2012 1 What Does All This Mean? Healthcare

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7/16/2012

What Does All This Mean? Organizing Around 3 Skills for Reliability

Craig Clapper, PE, CMQ/OE Chief Knowledge Officer, Health Performance Improvement

Healthcare Reliability Dictionary Quality

An objective appraisal (from a producer perspective) of safety (protection from harm) and effectiveness

Satisfaction

A subjective appraisal (from a user perspective) of quality > expectations

Value

A subjective appraisal of satisfaction relative to cost and time (to realization).

Reliability

A probability that a system will yield a specified result; expressed as a ratio (0.01 or 1:100 or 1%) or a frequency ( 1 per yr)

© 2012 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Risky

A proposition where effectiveness > potential harm

This material is a proprietary document of Healthcare Performance Improvement LLC. Reproducing, copying, publishing, distributing, presenting, or creating derivative work products based on this material without written permission from Healthcare Performance Improvement is prohibited.

Unsafe

A proposition where potential harm > effectiveness

Hospitals Are Dangerous Arm yourselves accordingly

Death By Numbers 44,000 to 98,000 patient deaths per year from medical errors To Err is Human, Institute of Medicine (1999)

A Lot of Talk Patient safety publications before and after the IOM report, To Err is Human Quality & Safety in Health Care (2006)

“Based on our review of the scant evidence, we believe that preventable medical harm still accounts for more than 100,000 deaths a year… the Centers for Disease Control and Prevention (CDC) estimates that hospital-acquired conditions alone kill 99,000 each year…

In this report, we give the country a failing grade on progress…” Consumers Union (2009)

What Will It Take? Patient Safety Rounds + Address TJC Patient Safety Alerts + Non-Punitive Approach to Reporting + Crew Resource Management + Strategies in Targeted Venues (e.g. bundles to reduce VAP or SSI)

But will this produce significant, sustained reduction in Serious Safety Events and improved Quality across the organization?

The Swiss-Cheese Effect Multiple Barriers - technology, processes, and people - designed to stop active errors (our “defense in depth”) EVENTS of HARM

Active Errors by individuals result in initiating action(s)

PREVENT The Errors

Latent Weaknesses in barriers

DETECT & CORRECT The System Weaknesses Adapted from James Reason, Managing the Risks of Organizational Accidents (1997)

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Influencing Behaviors at the Sharp End Design of

Design of

Policy & Protocol

Culture

Design of

Structure

Design of

Work Processes Design of Technology & Environment

High reliability organizations (HROs) “operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents.”

Behaviors

Managing the Unexpected (Weick & Sutcliffe)

of Individuals & Groups “You have to manage a system. The system doesn't manage itself.”

"A bad system will DEFEAT a good person every time.“

W. Edwards Deming

W. Edwards Deming

Outcomes Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994) © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Risk is a function of probability and consequence. By decreasing the probability of an accident, HRO’s recast a high-risk enterprise as merely a high-consequence enterprise. HROs operate as to make systems ultra-safe.

Optimizing Reliability 10-6 Design to Optimize Human Performance at the point of people interface:  Easy to do the right thing – impossible to do the wrong thing  Intuitive design  Mistake proofing by design (i.e. poka yoke)

10-5 10-4

Reliability Culture

10-3 10-2

Process, Protocol &Technology

10-1

   

Behavior Accountability Human Factors

Process, Protocol &Technology

Safety as the core value Behavior expectations for error prevention Collaborative Interactive Teams Leadership behaviors for reliability

 Resource allocation  Evidence-based practice (e.g. bundles)  Technology enablers

"At the sharp end, there is almost always a discretionary space into  which no system improvement can completely reach. Systems  cannot substitute the responsibility borne by individuals within  that space." Sidney Dekker Just Culture: Balancing Safety & Accountability (2007)

© 2010 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Rules About Data

Published Cases

1. Heisenberg Uncertainty Principle : all data is crap (but some data is more useful than other data)

2. Consumer Reports Effect : all crap data is believed 3. Kitty Litter Effect : dig and you will find lumps

• 89% reduction in 2 years • $ 10 M savings first year • $ 11 M savings second year

(bad data invariably is indicative of a real problem)

