Dr Paul Barach | Thomas Jefferson University (original) (raw)

Papers by Dr Paul Barach

The Evolving Scholar, Dec 31, 2021

Cambridge University Press eBooks, Apr 7, 2015

PubMed, Apr 8, 1999

... Our position is that the likelihood of clinical harm even for the unlucky few who are at ri... more ... Our position is that the likelihood of clinical harm even for the unlucky few who are at risk can be virtually eliminated by proper education of patients. MICHAEL E. MCIVOR, MD Heart Institute of St. Petersburg St. Petersburg, FL 33701 ...

Anesthesiology Clinics of North America, Mar 1, 1999

ABSTRACT

Pediatric emergency care, Dec 17, 2020

Population medicine, Apr 26, 2023

Annals of Internal Medicine, May 18, 2004

Informa Healthcare eBooks, Jul 27, 2001

Mayo Clinic Proceedings, Nov 1, 2021

Outsourcing in health care has become increasingly common as health system administrators seek to... more Outsourcing in health care has become increasingly common as health system administrators seek to enhance profitability and efficiency while maintaining clinical excellence. When clinical services are outsourced, however, the outsourcing organization relinquishes control over its most important service value: high-quality patient care. Farming out work to an external service provider can have many unintended results, including inconsistencies in standards of care; harmful medical errors; declines in patient and employee satisfaction; and damage to clinicians' morale and income, and to the health organization's culture, reputation, and long-term financial performance. Research on outsourcing in the areas of emergency medicine, radiology, laboratory services, and environmental services provides concerning evidence of potentially large downsides when outsourcing is driven by short-term cost concerns or is planned without diligently considering all of the ramifications of not keeping key clinical and nonclinical services in-house. To better equip health system leaders for decision-making about outsourcing, we examine this body of literature, identify common pitfalls of outsourcing in specific clinical and nonclinical health services and scenarios, explore alternatives to outsourcing, and consider how outsourcing (when necessary) can be done in a strategic manner that does not compromise the values of the organization and its commitment to patients.

The Journal of emergency medicine, Mar 1, 2022

American Journal of Medical Quality, Mar 1, 2021

The health care sector has made radical changes to hospital operations and care delivery in respo... more The health care sector has made radical changes to hospital operations and care delivery in response to the coronavirus disease (COVID-19) pandemic. This article examines pragmatic applications of simulation and human factors to support the Quadruple Aim of health system performance during the COVID-19 era. First, patient safety is enhanced through development and testing of new technologies, equipment, and protocols using laboratory-based and in situ simulation. Second, population health is strengthened through virtual platforms that deliver telehealth and remote simulation that ensure readiness for personnel to deploy to new clinical units. Third, prevention of lost revenue occurs through usability testing of equipment and computer-based simulations to predict system performance and resilience. Finally, simulation supports health worker wellness and satisfaction by identifying optimal work conditions that maximize productivity while protecting staff through preparedness training. Leveraging simulation and human factors will support a resilient and sustainable response to the pandemic in a transformed health care landscape.

Research Square (Research Square), May 4, 2022

Journal of Hospital Administration, Jun 1, 2018

European journal of public health, Sep 1, 2020

JAMA, Sep 4, 2018

In Reply This systematic review and meta-analysis1 addressed 1 of 6 research questions that compr... more In Reply This systematic review and meta-analysis1 addressed 1 of 6 research questions that comprised a larger project funded by the Agency for Healthcare Research and Quality in partnership with the National Heart, Lung, and Blood Institute. The protocol was registered with PROSPERO (CRD42016047985) and the final report is publicly available.2 Prior to publication, the draft report was posted for public comment and underwent peer review. This project was designed and conducted by a team without related conflicts of interest and no biases toward a particular result. As such, to our knowledge, no unpublished data were intentionally removed from any of the analyses. Regarding the analysis comparing SMART with a higher dose of inhaled corticosteroids and LABA controller therapy with an end point of exacerbation risk, the 2 studies in question were excluded from the pooled estimate for valid reasons. First, the study by Ställberg et al3 included patients with both the same and higher inhaled corticosteroid doses in the comparator group; therefore, it was not pooled with studies that examined solely higher dosing. Second, the study by Pavord et al4 did not specifically provide the number of study participants in each group who experienced a severe exacerbation; rather, they reported the time to first exacerbation or mean rate of severe exacerbations per patient-year. Therefore, the results shown in Figure 3 represented the best available evidence at the time for the outcome of exacerbation risk.

Despite serious and widespread efforts to improve the quality of health care, many patients still... more Despite serious and widespread efforts to improve the quality of health care, many patients still suffer preventable harm every day. Hospitals find improvement difficult to sustain, and they suffer “project fatigue” because so many problems need attention. No hospitals or health systems have achieved consistent excellence throughout their institutions. High-reliability science is the study of organizations in industries like commercial aviation and nuclear power that operate under hazardous conditions while maintaining safety levels that are far better than those of health care. A high reliability organization (HRO) is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity. The definition of a high reliability organization extends beyond patient safety to encompass quality care - and ultimately value. Recommendations and innovations focused on healthcare individual processes do not address the larger and often intangible systemic and cultural factors that create vulnerabilities throughout the entire system. In addition, an open, transparent, and just culture which would allow a deeper understanding of these factors does not appear to be forthcoming. Adapting and applying the lessons of this science as well as applied human factors thinking to health care offer the promise of enabling hospitals to reach levels of quality and safety that are comparable to those of the best high-reliability organizations. Hospitals can make substantial progress toward high reliability by undertaking several specific organizational change initiatives. Further research and practical experience will be necessary to determine the validity and effectiveness of this framework for high-reliability health care.

American Journal of Medical Quality, Jan 15, 2020

The Evolving Scholar, Dec 31, 2021

Cambridge University Press eBooks, Apr 7, 2015

PubMed, Apr 8, 1999

Anesthesiology Clinics of North America, Mar 1, 1999

ABSTRACT

Pediatric emergency care, Dec 17, 2020

Population medicine, Apr 26, 2023

Annals of Internal Medicine, May 18, 2004

Informa Healthcare eBooks, Jul 27, 2001

Mayo Clinic Proceedings, Nov 1, 2021

The Journal of emergency medicine, Mar 1, 2022

American Journal of Medical Quality, Mar 1, 2021

Research Square (Research Square), May 4, 2022

Journal of Hospital Administration, Jun 1, 2018

European journal of public health, Sep 1, 2020

JAMA, Sep 4, 2018

American Journal of Medical Quality, Jan 15, 2020

Hospital emergency departments today are undoubtedly noisy, and this noise can cause human error,... more Hospital emergency departments today are undoubtedly noisy, and this noise can cause human error, adverse medication events, and limit the ability of clinicians to provide high-quality and safe patient care. The average sound pressure levels, analyzed in previous studies for hospitals around the world, substantially exceed the World Health Organization guidelines. These sounds-emitting from sources ranging from monitor alarms, ring binders, overhead paging, trash bins, and echogenic surfaces, to patients crying out-can be abrupt, yet not sustained. The problem of hospital noise requires deep learning and insight beyond those provided by mere sound pressure level measurements and even loudness evaluations. In order to evaluate how noise impacts hospital staff distraction and performance, and its subsequent propensity for human error, we conducted study at a busy, urban hospital emergency department. The effects on physician cognitive load and working memory due to various sonic occurrences within the hospital emergency department were assessed using cognitive executive function evaluations with binaurally-augmented acoustic environments as the backdrop. The paper will discuss the methods deployed for cognitive testing using binaural augmentation, share initial results, and offer meaningful interpretations as well as potential recommendations which address these results.

1st International Forum on Sustainable Development and Cities of the Future: Economy, Well-being,... more 1st International Forum on Sustainable Development and Cities of the Future: Economy, Well-being, Ecology, Health
Moscow May 15-17, 2018

Developing and assessing Entrustable Professional Activities as the Basis of Assessment of Patien... more Developing and assessing Entrustable Professional Activities as the Basis of Assessment of Patient Safety

.18th Ottawa Conference in the United Arab Emirates.

Improve Care:Research Evidence and Strategies Evaluating policy and service interventions: frame... more Improve Care:Research Evidence and Strategies

Evaluating policy and service interventions: framework to guide selection and interpretation of study end points

Management interventions may be divided into two categories; targeted service interventions with narrow effects, and generic service interventions that (like policy interventions) have diffuse effects
Measurement of clinical processes rather than patient outcomes may be more cost effective in evaluations of targeted service interventions. Clinical processes are not usually suitable primary end points for policy and generic service interventions because the effects at this level are too diffuse. Multiple clinical processes are consolidated on a small number of outcomes, which are the default primary end point for policy and generic service interventions.

