Quality Matters,
S
pring
O h io !
2015
Newsletter of
Ohio Association for Healthcare Quality
PUT TI NG ON E R RS
“Three articles in this issue of the OAHQ newsletter come from the
same source, Healthcare Performance Improvement, LLC (HPI).
Founded in 2006, HPI is a consulting firm which guides organizations
in comprehensive safety and reliability culture improvement. Their
engagements include three phases – a diagnostic assessment phase,
intervention implementation, and building accountability systems.
For more information, visit www.hpiresults.com”.
Written by Craig Clapper, PE,
CMQ/OE, Healthcare Performance
Improvement
To err is human – to malfunction
is left for devices. Dr Brent James,
chief quality officer of Intermountain
Healthcare based in Salt Lake City,
observed that few harm events
were caused by human error. Dr
James’ observation was published as
commentary in the 13 June 2011 issue
of Modern Healthcare and is worthy of
being quoted at length:
… less than 5% of care-associated
adverse events trace back to human
error. The vast majority of such
events result from predictable system
failures. Using the term “error” to
describe these events is a serious
mistake. It focuses the mind, and
the search for solutions, on the 5%
subcategory, at the expense of the
95%.
Can this be true? And if so, what
does this say for all of us diligently
working to prevent human error using
non-technical skills to put our safety
cultures to work? And adding more
fuel to the controversy, a rebuttal now
appears on Wikipedia discounting
Heinrich’s law.
Herbert William Heinrich was an
American industrial safety pioneer
from the 1930s. In 1931, he published
a book that provided statistics that
later became known as Heinrich’s
law. From a review of thousands of
accident reports, Heinrich concluded
I n T his I ssue :
page two:
page six:
page seven:
President’s Update
OAHQ 2015 Conference Registration Form
Shirley M. Toepfert Award
that for every accident that causes
major injury, there are 29 accidents
that cause minor injuries and 330
accidents that cause no injuries. He
perceived that 88% of accidents were
caused by “man-failure.” Heinrich’s
88-10-2 ratios indicate that among
the proximate causes, 88 percent are
unsafe acts, 10 percent are unsafe
mechanical or physical conditions and
2 percent are unpreventable.
The main evidence used against
Heinrich’s law was from Dr. W Edwards
Deming. In 1981, sales by the Ford
Motor Company were falling. Between
1979 and 1982, Ford had incurred $3
billion in losses. Ford’s new division
quality manager, John A Manoogian,
engaged Dr. Deming to start a
quality movement at Ford. Deming
pointed to Ford’s culture and Ford’s
leadership method. To Ford’s surprise,
Deming talked not about quality but
about leadership. He told Ford that
management actions were responsible
for 85% of all problems.
Continued on page 4.
Q u a l it y
TODAY
F rom T he P resident
WOW! The winter weather is finally
over, I hope! Those cold, frigid,
temperatures and the snow too!
Enjoy the change of the seasons.
Sunshine, flowers, and gardens will
be here soon, and so will the OAHQ
conference.
Mark your calendars! The OAHQ
Annual Conference is May 14-15,
2015 at Embassy Suites, Airport,
and the same location as previously.
You may well recognize our
speakers; they are always inspiring
and engaging. Two favorites, Jim
Conway and Sue Dill are returning.
In addition, speakers include your
colleagues and physicians from the
Ohio Hospital Association and the
Ohio Perinatal Quality Collaborative.
New this year, we have added a
bonus session for an additional
CE, after the Thursday program
concludes.
Publication opportunities are
available for our OAHQ Newsletter.
Awards will be given for article
submissions that are published in
our Newsletter. Share your quality
improvement stories. Submit
articles for your newsletter, Quality
Matters, OHIO!
We all contribute to our professions
in so many different ways, each
having an impact. OAHQ is your
organization. It represents what
we are and is here to serve you, to
inspire you professionally. We are
committed to the quality healthcare
Page 2
professional
and
promoting
opportunities
for
certification.
We continue
to offer the
highest level
of educational opportunities to
achieve the CPHQ designation.
CPHQ education sessions will be
scheduled for you during 2015.