4. Kubler-Ross Effect : physicians grieve all bad data 1) 2) 3) 4) 5)

Denial Anger Bargaining Depression Acceptance

• 50% reduction in 18 months • AHA Quest for Quality Award 2004 • TJC Eisenberg Quality Award 2005

“Can Your Nurses Stop a Surgeon?” Hospitals & Health Networks, September 2007

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SSER

Serious Safety Event Rate

Personal Safety Improvements

5 Hospital System – Southern US January 2008- October 2011

(5 hospital system – South Eastern US)

Rolling 12 month Serious Safety Events expressed per 10,000 adjusted patient days 1.00

0.80

78% Reduction SSER across the System in 29 Months 2 Hospitals at Zero Events for over 12 months!

0.60

116 days since last event across the system 0.40

0.20

$600,000

$500,000

Over 300 Serious Injuries prevented 90% reduction in OSHA IIR 

$400,000

$300,000

$100,000

Jul-11

$0 CY 07

CY 08

CY 09

CY 10

Oct-11

Sep-11

Aug-11

Apr-11

Jun-11

May-11

Jan-11

Mar-11

Feb-11

Dec-10

Nov-10

Jul-10

Oct-10

Sep-10

Aug-10

Apr-10

Jun-10

May-10

Jan-10

Mar-10

Feb-10

Dec-09

Nov-09

Jul-09

Oct-09

Sep-09

Aug-09

Apr-09

Jun-09

May-09

Jan-09

Mar-09

Feb-09

Dec-08

Nov-08

Jul-08

Oct-08

Sep-08

Aug-08

Apr-08

Jun-08

May-08

Jan-08

Mar-08

Complementary Strategies Codes Outside the ICU

Over $1, 200,000 saved year to date!

$200,000

Month

0.00 Feb-08

Event Rate

116 days since last event across the system

Workman's Compensation Costs

Monthly Lost Time Claims July 06 - April 2011

Apr-11 Mar-11 Feb-11 Jan-11 Dec-10 Nov-10 Oct-10 Sep-10 Aug-10 Jul-10 Jun-10 May-10 Apr-10 Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 Mar-09 Feb-09 Jan-09 Dec-08 Nov-08 Oct-08 Sep-08 Aug-08 Jul-08 Jun-08 May-08 Apr-08 Mar-08 Feb-08 Jan-08 Dec-07 Nov-07 Oct-07 Sep-07 Aug-07 Jul-07 Jun-07 May-07 Apr-07 Mar-07 Feb-07 Jan-07 Dec-06 Nov-06 Oct-06 Sep-06

20 18 16 14 12 10 8 6 4 2 0

)

78% Reduction SSER across the System in 29 Months 2 Hospitals at Zero Events for over 12 months!

Process Bundle

People Bundle

Surgical Site Infections 4 for VAP Prevention 1. Elevation of the head of the bed to 

Hand Hygiene

Central Line Infections

Culture

               

between 30 and 45 degrees 2. Daily “sedation vacation” and daily  assessment of readiness to extubate 3. Peptic ulcer disease (PUD) prophylaxis 4. Deep venous thrombosis (DVT)  prophylaxis (unless contraindicated)

…and on, and on, and on…

Read More: Community Health Network Reduces Deadly Infections Through Culture of Reliability, American Society for Quality (June 2008)

© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Improving Quality Using High Reliability East Coast System ‐ 8 Hospitals

Finance’s Interest in Safety Multi-Hospital East Coast System

National Data Source: ASHRM Hospital Professional Liability & Physician Liability 2009 Benchmark Analysis

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Reliability Culture - Genius of the AND Safety Focus +

performed as intended consistently over time

= No Harm

Evidence‐Based + Process Bundles

performed as intended consistently over time

= Clinical Excellence

Patient Centered +

performed as intended consistently over time

= “Satisfaction”

RELIABILITY CULTURE “Failure Prevention”

Financial Focus +

performed as intended consistently over time

= Margin

Three Skills

Hierarchy of Reliability Culture

1) WHAT (What is the evidence‐based, best practice?) 5. Human Factors Integration 4.1 Critical Thinking

  

4.2 Collegial Teamwork

Behavior Expectations for

2) HOW (How should a complex system be arranged to do that reliably?)