When the policy or generic service intervention is inexpensive, cost effective and plausible outcomes may be undetectable at the patient level.
In such cases the effects of the intervention can still be studied at process levels further to the left (upstream) in an extended version of Donabedian’s causal chain.

Changing established behaviour of any kind is di cult. It is particularly challenging in complex ... more Changing established behaviour of any kind is di cult. It is particularly challenging in complex critical healthcare settings because of the varied relationships between a wide range of organisations, professionals, patients, and carers. Barriers to change can take a long time to overcome when discussing guidance for implementation in clinical practice; a clinical guideline can take up to 3–5 years to be fully implemented. One may need to consider the scale of change that can be achieved realistically when seeking to implement behavioural change when even small changes require trust-building measures and can have a positive impact, especially if the change involves an action that is repeated o en. Certain trust-building factors may help to foster an environment that is conducive to behaviour change. An organisation where there is strong leadership, authentic communication, and transparent governance has a much greater chance for success. No matter how nec- essary change seems to upper management, the barriers must be authentically acknowledged and not swept under the carpet if a strategic change is to be implemented successfully. The key to successful change is in the planning, messaging, and implementation. However, barriers to changing established practice may prevent or impede progress in all organisations, whatever the culture. e three greatest barriers to organisational change are most o en the following:
inadequate culture-shift planning,
lack of employee involvement,
awed communication and leadership strategies.

Designing Hospitals and Healthcare Facilities for Safety, Reliability & Better Patient Satisfacti... more Designing Hospitals and Healthcare Facilities for Safety, Reliability & Better Patient Satisfaction

Imagine a physical environment in Korea that helps reduce harm, infections, errors, falls, noise, confusion, anxiety and workforce injuries, while improving provider joy at work! Better environments transform the culture, improve patient safety and satisfaction and save money.

The framework of health care delivery is shifting rapidly across the world. Capital budgets and operational efficiency are critical in this time of shrinking reimbursement, increasing share of risk, and evolving models of care delivery. Getting the best value for your capital expenditures is key to your success. Capital projects that are informed by high-reliability organizational (HRO) initiatives can help your clients respond effectively to current pressures to reduce cost and improve quality. Creating a strategy for the future with experimenting with new methodologies and thinking processes that will be essential in the design of future healthcare facilities.

Facility design in Korea can affect how people work, and what processes, systems and technologies they will require to support the functioning of their work environments. Different ways of working and different configurations of clinical teams will emerge to ensure appropriate acquisition and use of new skills and competencies to produce quality outcomes. Higher reliability comes from authentic conversations, bold leadership and an organizational culture that enables staff to be fully present and honest in their feedback on better design, harm prevention and process improvement.

Reliability principles — methods of evaluating, calculating, and improving the overall reliability of a complex system — have been used effectively in industries such as manufacturing to improve both safety and the rate at which a system consistently produces appropriate outcomes. Even the most advanced healthcare organizations acknowledge that they are on a journey to achieving high reliability and need to address four essential building blocks: (1) a culture devoted to quality; (2) responsibility and accountability of staff; (3) optimizing and standardizing processes and (4) measurement of performance.

The talk will review the concepts of evidence-based quality, safety and population heath and review the forces and governments are facing in designing hospitals for the future. Engaging clinicians and patients in the design and operational process remains the biggest obstacle in addressing the growing implementation gap in providing cost effective and reliable care.

Healthcare executives report that 19% (12/62) and 8% (5/59) have already implemented EHR and CPOE... more Healthcare executives report that 19% (12/62) and 8% (5/59) have already implemented EHR and CPOE, respectively. • 50% (28/62) and 54% (32/59) plan to implement EHR and CPOE, respectively, within the first year following the survey; 35% (23/65) and 34% (23/67) felt that EHR and CPOE, respectively, were very " unimportant, " " unimportant, " or " neutral " in attaining their institutions mission and/or advancing their patient safety goals. • 58% (29/50) and 70% (37/53), felt that EHR and CPOE, respectively, would be met with resistance by physicians substantial enough to be considered an " extensive barrier " for institutional implementation, and/or that each was unlikely to be used by their physicians (table 1). • Analysis of correlated responses demonstrated that executives were more likely to report perceptions of physicians unwillingness to use EHR and CPOE, than they were about the resistance of physicians being a barrier to hospital implementation of these systems (p=0.029 * and p=0.05 ** , respectively). (tables 2, 3) • 63% (31/49) and 75% (38/51) feel their hospital was going to be met with substantial resistance by their physicians, and thus impede institutional implementation of EHR and CPOE, respectively (tables 4, 5). The survey contained 44 questions, both open-and closed-ended. It was designed, pre-tested, and fielded between January 9-27, 2004, and then extended till 6/21/2004. Over 60% (121/200) responded to the web-based questionnaire. Since not all questions were answered, comparisons were made from completed responses. Answers to questions of perceived physician utilization and resistance to EHR and CPOE in both institutional and statewide systems were matched and compared. McNemar's test was used to compare the correlated responses for perceptions of physician willingness to use HIT and their resistance to institutional implementation. Background: Literature suggests that health information technology (HIT) could significantly advance patient safety. The current status of HIT implementation in Florida Hospitals is varied and of little penetration, which may hinder patient safety. Florida's 2003 Senate Medical Liability Reform Bill proposed the development of a statewide HIT infrastructure to improve patient safety, including implementation of electronic health records (EHR), computerized physician order entry (CPOE), and other IT applications.

We use fault trees to model medical errors associated with transitions of care. Model predictions... more We use fault trees to model medical errors associated with transitions of care. Model predictions are close to independent estimates obtained from the literature on medical errors, and risk analysis suggests that transitions affect performance by hospital units.

Despite serious and widespread efforts to improve the quality of health care, many patients stil... more Despite serious and widespread efforts to improve the quality of health care, many patients still suffer preventable harm every day. Hospitals find improvement difficult to sustain, and they suffer “project fatigue” because so many problems need attention. No hospitals or health systems have achieved consistent excellence throughout their institutions. High-reliability science is the study of organizations in industries like commercial aviation and nuclear power that operate under hazardous conditions while maintaining safety levels that are far better than those of health care. A high reliability organization (HRO) is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity. Recommendations and innovations focused on healthcare individual processes do not address the larger and often intangible systemic and cultural factors that create vulnerabilities throughout the entire system. In addition, an open, transparent, and just culture which would allow a deeper understanding of these factors does not appear to be forthcoming. Adapting and applying the lessons of this science as well as applied human factors thinking to health care offer the promise of enabling hospitals to reach levels of quality and safety that are comparable to those of the best high-reliability organizations. Hospitals can make substantial progress toward high reliability by undertaking several specific organizational change initiatives. Further research and practical experience will be necessary to determine the validity and effectiveness of this framework for high-reliability health care.

Background The majority of adverse patient events are preceded by predictable data patterns. Data... more Background
The majority of adverse patient events are preceded by predictable data patterns. Data mining methods, baysien networks and prediction models are emerging as methods for discovering patterns from large datasets, deducing knowledge from these patterns. They represent the uncertainties underlying clinical decision making. The knowledge of these patterns apriori may help mitigate and help prevent the intra and post-operatively clinical outcomes.

Methods
We analyzed a clinical anesthesia information management system (AIMS) at a tertiary academic hospital. The database query was used to identify adverse events (AEs) and their precursor patterns. A decision tree generator. C4.5, was used to induce a model from available data. We generated data files from the AIMS database. The data was pre-processed as input into a C4.5 generator. The output was in the form of a decision tree that was used to predict the occurrence of AEs.

Results
The database included data from more than 21,000 patients treated during a twelve month period. Each patient file included 20 vital sign parameters, that were automatically measured in the operating room by PICIS EMR software and recorded every 1-5 minutes in the AIMS. Among the 21,000 patients, 500 patients had vital sign fluctuations that met the criteria of an AE. We used refined definitions for four types of patient complications to improve the prediction ability of our analysis: hypertension, hypotension, hyperthermia and hypothermia. The four AEs were chosen due to their ease of measurement and less ambiguous definitions. We introduced two concepts: leading time (T1), and window size (T2), which denote the times in advance we can make the predictions and data we need to complete these predictions, respectively. We tested different pairs of (T1, T2) for each of the four AEs and then chose optimal pairs that result in the highest prediction accuracy.

Conclusions
We present an innovative data-mining based AE prediction model that has potential for making intra-operative care safer. We achieved a 70% accuracy for predicting AEs from the dataset a priori. We also found that voluntarily submitted quality assurance documentation greatly under-reported the incidence of many AEs among the 21,000 patients. The model we propose has the potential to alert clinicians to AE precursor conditions that might help prevent these events from progressing to patient harm.

