Patient safety team, NHS Improving Quality, reliability by design More at: http://www.nhsiq.nhs.uk/improvement-programmes/patient-safety.aspx

1. © NHS Improving Quality 2014
Reliability by Design
Patient Safety Team - NHSIQ

2. © NHS Improving Quality 2014
Today
• Recap on reliability
• Learn from efforts to date
• Consider human factors and reliability
• Design a process using human factors
• Using FMEA to identify where to focus
• Develop a charter to accelerate your improvement work

3. © NHS Improving Quality 2014
Homework!
• Decide on a process to work on:
• measure current reliability using a small scale audit and asking 5
users to describe the process
• familiarise yourselves with the process, observe
• measure the system capability using the approach Matt
described
• start doing PDSAs in order to standardise to achieve 80%
reliability
• look back to your notes from core module to guide you in the
selection of your test population and in setting the aim.
• Your storyboard should reflect this work on standardisation.

4. © NHS Improving Quality 2014
Why are Processes Not Working?
• Reliance on vigilance and hard work
• Use of benchmarks and an acceptance of sub-optimal
outcomes
• Clinical autonomy, variation and permissive culture
• Little deliberate design using reliability concepts

5. © NHS Improving Quality 2014
Non-catastrophic
Processes
•Definition: Failure of the process does not lead to death or
severe injury within hours of the failure
• Very poor reliability < 80%
• Loss of connection with outcome
• The resilience of biology
• Violation and migration
• There is no feedback

6. © NHS Improving Quality 2014
Improvement Concepts Associated
with ≤ 80% Performance
• Primarily can be described as intent, vigilance,
and hard work
• Written policies/procedures
• Personal checklists
• Feedback of information on compliance
• Suggestions of working harder next time
• Awareness and training

7. © NHS Improving Quality 2014
Improvement Concepts Associated
with 95% Performance
• Focus on human factors
• Standardised process based on best available evidence
• Minimised variation
• Make desired action the easiest /default action
• Use existing habits and patterns in system design
• Design in failure prevention, identification and mitigation

8. © NHS Improving Quality 2014
The Way Forward –
Can Medicine be Standardised?
• What about the art of medicine?
• Patients are different
• This is not like making aircraft
• I do not want to practice cook-book medicine
• We can standardise our processes
• Allows cognitive capacity to be used for those who do not
fit the standardised process
• Variation is based on patient need

9. © NHS Improving Quality 2014
Why do we Vary?
• Because the patient needs variation from a
standardised process
• OR
• Because the clinician does it their way on that
day
• OR
• Because there is not a deliberately designed
process

10. © NHS Improving Quality 2014
Variation in Healthcare;
A Major Cause of Error and Harm
• Erodes reliability and quality
• Creates wide performance margins
• Unreliable administrative and clinical support systems
• Training bias
• Permissive clinical autonomy
• Can be reduced without insulting professional autonomy
• Standardisation allows focus on patient variation

11. © NHS Improving Quality 2014
Level of Reliability
1. Get to 80% reliable in step 1 by standardising your process
• 2. Get 80% of the failures dealt with in step 2 and 3 by
designing barriers and mitigations
• 80% + 80% of 20 = 96% reliability
• 3. Analyse failure and redesign

12. © NHS Improving Quality 2014
Practically, that means:
1. Describing your high level process and area of most defects
then choose a segment and identify the components
2. Hypothesis and PDSA to achieve 80% reliability with
standardisation
3. Hypothesis and PDSA to achieve 95% reliability with barriers
and mitigation

13. © NHS Improving Quality 2014
A Quick Test of Standardisation
• Choose an area:
• ask 5 members of staff how the process works
• if you get more than 2 different answers you have a chaotic
process
• Example:
• who administers the 0-60 minute pre-op antibiotics?
• how do you check the angle of the bed head for ventilated
patients?
• how do we patient observations?
• can you describe the central line bundle?

14. © NHS Improving Quality 2014
Success of Step 1
• Success is standardisation of this step: how we
do this around here
• Consensus standardisation
• Reduced variation
• Improved reliability
• Improved safety
• Improved efficiency and productivity
• 80% reliability achieved

15. © NHS Improving Quality 2014
Paradigms and Habits
• Stuck on an escalator