4. Human Error Prevention Think your way into a new way of acting

Behavior Expectations for 

3. High Reliability Leadership

Challenge: Maintaining urgency for and monitoring change

Knowing  Doing

Research & literature review Benchmarking & collaboratives Positive Deviance

  

Act your way into a new way of thinking Challenge: To re-construct from tactics to principles

2. Knowledge of Reliability “Science”

Human Factors Integration Focus & Simplify protocol Error Proofing

3) CHANGE   

1. Values & Beliefs About Safety & Reliability

(How to make the change happen and stick?)

Behavior-based model Sponsors (imperator), Champions (boosters), and Change Agents Disciplined application of PDCA cycle and plans.

© 2010 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Best Practice? 1. Search first for legal and regulatory 2. Search next for consensus standards

What is Human Factors? 

The science of understanding the properties of human capability (Human Factors Science).



The application of this understanding to the design and development of systems (Human Factors Engineering).



The practice of applying Human Factors Engineering to a system (sometimes referred to as Human Factors Integration).

3. Search next for published best practices and

studies 4. If nothing available, select benchmarking group

and collect data •

Benchmarking group can include sister hospitals, nationally listed top programs, magnet hospitals, other professionally ranked hospitals

•

Positive Deviance

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Processes & Procedures Today

Focus & SimplifyTM Form follows function 

Two columns for novice-to-expert application  



Three columns for multi-actor procedure Sequential action steps written as clear, concise phrases beginning with an action word Cautions and Notes placed before the step to which they apply Job Aids referenced with related action steps



 

How do we transform our work processes and procedure documentation to achieve better outcomes??

Minimizing Policy Burden Safety Critical Less-Critical Task/Activity Task/Activity (High Reliability Required)

Complex Task/Activity

Detailed Procedure with Verbatim Compliance

(Lower Reliability Required)

Guideline Without Verbatim Compliance

“Required Action Steps” for all “Supplemental Guidance” when further information is needed