The US healthcare delivery system in general, and pediatric care in particular, while offering so... more The US healthcare delivery system in general, and pediatric care in particular, while offering some of the best healthcare in the world is inefficient, expensive, at times harmful and not well designed for wellness nor co-production with children and their carers. There is a growing regulatory, media and public trust gap climate that is stifling innovation and undermining the courage to change
Major changes are needed in the delivery model to address these challenges. Given the pressures on healthcare, the systems that will thrive will focus on quality of care (including cost efficiency), through innovative healthcare delivery that results from the alignment of incentives with payers, patients and other participants in the healthcare equation.
Human factors and design thinking are approaches that can affect the design of how people work, and what processes, systems and technologies they will require to support the functioning of the work environment. Our work is about the people, the organization of work, and the spaces that support quality and resilience Innovation is best designed by listening to those on the front lines of healthcare delivery—patients and clinicians—and incorporating relevant knowledge from other scientific disciplines such as operations, research, organizational behavior, social sciences, industrial and biomedical engineering and human factors psychology. Effectively engaging clinical staff and particularly physicians is critical to this change in the design and delivery of effective health- care systems.
A human factors analysis addresses an organization as a complex socio-technical system; it identifies the stress points in the system and redesigns it to prevent errors from occurring, traps them while they are inconsequential, or mitigates their effects. And while technical skills are fundamental to good outcomes, the non-technical skills—coordination, cooperation, listening, negotiating, and so on— also can markedly influence the performance of individuals and teams and the outcomes of treatment. More positively, redesign of systems helps providers and patients do the right thing with less cost and effort.
High reliability—or consistent performance at high levels of safety over prolonged periods— is a hallmark for non-health-related, high-risk industries, such as aviation and nuclear power generation. High reliability is centered on supporting and building a culture of trust, transparency, and psychological safety. The ultimate goal of higher reliability of care comes from authentic conversations, bold leadership and an organizational culture that enables staff to be fully present, secure, and honest in their feedback on better design, harm prevention and process improvement.

The US healthcare delivery system in general, and pediatric care in particular, while offering s... more The US healthcare delivery system in general, and pediatric care in particular, while offering some of the best healthcare in the world is inefficient, expensive, at times harmful and not well designed for wellness nor co-production with children and their carers. There is a growing regulatory, media and public trust gap climate that is stifling innovation and undermining the courage to change
Major changes are needed in the delivery model to address these challenges. Given the pressures on healthcare, the systems that will thrive will focus on quality of care (including cost efficiency), through innovative healthcare delivery that results from the alignment of incentives with payers, patients and other participants in the healthcare equation.
Human factors and design thinking are approaches that can affect the design of how people work, and what processes, systems and technologies they will require to support the functioning of the work environment. Our work is about the people, the organization of work, and the spaces that support quality and resilience Innovation is best designed by listening to those on the front lines of healthcare delivery—patients and clinicians—and incorporating relevant knowledge from other scientific disciplines such as operations, research, organizational behavior, social sciences, industrial and biomedical engineering and human factors psychology. Effectively engaging clinical staff and particularly physicians is critical to this change in the design and delivery of effective health- care systems.
A human factors analysis addresses an organization as a complex socio-technical system; it identifies the stress points in the system and redesigns it to prevent errors from occurring, traps them while they are inconsequential, or mitigates their effects. And while technical skills are fundamental to good outcomes, the non-technical skills—coordination, cooperation, listening, negotiating, and so on— also can markedly influence the performance of individuals and teams and the outcomes of treatment. More positively, redesign of systems helps providers and patients do the right thing with less cost and effort.
High reliability—or consistent performance at high levels of safety over prolonged periods— is a hallmark for non-health-related, high-risk industries, such as aviation and nuclear power generation. High reliability is centered on supporting and building a culture of trust, transparency, and psychological safety. The ultimate goal of higher reliability of care comes from authentic conversations, bold leadership and an organizational culture that enables staff to be fully present, secure, and honest in their feedback on better design, harm prevention and process improvement.

Japan Association of Thoracic Surgery, Kobe, Japan, Oct 2016

Imagine a physical environment in Russia that helps reduce harm, infections, errors, falls, noise, confusion, anxiety and workforce injuries, while improving provider joy at work! Better environments transform the culture, improve patient safety and satisfaction and save money.

Facility design in Russia can affect how people work, and what processes, systems and technologies they will require to support the functioning of their work environments. Different ways of working and different configurations of clinical teams will emerge to ensure appropriate acquisition and use of new skills and competencies to produce quality outcomes. Higher reliability comes from authentic conversations, bold leadership and an organizational culture that enables staff to be fully present and honest in their feedback on better design, harm prevention and process improvement.

High reliability concepts are tools that a growing number of hospitals are using to help achieve ... more High reliability concepts are tools that a growing number of hospitals are using to help achieve their safety, quality, and efficiency goals. Hospitals do most things right, much of the time. But even very infrequent failures in critical processes can have terrible consequences for a patient. Creating a culture and processes that radically reduce system failures and effectively respond when failures do occur is the goal of high reliability thinking.

At the core of high reliability organizations (HROs) are five key concepts, which we believe are essential for any improvement initiative to succeed:
• Sensitivity to operations. Preserving constant awareness by leaders and staff of the state of the systems and processes that affect patient care. This awareness is key to noting risks and preventing them.
• Reluctance to simplify. Simple processes are good, but simplistic explanations for why things work or fail are risky. Avoiding overly simple explanations of failure (unqualified staff, inadequate training, communication failure, etc.) is essential in order to understand the true reasons patients are placed at risk.
• Preoccupation with failure. When near-misses occur, these are viewed as evidence of systems that should be improved to reduce potential harm to patients. Rather than viewing near-misses as proof that the system has effective safeguards, they are viewed as symptomatic of areas in need of more attention.
• Deference to expertise. If leaders and supervisors are not willing to listen and respond to the insights of staff who know how processes really work and the risks patients really face, you will not have a culture in which high reliability is possible.
• Resilience. Leaders and staff need to be trained and prepared to know
how to respond when system failures do occur.

This talk shows how hospital leaders have taken these basic concepts and used them to develop and implement initiatives that are key to enhanced reliability.

The talk will review how the concepts have been used to:
• Change and respond to the external and internal environment
• Plan and implement improvement initiatives
• Adjust how staff members do their work
• Implement improvement initiatives across a range of service types and
clinical areas
• Spread improvements to other units and facilities

Applying high reliability concepts in your organization does not require a huge campaign or a major resource investment. It begins with leaders at all levels beginning to talk honestly about the challenges, sharing day transparently, and thinking deeply about how the care they provide could become more reliable.

Flemish Colon Cancer Learning Collaborative Kick-off, Leuven University Hospital, Belgium, Jan 16... more Flemish Colon Cancer Learning Collaborative Kick-off, Leuven University Hospital, Belgium, Jan 16, 2018

ICU Clinical Leadership Workshop; Brussels, Belgium, Jan 17-19, 2018

ICU Clinical Leadership Workshop; Brussels, Belgium; Jan 17-19, 2018

Clinical Leadership Workshop, Jan 17-19, 2018 Brussels, Belgium

2018 Clinical Leadership Workshop, Brussels, Jan 17-19, 2018

Systems Approaches to Surgical Quality and Safety: From Concept to Measurement

The framework of health care delivery is shifting rapidly. Capital budgets and operational effici... more The framework of health care delivery is shifting rapidly. Capital budgets and operational efficiency are critical in this time of shrinking reimbursement, increasing share of risk, and evolving models of surgical care delivery. Surgical outcomes that are informed by high-reliability organizational (HRO) initiatives can help hospitals respond effectively to current pressures to reduce cost, improve quality while enhancing staff engagement and joy.

Research into surgical outcomes has primarily focused on the role of patient pathophysiological risk factors, and on the skills of the individual surgeon. The outcome of surgery is, however, also dependent on the quality of care received throughout the patient’s stay in hospital and the performance of a considerable number of health professionals, all of whom are influenced by how they learn, and the environment in which they work. Drawing on the wider literature on safety and quality, risk management in healthcare, and recent papers on surgery and human factors, this talk argues for a much wider assessment of factors that may be relevant to surgical outcome. In particular, we suggest the development of an “operation profile” to capture all the salient features of a surgical operation. The aims of this initiative are: to expand operative assessment beyond patient factors and the technical skills of the surgeon; to extend assessment of surgical skills beyond bench models to the operating theater; to provide a basis for assessing interventions and to provide a deeper understanding of surgical outcomes, staff welfare and patient wellness.

