of. . . looking for evidence of alleged sex crimes. • But officials found a rocket-propelled grenade and at least five machine guns at the Empire Court residence, said R. L. Davis, spokesman for the sheriff's department.

Other High Priority (and worthwhile) initiatives g g g Electronic Medical Record- $4 Billion- data potential? New and seismic facilities Service and access goals Efficient throughput, well designed facilities Mandate to ensure and oversee competencies of providers Multiple efforts to teach CRM and Human Factors in multiple settings • Some question about how to get these behaviors to take root g Domain based safety initiatives • Perinatal Safety • Med/Surg Rescue • Surgical Team Communications

Life on Med/Surg Ward g How often is there a process failure? • • g g Every 70 minutes 94% of these, RN tries to work around 6% of these the problem is reported ? How often it is fixed This is deeply programmed into healthcare providers The Problem is NOT careless people messing up a perfect system….

Journey So Far…. g g Several Stages of Denial-Acceptance-Action Better understanding of the problem • Systems • Communications • Fundamental skill and judgment deficits g What Do We REALLY Need To Do to become Reliable? • Consistent, reliable processes for the things we can anticipate • (Highly Reliable Surgical Team Briefings, Pure CRM) • Anticipate, detect and manage the unexpected g By the way, we better get some data to show • Frequency and cost of harm • Progress

Deming’s Lenses for Simulation g System • Great Probe for systemic learning g Psychology • Works very well for frontline g Data • Excellent PDSA. . . Less well established for systems g Variation

Recent Sim Observations. . g g g g It Works! It Works Better if Everyone Actually Does It!! Amazing growth in the field It addresses safety and competency issues that we can’t get to otherwise, and this matters to KP It will be required? !? It only takes 3 days to do this It doesn’t have to be super hi tech We have unique opportunities in KP

Simulation- How do we answer these questions? g g g How many times have you done this before? Do You have to manage emergencies? Do your teams have to manage emergencies? Do you practice as teams for these emergencies? Do you routinely debrief your drills and your real events? Would you learn from a near miss? Would your systems change?

What Is Our Aim at Kaiser? g g If mistakes happen (and they will) we can trap them by working together as a Team We can build systems that are safer Everyone becomes the expert on Safety We cannot become error free, but we can create a system that is harm free- and this will require testing of systems and training of providers 22

Error Reduction and Trapping A Cultural Change g g g Ask for help when overloaded Get a second opinion when in doubt. Honor others who call for help • Wisdom, not weakness g It is more important for my patient to do well than for me to look slick 23

Simulation – its role in providing safe reliable care g g g Improve patient safety without endangering actual patients and to practice high risk, low volume situations where error is more likely to occur Practice without risk, curricular standardization, and pedagogic efficiency Imitates reality, offers almost limitless opportunities to have things “go wrong, ” and provides corrective feedback as a guide to future action Migrate the basic training of hazardous procedures from the patient until skill is attained Address skills, communication issues that will not be fixed (and may get worse) with automation

Simulation – its role in providing safe reliable care How do we do this better? g g Appreciate that highly skilled people, trying hard to do the “right thing”, will make mistakes in complex environments – how do we manage those errors and keep everyone safe? Shift our focus from “who did it” to “how do fix it so the same problem will not reoccur? ” Create an environment of psychological safety – where everyone and anyone feels comfortable to raise a concern NEVER assume safety, always take a minute to assure it

Simulation – its role in providing safe reliable care Proven Training Techniques: Human Factors Skills that build teams, improve communication, reduce and trap the errors that will always occur • Briefings, Assertion, Situational Awareness g Very trainable g Measurable • Reduce accidents • Improve Staff Retention g

Causes of accidents in medicine 70% due to Human Factors (preventable? ) Not lack of medical knowledge g But problems with transferring theoretical knowledge into actions under the real world conditions of a hospital setting g Problems with complexity g Team, Communication g

Perinatal Patient Safety Project g Focus • Human factors training • Multidisciplinary team for problem solving – Recurring clinical problems – Recurring organizational systems problems • Just Culture statement • Provider and staff support • Transfer successful practices • Critical Events Team Training (CETT)