Laboratory Proficiency Testing 6 department procedures… Job Aid: External Proficiency Testing Checklist E X T E R N A L P R O F IC IE N C Y T E S T IN G F o r ex tern a l p ro f icien c y tes tin g , S en ta ra L ab o rato r y S erv i ces P O C T p ro g r am is en r o lled in th e a p p ro p r iate av a ila b le g r ad e d C A P s u rv e y s o r C A P - ap p ro v ed a ltern ativ e p r o fici en c y tes tin g p ro g ra m s fo r p a tie n t tes tin g p e rfo rm ed . F o r th o s e a n al ytes w h e re g rad e d p ro f icien c y te stin g is n o t a v ailab le , an in te rn a l p ro fic ien c y tes tin g p r o g ram is e s tab lis h ed an d is ex e rcis e d s em i-a n n u a lly. P ro fic ien c y s p ec im en s a re re ceiv e d o n a re gu lar s c h e d u le th ro u g h o u t th e c ale n d ar y ea r. It is th e r es p o n s ib ility o f all s ta ff to a s s u re th at th e s p e cim e n s ar e p r o p er ly s to red w h e n re ce iv ed ; th a t th e d ate o f r ec eip t is in d ica ted o n th e p ap erw o rk ; a n d th at th e P O C T s ta ff is in fo r m ed o f th e a rriv a l o f th e s u rv e y m ate rial. A ll in s tru c tio n s n ee d ed to p e rfo rm th e s u r v e y are in clu d e d w ith ea c h s h ip m en t. S p ec im en s w ill b e d es ig n ate d to a s p e cif ic n u rs in g u n it to e n s u re th at a ll te s tin g p er s o n n el p a rticip ate in th e p ro ficie n c y p ro g ra m . In s o m e in s tan c es d u e to th e la rg e n u m b er o f u n its p e rfo rm in g te s tin g , it m ay b e n ec es s a ry f o r m u ltip le u n its to p e rfo r m th e s am e s u rv e y . In th is ca s e, a s in g le u n it w ill b e d es ig n ate d as th e p rim ar y u n it an d th e ir r es u lts w ill b e s u b m itted to th e p ro v id e r. T h e n ad d itio n a l u n its w ill te s t th e s am p le s an d th o se re s u lts w ill b e retain e d in th e P O C T o ffic e. P ro f icien c y s u r v e y s p ecim e n s ar e to b e h an d le d in th e s a m e m a n n er as p a tie n t s p e cim en s . N o p ro f icien c y tes tin g s p e cim e n s m ay b e re fe rre d to an o th er la b o ra to r y. F o r e ac h an aly te p e rfo rm e d , th e a p p ro p r iate in fo rm a tio n is to b e re co rd ed o n th e P ro fic ien c y S u rv e y In f o rm atio n S h e et. T h e h ea lth ca re p ro f es s io n al p e rfo rm in g th e p ro ficie n c y te s tin g m u s t s ig n th e attes ta tio n s tatem e n t o n th e o r ig in al d o c u m en tatio n th a t v erif ies th at th e s p ec im en s w ere tre ated in th e s a m e m an n e r a s p atie n t s am p le s . T h e res u lts a re tr an s c rib ed an d r ev ie w e d b y th e P O C T S e n io r T e ch n o lo g is t p rio r to s en d in g th e o rig in al f o rm s to th e p ro v id e r. T h e tra n s crib e d re s u lts ar e d o u b le ch eck ed b y o n e o th er p e rs o n . T h e M e d ical D irec to r o r d es ig n e e s ig n s th e fin a l d o c u m en tatio n b e fo r e b e in g m ailed . A ll o rig in al s u r v e y res u lts m u s t b e m ailed /fa x e d to th e p ro v id er w ith in th e tim e f ram e in d ica ted f o r th e an a lyt e. T h e re m u s t n o t b e a n y in ter la b o ra to r y c o m m u n ica tio n o n p ro f ic ien cy tes tin g d a ta b e fo r e r es u lts ar e s u b m itted . C o p ies o f th e re s u lts are file d in th e P O C T o f fic e. T h e re m ain in g s p e cim en s s h o u ld b e s to re d ap p r o p ria tely b as e d o n th e ty p e o f s p ec im en ( fro ze n o r re fr ig er ated ) in th e d e sig n a ted f re ez er o r re fr ig er ato r u n til re s u lts are o b tain ed fr o m th e p ro v id er an d it is d e te rm in ed th at n o fu r th er an a ly s is is n e ce s s a ry . T h e in d iv id u al th a t m a ils th e s u rv e y is re s p o n s ib le f o r m ak in g s u re th at th e s p e cim e n s ar e s to re d p ro p erl y. A p p r o x im ate ly f o u r to s ix w ee k s afte r th e re s u lts are re ce iv ed b y th e p ro v id e r, a s u m m ar y o f r es u lts an d in te rlab o ra to ry co m p aris o n is r etu rn e d to th e lab o ra to r y fo r r ev ie w a n d an y n e ces s a r y c o rr ectiv e ac tio n . A t th is tim e, th e P O C T s taff w ill als o ev alu ate th e r es u lts o f an y ad d itio n al u n its th a t p erf o rm ed th e s u r v e y a n d d e te rm in e if co r re ctiv e actio n is re q u ired . T he acc red itin g p ro g ra m assig ns to e ac h re sult a sta nd a rd d ev ia tio n ind e x to d e scrib e ho w far a re sult is fro m th e gro u p m ea n a s m ea sure d in sta nd ard d ev ia tio n u n its. R e sults a re rev ie w ed an d

Division: Department: Category: Locations:

Original Date:

Sentara Hospitals

Rev. 5/05/05

Review/Revision Date:

Laboratory Services

Approved By:

Quality Management SBH, SCH, SLH, SNGH, SVBGH, SW CH

Owner:

Medical Director Clinical Specialist, POCT

Checklist: Required Action Steps:

2nd Checks

Completed by: 

1.

Receive kit. Initiate External Proficiency Testing Checklist.



Date:____________

2.

Date & store kit.



Tech No._________

3.

Notify appropriate person. Hand off checklist to Process Owner.



Tech No._________

Tech No._________



Notified (name):_________

4.

Make copy of paperwork.



Tech No._________

5.

Order in Cerner.



Tech No._________

6.

Assign to testing personnel. Schedule follow/up with testing personnel.



Date due:_________



Assigned to (name):______



Assigned to (name):______



Assigned to (name):______



Assigned to (name):______



7.