Hospitals and OR design affects the design of how people work, and what processes, systems and technologies they will require to support the functioning of the work environment. Different ways of working and different configurations of clinical teams will emerge to ensure appropriate acquisition and use of new skills and competencies to produce quality outcomes. Higher reliability comes from authentic conversations, bold leadership and an organizational culture that enables staff to be fully present and honest in their feedback on better design, harm prevention and process improvement.

Reliability principles — methods of evaluating, calculating, and improving the overall reliability of a complex surgical system — have been used effectively in industries such as manufacturing to improve both safety and the rate at which a system consistently produces appropriate outcomes. Even the most advanced healthcare organizations acknowledge that they are on a journey to achieving high reliability and need to address four essential building blocks: (1) a culture devoted to quality; (2) responsibility and accountability of staff; (3) optimizing and standardizing processes, and (4) measurement of surgical performance.

The presentation will review the foundational concepts of evidence-based surgical quality and safety and develop a better appreciation for the forces and pressures surgeons and surgical leaders are facing. Engaging surgical clinicians in the design and operational process remains the biggest obstacle in addressing the growing implementation gap in providing cost effective and reliable surgical care.

NSW Clinical Leadership Day 2012

Assessing and Improving Cardiac Team Performance, Safety and Reliability , ICC May 28, 2016

Crew Resource Management and Safety

Islambad, Pakistan, 1st International Conference On Patient Safety, May 7-8

1st International patient Safety Conference, Islamabad, May 7-8, 2016

CCHF invites you to learn from hospital leaders, industry partners and project experts, how techn... more CCHF invites you to learn from hospital leaders, industry partners and project experts, how technology innovations are being planned, designed and integrated to improve care, quality, workflow, and safety in new and existing builds. The complexity and speed of evolving information technology, medical and non-medical innovations poses new challenges and opportunities in improving patient centred care.
Hospital administrators, clinical leads and the experts planning, designing and constructing healthcare facilities need to work differently to meet the challenge. New ways are being established of collaborating, integrating services, systems and programs to constantly improve care, and in Ontario, meeting the new requirements of health funding reforms.
Join us for a very informative day to learn about these cutting-edge technologies, approaches for integration and how they are transforming healthcare facilities.
At this event, the audience plays an important role in advancing the discussion and understanding. Our audience is comprised of healthcare leaders and multi-disciplinary experts that provide expertise to the healthcare facility sector. Please join us for our Toronto winter session!
Canadian Centre for Healthcare Facilities (CCHF) is a national, not-for-profit association. CCHF’s goal is to help the healthcare facility sector achieve the highest quality healthcare facilities, responsive to patient care needs, through the planning, design, construction, and operation phases. CCHF will do this by:
• Connecting: Bringing together cross-disciplinary stakeholders (hospital administrators, clinical experts, researchers, engineers, architects, designers, construction managers)
• Sharing: Approaches to improving the design of healthcare facilities, including: design for innovations, evidence-based design, lean, patient centred design, design and facilities standards, post-occupancy evaluations
• Learning: Building knowledge networks through research, case studies and expert input
• Inspiring: Bringing together innovative thinkers and leaders to share their expertise as
speakers, sponsors, attendees and program advisors.

Keynote to launch three-hour summit focusing on how Design Thinking goes beyond the traditional e... more Keynote to launch three-hour summit focusing on how Design Thinking goes beyond the traditional economic factors of production, land, labour and capital and focuses on collaborative partnerships to unite people, ideas and things in a holistic framework.

Healthcare executives and design professionals will learn how Design Thinking was applied in actual case studies and how projects transitioned beyond theory to practice. Hear from design practitioners at every level of the system who have successfully employed design thinking methodologies in healthcare to go beyond good and create meaningful patient experiences.

Patients experience multiple transitions as they navigate the increasingly complex and dangerous ... more Patients experience multiple transitions as they navigate the increasingly complex and dangerous healthcare system. This remains a major priority for healthcare systems. Safety depends on explicit communication and coordination between and among healthcare professionals. The session will review a content and process-driven improvement strategy for redesigning and standardizing communication and coordination during patient transitions and readmissions. The session will review a mixture of quantitative, qualitative and improvement methods including critical incident interviews, focus groups, observations and process mapping. The talk will outline a plan for Fisher-Titus to apply a systematic program to influence physician behavior to improve transitions of care and reduce patient readmissions.

Learning Objectives:
1.Identify the transitional care outcomes and components that matter most to patients and caregivers using human factors and adverse event analysis methods.

2. Develop a standard process to optimize patient transitions using a process mapping methodology from the patient/care giver perspectives.

3. Discuss barriers and facilitators for successful interventions and local implementation

4. Discuss recommendations for dissemination and implementation of effective transitions of care.

Keynote, SEACARE Annual meeting

Socio-cultural Perspective on Patient Safety, 2015

It seems that despite unprecedented levels of spending, preventable medical errors abound, uncoor... more It seems that despite unprecedented levels of spending, preventable medical errors abound, uncoordinated care continues to frustrate patients and providers, and health care costs continue to rise. Although there has never been more awareness and resources devoted worldwide to overall system improvement, care experience, quality and safety, while advocating for system-wide culture change, there remain opportunities to achieve savings, reduce risks and improve performance. Current
approaches are not producing the pace, breadth, or magnitude of improvement that patients demand and providers expect. Proscriptive rules, guidelines and checklists are helping to raise awareness and present some harm but are falling short from helping to provide an ultrasafe system (Amalberti et al. 2005). A new system centered around the patient and their clinical microsystem that renders clinical care processes more predictable, effective, efficient and humane is needed
(Mohr et al. 2004).

E. Vanderheiden, C.-H. Mayer (eds.), Mistakes, Errors and Failures across Cultures, 2020

Training of clinicians in both nursing and medicine is often focused on improving their individua... more Training of clinicians in both nursing and medicine is often focused on improving their individual competencies in the hope to reduce error and patient harm rates to a negligible level. Medicine attracts the brightest students in most countries through a highly competitive selection process. Despite this, 5-10% of patients admitted to hospital continue to suffer complications with significant morbidity and mortality. Disappointingly error rates in many areas have not significantly changed for decades. The dominant philosophies of error reduction are 'Safety 1' and 'Safety 2'. The principle of 'Safety 1' focuses on measurement and understanding of errors. 'Safety 2' is looking for resilient systems in which we seek to understand how people manage to create safety despite system weaknesses and endeavour to better appreciate successful safe working practices. In this chapter in build on Safety 1 and 2, and introduce the concept of Safety 3.0. In contrast to the principles applied to reducing errors in hospitals, the high-reliability industries have used another approach to assure reliable, reduction of failures and to enhance safety: modular redundancy. This approach assures that safety-critical parts of technical systems exist in triplicate or quadruplicate backups and the failure of individual parts does not lead to catastrophic system failures and fatal outcomes. This might be the key to reliable safety of complex social-technical systems such as aviation, nuclear power, space travel and more. The application of this principle is still rare in healthcare, but acceptance of the need for a robust safety management system based on redundancy of safety-critical

The healthcare system has only recently begun to approach patient safety in a more systematic way... more The healthcare system has only recently begun to approach patient safety in a more systematic way. There is a clear need to improve the qual- ity of child sedation that presently permits an alarmingly high annual rate of medical errors that harm children and drive up costs. Effective sedation, controlling pain and anxiety, improves patient and parent satisfaction. Pediatric sedation is rapidly growing in its use around the world owing to its simplicity, cost savings, tolerance, and rapid emergence. The usual approach within medicine has been to stress the responsibility of the individual, and to encourage the belief that the way to eliminate adverse events is to get individual clinicians to perfect their practices. This simplistic approach to the safety of pediatric sedation not only fails to address the important and complex systematic flaws that contribute to the genesis of adverse events in sedation, but also perpetuates a myth of infallibility that is a disservice to both clinicians and their patients.

The focus on the actions of individuals, without addressing the underlying microsystem, as the sole cause of adverse events inevitably results in continued system failures and the resultant injuries and deaths of children.
Strategies to make sedation care more reliable and even safer might include: adoption of reliability engineering principles, setting up robust near miss reporting systems, applying critical event analysis tools, wide adoption of simulation and sedation team training, adopting checklists, standardizing medication protocols, implementing robust hand off protocols and patient identification checklists, and adherence to the ASA Sedation practice parameters.

The surgical environment contains abundant opportunities for adverse events, and patients under s... more The surgical environment contains abundant opportunities for adverse events, and patients under surgical care are at risk for harm. The monitoring of surgical safety has focused almost exclusively on treatment-related concerns, especially on complications of surgery. Diagnostic errors have received little attention. Coincident with the growing awareness about the importance of diagnostic error in general and the recently issued report from the Institute of Medicine on Improving Diagnosis in Health Care [1], it is appropriate to consider what is known about diagnostic error in surgery, while acknowledging that the vast majority of knowledge in this domain has evolved from internal medicine and emergency medicine.

