AIR FORCE MEDICAL SERVICE
An Introduction to Reliability and Safety Culture Transformation
18 November 2015
&
Partnering to serve the United States Air Force Medical Service
Trusted Care in the AFMS
 The Air Force Medical Service (AFMS) has committed to providing Trusted
Care and achieving Zero Harm through a renewed focus on:
 Leadership engagement
 Culture of safety
 Continuous process improvement
 Patient centeredness
 The recently disseminated Trusted Care Concept of Operations (CONOPS)
provides background on the Trusted Care journey, defines Trusted Care
principles, describes the current and desired future states of Trusted Care
within the AFMS, and identifies steps and enablers for achieving the desired
future state
&
Trusted Care Safety and Reliability Engagement
 As the AFMS rolls out Trusted Care transformation enterprise-wide, it has
engaged Booz Allen and Healthcare Performance Improvement (HPI) for
care site transformation engagements at nine CONUS MTFs
 These engagements focus on improving safety and reliability through a
three-phased approach of diagnostic assessment, implementation, and
sustainment
 Results and lessons learned from these engagements will inform Trusted
Care transformation across the AFMS
 These engagements also will be supported by enterprise-wide strategic
communication and change management support from the Booz Allen team
&
Ongoing Partnership to Support AFMS Transformation
&
Trusted Care Safety and Reliability Engagement – 9 MTFs
Wright-Patterson
Mountain
Home
Travis
Nellis
Joint Base
LangleyEustis
Joint Base
ElmendorfRichardson
59th Wing
Eglin
Keesler
&
HPI – A Reliability Company
Methods based on science and facts
 Science of human error and event prevention
 Practical experience in high-reliability industries including
nuclear power and aviation
Experienced-based consulting and coaching
 Entered healthcare in 2002
 Comprehensive safety and reliability culture transformation
in over 800 hospitals
 Consulting team with HRO experience and healthcare
experience (clinicians, non-clinicians, and physicians)
HPI Client Community count as of December 2014
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 5
High Reliability Organizations
HROs “operate under very trying conditions all the time and yet
manage to have fewer than their fair share of accidents.”
3 Principles of Anticipation
“Stay Out of Trouble”
Preoccupation with Failure
Sensitivity to Operations
Reluctance to Simplify
2 Principles of Containment
“Get Out of Trouble”
Commitment to Resilience
Deference to Expertise
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 6
Anatomy of a Safety Event
Multiple Barriers - technology,
processes, and people - designed to stop
active errors (our “defense in depth”)
EVENTS of
HARM
Active Errors
by individuals result
in initiating action(s)
Latent Weaknesses in barriers
PREVENT
DETECT & CORRECT
The Errors
The System Weaknesses
From James Reason, Managing the Risks of Organizational Accidents, 1997
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 7
Shaping Behaviors at the Sharp End
Design of
Design of
Work
Processes
Culture
Design of
Structure
Design of
Policy &
Protocol
Design of
Technology &
Environment
Behaviors
of Individuals & Groups
Outcomes
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 8
Complementary Strategies
Codes Outside
the ICU
Surgical Site
Infections
Hand
Hygiene
Central Line
Infections
Culture
Behavior Expectations for Error Prevention &
High Reliability Performance Management
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 9
Our Approach
Diagnostic
Assessment
Safety Climate Survey,
Safety Governance Index,
Common Cause Analysis
Safety Culture
Improvement
Interventions
Habit Formation
& Sustainment
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 10
A deviation from generally accepted
performance standards (GAPS) that…
Serious Safety Event
Serious
Safety
Events
• Reaches the patient
• Results in moderate to severe harm or death
Precursor
Safety
Events
Precursor Safety Event
• Reaches the patient
• Results in minimal harm or no detectable harm
Near Miss Safety Event
• Does not reach the patient
• Error is caught by a detection barrier
or by chance
Near Miss Safety Event
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 11
Typical SSER Curve
Serious Safety Event Rate
Apparent increase due to healthier
event/problem reporting culture
Significant performance improvement
as a result of prevention activities
Actual increase due to complacency
or reverting to old habits
Long-term improvement through
sustained prevention
Start of
Culture Change
Time
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 12
Common Cause Analysis
A collective examination of past events for “common causes”
(not common outcomes)
E1
E2
E3
E4
E5
E6
Event (E): a condition that
results from a deviation from
practice expectations or
standard of care
Analyze by:
IA1
IA2
IA3
IA4
IA5
IA6
IA7
IA8
IA9 IA10 IA11
IA12
Inappropriate Act (IA): a human error that
violates performance expectations or takes
a task outside acceptable limits
IA13 IA14 IA15
Profession, Organization,
Key Process, Key Activity,
Human Error Type,
Individual Failure Mode,
System Failure Mode
Common Causes
© 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 13
Causal Factors of Inappropriate Acts
System & Management
Failure Modes
(26)
Individual
Failure Modes
(20)
Structure (4 modes)
Culture (8 modes)
Process (5 modes)
Policy & Protocol (4 modes)
Technology &
Environment (4 modes)
Competency (3 modes)
Consciousness (6 modes)
Communication (3 modes)
Critical Thinking (4 modes)
Compliance (4 modes)
Inappropriate Act
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 14
Humans Work in Three Modes
Knowledge-Based Performance
“Figuring It Out Mode”
Rule-Based Performance
“If-Then Response Mode”
Skill-Based Performance
“Auto-Pilot Mode”
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 15
AFMS Recommendations
Improvement Themes
Overall Goal: Establish Safety as a Core Value
Create a highly reliable environment for safe practices with global safety
metrics and control loops to ensure continuous improvement.
Leadership Methods
Learn, adopt and practice leader skills for building and sustaining a culture
of safety and performance excellence.
Error Prevention
Implement behavior expectations for error prevention targeted at common
causes of past events.
Learning Organization Improvements
Integrate enhanced cause analysis techniques into existing best-practice
quality and safety programs to accelerate learning from events, including
those solely under the purview of peer review. Spread the learning
through a robust lessons-learned program.
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 16
Defining and Demonstrating Safety First
“There is no priority higher than patient
safety. If there is a conflict between safe
practice and speed, efficiency or volume,
then safety wins – hands down.”
James M. Anderson
President & CEO
Cincinnati Children’s Hospital Medical
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Safety First
Leadership Team Commitments
1.
Put safety first on every meeting
agenda
2.
Link decisions to safety: When
describing decisions to staff and
managers, relate them to safety
when appropriate
3.
Encourage reporting of near
miss events in the PSN
4.
Recognize staff who “raised the
safety question” including
physically going to the work unit
to recognize individual staff
member(s)
Slide 17
AFMS Recommendations
Improvement Themes
Overall Goal: Establish Safety as the Core Value
Create a highly reliable environment for safe practices with global safety
metrics and control loops to ensure continuous improvement.
Leadership Methods
Learn, adopt and practice leader skills for building and sustaining a culture
of safety and performance excellence.
Error Prevention
Implement behavior expectations for error prevention targeted at common
causes of past events.
Learning Organization Improvements
Integrate enhanced cause analysis techniques into existing best-practice
quality and safety programs to accelerate learning from events, including
those solely under the purview of peer review. Spread the learning
through a robust lessons-learned program.
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 18
Daily Safety Huddle at Advocate





