Kaiser Permanente: A Journey in In-Situ Medical Simulation

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Kaiser Permanente A Journey in In-Situ
Medical Simulation

• Stanford University, 2008
• Paul Preston, MD
• Permanente Medical Group
• Regional Safety Educator

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Thanks for the Invitation!

• Without your leadership, we wouldnt have a
  program
• You keep sending us great people who ask for this
• I hope we can deliver
• Ever bring coals to Newcastle?

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Agenda

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

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The Start of a Journey

• What you need here is a Doctor who thinks like
  an Engineer
• Sometimes I wonder if were training exotic fish
  then putting them into the same polluted pond

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Why is he wearing a tie?
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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
Ohio Region
Colorado Region
Mid-Atlantic Region
Southern California
Georgia Region
Hawaii Region
141,909 employees, 12,012 physicians
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Accident Causation
Latent Failures
Attention Distractions
Incomplete Procedures
Deferred Maintenance
Inadequate Training
Clumsy Technology
Triggers
Psychological Precursors
Unsafe Acts
Organization
Team
Accident
Individual
Defenses
Technical
Modified from Reason, 1990
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• 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?

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Sim Champion Building Support....
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The Latest Crisis

• 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.
• 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.

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Other High Priority (and worthwhile) initiatives

• 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
• Domain based safety initiatives
• Perinatal Safety
• Med/Surg Rescue
• Surgical Team Communications

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Life on Med/Surg Ward

• How often is there a process failure?
• 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.

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Journey So Far.

• Several Stages of Denial-Acceptance-Action
• Better understanding of the problem
• Systems
• Communications
• Fundamental skill and judgment deficits
• 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
• By the way, we better get some data to show
• Frequency and cost of harm
• Progress

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Demings Lenses for Simulation

• System
• Great Probe for systemic learning
• Psychology
• Works very well for frontline
• Data
• Excellent PDSA... Less well established for
  systems
• Variation

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Recent Sim Observations....

• It Works!
• It Works Better if Everyone Actually Does It!!
• Amazing growth in the field
• It addresses safety and competency issues that we
  cant get to otherwise, and this matters to KP
• It will be required?!?
• It only takes 3 days to do this
• It doesnt have to be super hi tech
• We have unique opportunities in KP

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Simulation- How do we answer these questions?

• 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?

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What Is Our Aim at Kaiser?

• 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

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Error Reduction and TrappingA Cultural Change

• Ask for help when overloaded
• Get a second opinion when in doubt.
• Honor others who call for help
• Wisdom, not weakness
• It is more important for my patient to do well
  than for me to look slick

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Simulation its role in providing safe reliable
care

• 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

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Simulation its role in providing safe reliable
care

• How do we do this better?
• 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

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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
• Very trainable
• Measurable
• Reduce accidents
• Improve Staff Retention

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Causes of accidents in medicine

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

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Perinatal Patient Safety Project

• 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)

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Reoccurring Clinical Problems

• 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

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High Reliability Organization

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

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SimulationTraining
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Can Simulation Help Us become Harm Free?

• Team based emergency Fetal Heart Rate and
  emergency training- entire care team
• Apgars less than or equal to 6 at 5 minutes 86.6
  /10,000 births to 44.6 /10,000 births
• Hypoxic encephalopathy 27.3 /10,000 births to
  13.6/10,000 live births
• 70 reduction in brachial plexus injuries with
  shoulder dystocia
• Draycott, T. et. al., BJOG 2006, 2007

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Patient Safety Program/simulation started in
Perinatal
Roll out dates by KP Region
Q1 2004
Q1 2006
Q2 2005
Q2 2003
Q3 2005
Q1 2004
Q3 2006
Q3 2004
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More on Kaiser

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

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Unique to Kaiser just this month

• 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 couldnt believe how much we found on the
  first day, and how much better we look now.

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Roseville Recent Critical Events Training
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Santa Clara Recent Critical Events Training
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Unique to Kaiser just this month

• Sim Demonstration to Board of Directors
• A Pilot is one of our Directors
• Sudden VFib arrest, in the Boardroom
• You cant die now, we have Valentines dinner
  reservations....
• Sim at 60th TPMG Anniversary
• Working Simulation into future inpatient EMR
  deployment

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Best Practice Learned from CETT Team Roles
Positions

• 1 Airway Manager
• Anesthesiologist/CRNA

2 Airway Assistant RT draw ABGs
6 Chest compressions
3 Bedside Nurse/Floor RN briefs team, IV, labs,
dispense items, CPR
7 Procedure MD chest tubes, ABGs, etc.
4 Critical Care RN prepare
drugs,
defib., ID monitor rhythm
8 Recorder RN
5 Team Leader
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Back Counter/Cupboards
Back Counter/Cupboards
Baby Warmer
RN 3
Back Table
Bucket/Lap Bags
OR Table
RN 1
RN 2
Bovie/Suction
OR 1
Anesthesia
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Some Considerations at Kaiser

• 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
• Tight linkage to organizational needs
• Places where communication, lack of training lead
  to measured harm
• Align with other efforts
• CRM, Human Factors for Routine Communications

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Some Considerations at Kaiser

• 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
• Fix the Problem using a lot of interventions at
  once

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Critical Event Team Training ( CETT) Training
Strategy

• Training on
• Human factors and team skills
• Reality and types of Human Errors
• Orientation to Simulator
• 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
• Blame free, confidential training

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Other Key Crisis Management Skills

• Declaring emergency
• Early
• Clearly
• Leadership, optimal team structure
• Attention allocation
• Task prioritization and distribution
• Effective, efficient resource use
• Clear orders, cross check and verification

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Make Routine Debriefing Part of Team Culture

• 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

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Link to Operations, Other Efforts

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

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CRITICAL EVENT DRILLSWhat 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

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Variety

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

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How To Look Great (and rescue your patients)

• Optimum Location, people and equipment
• Brief the Team
• Know the environment, clearly delegate tasks
• Clear Leader- (This may change!)
• Regain Situational Awareness
• Chaos is Never OK

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Future Vision

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

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Future Vision- continued

• 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

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Data...

• What is our aim?
• How will we know the change is an improvement?
• What will we try?

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Our IDEAL Data Set

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

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What Might We Have In Perinatal?

• 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, 3d degree
  laceration, infant death, VBAC- why these?
• 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

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What Might We Have In Perinatal?

• 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

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Process Measure Results
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Perinatal- Balancing?

• Care Experience
• Cesarean Rates!
• Timeliness of Cesarean Sections
• Really 2 very different processes
• STAT C/S Rescue
• Elective C/S Throughput
• LOS
• Staffing

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Unique Kaiser Opportunities

• Extraordinary Leadership from National and
  Regional Risk- equipment, 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!
• A remarkable cadre of trainers