The increased international focus on improving patient outcomes, safety and quality of care has l... more The increased international focus on improving patient outcomes, safety and quality of care has led stakeholders, policy makers and healthcare provider organizations to adopt standardized processes for evaluating healthcare organizations. Accreditation and certification have been proposed as interventions to support surgical patient safety and high quality healthcare. Guidelines recommend accreditation but are cautious about the evidence, judged as inconclusive. The push for accreditation continues despite sparse evidence to support its efficiency or effectiveness. Accreditation continues to grow internationally but due to scant evidence, no conclusions could be reached to support its effectiveness.

The surgical space, by nature, is a high-risk hypercomplex environment where hazards lurk around every corner and for every patient. Health care institutions continue to face challenges in providing safe patient care in increasingly complex and demanding technical, organizational, and regulatory environments. Real, sustainable change comes from the organizations and hardworking staff that deliver care to patients. It is odd that something so important and personal as health care does not have widely acknowledged or adopted “industry standards” of inspection, reporting, and improvement.

Both high reliability theory and systems theory provide conceptual and practical frameworks for supporting accreditation driven approaches towards delivering safe and reliable care. Although many ambiguities and conflicts arise from the implementation of these theoretic constructs, they should guide the development of work processes and stimulate innovation in designing ways to provide safe and effective care within health care systems. Organizing surgical care around the pursuit of safety and reliability as an overarching priority is a professional obligation for all members of the health care team. This goal can be accomplished by organizing around and shaping a culture focused on reliable performance but requires substantial investments in human capital.

This book focuses exclusively on the surgical patient and on the perioperative environment with i... more This book focuses exclusively on the surgical patient and on the perioperative environment with its unique socio-technical and cultural issues. It covers preoperative, intraoperative, and postoperative processes and decision making and explores both sharp-end and latent factors contributing to harm and poor quality outcomes. It is intended to be a resource for all healthcare practitioners that interact with the surgical patient. The first section presents foundational principles of safety science and related social science. The second exposes barriers to achieving optimal surgical outcomes and details the various errors and events that occur in the perioperative environment. The third section contains prescriptive and proactive tools and ways to eliminate errors and harm. The final section focuses on developing continuous quality improvement programs with an emphasis on safety and reliability.
Surgical Patient Care: Improving Safety, Quality and Value targets an international audience which includes all hospital, ambulatory and clinic-based operating room personnel as well as healthcare administrators and managers, directors of risk management and patient safety, health services researchers, and individuals in higher education in the health professions.

http://www.springer.com/us/book/9783319440088

The World Health Organization (WHO) has categorized the countries of the Eastern Mediterranean Re... more The World Health Organization (WHO) has categorized the countries of the Eastern Mediterranean Region (EMR) into three groups based on population health outcomes, health system performance, and level of health expenditure. Group 1 comprises the Gulf Cooperation Council (GCC) countries—namely, Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates—will face an unparalleled and unprecedented rise in demand for health care over the course of the next two decades. It is estimated that total health-care spending in the region will reach US$60 billion in 2025, up from US$12 billion today. No other region in the world
faces such rapid growth in demand with the simultaneous need to realign its health-care systems to be able to treat the disorders of affluence. These countries have seen considerable socioeconomic and health development in the region over the past decades.

Over the past 30 years Health information tech- nology (HIT) has been positioned as a battle betw... more Over the past 30 years Health information tech- nology (HIT) has been positioned as a battle between two classes of technology solutions, that is Clinical Enterprise Resource Planning (CERP aka EMR) versus best-of-breed systems. The CERP systems are provided by the largest vendors as whole of hospital or whole of organization solutions intended to satisfy all users in the organization. Experience shows that they fail to fulfill that promise. Best-of-breed solutions are tailored to suit a particular community of users to perform specialized tasks such as surgical scheduling, tracking, and clinical details. These systems get higher rankings from users for usability and efficiency but create problems for IT departments by requiring individual maintenance tasks for each installed system, and silo data which is needed for back office administration and analytics. In the last 10 years, the best-of-breed solution has been in retreat with the onslaught of CERP vendors holding sway over the decision makers with a promise of increased revenue for more detailed billing and common access to all data . At the same time, the clinicians at the coalface of care are complaining bitterly about CERP systems, which have unsuitable interfaces, add more work, and fail to respond to change requests.

Surgical Patient Care: Improving Safety, Quality and Value, Springer, 2017, http://www.springer.com/us/book/9783319440088

Changing established behaviour of any kind is difficult. It is particularly challenging in comple... more Changing established behaviour of any kind is difficult. It is particularly challenging in complex critical healthcare settings because of the varied relationships between a wide range of organisations, professionals, patients, and carers. Barriers to change can take a long time to overcome when discussing guidance for implementation in clinical practice; a clinical guideline can take up to 3–5 years to be fully implemented. One may need to consider the scale of change that can be achieved realistically when seeking to implement behavioural change in intensive care units (ICUs); even small changes require trust-building measures and can have a positive impact, especially if the change involves an action that is repeated often. Certain trust-building factors may help to foster an environment that is conducive to behaviour change. An organisation where there is strong leadership, authentic communication, and transparent governance has a much greater chance for success. No matter how necessary change seems to upper management, the barriers must be authentically acknowledged and not swept under the carpet if a strategic change is to be implemented successfully. The key to successful change is in the planning, messaging, and implementation. However, barriers to changing established practice may prevent or impede progress in all organisations, whatever the culture.

The three greatest barriers to organisational change are most often the following:
�� inadequate culture-shift planning,
�� lack of employee involvement,
�� flawed communication and leadership strategies.

Organisations also need a clear system in place to support ongoing measurement, implementation, and assessment, and effective ways to address the normalised deviance. This chapter aims to provide practical advice to intensive care providers and administrators on how to encourage and support healthcare professionals and managers to change their clinical practices

Barach P. Addressing barriers for change in clinical practice. In Quality Management in Intensive Care: A Practical Guide. (Eds) Bertrand Guidet, Andreas Valentin and Hans Flaatten, Cambridge University Press, 2016.
978-1-107-50386-1.

Based on the proceedings of a joint ECRI and Department of Health conference to introduce the Nat... more Based on the proceedings of a joint ECRI and Department of Health conference to introduce the National Patient Safety Agency

Patients’ rights have been formulated in a number of documents and guidelines from various intern... more Patients’ rights have been formulated in a number of documents and guidelines from various international bodies. Laws and declarations on patients’ rights do not automatically make health care safer, but can help to empower patients. Empowered patients are in a better position to manage their own health and health care and to participate in efforts to improve safety. The report presents an overview of legal aspects influencing patient safety and describes examples of patient involvement. It highlights the need to strengthen a continuum of information between various levels of care, including patient experiences, health literacy and engagement. The work is expected to contribute to the wider process of evidence collation aimed at finding efficient ways to build realistic and informed expectations of health care, while encouraging patients to be vigilant and knowledgeable to ensure maximum safety standards. Recommendations are formulated with respect to the macro, meso and micro levels of health service delivery.

This unique compendium of case studies on patient safety – told from the perspective of the patie... more This unique compendium of case studies on patient safety – told from the perspective of the patient and family – illustrates 24 stories of preventable health care errors that led to irreparable patient harm. The reader is guided through a structured analysis of the events, eliciting lessons learned and strategies for preventing similar events in the future. Learning objectives for each case facilitate the reader’s development of a set of core competencies related to improving safety and quality of health care.

Health professional students including medicine, nursing, pharmacy, health administration, public health, as well as practicing professionals such as patient safety officers, chief quality officers, risk managers, and health service researchers will gain valuable insight into the real-world of medical errors and a better understanding of how they can be prevented through practical, actionable methods.

ABSTRACT Patients’ rights have been formulated in a number of documents and guidelines from vari... more ABSTRACT
Patients’ rights have been formulated in a number of documents and guidelines from various international bodies. Laws and declarations on patients’ rights do not automatically make health care safer, but can help to empower patients. Empowered patients are in a better position to manage their own health and health care and to participate in efforts to improve safety. "e report presents an overview of legal aspects influencing
patient safety and describes examples of patient involvement. It highlights the need to strengthen a continuum of information between various levels of care, including patient experiences, health literacy and engagement. "e work is expected to contribute to the wider process of evidence collation aimed at finding
effeceint ways to build realistic and informed expectations of health care, while encouraging patients to be vigilant and knowledgeable to ensure maximum safety standards. Recommendations are formulated with respect to the macro, meso and micro levels of health service delivery.