8:30 am at most hospitals
All departments directors and managers
Most held in person, some by phone
All led by hospital president or VP by exception
100% attendance expectation – send a
representative if you can’t participate
Dominica Tallarico, President
Advocate Condell Medical Center
The Daily Safety Huddle is the best thing we’ve done – I can’t imagine not having it each and
every day.
Susan Nordstrom-Lopez,
President, Advocate Illinois Masonic Hospital
© 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 19
AFMS Recommendations
Improvement Themes
Overall Goal: Establish Safety as the Core Value
Create a highly reliable environment for safe practices with global safety
metrics and control loops to ensure continuous improvement.
Leadership Methods
Learn, adopt and practice leader skills for building and sustaining a culture
of safety and performance excellence.
Error Prevention
Implement behavior expectations for error prevention targeted at common
causes of past events.
Learning Organization Improvements
Integrate enhanced cause analysis techniques into existing best-practice
quality and safety programs to accelerate learning from events, including
those solely under the purview of peer review. Spread the learning
through a robust lessons-learned program.
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 20
Sentara Healthcare
Behaviors for Error Prevention
1. Pay Attention to Detail

STAR (Stop/Think/Act/Review)
2. Communicate Clearly

Repeat Backs & Read Backs

Clarifying Questions

Phonetic & Numeric Clarifications

SBAR
3. Have a Questioning Attitude

Validate & Verification
4. Handoff Effectively

5P’s (Patient/Project, Plan,
Purpose, Problems, Precautions)
5. Never Leave Your Wingman

Peer Checking

Peer Coaching
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 21
AFMS Recommendations
Improvement Themes
Overall Goal: Establish Safety as the Core Value
Create a highly reliable environment for safe practices with global safety
metrics and control loops to ensure continuous improvement.
Leadership Methods
Learn, adopt and practice leader skills for building and sustaining a culture
of safety and performance excellence.
Error Prevention
Implement behavior expectations for error prevention targeted at common
causes of past events.
Learning Organization Improvements
Integrate enhanced cause analysis techniques into existing best-practice
quality and safety programs to accelerate learning from events, including
those solely under the purview of peer review. Spread the learning
through a robust lessons-learned program.
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 22
Learning from Events
…so we don’t repeat them
WHY did they
experience the error
(system failure mode)
• Structure
• Culture
• Process
• Policy & Protocol
• Environment &
Technology
and…
HOW did they
experience the error
(individual failure mode)
• Competency
• Consciousness
• Communication
• Critical Thinking
• Compliance
What went
wrong…
WHO did WHAT because…
© 2014 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 23
"Good ideas are not adopted automatically.
They must be driven into practice with
courageous impatience. Once implemented
they can be easily overturned or subverted
through apathy or lack of follow-up, so a
continuous effort is required."
Admiral Hyman G. Rickover
1900-1986
Partnering with Booz | Allen | Hamilton to serve the Air Force Medical Service
Slide 24
The Booz Allen & HPI Consulting Team
Serving Air Force Medical Services
Kerry Johnson
HPI Founding Partner
[email protected] | (602) 617-4261
Rich Stone, MD, MAJ GEN USA Ret.
BAH Principal
[email protected] | (703) 559-6220
Steve Kreiser, CDR, USN Ret.
[email protected] | (757) 353-7833
Stephanie Keyser
[email protected] | (703) 559-6174
David Edgington, MAJ GEN USAF Ret.
[email protected] | (757) 270-9025
David Goldberger
[email protected] | (240) 393-9141
Jennifer Martin, RN
[email protected] | (757) 472-3901
&
Slide 25