DARE

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DARE!

• A 100 result of our
• Partnership for Patient Safety
• We all know a Peter.

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Kindly introducing.

• John Prooi Corporate Vice President Safety,
  Health, Environment and Manufacturing at
  DSM john.prooi_at_dsm.com
• Harry Molendijk neonatologist, medical director
  of Centre for Patient Safety at Isala Clinics
  Zwolle, chairman Dutch Patient Safety
  Platform a.molendijk_at_isala.nl

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Who are we ?

• Worldwide manufacturer. Active in nutritional
  pharma ingredients and performance materials
• 22.000 employees at 250 locations in 50 countries
• Sustainable company with respectful age of 105
  years

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Isala Clinics Zwolle Who are we?

• 1000 beds, 6000 employees non-academic teaching
  hospital, situated on two locations

NICU
Our neighbour DSM
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Our messages

• Safety principles are universal
• Working with high-risk industries accelerates the
  safety efforts in health care
• Together we can make patient unsafety
• HISTORY!

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My change

• What changed my clinical focus to safety?
• Well.
• A baby died, merely because we intubated it
  wrongfully

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My world Neonatal Intensive Care

• Tiny infants in incubators are comparable to
  passengers in airplanes at altitude of 30.000
  feet
• Both will die almost instantly when they are
  exposed to the hostile environment
• The difference is..

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A quality chasm!

• Whereas pilots adhere strictly to protocol, are
  teamwork trained and half-yearly simulator-tested
  for competence
• we, as caregivers, are trained solely for
  skills, rarely for team performance, have a low
  compliance to protocol, and our competence is
  only tested when the patient comes along

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Isala Clinics Zwolle

• In 2001 1012 incident reports
• - 1 reported accidental death
• In 2006 5933 incident reports
• - 15 reported accidental death
• - (however, still underreporting)
• What happened in the years between ?

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Isala History 2001 - 2006

• December 2001 NICQ-conference, Washington DC
• January 2002 implementation of ward-based,
  nurse-led patient safety committee
• What did we learn?

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This is not just a NICU
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This is an EPHE !!!!
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The EPHE - concept
Error Provoking Hospital Environment!
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Pneumothorax
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Fall 2003

• And then I send an e-mail message to mr John
  Prooi, at Unlimited. DSM.
• John, what made you respond?

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My turn Why did I respond ?

• Good personal contact
• Own learning curve / experience
• Supporting others is one of our values
• Boosted by a recent sad accident

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Fatal accident 4 years ago

• 3 contractor people died
• Why ?
• Procedures not adequate
• Operators used own ones
• Not enough control by management

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Our reaction

• Support for family and colleagues
• Thorough analysis
• Full transparency about causes (internally
  externally)
• 3-year program of compliance for all units
• Safety leadership training for all leaders (1500)

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The times ., they are changing
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Our change started in 1975
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Evolution in safety
Hardware / Personal protection equipment Safety
of chemical process
Organisation / systems
Incidents
Behavior individual employees
Team behavior
Lifestyle
Time
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Consistent approach

• Policy
• SHE Management System
• Risk Analyses
• Incident reporting / learning from incidents
• Behavioral safety
• Training
• Performance indicators

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SHE Management System
SHE Policy
Introduction
1
...............
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Requirements (what, must)
Incident Reporting Analysis
SHE
Risk Analysis
Customers
Leadership
SHE Practices (how, may)
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Our evolution
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Our achievements

• Reduction of injury index with more than 90 over
  20 years
• Third parties/contractors included
• In our industry in best 25 of world
• but not
  excellent

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Compliance Behaviour
Hardware / Safety of Chemical Process

• Knowledge Experience
• Learning Training
• Everyone from top to bottom is responsible

Organisation/ Procedures/ Systems

Incidents
Individual behavior

Team behavior

Lifestyle
I
P
Time
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Involvement top management

• Visible
• Example setting
• Authentic
• CONDITIO
  SINE QUA NON

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DSMs learning's

• Not a priority but a Value
• On top of agenda
• From closed transparent
• From TELL ME via SHOW ME to INVOLVE ME
• Learning from others is essential
• Internally
• Airplane industry
• Petrochemical industry

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First date

• And then I received an e-mail message
• from a guy named Harry

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Partnership for Patient Safety phase 1 First
encounter

• Dec. 3rd 2004 we brought together front line
  personnel from both parties...
• ...analysed 3 real life, potentially critical
  incidents, and...
• Most striking learning point how little did we
  from Isala know.

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Example Case
Emergency Cesarean section, meconium
stained amniotic fluid Problem suctioning unit
did not work Potentialy catastrophic
outcome Recovery by mouth to tube suctioning
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Partnership for Patient Safety learning the
language
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Partnership for Patient Safetyphase 2 Learning
from DSM

• Isala - organised our infrastructure (Section
  for Quality, Centre for Patient Safety)
• - mobilised our workers and patients for
  safety
• - learned from DSM how to perform Root Cause
  Analysis
• DSM - shared its Safety Leadership and Safety
  Expert Course with Isala. We got the
  Board on Board
• DARE movie was a direct result of this
• sold over 300 copies in The Netherlands

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Partnership for Patient Safety phase 3 Working
with DSM

• Participation in true incident analysis
• 11 fold overdose of infused morphine with fatal
  outcome
• Deadly fall from hospital bed
• Continuation of anticoagulation treatment after
  head trauma, contributing to severe intracranial
  hematoma
• Wrong-side surgery

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Achieved improvements

• Daily checklist at critical control points in
  preparation of resuscitation unit
• What, how, what actions, back to norm
• gt 95 sustained compliance to the checking
  procedure
• Problem has not re-occurred, others were
  prevented
• Introduction of Time-Out in OR
• Many examples of an early catch
• Safe Infusion Practice project
• www.centrumpatientveiligheid.nl

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Back to John

• John, where are we now

?

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Our journey into a mature safety culture
Improvement Safety Culture
Everybody !
Management first line shopfloor

DSM
Management First line
Involvement
Isala
Management
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Our mutual future

• Sharing with others
• Continuation collaboration DSM-Isala Clinics
• Support to two more hospitals in The Netherlands
• Dutch Chem. Industry support in 10 hospitals
  (Shell, Dupont, GE, DSM).
• Extension into Europe ?
• Support by DSM
• Support by European Chemical Industry (CEFIC)

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DSMs rewards

• Motivation pride for our people
• Experiencing the value of safety investigation
• Reputation

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Isala rewards

• Isala has put on its safety lenses
• Isala found a professional coach
• We got the board on board
• Reaching out to the front line personnel
• Yes, but..

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But..

• How many lives are saved?
• Dutch Prevent Harm, Save Lives campaign might
  tell

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Our messages

• Safety principles are universal
• Working with high-risk industries accelerates the
  safety efforts in health care
• Together we can make patient unsafety
• HISTORY!

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DARE to SHARE!