This book is the second in a two-volume set of textbooks and focuses on quality improvement and p... more This book is the second in a two-volume set of textbooks and focuses on quality improvement and patient safety, supporting the coverage of outcomes analysis in its sister title. There has been a huge research effort undertaken in pediatric cardiac care to understand and measure what is done, to establish collaborative definitions and tools of measurement, and to determine robust benchmarks and methodologies to analyze
outcomes. This book concentrates on implementation science in terms of continuous quality improvements and safety science and systems.

Pediatric and Congenital Cardiac Care: Volume 2 - Quality Improvement and Patient Safety reveals the remarkable developments that have been seen in the fields of pediatric
cardiology and cardiac surgery. This unique collaboration between four Editors from disparate medical disciplines (cardiac surgery, cardiology, anesthesia, and critical care) incorporates an international community of scholarship with articles by luminaries
and cutting edge thinkers on the current and future status of pediatric and congenital cardiac care. The goal of this and its companion volume is to understand and advance the profession and its activities, to use common terms, and to improve the management of risk and safety in order to enhance pediatric and congenital cardiac care.

This book is the first in a two-volume set of textbooks and focuses on outcomes analysis in pedia... more This book is the first in a two-volume set of textbooks and focuses on outcomes analysis in pediatric cardiac care, supporting the coverage of quality improvement and patient safety in its sister title. There has been a huge research effort undertaken in pediatric and congenital cardiac care to understand and measure what is done, to establish collaborative definitions and tools of measurement, and to determine robust benchmarks
and methodologies to analyze outcomes. This book concentrates on implementation science in terms of continuous quality improvements and safety science and systems.

Pediatric and Congenital Cardiac Care: Volume 1 – Outcomes Analysis reveals the remarkable developments that have been seen in the fields of pediatric cardiology and cardiac surgery. This unique collaboration between four Editors from disparate medical disciplines (cardiac surgery, cardiology, anesthesia, and critical care) incorporates an international community of scholarship with articles by luminaries and cutting edge thinkers on the current and future status of pediatric and congenital cardiac care. The goal of this and its companion volume is to understand and advance the profession and its activities, to use
common terms, and to improve the management of risk and safety in order to enhance pediatric and congenital cardiac care.

Vol. 38 International Anesthesiology Clinics

Third expert panel perspective on important and urgent issues in perioperative patient safety

JBara Innovations was contracted by Sydney IVF (SIVF) to address a perceived need to improve the ... more JBara Innovations was contracted by Sydney IVF (SIVF) to address a perceived need to improve the efforts around improving safety and quality of care. We present a comprehensive quality improvement and risk management programme that centers on the laboratory as a whole and as part of the clinical microsystem. Our methods targeted areas for improvement which feed directly into recommended interventions and supports innovative practices. Our combined sources of information allowed us to target problem areas at both the systemic and cultural levels with a particular emphasis on improving professional and business alignments that lead to errors and poor quality outcomes. Finally, attempts to redesign the SIVF service model will be informed by bringing the patient’s voice back into the center of the all activities of the SIVF microsystem.
The goals of the project were to:
• Identify the role of the patient at SIVF using process mapping and analysis of available sources of data
• Consult with patients about their experience and inform SIVF of strengths and areas in need of improvement
• Examine staff attitudes, organizational policies and HR documents towards work practices, safety, communication and staff welfare using survey and interview tools
• Identify the learning culture at SIVF around reporting of non-routine events and patient harm.
• Develop and deliver a training program that focuses on recognizing the patient as the center of the IVF process
The goals will be accomplished in three phases:
Phase I: Pre-intervention assessment and data collection Phase II: Intervention design based on Phase I
Phase III: Re-evaluation after the interventions.
Phase I is complete and this report summarizes the results from Phase I and sets the stage for Phases II, the training phase. The data indicate that there are many positive aspects of Sydney IVF which include:
• A strong reputation for the highest quality IVF treatment
• An internationally recognized track record for innovation and pioneering IVF techniques
• High levels of staff loyalty and pride in the company’s achievements
• A strong culture of continuous improvement and change readiness
• A commitment to personalized patient centred care.

The results from Phase I of the project indicate there is vibrant strategic plan but that at times execution lags. There is scope for improvement helping Sydney IVF maintain their strong brand and manage their risks more astutely. Sydney IVF needs to protect it’s free thinking and creative behaviors that launched them on their journey to market leadership. Combining innovation and scale is a pressing challenge and will require hiring creatively throughout the organization while adopting more integrated ways to manage risk not just collect risk information.
For SIVF’s growth a structured process is critical for innovation to scale through all departments in the company. Innovation has to be sponsored and strongly supported by management. The recommendations provide a platform for future efforts to improve the resilience and enhance the brand and safety of care provided by Sydney IVF.

In the quest to improve healthcare, increasing attention is being paid to gaining control over qu... more In the quest to improve healthcare, increasing attention is being paid to gaining control over quality, by making care safe, effective, timely and centered on patient needs. Payers, regulators and governments are also seeking evidence of safe, high- quality care, yet reporting that paints a meaningful picture that is open to sector-wide comparison does not yet exist.

This report shows that a relentless focus on accurately reported outcomes of care is the critical glue that can bring together patients, professionals,
providers and those paying for and regulating care.

Neurotrauma is one of our most dramatic and devastating causes of major disability and life long ... more Neurotrauma is one of our most dramatic and devastating causes of major disability and life long suffering.
The provision of effective, safe and reliable neurotrauma services requires a diverse range of health professionals, services and external agencies. These need co-ordination and collaboration to help overcome a myriad of system challenges such as separate funding, administration, different governance and reporting structures.
There exists the opportunity to reshape service delivery, patient outcomes, efficiencies and enhance collaboration with health care providers through the establishment of a single dedicated Neurotrauma Precinct founded on best practice principles and innovation.
The Neurotrauma precinct would be dedicated to end-to-end treatment from time of injury to well being at home. This continuum includes: retrieval, acute care, rehabilitation, community transition, and re-socialization focusing on social and economic participation of people who have sustained a major traumatic brain injury or spinal cord injury (“neurotrauma”).
In the face of health reform and increased devolution of responsibilities, specialist statewide services in particular low incidence areas such as neurotrauma can deliver excellent outcomes, which are not financially feasible without a carefully designed system based around specialist capabilities. The Lifetime Care and Support Authority (LTSCA) has the required infrastructure and governance to ensure that efforts to improve the system support each and every person who sustains a major traumatic brain injury or spinal cord injury, his or her families and care givers at home.
People who sustain neurotrauma currently have suboptimal outcomes in NSW. The Spinal Cord Injury and Brain Injury Directorates both suffer from a lack of strategic support and a service delivery framework which has been the victim of funding constraints and a lack of a focus on the entire injury-recovery continuum in recent years.
Best practice outcomes for people who have sustained neurotrauma are achieved by dedicated, specialist centres that combine fast retrieval, acute care and sustained, coordinated rehabilitation care. These centres may include surgery and intensive care where required, linked to inpatient and outpatient rehabilitation and lifetime care and support programs aimed at re-socialisation and re-integration into society.
Remaining patient-centric during major reform while making bold steps towards accountability and transparency will ensure NSW remains a leader in overseeing delivery of care in the nation.

The Lifetime Care and Support Authority (LTCSA) through the Lifetime Care and Support Scheme (LTC... more The Lifetime Care and Support Authority (LTCSA) through the Lifetime Care and Support Scheme (LTCSS) provides treatment, rehabilitation and attendant care services to severely injured people in motor accidents in NSW, regardless of who is at fault in causing the accident.

People eligible for the Scheme will have suffered a spinal cord injury, moderate to severe brain injury, multiple amputations, severe burns, or will be blind as a result of the accident. The majority of the participants to the scheme have catastrophic neurological injury (ie. Severe spinal cord or brain injury).

Catastrophic neurological injury represents a major cost in respect to healthcare, equipment and environment modifications, long term care costs, and in terms of productivity losses.

