quality and safety: are you creating an environment for safe, high quality care? carolyn obrien,...
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Quality and Safety: Are you creating an environment for safe, high quality care?
Carolyn O’Brien, MSN, RN
Mayo Clinic
• International reputation for excellent patient care
• Long tradition of focus on quality care, putting the patient first
• Primary Value:• “The needs of the patient come first”
Mission and Vision
• To inspire hope and contribute to health and well-being by providing the best care to every patient through integrated clinical practice, education and research
• Mayo will provide an unparalleled experience as the most trusted partner for healthcare
• In order to be trusted, we must be safe
How does Mayo define Quality?
• Service
• Outcomes
• Safety
Service
• Patient Satisfaction
• Awarded #1 hospital in patient satisfaction in 2010 and 2011 by Professional Research Consultants, Inc. (PRC) –patient satisfaction vendor
• Strong organizational focus and leadership involvement
Outcomes
• Quality Improvement (QI)• Strongly woven into the fabric of our
organization• Improve outcomes by improving systems
and processes
• Positive, healthy culture is determining factor in success or failure of performance improvement interventions
Safety
• Foundation of Quality Care
• Mayo’s Commitment to Safety• Healthy culture, where staff speak up about
safety concerns and work in an environment where we learn from and respond fairly to errors
• Safe behaviors• Safe systems and processes
Culture and Patient Safety
• Required elements for a healthy culture• Psychological safety• Organizational fairness• Transparency
Psychological Safety
• Definition: “people’s perception of the consequences associated with taking personal risks.” (TEM Field Manual, 2012)
• Present when people feel free to speak up and questions are welcomed
• Mutual respect is key• Professional tone of communication• Flattened hierarchy between disciplines• Management of disruptive behavior
How do we know if we have psychological safety?
• Staff are not hesitant to speak about patient safety concerns
• Staff are treated with respect when concerns are expressed
• Concerns are acted on
How do we promote psychological safety?
• Unit and organizational leaders encourage staff to raise concerns and welcome it
• Encourage feedback and act on it
• Celebrate and praise new ideas
Organizational Fairness
• Historically- healthcare has been a culture of blame and punishment, a punitive culture
• A punitive culture discourages staff from speaking up
• Safety depends on people speaking up• Reporting errors• Reporting and identifying “near misses”
Just Culture
• “Leaders, managers and staff all value safety and create an environment where mistakes can be shared and learning occurs through identification of faulty processes and at-risk behaviors (J of Nurs Qual Vol 22, No.3 pp 210-212)
• Encourages staff to use their unique position on the “frontline” to identify safety issues and speak up
Fair and Just Culture
• Moving from culture of blame, to “fair and just”
• Responding to errors in a fair and consistent manner
• System of accountability
• Systems and behaviors are examined
• Not individuals and outcomes(Mayo Clinic and Pascal Metrics, Inc. 2012)
Individual Behavioral Choice
• Human error• Inadvertent action • Lapse, slip, mistake• Often involve underlying system issues• Increases with complexity of task
Individual Behavioral Choice
• Risky (Drift)• Behavioral Choice that increases risk where
risk is unrecognized or mistakenly believed to be justified
• Drift- “individual drifts away from what has been taught through the human desire to accomplish more or through a fading perception of risk as the individual becomes increasingly comfortable or competent in their work”
(Outcomes Engineering, LLC, 2007)
Individual Behavioral Choices
• Reckless• Behavioral choice to consciously disregard a
substantial and unjustifiable risk• Putting self-interest above that of the patient
or organization
Management Response
• Thoughtful deliberation related to staff choices
• Human error• Console and Learn
• Risky • Coach/Learn
• Reckless• Corrective Action
Transparency
• Leaders conduct rounds to seek out and discuss current processes and opportunities for improvement
• Outcomes, adverse event, near misses are openly discussed on regular basis and data is shared with all caregivers
• Learning is visible - Boards on units that show active work on process improvement
This is Mayo Clinic’s Commitment to Safety
System Competency
Behavioral Competency
Clearly Defined Behaviors
• Pay attention to detail
• Communicate clearly• Have a questioning
and receptive attitude
• Hand-off effectively• Support each other
Accountability for Behavior
Preventable Harm
Commitment to Safety in a fair & just culture
Standardization & Diffusion of Best Practices
Safe Care & Value
• Handoffs and transitions
• Medication errors• Rapid response team
and deteriorating patient
Approved by BOG/Management Team 1/24/2011
Pay Attention to Detail
• Intentional focus on specific task to avoid errors
• Mindful of task and ramifications
• Eliminate distractions-noise, interruptions, other thoughts
(Mayo Clinic and Pascal Metrics, Inc.)