Remember the Board meetings
are open for you to attend,
should you choose. Contact
any of the Board members for
meeting information. The OAHQ
website lists Board members
contact information and the
Board meeting schedule. We
have currently expanded the
Board membership to maintain
geographical diversity.
To be successful as an
organization, we need you. Don’t
forget to maintain your OAHQ
membership. Please volunteer
to support your organization.
Opportunities are endless and
are needed for Leadership,
Board membership, conference
planning, newsletter publications,
and so much more. The future
looks promising as we work
together to achieve the goals we
have set for the organization.
Culture Change:
A Real Pain in the
...Mouth?
Written by Tiffany Obetts, RN, BSN,
Healthcare Performance Improvement
Consultant
I recently had braces put on as an
adult. As I sat there those first couple
days with a very sensitive mouth, I
couldn’t help but think of the work
we do in safety and reliability culture
change. It all starts with a great idea.
You want to change something. You
want to improve your smile, you want
to improve your culture. You set forth
with a plan! Braces for 9 months!
Reliability Culture Implementation in
18 months!
It’s hard at first. You feel tension
start to creep in, there’s some pain
and some activities that were once
easy, get a little harder (like eating
anything!). In our work, that might
Continued on page 4.
Remember, YOU are OAHQ.
Please know it has been my
pleasure to serve you once again as
your OAHQ President.
Enjoy the spring season. Support
and remember our military troops
and their families.
Be Safe. Take care of one another.
LIVE, LAUGH, LOVE.
Warmest regards,
B. Jody Ciccone Snyder, RN, BS,
MPH, CPHQ
2015 OAHQ President
Quality Matters, Ohio!
Q u a l it y
TOMOR ROW
Saving Carol Decker
Written by Craig Clapper, PE,
CMQ/OE, Healthcare Performance
Improvement
Five days after the cesarean,
one of her physicians said, “She
might make it.” Not the words
one would want to hear. Carol
Decker did live and survive sepsis.
Carol was discharged to home 97
days after her daughter’s birth in
June 2008. To survive sepsis - she
required amputations of both feet
and the left hand, a tracheotomy,
surgical removal of dead tissue
on her abdomen, arms and back,
and five rounds of skin grafts. And
Carol also lost her sight – she has
never seen her baby girl.
Carol Decker, inset top with
daughters Chloe and Safiya, is
one of an estimated 750,000
cases of severe sepsis every year
in the US. The mortality rate is
28-50% (compared to AMI at 2.79.6% and stroke at 9.3%). One
patient dies every three minutes.
(These data are from Surviving
Sepsis Campaign: http://www.
survivingsepsis.org/Background/
Pages/UnderstandingProgress.
aspx.)
Not all patient deaths caused by
sepsis are harm. Not all sepsis
outcomes with major losses of
function are harm. Carol Decker’s
case was likely harm – before
delivering by cesarean in the
middle of her ordeal, Carol had
been to an emergency room, her
OB physician’s office, and an OB
unit of an acute care hospital.
Someone could of or should of
recognized her sepsis. This is
Quality Matters, Ohio!
likely a delay in treatment or
diagnosis.
2. Teams need to think
together in infrequent,
complex, and time
dependent work. These
situations are highly prone
to error. Resilience is the
ability of the team to
recognize when the team
is off track – and think
together to get back on
track. Does our safety
culture include behaviors
for team thinking? And
do we practice together
in simulation to develop
resilience?
Infrequent, complex, and time
dependent – three factors in a
high reliability organization that
indicate the need for a standard
protocol and training on that
protocol. The best method for
training – simulation. Learning is
doing with feedback. If there is
no doing, there is no learning. If
there is doing with no feedback,
then we are learning something
– but are we learning the right
practice habits? Practice does
not make perfect. Practice
makes permanent. Debrief
3. Carol Decker also lost her
simulations – and
ring finger on her
everyday patient
right hand. No one
care – to ensure that
removed the ring on
“Infrequent, complex, that finger – and the
we are learning the
and time dependent swelling resulted in
right practice habits.
– three factors in
a loss of circulation.
Questions to
a high reliability
This is a small lesson
Consider:
organization that
in attention to detail
indicate the need for (only small when
1. Most people
a standard protocol
compared to the
overestimate
and training on that horror of Carol’s
their
protocol.”
overall issues). How
performance
are our people doing
under pressure.
in attention to detail?
