Kaiser Permanente:
A Journey in
In-Situ Medical Simulation
Stanford University, 2008
Paul Preston, MD
Permanente Medical Group
Regional Safety Educator
Thanks for the Invitation!
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Without your leadership, we wouldn’t have a
program
You keep sending us great people who ask
for this
I hope we can deliver
Ever bring coals to Newcastle?
Agenda
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Simulation - its role in safe, reliable care
Simulation outside of Kaiser Permanente
Adapting Simulation to Kaiser Permanente
How this is relating to our other systemic goals
How we may be able to measure this (Help!)
Our vision for the future
Have fun!
The Start of a Journey
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“What you need here is a Doctor who thinks like an Engineer”
“Sometimes I wonder if we’re training exotic fish then putting
them into the same polluted pond”
Why is he wearing a tie?
Kaiser Permanente Program
Founded: 1945
Largest non-profit
HMO
8.3 million
members
Headquarters
Oakland, CA
Northwest
Region
Northern
California
Southern
California
30 hospitals
431 medical offices
Colorado
Region
Ohio
MidRegion Atlantic
Region
Georgia
Region
Hawaii
Region
141,909 employees, 12,012 physicians
Accident Causation
Latent
Failures
Defenses
Modified from Reason, 1990
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Core Mission- Prepaid, Non-Profit, Comprehensive Healthcare
Great Health Maintenance, “World Class Hospitals”
NOT Research, Teaching, Cutting Edge
Interesting History- Why does Kaiser have hospitals?
Sim Champion Building Support....
The Latest Crisis
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Report criticizes Kaiser for lack of action
• Federal inspectors fault its Fresno hospital's response to
complaints about a doctor who allegedly fatally botched two
deliveries.
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CARMICHAEL, Calif. -- A Kaiser Permanente plastic surgeon
remained in jail Wednesday accused of inappropriate sexual
contact with his patients and keeping a cache of weapons at his
Carmichael home, police reported.
• Sacramento County Sheriff's Department officials went to the home
of ... looking for evidence of alleged sex crimes.
• But officials found a rocket-propelled grenade and at least five
machine guns at the Empire Court residence, said R.L. Davis,
spokesman for the sheriff's department.
Other High Priority (and worthwhile) initiatives
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Electronic Medical Record- $4 Billion- data potential?
New and seismic facilities
Service and access goals
Efficient throughput, well designed facilities
Mandate to ensure and oversee competencies of providers
Multiple efforts to teach CRM and Human Factors in multiple
settings
• Some question about how to get these behaviors to take root
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Domain based safety initiatives
• Perinatal Safety
• Med/Surg Rescue
• Surgical Team Communications
Life on Med/Surg Ward
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How often is there a process failure?
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Every 70 minutes
94% of these, RN tries to work around
6% of these the problem is reported
? How often it is fixed
This is deeply programmed into healthcare providers
The Problem is NOT careless people messing up a perfect
system….
Journey So Far….
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Several Stages of Denial-Acceptance-Action
Better understanding of the problem
• Systems
• Communications
• Fundamental skill and judgment deficits
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What Do We REALLY Need To Do to become Reliable?
• Consistent, reliable processes for the things we can anticipate
• (Highly Reliable Surgical Team Briefings, Pure CRM)
• Anticipate, detect and manage the unexpected
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By the way, we better get some data to show
• Frequency and cost of harm
• Progress
Deming’s Lenses for Simulation
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System
• Great Probe for systemic learning
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Psychology
• Works very well for frontline
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Data
• Excellent PDSA... Less well established for
systems
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Variation
Recent Sim Observations....
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It Works!
It Works Better if Everyone Actually Does It!!
Amazing growth in the field
It addresses safety and competency issues that we can’t
get to otherwise, and this matters to KP
It will be required?!?
It only takes 3 days to do this
It doesn’t have to be super hi tech
We have unique opportunities in KP
Simulation- How do we answer these questions?
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How many times have you done this before?
Do You have to manage emergencies?
Do your teams have to manage emergencies?
Do you practice as teams for these emergencies?
Do you routinely debrief your drills and your real
events?
Would you learn from a near miss? Would your
systems change?
What Is Our Aim at Kaiser?
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If mistakes happen (and they will) we can trap them by working
together as a Team
We can build systems that are safer
Everyone becomes the expert on Safety
We cannot become error free, but we can create a system that
is harm free- and this will require testing of systems and training
of providers
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Error Reduction and Trapping
A Cultural Change
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Ask for help when overloaded
Get a second opinion when in doubt.
Honor others who call for help
• Wisdom, not weakness
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It is more important for my patient to do well
than for me to look slick
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Simulation – its role in
providing safe reliable care
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Improve patient safety without endangering actual
patients and to practice high risk, low volume
situations where error is more likely to occur
Practice without risk, curricular standardization, and
pedagogic efficiency
Imitates reality, offers almost limitless opportunities
to have things “go wrong,” and provides corrective
feedback as a guide to future action
Migrate the basic training of hazardous procedures
from the patient until skill is attained
Address skills, communication issues that will not be
fixed (and may get worse) with automation
Simulation – its role in
providing safe reliable care
How do we do this better?