Prepare & perform testing.

8.

Enter test results on forms. Deliver to Process Owner.



Tech No._________

9.

Transcribe results to Master forms.



Tech No._________



Tech No._________



Scheduled f/u (date)_________

Tech No._________

On-line: Enter results, Print, Review, Submit.

Simple Task/Activity

Standing Order or Checklist with Verbatim Compliance

Common Sense or Skill-ofthe-Craft

Paper: Transcribe to Master, Error Check, Submit by fax.  Second check (name): _________________________________

10. Validate transcribed results. nd (2 independent check) 11. File result forms with checklist.

to 1 procedure and job aid

References:

Policy

List primary guiding Policy

Procedures

External Proficiency Testing

Key Process, If Applicable: Key Process

Mistake Proofing by Design

Lower

Reliability

Higher

a.k.a. Poka-Yoke (ポカヨケ)

Poka-Yoke from Home to Healthcare

Eliminate: Redesign so error prone task is no longer necessary Replace: Automate a manual task Prevent: Design components so that a mistake is impossible Facilitate: Provide visual cues and reminders Detect: Add requirements designed to detect mistakes Checklists Second checks and double checks

Mitigate: Add redundancy to mitigate the impact of a process failure

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Error Proofing Tactics

Changing Behaviors

Norman’s Tactics for Knowledge in the Environment

Agency for Healthcare Research  and Quality Prepared by John Grout (Berry College)

Constraints

Provide design features that  compel or exclude actions.  Constraints may be physical,  semantic, cultural, or logical . 

Affordances

Provide guidance for operation  of device by providing features  that allow certain actions.

Natural Mappings

Design one‐to‐one  correspondence between  controls and device being  controlled. 

Visibility

Make operation of the device  visible.

Feedback

Give each action an immediate  and obvious  effect.

Set  Expectations

Educate &  Build Skill

Reinforce &  Build  Accountability

© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Non-Technical Skills

Power Distance

Non-technical skills describe how people interact with technology, environment, and other people. These skills are similar across a wide range of job functions. These skills include attention, information processing, and cognition. Generic non-technical skills:  Situational awareness  Attention  Communication  repeat backs    

call outs phonetic & numeric clarification clarifying questions inquiry, advocacy, assertion

 Critical thinking  Protocol use  Decision-making

Large Distance

Small Distance

• Relations are autocratic and paternalistic • Power acknowledged based on formal, hierarchical positions

• Relations are consultative and democratic • Relate as equals regardless of formal positions

The perceived distance – not necessarily the real difference – as seen by the subordinate Flin, O’Connor, and Crichton Safety at the Sharp End

Reference: Hofestede, Geert. Culture’s Consequences, 2001 (2nd edition).

Collegial Interactive Teams (CIT) = Tone + Tools Context

• Patient focused – like we’re caring for a loved one

Collegiality

• Greetings & introductions • Eye contact & open body language • Relationships • Team goals – use “we” and “us” vs. “I” and “you”

Confidence in Speaking Up

Make Reliability a Reality

Coordination

• Who’s in charge • Roles & responsibilities • Brief>Execute>Debrief – pocket card in-hand

Communication

• Information – ready & in hand • 3-way repeat backs • Clarifying questions • Phonetic/numeric clarifications • SBAR for requests

• Cross Monitoring – peer checking & peer coaching • “If anyone – regardless of role or experience – senses a problem that would compromise safe, quality care, I expect you to speak up.”

Culture of Safety Patient first, every time Safety first Importance of attention (self‐check) Importance of compliance (Red Rules) Cross monitoring Speaking‐up for safety as a concept (Train using leader modules)

Safety  Culture

Critical  Thinking Collegial Critical Thinking Questioning Attitude Proactive hindsight STEP SORT (Train using case study in modules)

Interactive Team

Collegial Interactive Teams Situational awareness Communication bundle: • Repeat‐back • Call out • Phonetic & numeric clarification • Clarifying questions Speak‐up (inquiry‐advocacy‐assertion) Brief‐Execute‐Debrief (Train in teams using simulation)

STEP = Story, Test story, Eliminate gaps in story, Plan to proceed SORT = Statement of problem, Options, Rule-out options, Test and take action

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Questioning Attitude

Cross Monitoring

with Validate & Verify Technique Validate: Does it make sense to me?

