High Reliabilityorganizations For NLT

KSUMC PATH TO:
‫ا َ َج ِميعًا‬
َ َّ ‫ن‬‫لن‬ ‫ا‬َ ‫ي‬ ‫ح‬
ْ َ ‫أ‬ ‫ا‬‫م‬َ َّ ‫ن‬َ ‫أ‬‫ك‬َ َ ‫ف‬ ‫ا‬‫ه‬َ ‫ا‬ ‫ي‬ ‫ح‬
ْ َ
َ ‫َو َم ْن أ‬
(And if anyone saved a life, it would be as if he
saved the life of the whole people)
WHY WE’RE HERE
Our mission calls us to deliver holistic care.
For KSUMC, holistic care means caring for the physical, emotional, social,
and spiritual well-being of the whole person by:
• Attending to their needs through compassionate relationships and
empathetic, effective communication.
• Inviting shared decision making among patients, providers and care
teams.
• Delivering safe, reliable, evidence-based, and interdisciplinary care
consistent with individual preferences.
High Reliability Organizations
Healing Without Harm 2020
WHAT IS HIGH RELIABILITY?
• Reliability: The probability that a system, structure,
component, process or person will successfully perform the
intended function(s).
• High reliability industries are everywhere; most people just don't
realize it — they range from amusement parks and zoos to oil drilling
rigs, air traffic control and nuclear submarines.
• High reliability is the ongoing safe operation of an organization or
entity without a mishap or adverse event.
“They have to be high reliability:
If they're unsafe, people wouldn't work or go there,”
M. Michael Shabot, MD, FACS, FCCM, FACMI
CMO of Memorial Hermann Healthcare in Houston
SAFETY EFFICIENCY AND EFFECTIVENESS PATIENT/FAMILY
“Zero Preventable Harm” TIMELINESS “Seamless Care” CENTERED CARE
“Right Care at the Right “All for One”
Create safer care through Time” Deliver effective care through
achieving: achieving: Transform KSUMC Patient’s
Deliver efficient care through Experience through achieving:
achieving:
• Zero Hospital Acquired
CLABSI • Zero Incidence of • Planetary designation
• Zero SSI Preventable Venous • Engagement of patients and
• Zero Hospital Acquired • Zero delay in managing Thromboembolism (VTE) in all families in 100% of Quality
Pressure Injury Stage II or patient symptom in-patient population Aims Initiatives
above in all in-patient • Zero delays in providing • Zero readmission within 30 • Patient and family focus
population necessary patient education with same diagnosis • Preoccupation with safety
• Zero Falls with Injury or Death • Zero delay in collaborating • Zero delay in administration • Openness and acceptance to
• Zero Harm related to with health care partners of medication critique
Antithrombotic Medications i.e.PT, OT, Nutritionist and • Zero delay in managing • Support for patients to be
• Zero Hospital acquired others critical Lab results involved in their plans of care
Infections • Zero Delay in Discharge • Maintaining appropriate
• Zero accidental removal of Medications length of stay
lines and drains
HIGH RELIABILITY ORGANIZATIONS (HROs)
• Are those organizations that are high-risk, dynamic, turbulent, and

potentially hazardous, YET operate nearly ERROR FREE.
RELIABILITY FROM PATIENT’S PERSPECTIVE
• Don't kill me (no needless deaths)
• Don't make me feel helpless
• Don't keep me waiting
• Don’t waste resources - mine or anyone
else's
SAFETY + Quality + Satisfaction = Exceptional Care
Berwick, Donald. My Right Knee. Ann Intern Med,

January 18, 2005, Volume 142, no. 2, 121-125
HEALING WITHOUT HARM BY END OF 2020
• Healing without Harm by 2020 is a destination in quality,

safety, and experience for patients and caregivers.
• This destination is possible through the principles and

practices of high reliability.
KSUMC SENTINEL EVENTS, MORBIDITY AND
MORTALITY
Sentinel Events related to Mortality KSUMC Morbidity
Psych Ob-Gyne SICU L&D Neuro DEM
2 2
1 1 1 1 1
0 0
2017 2018 2018
KSUMC KEY PERFORMANCE INDICATORS
PATIENT FALLS
IN-PATIENT AREAS DAY CARE AREAS
0.657
0.7 0.583 0.03%
0.556 0.02% 0.02%
0.6 0.516 0.03%
0.45 0.434
0.5 0.395 0.371 0.02%
0.4
0.02%
0.3 0.23
0.176 0.173 0.01%
0.2
0.064 0.076 0.072 0.057
0.1 0.01% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
0 0.00%
Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19
Rate per 1,000 Patient Care Days PERCENTAGE
OUT-PATIENT AREAS DEPARTMENT OF EMERGENCY