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Appreciate that highly skilled people, trying hard to do
the “right thing”, will make mistakes in complex
environments – how do we manage those errors and
keep everyone safe?
Shift our focus from “who did it” to “how do fix it so
the same problem will not reoccur?”
Create an environment of psychological safety –
where everyone and anyone feels comfortable to
raise a concern
NEVER assume safety, always take a minute to
assure it
Simulation – its role in
providing safe reliable care
Proven Training Techniques: Human Factors
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Skills that build teams, improve
communication, reduce and trap the errors
that will always occur
• Briefings, Assertion, Situational Awareness
Very trainable
Measurable
• Reduce accidents
• Improve Staff Retention
Causes of accidents in
medicine
70% due to Human Factors (preventable?)
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Not lack of medical knowledge
But problems with transferring theoretical
knowledge into actions under the real world
conditions of a hospital setting
Problems with complexity
Team, Communication
Perinatal Patient Safety Project
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Focus
• Human factors training
• Multidisciplinary team for problem solving
–Recurring clinical problems
–Recurring organizational systems
problems
• Just Culture statement
• Provider and staff support
• Transfer successful practices
• Critical Events Team Training (CETT)
Reoccurring Clinical Problems*
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Inability to recognize and respond to fetal distress,
Inability to effect timely cesarean birth for fetal
distress,
Inability to resuscitate a depressed infant,
Inappropriate use of pitocin, leading to uterine
hyperstimulation, uterine rupture, & fetal distress.
Inappropriate use of forceps / vacuum leading to
fetal trauma and shoulder dystocia.
“If you get these things right, you eliminate 80% of perinatal liability
claims”- Eric Knox
*MMI Company data of 250 hospitals over 10 years
High Reliability Organization
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Safety is the highest priority
Preoccupation with what could fail
Open environment to discuss error
Everyone encouraged to speak up about
hazards
Rewards for safe actions
Training for hazardous situations
• What high risk industry would expect great
team performance, free of errors, without
practice?
Simulation
Training
Can Simulation Help Us
become Harm Free?
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Team based emergency Fetal Heart Rate and
emergency training- entire care team
Apgars less than or equal to 6 at 5 minutes:
86.6 /10,000 births to 44.6 /10,000 births
Hypoxic encephalopathy: 27.3 /10,000 births
to 13.6/10,000 live births
70% reduction in brachial plexus injuries with
shoulder dystocia
– Draycott, T. et. al., BJOG: 2006, 2007
Patient Safety Program/simulation
started in Perinatal
Roll out dates by KP Region
Q1
2004
Q1
2006
Q2 2005
Q2
2003
Q3
2005
Q1
2004
Q3 2006
Q3 2004
More on Kaiser
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Risk data as driver of simulation
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Remarkable front line support
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Systems approach
• Training of entire team, in situ
• Probe for systems weakness, strengths
• Linkage to operations
Unique to Kaiser –
just this month
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Roseville- 30 new trainers, plan to test new
Mom/Baby facility before opening
Used to test new facilities, services
• Cardiac Cath Lab and North Valley
• Santa Clara- exhaustive testing of new
cardiac cath and surgical capabilities
“ I couldn’t believe how much we found on
the first day, and how much better we
look now”.
Roseville: Recent Critical
Events Training
Santa Clara: Recent Critical
Events Training
Unique to Kaiser –
just this month
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Sim Demonstration to Board of Directors
• A Pilot is one of our Directors
• Sudden VFib arrest, in the Boardroom
• “You can’t die now, we have Valentine’s dinner
reservations....”
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Sim at 60th TPMG Anniversary
Working Simulation into future inpatient EMR
deployment
Best Practice Learned from
CETT: Team Roles & Positions
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Airway Manager:
Anesthesiologist/CRNA
2
Airway Assistant: RT
draw ABGs
6 Chest compressions
7
3 Bedside
Nurse/Floor RN
Procedure MD
briefs team, IV, labs,
dispense items, CPR
chest tubes, ABG’s, etc.