Peer Checking Watching-out for each other. Peers share situational awareness and provide on-the-spot second opinions.

Technology Patient

Professionals

Involves feedback. Peers provide a 5:1 ratio of positive to negative feedback to reinforce good habits, extinguish poor habits, and build better practice habits.

Verify: Check with an

Medical Record Documentation

independent, qualified source

Multiply Your Error Probability 0.001 x 0.001 = 10-6

Procedures & References

Making it Stick:

Leading Causes of Action Failure

“It’s Hawthorne Until Habit” 100%

Peer Coaching

Awareness

 Hidden non-commitment

Skill Acquisition

(there seems to be agreement, but managers later back out)

 Soft cost – benefit analysis

Event Rate

Novice  ‐ Advanced Beginner  ‐ Competent   ‐ Proficient  ‐ Expert Source: Patricia Benner, From Novice to Expert (1984)

(the best root solution is always the cost effective solution)

Unconsciously incompetent ‐ Consciously incompetent  ‐ Consciously competent  ‐ Unconsciously competent

 Medical Staff resistance

"Four Stages of Learning," a theory posited by 1940's psychologist Abraham Maslow 

(Involve physicians early in the process and rely on tactful diplomacy)

Habit Formation

20%

 Poor implementation accountability

Performance

(Corrective Action Plan should have responsible parties by name and date)

2 Years

Time

From Maximize Patient Safety with Advanced Root Cause Analysis; Corbett, Clapper, & Johnson; 2004.

© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Plan the Work – Work the Plan

Managing Complex Change

A4 Action Plans Vision

One-page, problem, causes, and actions with names & due dates

Incentives

Resources

Action Plan

= Change

Skills

Incentives

Resources

Action Plan

= Confusion

Incentives

Resources

Action Plan

=

Anxiety

Resources

Action Plan

=

Gradual Change

Action Plan

= Frustration

Vision

“A4” refers to the size of the paper. The plan is intended to fit on a single page. A4 is a lettersized page; A3 is legal.

Effective

Skills

Vision

Skills

Vision

Skills

Incentives

Vision

Skills

Incentives

Resources

=

False Starts

Source: Brandeis University Center for Youth & Communities

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Rapid Cycle Feedback

Simulation Continuum

Learning is “doing” with “feedback”

Simulation in the Lab

Optimal Feedback Cycle

Technical Skills

Technical + Non‐Technical  Skills

Build real-time simulation as a leadership competency!

Simulation at the Line

Non‐Technical  Skills (Individual & Team)

Real‐Time Sim

Pre‐Job Briefing

Teaching on the Spot To build and reinforce  technical skills and  critical thinking skills

Performance

Do

Feedback

Traditional Feedback Cycle

Time

© 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Is there any technical  skill that does not also   require non‐technical  skills? NO! Eliminate technical simulation in  isolation!

Off‐Line Education & Training Best Use

Initial education on new concepts; intensive skill  development

Real‐Time Simulation Reinforcement and application of known concepts;  development of critical thinking and analytical problem  solving

Location

Classroom, training lab, meeting

On‐the‐job

Nature

Objective‐bound

Time‐bound

Prep Time

Longer

Touch Time

Longer (>30 minutes, typically hours)

Short (30/60/90 seconds; typically <5 minutes)

Frequency

Episodic; longer time between sessions

Often; shorter time between touches

Facilitator

Trained instructors or manager

Manager  or coworker

Costs

Salary of instructors/learners; supplies

None

Short to none

© 2011 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

A Triple Play “What you do every day is what you do in an emergency.” Joe Martin, Battalion Chief - LAFD

Sim Center

Sim Center

Technical skills

Team skills

In‐Situ Sim

Protocol EBM + human factors

A fool’s choice: o technical skills in isolation, or o team skills in isolation Practice only makes permanent.

Technical + CIT skills

Environment

Perfect practice makes perfect.

Craig Clapper, PE, CMQ/OE

Healthcare Performance Improvement, LLC

Partner & Chief Knowledge Officer

5041 Corporate Woods Drive, Suite 180 Virginia Beach, VA 23462 (757) 226-7479 www.hpiresults.com

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