Reoccurring Clinical Problems* g g g Inability to recognize and respond to fetal distress, Inability to effect timely cesarean birth for fetal distress, Inability to resuscitate a depressed infant, Inappropriate use of pitocin, leading to uterine hyperstimulation, uterine rupture, & fetal distress. Inappropriate use of forceps / vacuum leading to fetal trauma and shoulder dystocia. “If you get these things right, you eliminate 80% of perinatal liability claims”- Eric Knox *MMI Company data of 250 hospitals over 10 years

High Reliability Organization Safety is the highest priority g Preoccupation with what could fail g Open environment to discuss error g Everyone encouraged to speak up about hazards g Rewards for safe actions g Training for hazardous situations • What high risk industry would expect great team performance, free of errors, without practice? g

Simulation Training

Can Simulation Help Us become Harm Free? Team based emergency Fetal Heart Rate and emergency training- entire care team g Apgars less than or equal to 6 at 5 minutes: 86. 6 /10, 000 births to 44. 6 /10, 000 births g Hypoxic encephalopathy: 27. 3 /10, 000 births to 13. 6/10, 000 live births g 70% reduction in brachial plexus injuries with shoulder dystocia g – Draycott, T. et. al. , BJOG: 2006, 2007

Patient Safety Program/simulation started in Perinatal Roll out dates by KP Region Q 1 2004 Q 1 2006 Q 2 2005 Q 2 2003 Q 3 2005 Q 1 2004 Q 3 2006 Q 3 2004

More on Kaiser g Risk data as driver of simulation g Remarkable front line support g Systems approach • Training of entire team, in situ • Probe for systems weakness, strengths • Linkage to operations

Unique to Kaiser – just this month g g Roseville- 30 new trainers, plan to test new Mom/Baby facility before opening Used to test new facilities, services • Cardiac Cath Lab and North Valley • Santa Clara- exhaustive testing of new cardiac cath and surgical capabilities “ I couldn’t believe how much we found on the first day, and how much better we look now”.

Roseville: Recent Critical Events Training

Santa Clara: Recent Critical Events Training

Unique to Kaiser – just this month g Sim Demonstration to Board of Directors • A Pilot is one of our Directors • Sudden VFib arrest, in the Boardroom • “You can’t die now, we have Valentine’s dinner reservations. . ” Sim at 60 th TPMG Anniversary g Working Simulation into future inpatient EMR deployment g

Best Practice Learned from CETT: Team Roles & Positions 1 Airway Manager: Anesthesiologist/CRNA 2 Airway Assistant: RT draw ABGs 6 Chest compressions 7 3 Bedside Nurse/Floor RN Procedure MD briefs team, IV, labs, dispense items, CPR chest tubes, ABG’s, etc. 4 Critical Care RN prepare drugs, defib. , ID & monitor rhythm 8 Recorder RN 5 Team Leader

Bab y. W Back. Counter/Cupboards RN #3 arm er s p a L g Ba t/ e k Back Table c u B RN #1 RN #2 c u /S e i v o B it on OR Table Anesthesia OR 1

Some Considerations at Kaiser g g We loved (and have greatly benefited from) what YOU and colleagues were doing Multidisciplinary- target the entire team • Single discipline efforts less likely to be funded or change the culture g Tight linkage to organizational needs • Places where communication, lack of training lead to measured harm g Align with other efforts • CRM, Human Factors for Routine Communications

Some Considerations at Kaiser g Limited Resources • Work In Situ, no dedicated lab • Intermediate Fidelity of Simulation Gear, but • Great fidelity of environment Not the “final validation” study of simulation as a modality g “Fix the Problem” using a lot of interventions at once g

Critical Event Team Training ( CETT) Training Strategy Training on: • Human factors and team skills • Reality and types of Human Errors • Orientation to Simulator g Intermediate fidelity, in-situ simulation training • Actual occurrences used as basis for scenarios • Focus on apparent weaknesses in our system • Situations where assessment, communication are important g Blame free, confidential training g