Key Issues and Challenges

Key issues and challenges with the current system include:
1. Funding, Governance & Service Arrangements
a) Services are fragmented across the continuum of care. They are episodic and segregated by organisational boundaries. Aligning this system to delivering high quality life long outcomes requires substantial navigation and negotiation by both participants and those delivering care and support.
b) There is a lack of clarity/accountability concerning how funds are used.
c) There are limited agreed standards and performance measures
concerning delivery of a service and the effectiveness of the service.
2. Organisation Arrangements
a) Delivery of acute services is arranged across several major trauma centres. This arrangement impedes learning and improvement and creates difficulties in achieving minimal service volumes.
b) Care tends to be organised around a narrowly focused episode rather than the end to end journey. This means there is lack of continuity as the patient moves across the continuum of care.
c) Services in the community are fragmented and often inadequate. This is causing blockages within the inpatient facilities and limiting access to patients needing care.
d) The specialist trauma workforce is currently limited, and specialised trauma training is not as expansive as other jurisdictions and specialties.
3. Processes
a) There is variability and differences in services and practices.
b) Where protocols and standards do exist, there is lack of robust process to monitor compliance and to systematically revise protocols and standards.
c) The system is linear and applies a “one size fits all” paradigm of care. It tends to lose focus on lifetime outcomes, and doesn’t easily permit entry and access according to the needs of different patients.
4. Data & Outcomes
a) Lack of evidence and information relating to the optimal methods to provide care and services to neurologically injured patients.
b) Data that does exist tends to be limited to a particular organisation, administratively focused, and is insufficient for understanding system performance and outcomes.
c) Inadequate process and governance arrangements for seeing the findings from research implemented into practice.

Key Opportunities
Changes are required to the current system in order to deliver improved life time out comes for patients with catastrophic neurological injury. This needs to occur within the context of health reform, industry trends, and broader technology and management changes and practices.
Of particular relevance are:
a) National efficient pricing and performance measures tied to funding is expected to be developed as part of National Health Reform. Over time it is expected that this mechanism will move to a more outcome based funding model.
b) Proposed National Injury Insurance Scheme will increase the scale and make it more economically feasible to orient services to improve lifetime outcomes for patients with catastrophic neurological injury.
c) NSW Health policy has recommended further concentration of trauma services, development of specialist skills and workforce, and embedding continuous quality and safety improvement in the health system.
d) Technology, industry changes, and clinical innovations enable care and services to be delivered in a more accessible and cost effective way.

Patient safety and patient centred quality have emerged as key drivers in healthcare reform. The ... more Patient safety and patient centred quality have emerged as key drivers in
healthcare reform. The framework of health care delivery is shifting rapidly across Australia given growing calls for radical change and cost containment. Things have changed since early days; safety and quality benchmarks are often integrated into strategic goals and there is more focus on patient-centered care. Patients, however, still experience needless harm and often struggle to have their voices heard, processes are not as efficient as they could be, and costs continue to rise at alarming rates while quality flat lines. The systems that will thrive will focus on cost efficiency, quality of care, innovative health care delivery, and alignment of incentives with payers, patients, and other participants in the health care equation.
Australia is undergoing the largest single period of new healthcare facility procurement in its history.

The combined force of the NSW Health/Australian reforms and workforce and financial pressures against a backdrop of rising demand, increasing complexity and changes in demographics, means the delivery of health care in the current configuration cannot be sustained. NSW is being ''overwhelmed'' by rising healthcare costs with nearly 30% of the state budget expended in the delivery of healthcare. NSW Treasury estimates that total spending over the next 20 years will exceed 55 per cent of the state budget.

A radical re-think is required to devise new ways of procuring healthcare facilities. Despite unprecedented levels of capital spending on health infrastructure, the facilities planning process and its design outcomes continue to frustrate patients, providers and communities. Without reform, NSW's ability to maintain the high level of service currently provided will be compromised.

There is a window of opportunity to change the face of NSW health care very significantly, opened by the National Health & Hospitals Reform, the Special Commission of Inquiry into Acute Care in NSW Public Hospitals (Garling Commission) and the system-wide response: Caring Together - the Health Action Plan for NSW, and strategies to address the variation in clinical services and outcomes across NSW. However, engaging and partnering with clinicians remains one of the biggest obstacles in addressing the growing implementation gap in providing cost-effective and quality care in NSW.

JBara Innovations was contracted by NSW Health Infrastructure (HI) to develop a quality improvement project that would provide coherent, evidence-based clinical input into the planning and development of healthcare facilities in NSW and inform Health Infrastructure of apparent strengths and opportunities for improvement..

The goals of the project were to:
• Identify evidence-based best practice in mental health facility design, in regard to fitness-for-purpose and effectiveness in delivering care.
• Identify the perceived role and impact of Health Infrastructure (HI) on the efficiency and effectiveness of mental healthcare facilities procurement in NSW.
• Consult with Mental Health Units in New South Wales, the NSW Ministry of Health (MOH), and planning & design professionals about their experience with Health Infrastructure.
• Examine staff attitudes and organizational policies in regard to the current planning and procurement process in NSW.
• Prepare an environmental scan of current practices to identify issues and gaps in the planning process, deficiencies in current roles and responsibilities, and options for improvement and change.

Since 2007, Health Infrastructure has been responsible for health facility project planning, direction, management and commissioning. Historically, the procurement process has not always been smooth with a growing trust gap between stakeholders and the former NSW Department of Health. HI’s efforts to build trust and credibility have been complicated by the cautious attitudes held by clinicians, contractors and communities toward the Department1,2. The restructure announced by the new Director General of Health, Dr Mary Foley, on 24th August 2011 acknowledged HI’s core role in the planning of health facilities in the state and emphasized the need for
1 Despite the devolution of Area Health Services into Local Health District, Area names are generally retained in this Report, as all sites visited were commissioned under the Area framework. The organizational structure of the delivery system does not alter the recommendations of the Report, although it may make responsiveness to those recommendations more feasible. Local Health Districts are referred to in the recommendations.

Poor communication between stakeholders led to a twelve week closure of the Hornsby Mental Health Intensive Care Unit for retrofitting, at a cost of half a million dollars and negative local media:Hornsby and Upper North Shore Advocate: May 13, 20 2010; October 13, 14, 16 2008.
Health Infrastructure Quality Improvement Project HI to “address concerns about stakeholder management, particularly clinical engagement, responsiveness and cost and budgetary transparency.”

The challenge was to devise and implement the change. HI had been aware of the challenges, and prior to the release of the Director General’s report had commissioned JBara Innovations to identify opportunities to improve the process and engagement of stakeholders. Implementation of the ten recommendations that arise from this study will support a collegiate and productive process in the procurement of high value, safe, functional and therapeutic healthcare facilities in NSW.

This Report includes an extensive literature review, key informant interviews, site visits, a review of project documentation and reports focused on the process of mental health facility procurement in NSW. The literature suggests that the built and natural environments exert a range of impacts on patients and staff.

The data indicates that change should target both the systemic and cultural levels, with a particular emphasis on improving professional and business alignments that lead to project delays, budget overruns and political remonstrations. Effective redesign and improvement of the HI service model will involve bringing the voices of the many stakeholders into a shared dialogue with HI.

The data indicate that Health Infrastructure’s work and leadership is perceived in a positive manner, and it is particularly noted for:
• being a learning organization, actively changing procedures and methods on the basis of experience and reflection
• a strong reputation for leadership
• a recognized track record for innovation and pioneering health facility
procurement techniques
• high levels of staff loyalty and pride in achievements
• a strong culture of continuous improvement and change readiness

The data also indicate some scope for HI to more effectively refine its governance model, manage its risks, and appreciate the impact of its decisions on the level and NSW Government. Future arrangements for type of clinical risks in the system.4 Upstream ‘latent factors’ enable, condition, or exacerbate the potential for ‘active errors’ and patient harm.

Understanding the characteristics of a safe, resilient and high performing system requires research to optimize the relationship between people, tasks and dynamic environments. The socio-technical perspective incorporates the concept of latent conditions whereby the cascading nature of human error is understood as beginning with the decisions and actions of management; including decisions made during planning, design and procurement of health facilities. Identified risks were particularly associated with: the rapid churn in the formal membership of decision making bodies; frequently disrupted communication processes; an overly lengthy time horizon between development of the Clinical Services Plan (CSP) and Procurement Implementation (PI); fast tracking of service planning processes to meet dominant stakeholder agendas; limited health facility planning expertise inside the organization; and use of negotiated guidelines as project control tools, instead of tools to engage users and providers in a structured dialogue during planning and design.

The Report sets out the key initiatives of an integrated quality improvement strategy that HI should consider incorporating into the scheduled program of capital works, currently valued in excess of one billion dollars. Although the study focuses on mental healthcare facilities, the findings we believe are applicable to all healthcare settings in NSW.

The project recommendations provide a platform to enhance the adaptability of the process of planning to particular circumstances, and to improve the design and procurement of NSW health facilities.