0.01% 160.00% 141.80%
0.01%
140.00%
0.01%
120.00%
0.00% 0.00% 100.00%
65.80%
0.00% 0.00% 80.00% 52.40% 53.60% 55.60% 52.70%
60.00%
0.00%
40.00%
0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 20.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.01% 0.03% 0.00%
0.00% 0.00%
PERCENTAGE RATE per 1,000 Patient Care Days
Starting January 2019, denominator for DEM KPIs were changed to Total Patients Seen instead of Patient
Care Days. Thus the results are already presented as percentages.
KEY PERFORMANCE INDICATORS
PRESSURE ULCER DEVELOPMENT
IN-PATIENT AREAS DEPARTMENT OF EMERGENCY
0.8 60.00%
53.60%
0.68
0.7 0.636
50.00%
0.57
0.6 0.53
40.00%
0.5 0.434
0.383
0.4 30.00%
0.283
0.3 0.235 0.226 20.00%
0.193
0.2 0.152
0.115
10.00%
0.064 0.062
0.1
0 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.01% 0.00% 0.00%
0 0.00%
Rate per 1,000 Patient Care Days Rate per 1,000 Patient Care Days
MEDICATION ADMINISTRATION ERRORS
0.14 100.00%
0.115
0.12
80.00%
0.1
0.08 0.064 60.00%
0.058 0.057
0.06 40.00%
0.04
20.00%
0.02 0 0 0 0 0 0 0 0 0 0 0 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
0 0.00%

100.00% 80.00% 67.00%
70.00%
80.00%
60.00%
60.00% 50.00%
40.00%
40.00% 30.00%
20.00%
20.00%
0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 10.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
0.00% 0.00%
PERCENTAGE Rate per 1,000 Patient Care Days
NEEDLE STICK AND SHARP INJURIES
0.02%
0.5 0.03%
0.386
0.4 0.02%
0.3 0.02%
0.185 0.17
0.2 0.01%
0.115 0.109
0.057 0.072 0.056 0.062 0.058 0.062
0.1 0.01%
0 0 0 0 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
0 0.00%

0.00% 0.00% 0.00% 0.12% 0.10% 0.10% 0.10% 0.10% 0.10%
0.00% 0.10%
0.00%
0.08%
0.00%
0.06%
0.00%
0.04%
0.00%
0.01% 0.01%
0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.02% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
0.00% 0.00%
PERCENTAGE Rate per 1,000 Patient Care Days
INTRAVENOUS INFILTRATION
0.08%
0.5 0.421 0.08%
0.07%
0.4
0.295 0.293 0.06%
0.291
0.3 0.05%
0.21 0.208 0.19 0.04%
0.2 0.114 0.03%
0.104 0.113 0.1 0.103
0.02%
0.1
0 0 0 0.01% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
0 0.00%
Rate per 1,000 Peripheral Device Care Days PERCENTAGE
DEPARTMENT OF EMERGENCY
100.00%
80.00%
60.00%
40.00%
20.00%
0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
0.00%
Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19
Rate per 1,000 Peripheral Device Care Days

PHLEBITIS
0.08%
0.35 0.08%
0.291
0.3 0.07%
0.25 0.06%
0.19
0.05%
0.2 0.15
0.04%
0.15 0.104 0.1 0.114 0.105 0.098 0.03%
0.1 0.02%
0.05 0 0 0 0 0 0 0 0.01% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
0 0.00%
Rate per 1,000 Peripheral Device Care Days PERCENTAGE
DEPARTMENT OF EMERGENCY
100.00%
80.00%
60.00%
40.00%
20.00%
0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
0.00%
Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19
Rate per 1,000 Peripheral Device Care Days