Communicate Clearly
• Accurate exchange of information that ensures comprehension
• Communication is intentional, respectful
• Be aware of body language and tone
• Verify accuracy and understanding
(Mayo Clinic and Pascal Metrics, Inc.)
Have a Questioning and Receptive Attitude
• Empowerment to speak up without fear in order to prevent harm
• Open and respectful to those asking questions
• Responsive and appreciative for concerns raised
• Mutual respect
(Mayo Clinic and Pascal Metrics, Inc.)
Hand off Effectively
• Interactive process of passing on specific information from one person to another, transferring responsibility
• Watch body language, tone, respectful, non-intimidating
(Mayo Clinic and Pascal Metrics, Inc.)
Support Each Other
• A spirit of teamwork, collaboration and cooperation across professions and at all staff levels
• Mutually supportive and respectful behavior- keeping a common goal first- the patient
(Mayo Clinic and Pascal Metrics, Inc.)
Safe Behaviors = How we communicate
• Effective communication is integral part of a healthy, safe culture• Communicate clearly- “speak up”• Handoff effectively• Questioning and receptive attitude• Support each other
How do nurse leaders at every level contribute to safe, high quality care?
• Create environment and culture where staff feel empowered to:• Speak up• Question the way we do things• Support one another• Are accountable for choices/actions• Learn from errors, don’t blame others
Leadership
• Unit and organizational culture is shaped by leaders attitudes and behaviors
• Effective leaders • Set a positive tone on unit• Share the plan, think out loud and elicit staff
input related to their expertise, ideas and concerns
• Are approachable, encourage open communication
Teamwork and Communication
• The next steps in keeping our patients safe and preventing harm focuses on teamwork
• High performing, effective teams have• Team Behaviors
• Structured communication• “Hard-wire” performance improvement
into everyday work• Team Attitudes
• Ensure psychological safety• Set expectation of excellence
31
A Team is a Group with:
• Common goals and a game plan• Agreed upon behaviors• Agreed upon attitudes
MAYO’S 5 SAFE BEHAVIORS ARE NORMS
32
A Team:
Plans Forward
Reflects Back
Briefings (huddle, pause, timeout, check-in)
Debriefings
Communicates Clearly Using Structured Critical Language
The associated behaviors:
33
Briefings
•Also known as:•Huddle•Pause•Timeout•Check-in
COMPONENTS
• Everyone knows the game plan
• Psychological Safety is ensured
• Expectation of excellence is set
34
Debriefings
•Debriefings can be the best tool for learning
•Three Questions
• What did we do well?
• What could we do better?
• What do we want to dodifferently tomorrow ornext time?
35
Critical Language:
•Positive Assertion•A PHRASE THAT STOPS THE WORK•“I just need a little clarity.”•“I am concerned, unclear, this is unsafe.”
•SBAR•Situation, Background, Assessment, Recommendation•Structured, predictable method of communication
•Repeat Back•Critical labs, medication dosages
“Mayo’s Model of Teamwork”Team Training
• ID unit, collect data, share results, team training
• Ensure psychological safety
• Embed team behaviors• Briefings, debriefings, critical language
• Improve processes
• Make work visible- transparent• Learning boards• Set goals• PDSA• Display knowledge gained
• Sustainable process to effect needed improvement
Team-Based Engagement
Collect Data
TeamTraining
Identify Unit
Implement Team
Behaviors 1
Improve Systems (based on
debriefings)2
Display the Data (learning
boards)
3
Eliminate
Preventable
Harm
Culture & Teamwork
Systems
©2011 MFMER | slide-38
Learning Board3 North
Ongoing Work: Further shifting our culture
• Model of teamwork
• How we….• do our work• communicate • identify safety concerns• improve safety• improve outcomes• improve quality
• It is a journey……
Questions?
References• Mayo Clinic and Pascal Metrics, “Commitment to Safety Team-based Engagement Model
(TEM)” PowerPoint, July 31, 2012.
• Mayo Clinic. (2012). Mayo Clinic Commitment to Safety. Retrieved July 28, 2012 from Mayo Clinic Web site: http://intranet.mayo.edu/charlie/commitment-to-safety/
• Mayo Clinic and Pascal Metrics, Inc., Team-based Engagement Model (TEM) Field Manual, 2012.
• Outcomes Engineering, LLC. (2007). Just Culture Training for Healthcare Managers. Plano, TX: Outcome Engineering, LLC.
• Volgesmeier, A., Scott-Cawiezell, J. (2007). A Just Culture The Role of Nursing Leadership. Journal of Nursing Quality, Vol 22, No.3 pp 210-212.
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