BUILDING THE SCIENTIFIC MIND, LEARNING IN THE PERSPECTIVE OF COMPLEX AND LONG-TERM CHANGE VANCOUV... more BUILDING THE SCIENTIFIC MIND, LEARNING IN THE PERSPECTIVE OF COMPLEX AND LONG-TERM CHANGE
VANCOUVER, BC, CANADA MAY 28-31, 2007
Prepared by Jan Visser in collaboration with Paul Barach, John van Breda and Yusra Laila Visser Eyragues, France : August 13, 2007

BUILDING THE SCIENTIFIC MIND LEARNING IN THE PERSPECTIVE OF COMPLEX AND LONG-TERM CHANGE VANCOUVE... more BUILDING THE SCIENTIFIC MIND LEARNING IN THE PERSPECTIVE OF COMPLEX AND LONG-TERM CHANGE
VANCOUVER, BC, CANADA MAY 28-31, 2007
Prepared by Jan Visser in collaboration with Paul Barach, John van Breda and Yusra Laila Visser Eyragues, France : August 13, 2007

Executive Summary--working with Booz Allen § As part of the establishment of the integrated tra... more Executive Summary--working with Booz Allen
§ As part of the establishment of the integrated transport authority (TfNSW), it was determined that the CRS (excluding Crashlab) would move from RMS to TfNSW given the preponderance of strategy and policy type functions within CRS
§ A Review has been undertaken subsequent to the decision to move CRS to determine whether all existing functions should remain in an integrated unit within the Policy & Regulation Division (PRD), or whether some other structural model would be more appropriate
§ The Review has determined that there is a strong case for change, specifically:
– With the realignment of responsibilities, accountabilities and capabilities between TfNSW and RMS, there is a case to separate “strategy, policy &
R&D” functions from “program management & delivery” functions
– The benefits expected from the 2008 CRS restructure have not been fully realised – in particular, there are opportunities to improve strategic focus, community acceptance of policy innovations and the Centre’s influence and collaboration
– Internal and external transport stakeholders indicated a decline in the level of confidence in CRS, and are concerned about its method of operation
– While NSW has achieved improvements in road safety outcomes in line with other States, they lag international leaders by a considerable margin
§ The Steering Committee has endorsed a future model for road safety that has a lean strategy, policy and R&D unit in PRD, and that has a greater
focus on community consultation and engagement. Remaining functions should be distributed to more appropriate divisions within TfNSW and RMS
§ The proposed structure for the road safety branch in PRD has 53 permanent positions – some of the positions would be considered “new” or “major change” from the current CRS structure. Under the proposed structure it is estimated that:
– 20 positions are potential surplus – 9 of these are vacant, 4 are administrative roles, 7 others – 10 positions are performing functions that are more aligned to TSD or PPD
– 5 positions are performing functions that are more aligned to RMS
§ Key next steps include (i) endorse functional model and organisation structure for PRD, (ii) agree location of residual functions, (iii) agree governance model with clear statement of accountabilities, (iv) commence people transition process

EXECUTIVE SUMMARY Healthcare is in a crisis that is fuellin... more EXECUTIVE SUMMARY

Healthcare is in a crisis that is fuelling dramatic reform in North Carolina while the framework of health care delivery is shifting rapidly across the US. The systems that will thrive will focus on cost efficiency, quality of care, innovative health care delivery and sustained clinician engagement.

In December 2013, AccessCare requested a proposal to identify opportunities to increase its efficiency and effectiveness in delivering healthcare services along with prioritizing next steps. Cirra (teaming up with Sterling Enterprises International and J Bara Innovation) propoed using a multi-phased approach consisting of Assessment – Discovery – Action – Manage – Sustain (ADAMS). AccessCare agreed to fund the Assessment and Discovery portions of the ADAMS approach as Phase 1 of ADAMS. AccessCare agreeing with the proposal requested that Cirra include Community Care of Wake and Johnston Counties (Wake-Johnston) along with Community Care of the Sandhills (Sandhills) as participants in Phase 1.

Phase 1 was launched on February 10 with a joint meeting held at AC offices. On May 29 an all day Discovery Workshop with AC, Wake-Johnston, and Sandhills clinical leaders, participating at AccessCare offices was held to conclude Phase 1.

The outcomes of the Discovery Workshop included:
1. Identification of strengths and weaknesses for each of the 3 networks.
2. Identification of near term (i.e., 6 months or less) actions, mid term (i.e., 18 months or less), and long term (i.e., 1 – 3 years) actions for each of the 3 networks.
3. Identification of near term, mid term, and long term actions common to all 3 networks.

Accompanying this Executive Summary is an Appendix. The Appendix summarizes the activities leading up to the Discovery Workshop and the outcomes from that Workshop which provide a foundation for launching Phase 2 of ADAMS. Phase 2 emphasizes capitalizing on the strengths identified, mitigating the weaknesses, prioritizing resourcing, and insuring a process that will deliver the Action, Manage, and Sustain portion of ADAMS.
An outcome of the Discovery Workshop was the determination that there are 6 primary initiatives that are common across the 3 networks participating that we recommend should be target areas for addressing in Phase 2 (Action-Manage-Sustain).

The 5 initiatives are:
1. Strategic Planning
2. Brand Management
3. Integrated Communications Plan
4. Performance Improvement, Monitoring, and Reporting
5. Information Services

It has long been recognized that medical care itself has the potential to cause harm.2 However, g... more It has long been recognized that medical care itself has the potential to cause harm.2 However, general acknowledgement that much iatrogenic injury may be due to preventable human error or system failure appears to have been slow in the coming. Healthcare is a risky business. Simply being in an acute hospital in Massachusetts carries, on average, a 200-fold greater risk of dying from the care process than being in traffic, and a 2000-fold greater risk than working in a chemical industry, or flying on a plane.

In November 1999, the Institute of Medicine (IOM) published a landmark report entitled “To Err is Human: Building a Safer Health System.” Produced by the IOM’s Committee on Quality of Health Care in America, the report estimated that 44,000 to 98,000 Americans die in hospitals each year as a result of medical errors. Nonfatal “adverse events” (injuries caused by medical management rather than by the underlying condition of the patient) are ten- hundredfold more numerous than deaths due to errors. The IOM Report estimated that total national costs for adverse events (lost income, lost household production, disability, health care costs) are between 38billionand38 billion and 38billionand50 billion annually. Based on the IOM Report and assuming similar care, in Massachusetts we can expect between 1000 and 2000 preventable deaths a year.

Release of the IOM Report generated enormous coverage in the media, and intense focus on this issue has continued unabated. There is substantial evidence that the majority of health care errors are preventable, and are the result of systemic problems rather than poor performance by individual providers. Proposals have surfaced in Congress and from the White House to
implement the IOM’s recommendations, and several bipartisan-supported Congressional hearings have fueled discussion and debate on the subject.

In Massachusetts, where much of the work in patient safety has been pioneered, there is proposed legislation which includes a near miss reporting system, changes in mandated reporting systems and the creation of a new state agency to coordinate and support patient safety efforts and research. It also calls for confidentiality protection to encourage sharing of sensitive data. It is vital that all stakeholders, government, the professions, healthcare administrators, industry and consumers be involved at all stages and that mechanisms for ongoing, effective consultation and communication be provided at local and state levels.

There are ethical, humanitarian, and financial imperatives to find out what is going wrong, to collate, and analyze the information, and to devise and implement strategies to better detect, manage, and prevent these problems. Despite clear policy guidance and compelling ethical rationale, which support disclosure of adverse events, there are legal, regulatory and cultural barriers that perpetuate the current situation. Patients and families sometimes are not being told about adverse events that have led to bad outcomes or injuries.

This report concludes with a set of recommendations that encourages open debate on patient safety initiatives in Massachusetts. The Commonwealth can help create a culture of safety. If the fear of litigation continues to countervail the efforts to improve patient safety, transformation from the present unsatisfactory situation into a culture promoting safety for our patients may never be fully realized.

The following discussion is intended to provide background from a number of perspectives on the impact of the role of the state on patient safety. Several options for state level action in Massachusetts are presented. These include:
• Recommendation 1: Create and endow a Patient Safety Center for the Commonwealth
• Recommendation 2: Structure a leadership vehicle for the future development of patient safety programs
• Recommendation 3: Mandatory adoption of error prevention strategies
• Recommendation 4: Implement Incident Reporting
Recommendation 5: Provide and ensure appropriate confidentiality protection
• Recommendation 6: Study alternatives to the current medical liability and accountability systems

When a patient’s transition from the hospital to home is less than optimal, the repercussions can... more When a patient’s transition from the hospital to home is less than optimal, the repercussions can be far-reaching – hospital readmission, adverse medical events, and even mortality (www.handover.eu). This discontinuity of care (i.e., the responsibility for the patient is handed over from one caregiver to another) can lead, if not acted upon properly, to severe adverse events to the patient and enhanced costs to the system. Deliverable 12 is the final report of workpackage 7 and the last deliverable of the European FP7 project.

Education Sciences , 2021