EXTRAVASATION RELATED TO CHEMOTHERAPY
100.00% 100.00%
90.00% 90.00%
80.00% 80.00%
70.00% 70.00%
60.00% 60.00%
50.00% 50.00%
40.00% 40.00%
30.00% 30.00%
20.00% 20.00%
10.00% 10.00%
0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
0.00% 0.00%
PERCENTAGE PERCENTAGE
INFECTION CONTROL RATES
CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION (CLABSI) CATHETER ASSOCIATED URINARY TRACT INFECTION (CAUTI)
25 5
21.1 4.25
20 4
3.1
15 3 2.35
1.8
10 2 1.56 1.5
5.9 1.03 1.2
4.6 4.2
5 1.831.57 2.1 2.7 2 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
CCU HDU MICU PICU SICU W23 W24 W25 W32 W33 NICU CCU HDU MICU PICU SICU W23 W24 W25 W32 W33 NICU
Q4 2018 Q1 2019 Q4 2018 Q1 2019
VENTILATOR ACQUIRED PNEUMONIA (VAP)

12 10.4 10.1
10
10
8
6
4 2.65
2.2
1.65
2
0 0 0 0 0 0 0 0
0
CCU CICU HDU MICU PICU SICU NICU
Q4 2018 Q1 2019
Preventable patient harm is a major source of staff inefficiencies
(FIRST VICTIM)
Preventable harm causes healthcare provider burnout and serious

psychological trauma
(SECOND VICTIM)
SERIOUS SAFETY EVENTS
Deviations from
Significant Serious Safety
best-practice causing
Patient Harm Event
care
Serious Safety Events include errors that result in death, permanent loss of function,
or injury, such as, but are not limited to:
• Transfusion Reaction
• Medication Error
• Misdiagnosis
• Hospital-Acquired Infections
• Treatment Error
• Delay in Treatment
• Wrong Site/Side surgery or procedure
• Falls with serious injury
ELIMINATING SERIOUS HARM IN HEALTHCARE
Journey to improving reliability – the next zero
To Optimized Outcomes
Reliability: not by process design alone
-8
10
10
-7 Human Factors
Integration
-6
10 Intuitive design
Impossible to do the wrong thing
Reliability
Obvious to do the right thing

-5
10
-4 Reliability Culture Core Values & Vertical Integration

10 Hire for Fit
Behavior Expectations for all
Fair, Just and 200% Accountability
-3
We are here
10
10
-2 Process Design Evidence-Based Best Practice
Focus & Simplify
Tactical Improvements (e.g. Bundles)
-1
10
Improvement Over Time .
© 2010 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
RULE-BASED ERRORS
What We’re Doing at the Time
We choose how to respond to a situation using a principle (rule) we were
taught, told or learned through experience.
TYPE OF ERROR EXAMPLE ERROR PREVENTION STRATEGY
Used the wrong rule - we were taught or Education about the correct rule
learned the wrong response for the situation
Misapplied a rule – we knew the right response Think a second time – validate/verify
but picked another response instead
Chose not to follow the rule – usually because Reduce burden, increase risk awareness, improve
we thought not following the rule was better coaching
option at the time (non-compliance)
KEY PRINCIPLES FROM HRO THEORY
• Maintain a powerful and uniform culture of safety (A “culture of

reliability” will be enhance safety by encouraging uniform and
appropriate response by field – level operators.
• Use optimal structures and procedures
• Provide intensive and continuing training of individuals and teams
• Conduct thorough organizational learning and safety management

HIGH-RELIABILITY SELF-ASSESSMENT TOOL
(HRST)
• Leadership: : (Commitment to Zero Harm to patients)
• Board, CEO, physicians
• Quality strategy, quality measures, information technology
• Safety culture (Empowering staff to speak up about patient risks )
• Trust and accountability
• Identifying unsafe conditions or practices
• Strengthening systems, measurement
• Robust process improvement: (Systematic data-driven
approach to solving complex problems)
• RPI = lean, six sigma, change management
• Methods, training, spread
HIGH-RELIABILITY SELF-ASSESSMENT TOOL (HRST)
cont’d
Robust process improvement: SIX SIGMA
Systematic approach to problem solving:

(RPI = lean, six sigma, change management)
• Far more effective than prior
approaches
• Using same tools increases
effectiveness
• Data starting to show high impact of
RPI
The Joint Commission has fully adopted RPI LEAN
CHANGE MANAGEMENT
SAFETY ACROSS THE BOARD (SAB)
Aim/Goal Primary Drivers Secondary Drivers
High Level Factors Needed to
Interventions/Process Changes Necessary to Achieve the Primary Drivers
Achieve the Aim
Patient Safety
Workforce Safety
High Reliability
Continuous Learning Environment
Culture Just Culture
Transparency
Patient and Family Engagement
Health Equity
Accountability
Caring for Staff
Resilience / Mindfulness
Safety Across the
Board Forward Thinking
Evidence-Based Processes
Strong Safety Performance Improvement
Processes
Systems Thinking Approach
Human Resources
Local Learning Systems
Engagement
Simultaneous Reporting, Monitoring and Measuring
Shared Safety Goals – At All Levels
HIGH-RELIABILITY ORGANIZATIONS
High Reliability Organization Concepts
Three Principles of Anticipation:

1. Preoccupation with failures
(What might go wrong?) Regarding small, inconsequential errors as
a symptom that something’s wrong
2. Sensitivity to Operations
(Is our process/system working? Focus on systems and processes and
how they affect patient care , awareness is key to noting risks and
preventing them.
Exceptionally
3. Reluctance to Simplify
Safe &
(ask why, why, why, why, and why to reach the roots of the problem) State of High
Encouraging diversity in experience, perspective, and opinion
Consistently
happening on the front-line)
Mindfulness Reliability High Quality of
Two Principles of Containment: (change in (Change in Care (improved
1. Deference to Expertise thinking processes patient safety
(Pushing decision making down and around to the person with the about patient and outcomes)
most related knowledge and expertise ,Decisions/design is done by safety) environments
people doing the work) affecting
2. Commitment to Resilience patient
(Developing capabilities to detect, contain, and bounce-back from safety)
events that do occur , The organization quickly contains and
mitigates errors , report, talk and learn from errors)
Modified from AHRQ
ARE THERE ANY HIGH RELIABILITY HOSPITALS?
Leading hospitals already started their journey to Zero Harm
• Atlantic Health • New York-Presbyterian
• Barnes-Jewish • North Shore-LIJ
• Baylor • Northwestern
• Cedars-Sinai • OSF
• Cleveland Clinic • Partners HealthCare
• Exempla • Sharp Healthcare
• Fairview • Stanford Hospital
• Floyd Medical Center • Texas Health Resources
• Froedtert • Trinity Health
• Intermountain • VA Healthcare System-CT
• Johns Hopkins • Virtua
• Kaiser-Permanente • Wake Forest Baptist
• Mayo Clinic • Wentworth-Douglass
• Memorial Hermann • MedStar Health
KSUMC OBJECTIVES TOWARD HROs
• Build universal awareness of high reliability science among KSUMC
hospitals
• Demonstrate that it is possible to achieve high reliability at scale
• Move all MC hospitals closer to high reliability for the benefit of every
patient in our institution
TO BE SAFE, WE NEED TO WORK SAFELY
STRATEGY
Set vision, strategy and objectives
OPERATING PLAN
Policies, Procedures
RESOURCES
Budgets, Positions, Capital
MEASUREMENT
Process/outcomes to achieve objectives
IMPROVEMENT
Departmental and cross-functional teams seek
improvement
ACCOUNTABILITY
Hold people accountable for choices
THE TARGET IS PERFECTION BUT IT’S A
JOURNEY: TAKE THE FIRST STEP
Eliminate Failures to Deliver Effective Care

Eliminate Preventable Harm
Ensure Service Excellence
Negotiate Timelines Not Targets

“All this will not be finished in the first one hundred days. Nor will it be finished in the
first one thousand days, nor in the life of this Administration, nor even perhaps in our
lifetime on this planet. But let us begin.” It a Journey …J.F.K Inaugural Speech 1961
ZERO HARM SCORECARD
• ZERO HARM SCORECARD
• Harm Count NOT Rates or Ratios
• Organization Level and Unit Level
• Definitions, Baseline, goals
• Transparency & Accountability

WITH A FOCUS
1. Aim: What are we trying to accomplish?
• Set Aims that are measurable, time specific and apply to defined population
2. Measurement: How we will know a change is an improvement?

• Establish measures to determine if specific change leads to improvement
3. Theory of improvement: What changes can we make that will result in

an improvement?
• Select interventions that are most likely to result in improvement
WHAT TO MEASURE?
PROCESS STRUCTURES OUTCOMES
Process measures indicate what a

provider does to maintain or Structural measures give consumers Outcome measures reflect the
improve health, either for healthy a sense of a health care provider’s impact of the health care service
people or for those diagnosed with capacity, systems, and processes to or intervention on the health status
a health care condition (e.g. The provide high-quality care (e.g. the of patients (e.g. The rate of
percentage of people with ratio of providers to patients). surgical complications or hospital-
diabetes who had their blood acquired infections).
sugar tested and controlled).
QUALITY AIMS SELECTION CRITERIA
SURGICAL
AN-
SITE PRESSURE DISCHARGE PATIENT
CLABSI FALLS VTE VAP THROMBOTIC
INFECTION INJURY MEDICATION ENGAGEMENT
MEDICATIONS
(SSI)
Transformation and Strategic