We do not rise
And do we as leaders even
to the occasion – we fall
know through our rounding
back to the level of our
activities? Perhaps this
training. So, how are we
should be the focus of our
as safety leaders doing
leader safety rounds this
in training our people on
week.
infrequent, complex, and
time dependent protocols?
This and other insights of HPI
Do we have a focused and
team members can be found
simplified protocol? With
at http://hpiresults.com/index.
role clarity? And trained in
php/insight.
simulation?
Page 3
Q u a l it y C ounts
Continued from page 1.
The attack on Heinrich’s law is based
on Deming’s 85% - and could also be
based on James’ 95%. Both assert
that human error is not the cause of
problems - and both are right. Systems
cause human error (and systems
also cause device malfunctions and
failures). People merely experience
error. A good way to say this is –
human error is the proximate cause
of harm (occurring at the sharp end
of the system) and systems error is
the distal cause of harm (occurring
at the blunt end of the system). Deep
recurrence control only happens when
distal causes are corrected.
However, we at HPI maintain that
while systems cause all human error
and device malfunctions/failures,
people are resilient (because they can
think and they care about patients)
and can prevent most of the errors
using non-technical skills. Based on
a study of harm in 96 hospitals over
two years, 74.5% of the acts leading to
serious harm could be prevented using
safety culture with non-technical
skills. There were 1,964 cases of
serious harm in the study and 4,614
acts leading to the cases of harm.
(And we also find that greater than
90% of the proximate causes leading
to serious harm are acts of people
(human error), leaving less than 10%
for device and equipment failures and
malfunctions.)
Questions to consider:
1. Do we view human error as the
starting point of our cause analysis
to prevent recurrence or the end
point of our analysis?
2. Are we careful to say “systems
cause error” and “people
experience error” to avoid casting
blame?
Page 4
Continued from page 2.
be when the Serious Safety Event
Rate (SSER) starts to rise, difficult
conversations start occurring, or
standing up in front of the hospital
board sharing your harm events.
performed consistently over time.
I wasn’t reliable in the very thing
that would sustain my change.
Eventually, the retainer no longer fit
and my teeth started to move back.
But, you keep at it. In time, it gets
a little easier and the pain may
subside. Then, it’s time to get that
new wire placed (in 6 weeks for
me, could be 6 months for you).
This may be a turning point in your
culture: you start getting tougher
on classification, you need to make
decisions on resourcing important
activities such as safety coaches
or expanding your cause analysis
program – the pain creeps back
in again, but you stick to it – the
popular saying goes, “no pain, no
gain”.
That’s the same thing with
our culture work! We have to
have strong reinforcement and
accountability loops so we don’t
lose the gains! Otherwise, our
previous pain and discomfort was
all for naught. After all, you are
improving something much more
significant than a smile. You are on a
mission to save lives.
And what about those gains? See,
I didn’t mention before that I
had braces once when I was 15. I
remember the initial pain and the
satisfaction the day the braces came
off and how beautiful my smile
was! However, the reinforcement
of wearing my retainer wasn’t
3. Are we proficient in fixing the
systems causes of human error?
Or, do we tend to try fixes for the
proximate causes?
4. Do we use our safety culture
and non-technical skills as
an additional level of patient
protection in preventing human
error? Or do we use only one – the
system fix or relying on people to
prevent?
This and other insights of HPI team
members can be found at http://
hpiresults.com/index.php/insight.
Consider these questions:
1. When you imagine the potential
beauty of your “safety culture
smile”, what do you see? What
are the steps you will need to
take to get there?
2. When the journey gets painful,
what are you going to do to
ensure you continue to move
forward and not go back to
those crooked teeth?
Ohio Association for Healthcare Quality
2015 Board of Directors
President
Jody Ciccone-Snyder
President-Elect Marsha Jevas
Past President Susan Butler
Treasurer
Patti Klingel
Committees
Conference
Membership
Continuing Ed
Members at Large
Jody Ciccone-Snyder
Marsha Jevas
Laurel Dolejs
Theresa Wnek
Marsha Jevas
Nancy Terwoord
Newsletter
Editor Designer Sandy Macovei
Laura O’Neill
Quality Matters, Ohio!