Other Key Crisis Management Skills Declaring emergency: • Early • Clearly g Leadership, optimal team structure g Attention allocation g Task prioritization and distribution g Effective, efficient resource use g Clear orders, cross check and verification g

Make Routine Debriefing Part of Team Culture g g g Look at routine and critical operations every day Recognize how regular debriefing is key to unit safety Practice skills on the CETT day Learn a constructive, blame free approach This is working in Crash Cesareans, Rapid Response, shoulder dystocias- structured tools are being developed to capture and report data

Link to Operations, Other Efforts g g Start with human factors Build a multidisciplinary team • Charged to improve their unit g Train entire teams • All providers and staff + a few confederates g g Experienced providers Direct linkage to unit leaders • Purpose: Find and fix system problems- The Unit Manager records the debriefings

CRITICAL EVENT DRILLS: What are they? • • • Lifelike Real time Normal noise - confusion - resources Situation must be diagnosed and managed by team exactly as in real life You will be doing your usual job at all times

Variety g g Rare and common scenarios Long and short Fast or slow evolving Everyone has a key role • But not in every scenario! g g Confederates as family, patients Carpet pad, pea soup as low tech aids • Cover this in briefing…. • Actual environment REALLY adds credibility

How To Look Great (and rescue your patients) Optimum Location, people and equipment g Brief the Team g Know the environment, clearly delegate tasks g Clear Leader- (This may change!) g Regain Situational Awareness • Chaos is Never OK g

Future Vision g Expansion into other clinical departments • Highly Reliable Surgical Team and Reliable Emergency Departments g 2008 National Quality and Brand Conference • Simulation Minicourse and KP Medical Simulation kick-off g Simulation available, funded and required throughout career

Future Vision- continued g g g Link performance improvement with simulation activities Kaiser Simulation Collaborative • Network/collaborative of simulation experts and users Toolkit to support simulation implementation within Kaiser • Library of simulation scenarios

Data. . . g g g What is our aim? How will we know the change is an improvement? What will we try?

Our IDEAL Data Set g About 8 measures • 2 outcome, 5 process, 1 -2 balancing g g Improvement and Accountability Run over time, rapid cycle, feedback to front line teams and leadership Sustainable- forever! Anyone can see how we are doing

What Might We Have In Perinatal? g Outcome • Med Mal- Has Limits, but CAN strongly argue for Simulation – We seem to be gaining ground here. . . • Physiologic Intermediate Data • Complications- Bleeding, brachial plexus injury, encephalopathy, infection, Retained Objects, Infxn • Current Benchmarks- C/S rate, 3 d degree laceration, infant death, VBAC - why these? g Process • Trigger Tools Concepts- Ascension, IHI, AHRQ, AOI scores-ADT, labs, pharmacy-Higher Capture than Reporting! • General Anesthesia • IHI type bundles- compliance with these – Induction: EGA, Pelvimetry, FHR (NICHD), hyperstim

What Might We Have In Perinatal? g Process • FHR Documentation/ Review/Action/Training • Evidence Based Training Programs – Instrumental, Shoulder Dystocia, Stat C/S Selected Chart Reviews, timing of Stat C/S – Human Factors, Safety Attitude Surveys • Active Safety Team, Board Rounds • Surgical Counts, Briefings – Observational Data • Time on divert, cancelled inductions • Systems Problems Found and Fixed • Glitch Book Data

Process Measure Results

Perinatal- Balancing? g g g Care Experience Cesarean Rates! Timeliness of Cesarean Sections • Really 2 very different processes • STAT C/S= Rescue • Elective C/S= Throughput g g LOS Staffing

Unique Kaiser Opportunities g g Extraordinary Leadership from National and Regional Riskequipment, time, support Appreciation for systems- role of simulation in testing facilities, fixing systemic problems, training new teams, hospital and tech design Unified systems Outcome data that others truly envy • Which we need to use much more! g A remarkable cadre of trainers