Priority
Sensitivity to Operation
(Internal Experts)
Patient Experience
Regulatory and
Accreditations
KPIs and Benchmarking
High Volume
High Cost
High Risk
Problem Prone
Evidence Based Medicine

QUALITY AIMS MILESTONE CHART 2019
Aug 2019 Dec 2019
Jun 2019 Establish 1st year QA Drivers Quality Aims
diagram & change ideas Q4 Evaluation &
Meet with Internal Experts
Review applicable KPI data
Prepare QA Scorecards Oct 2019 Progress Reports
Prepare Quality Aims (QA) Facilitate QA Standing meetings
Communication Plan Initiate QA monthly check-in meetings
Select & Approve of Quality Aims Submit QA Q3 Progress report Feb 2020 Apr 2020
Prepare QA Budget Plan & PI Council report Ongoing facilitation Ongoing facilitation
Present Quality Aims to C SUITE
Jul 2019 Nov 2019 Mar 2020

Formulate project team leads Facilitate QA Standing meetings Quality Aims
Complete charters and indicators Initiate QA monthly check-in meetings Q1 Evaluation &
Roll-out QA Communication Plan Submit QA Q3 Progress report & PI Council report Progress Reports
Establish 1st year QA Drivers
diagram & change ideas
Sep 2019 Jan 2020 May 2020
Facilitate QA Standing meetings Ongoing facilitation Q2 Evaluation &
Initiate QA monthly check-in meetings Progress Reports
Submit QA Q2 Progress report & PI Council report
SUMMARY
• Health care is complex
• When things go wrong, adopting a system approach is far more

productive for patient safety than a person approach
THANK YOU
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KSUMC PATH TO:

Our mission calls us to deliver holistic care.

• Are those organizations that are high-risk, dynamic, turbulent, and

SAFETY + Quality + Satisfaction = Exceptional Care

Berwick, Donald. My Right Knee. Ann Intern Med,

• Healing without Harm by 2020 is a destination in quality,

• This destination is possible through the principles and

Psych Ob-Gyne SICU L&D Neuro DEM

Rate per 1,000 Patient Care Days PERCENTAGE

OUT-PATIENT AREAS DEPARTMENT OF EMERGENCY

PERCENTAGE RATE per 1,000 Patient Care Days

Rate per 1,000 Patient Care Days PERCENTAGE

OUT-PATIENT AREAS DEPARTMENT OF EMERGENCY

PERCENTAGE Rate per 1,000 Patient Care Days

Rate per 1,000 Patient Care Days PERCENTAGE

OUT-PATIENT AREAS DEPARTMENT OF EMERGENCY

PERCENTAGE Rate per 1,000 Patient Care Days

Rate per 1,000 Peripheral Device Care Days PERCENTAGE

Rate per 1,000 Peripheral Device Care Days

Rate per 1,000 Peripheral Device Care Days PERCENTAGE

Rate per 1,000 Peripheral Device Care Days

Q4 2018 Q1 2019 Q4 2018 Q1 2019

VENTILATOR ACQUIRED PNEUMONIA (VAP)

Preventable harm causes healthcare provider burnout and serious

Obvious to do the right thing

-4 Reliability Culture Core Values & Vertical Integration

• Maintain a powerful and uniform culture of safety (A “culture of

• Use optimal structures and procedures

• Provide intensive and continuing training of individuals and teams

• Conduct thorough organizational learning and safety management

Systematic approach to problem solving:

Three Principles of Anticipation:

• Demonstrate that it is possible to achieve high reliability at scale

Eliminate Failures to Deliver Effective Care

Negotiate Timelines Not Targets

• Organization Level and Unit Level

• Definitions, Baseline, goals

• Transparency & Accountability

2. Measurement: How we will know a change is an improvement?

3. Theory of improvement: What changes can we make that will result in

PROCESS STRUCTURES OUTCOMES

Process measures indicate what a

Transformation and Strategic

KPIs and Benchmarking

Evidence Based Medicine

Jul 2019 Nov 2019 Mar 2020

• Health care is complex

• When things go wrong, adopting a system approach is far more

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