2015 OAHQ Conference May 14-15
OAHQ Member
Call for Newsletter
Articles – Fall 2015
THE PRIZE COULD BE YOURS!
Upon finalizing this Spring issue
of the OAHQ Newsletter, the
Committee has already begun
looking ahead to the 2015 Fall
issue.
We would like to tap into
the knowledge, expertise,
and meaningful activities
related to quality and process
improvement that we know are
ongoing within our membership
in your respective places of
work.
As we consider topics for the
next newsletter, we are offering
the following opportunity to
OAHQ members: if you submit
an article and it is published in
the Newsletter, you will receive a
$25 gift card.
Please consider submitting
an article or blurb that touts
the great work of you or your
team. We would be particularly
interested to learn about
initiatives related to improving
readmission rates, as that will be
the theme of the next issue, but
are open to considering other
topics as well. Thank you for
considering!
The deadline to submit your
article is October 1, 2015. Please
submit it to Sandy Macovei at
[email protected]. You
can also call Sandy at 513-5616617 with any questions.
Quality Matters, Ohio!
2015 CONFERENCE TEASERS
FROM OUR PRESENTERS
• Jim Conway, Adjunct Faculty,
Harvard T.H. Chan School
of Public Health,”Profound
learning across my almost
50 year career in healthcare;
the most important things
I’ve learned. This is lots
about leadership, quality,
safety, and patient and
family centered care and is
anchored of course in the
notion that “experience is
the name we give to our
mistakes.”
• Jeff Biehl, President,
Healthcare Collaborative,
Columbus, Ohio, “ We have
designed a 90 minute session
that teaches consumers
how to use questions to
improve the quality of
their healthcare at a lower
cost. We call it Patient
Engagement Education &
Training.”
• Sue Dill Calloway RN Esq.,
President, Patient Safety
and Healthcare Consulting
and Education, “CMS data
also show a high number
of deficiencies for QAPI, as
CMS rewrote all the QAPI
standards March 21, 2014”.
• Catherine Munn, MPH RHIA
CPHQ, Sr. Consultant, “more
news regarding quality and
ICD-10 as we continue to move
forward.”
• Edward Skompski,
Vice President, System
Improvements, “ The Joint
Commission has recognized
TapRoot as an approach
to root cause analysis for
comprehensive System
Analysis”.
• The Ohio Hospital Association
and the Ohio Perinatal Quality
Collaborative, “Improving
Ohio’s’ Infant Mortality Rate;
A Story of Collaboration.
This is an overview of health
disparity, scientific approach
in the area of prematurity and
progesterone, an overview
of multiple organization
collaboration”.
OAHQ Conference Brochures
Available Soon!
Page 5
C onference :
C rossroads
“Crossroads of Quality”
Registration
STATE CONFERENCE
May 14 & 15, 2015
of
Q ualit y
REGISTRATION FEES
2-Days 1-Day
OAHQ Member*
$295
*Early Bird by 3/31/15 $270
Non-Member
$190
$395$300
Includes breakfast, breaks and lunch.
Name Title Address City/State/Zip Business Affiliation Email (work) ( ) (home) ()
Phone (work) ( ) (home) ()
Please complete for CEU records:
Special Meal Requirements:
□ RN □ LPN □ CPHQ □ CCM
□ Vegetarian □ Other dietary needs: Registration Days (Please Check)
□
*Member Early Bird by 3/31/15$270.00
□
Member Rate - Thursday Only
$190.00 □
Member Rate - Friday Only
$190.00 □
Non-Member Rate - Both Days
$395.00 □
Non-Member Rate - Thursday Only $300.00 □
Non-Member Rate - Friday Only $300.00 □
Payment
*
Member Rate - Both Days $295.00•
•
Check made payable to
Ohio Association for Healthcare Quality
Credit Card (MasterCard or VISA)
Account # Exp. Date Amount $
Receipt and registration confirmation sent by email.
Mail to: OAHQ, P. O. Box 461045, Cleveland, OH 44146
Fax:330-468-1014
Questions? [email protected]
REFUNDS
Refunds until April 15, 2015 less a $25 processing fee. No refunds after April 15, 2015. Substitutions accepted.
