Developing a Culture of
Performance Improvement
James P. Bagian, MD, PE
Director
Center for Healthcare Engineering and Patient Safety
Department of Anesthesiology & Industrial and Operations Engineering
University of Michigan
jbagian@umich.edu
Objectives
• Paramount importance of selecting the appropriate goal
• Understanding underlying causes
• Formulating effective and sustainable intervention
• Critical factors to achieve successful implementation of change
No patient will be
inadvertently harmed
while under our care
GOAL
Our mission and challenge is to adopt measures and
implement programs that improve care
Identify the
Problem
Reporting Dashboard
Identifying
Root Cause/Contributing
Factors
Safety & Human Error:
Cornerstones
• People Don’t Come to Work to Hurt Someone or Make a
Mistake
• Must Keep Asking “Why?”
Safety – Human Error
Accident
LATENT
FAILURES
DEFENSES
Incomplete
procedures
Regulatory
narrowness
Mixed
Messages
Production
pressures
Responsibility
shifting
Inadequate training
Attention
Distractions
Clumsy
Technology
Deferred Maintenance
Safety – Human Error
Hindsight Bias
Causation/Actions:
Who vs.What &Why
• Who
– ‘Whose Fault Is This?’
– Actions focused on correcting individual
– ‘Corrects’ only after problem occurs
– Limited scope of action and generalizability
• What & Why
– Actions focus on systems level causation
– Widespread applicability
– Stronger preventive strategy
Systematic
(5 Rules of Causation)
• Cause and Effect
• Human Error Must Have Preceding Cause
• Failure to Follow Procedure By Itself Is NOT a Root
Cause
• Negative Descriptors Aren’t Actionable
• Failure To Act Is Not A Cause Without Pre-existing
Requirement To Act
Why,Why,Why,Why,Why,Why……..
Strength of Actions
Human Factors Engineering and “Actions”
• Warnings and labels (watch out!)
• Training (don’t do that)
• Procedure changes (work around that)
• Interlock, lock-in, lock-out, etc (design it so you
cannot do that – forcing functions)
• Is there one right action???
Weaker
Stronger
Action Hierarchy
Less memory or
reliance on individual
performance
Greater reliance on
memory and
individual
performance
Stronger Actions
Architectural/physical plant changes
New devices with usability testing before purchasing
Engineering control or interlock (forcing functions)
Simplify the process and remove unnecessary steps
Standardize on equipment or process
Tangible involvement and action by leadership in support of patient safety
Intermediate Actions
Redundancy
Increase in staffing/decrease in workload
Software enhancements/modifications
Education using simulation-based learning with a competency assessment
completed on a recurring basis
Eliminate/reduce distractions (sterile medical environment)
Checklist/cognitive aid
Eliminate look and sound-alikes
Repeat-back/Read-back
Enhanced documentation/communication
Weaker Actions
Double checks
Warnings and labels
New procedure/memorandum/policy
Traditional training
Additional study/analysis
Examples
Implementation
Getting to Sustainable Improvement
• Problem Identification
• Clear Goal Definition
• Involvement Of All Sectors
• Identify Systems Influences
• Identify Systems Controls
• Identify Constraints
• Critique – Go To Worst Critics Early On
• Pilot – Volunteers First Then Others
• Evaluate
Essential Elements For Sustainable Improvement
• Appropriate Goal Identification & Selection
• Transparent Prioritization
• Identification of Real Causes
• System-based Countermeasures That Address
Underlying Causes
• Stronger Actions That Are Explicit
• Measurement of Actions
– Process & Outcome
• Top Leadership Involvement/Visibility
Topics for Discussion
• Process vs Outcome Measures – which is most
important?
• Value of Pilots and Who Should Participate
• Transparency of Performance
• Respect for Work – Volunteers vs Real Job
There is no shame in failing while
attempting to achieve a worthy goal,
the only shame is in not attempting to
achieve a worthy goal.