4 Critical Care RN
prepare
drugs, defib., ID
& monitor rhythm
8 Recorder RN
5 Team Leader
Back
BackCounter/Cupboards
Counter/Cupboards
RN #3
Back
Table
RN #1
RN #2
OR
Table
Anesthesia
OR 1
Some Considerations at Kaiser
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We loved (and have greatly benefited from) what YOU and
colleagues were doing
Multidisciplinary- target the entire team
• Single discipline efforts less likely to be funded or change the
culture
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Tight linkage to organizational needs
• Places where communication, lack of training lead to measured
harm
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Align with other efforts
• CRM, Human Factors for Routine Communications
Some Considerations at Kaiser
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Limited Resources
• Work In Situ, no dedicated lab
• Intermediate Fidelity of Simulation Gear, but
• Great fidelity of environment
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Not the “final validation” study of simulation
as a modality
“Fix the Problem” using a lot of interventions
at once
Critical Event Team Training ( CETT)
Training Strategy
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Training on:
• Human factors and team skills
• Reality and types of Human Errors
• Orientation to Simulator
Intermediate fidelity, in-situ simulation training
• Actual occurrences used as basis for scenarios
• Focus on apparent weaknesses in our system
• Situations where assessment, communication are
important
Blame free, confidential training
Other Key Crisis
Management Skills
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Declaring emergency:
• Early
• Clearly
Leadership, optimal team structure
Attention allocation
Task prioritization and distribution
Effective, efficient resource use
Clear orders, cross check and
verification
Make Routine Debriefing Part of Team
Culture
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Look at routine and critical operations every day
Recognize how regular debriefing is key to unit safety
Practice skills on the CETT day
Learn a constructive, blame free approach
This is working in Crash Cesareans, Rapid Response,
shoulder dystocias- structured tools are being
developed to capture and report data
Link to Operations, Other Efforts
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Start with human factors
Build a multidisciplinary team
• Charged to improve their unit
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Train entire teams
• All providers and staff + a few confederates
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Experienced providers
Direct linkage to unit leaders
• Purpose: Find and fix system problems- The Unit Manager records the
debriefings
CRITICAL EVENT DRILLS:
What are they?
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Lifelike
Real time
Normal noise - confusion - resources
Situation must be diagnosed and managed by team exactly as in
real life
You will be doing your usual job at all times
Variety
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Rare and common scenarios
Long and short
Fast or slow evolving
Everyone has a key role
• But not in every scenario!
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Confederates as family, patients
Carpet pad, pea soup as low tech aids
• Cover this in briefing….
• Actual environment REALLY adds credibility
How To Look Great (and
rescue your patients)
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Optimum Location, people and equipment
Brief the Team
Know the environment, clearly delegate tasks
Clear Leader- (This may change!)
Regain Situational Awareness
• Chaos is Never OK
Future Vision
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Expansion into other clinical departments
• Highly Reliable Surgical Team and Reliable
Emergency Departments
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2008 National Quality and Brand Conference
• Simulation Minicourse and KP Medical Simulation
kick-off
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Simulation available, funded and required
throughout career
Future Vision- continued
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Link performance improvement with simulation
activities
Kaiser Simulation Collaborative
• Network/collaborative of simulation experts
and users
Toolkit to support simulation implementation
within Kaiser
• Library of simulation scenarios
Data...
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What is our aim?
How will we know the change is an improvement?
What will we try?
Our IDEAL Data Set
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About 8 measures
• 2 outcome, 5 process, 1-2 balancing
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Improvement and Accountability
Run over time, rapid cycle, feedback to front line teams and
leadership
Sustainable- forever!
Anyone can see how we are doing
What Might We Have In Perinatal?
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Outcome
• Med Mal- Has Limits, but CAN strongly argue for Simulation
– We seem to be gaining ground here...
• Physiologic Intermediate Data
• Complications- Bleeding, brachial plexus injury, encephalopathy,
infection, Retained Objects, Infxn
• Current Benchmarks- C/S rate, 3d degree laceration, infant death,
VBAC- why these?
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Process
• Trigger Tools Concepts- Ascension, IHI, AHRQ, AOI scores-ADT, labs,
pharmacy-Higher Capture than Reporting!
• General Anesthesia
• IHI type bundles- compliance with these
– Induction: EGA, Pelvimetry, FHR (NICHD), hyperstim
What Might We Have In Perinatal?
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Process
• FHR Documentation/ Review/Action/Training
• Evidence Based Training Programs
– Instrumental, Shoulder Dystocia, Stat C/S
Selected Chart Reviews, timing of Stat C/S
– Human Factors, Safety Attitude Surveys
• Active Safety Team, Board Rounds
• Surgical Counts, Briefings
– Observational Data
• Time on divert, cancelled inductions
• Systems Problems Found and Fixed
• Glitch Book Data
Process Measure Results
Sponge Count Audits
100%
95%
Compliance Percentages
90%
85%
Performed Correctly
80%
75%
Team Count
70%
Sweep Completed
65%
60%
Documentation
Completed
55%
50%
45%
40%
35%
May June July
Aug
Sep
Oct
Nov
Dec
Perinatal- Balancing?
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Care Experience
Cesarean Rates!
Timeliness of Cesarean Sections
• Really 2 very different processes
• STAT C/S= Rescue
• Elective C/S= Throughput
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LOS
Staffing
Unique Kaiser Opportunities
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Extraordinary Leadership from National and Regional Riskequipment, time, support
Appreciation for systems- role of simulation in testing
facilities, fixing systemic problems, training new teams,
hospital and tech design
Unified systems
Outcome data that others truly envy
• Which we need to use much more!
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A remarkable cadre of trainers