EXHIBITORS
Please stop and visit all of our exhibitors and thank them for supporting OAHQ. Their support is essential to
our conference.
Page 6
Quality Matters, Ohio!
Shirley M. Toepfert Distinguished Member Award
PURPOSE
The Shirley M. Toepfert
distinguished member Award
was developed to recognize
an OAHQ member for his/
her outstanding contributions
to the Ohio Association for
Healthcare Quality.
ELIGIBILITY
Eligible candidates include
any OAHQ member in good
standing.
SELECTION CRITERIA
Each category will be scored
on a 0-5 scale (0=not met; 5=
strongly met). A total score of
25 is possible, but a minimum
score of 15 is required for the
award to be granted each year.
LEADERSHIP
• Candidate has been an
officer, team leader and/
or member at a national or
state level.
• Candidate has been a
presenter, co-presenter, or
instructor at a national or
state workshop, seminar or
conference.
• Candidate has
demonstrated ability
to facilitate growth and
increase membership
RECRUITMENT SUPPORT
• Candidate actively
promoted membership
and participation by fellow
healthcare management
Quality Matters, Ohio!
• Candidate maintains annual
membership in OAHQ and
NAHQ.
• Candidate participates in
OAHQ Speaker’s Bureau.
• Candidate is consistently
available and willing to
volunteer time in nontraditional leadership roles in
support of OAHQ functions
(i.e. mailings, registration,
phone calls, etc.)
PUBLICATIONS/PRESENTATIONS
• Candidate has had
publication in professional
journal(s) related to
healthcare management
field.
• Candidate has consistently
contributed articles to the
OAHQ newsletter.
• Candidate has had poster
presentation at either state
or national meeting.
EDUCATION
• Candidate has sought
and/or completed further
degree educational
opportunities related to
healthcare management.
• Candidate has successfully
completed the CPHQ
certification.
• Candidate has provided
consultative services,
either voluntary or paid, in
healthcare management
to other Ohio facility.
Candidate is recognized as
a resource person in area of
consultation.
PERFORMANCE
IMPROVEMENT INITIATIVES
• Candidate is recognized
for developing and
implementing Performance
Improvement initiatives
facility or organization
that have demonstrated
improvement in health
care deliver, maintenance,
physician organizations,
customer satisfaction,
critical pathways/practice.
NOMINATION
Nomination forms available
from any member of the
OAHQ Board of Directors.
All nomination forms must
be submitted by April 15 of
each year. The OAHQ Board
will select the recipient
of the Shirley M. Toepfert
Distinguished Member Award
based on the criteria outlined in
this policy. The recipient will be
announced at the OAHQ Annual
Education Conference held
each year.
AWARD
The recipient will receive a
personalized plaque, one
year’s free OAHQ membership,
one paid attendance to the
Annual OAHQ Education
Conference, a feature article
in the OAHQ newsletter and a
local newspaper identified by
the recipient and a letter to the
recipient’s employer.
Continued on page 8.
Page 7
Shirley M. Toepfert Distinguished Member Award
Continued from page 7.
SHIRLEY M. TOEPFERT DISTINGUISHED MEMBER AWARD - NOMINATION FORM
Nominee’s Name: Title:
Organization:
Address:
City:
State:
Phone:
() Home Address:
City:
Cell: ()
State:
Email Address:
Zip: Zip: Current OAHQ Member?
Yes 
No 
Person Nominating Candidate: Current NAHQ Member? Yes 
No 
CPHQ Certified?
Yes 
No 
Relationship to Candidate: Your Address & Phone:
Why do you believe this candidate should be selected as the recipient of the Shirley M. Toepfert
Distinguished Member Award? (Use additional paper if more room is needed)
Can you provide the name(s) of one other person(s) who would support this nomination?
Name:
Address: Work Phone:
Home Phone: Signature: Date:
Mail Nomination to: OAHQ, P.O. Box 461045, Cleveland, Ohio 44146-1045.
Page 8
Formulated: 8/1995; Revised: 11/1999, 2/2001
Quality Matters, Ohio!