leonard plenary icch09 powerpoint
TRANSCRIPT
The Path to Safe & Reliable Healthcare
Michael Leonard, MD
Confidential
Profile of Market Leaders• Superior safety / quality and operational
efficiency is their non-negotiable core value• Transparency of clinical data and process• Leadership engagement and accountability -
senior and clinical, just culture• Learning organization - systematic flow of
information and intervention • Culture / risk maps, direct observation• Cultural work - teamwork & communication,
environment of respect• Reliable /resilient processes - robust process
improvement• Measurement and feedback - put it on the wall
Confidential
Team Practice Key Components
© 2008 Pascal Metrics3
LEADERSLeader Attributes
Respect is expected– Non-negotiable
& mutual Psychological safety is
assured– Everyone is fallible– All concerns are
important Excellence is expected
– Determination to fulfill goals
Choose team members– Knowledge
• Clinical• Improvement
– Skills– Attitudes– Behaviors
TEAMSTeam-member Behaviors The game plan is always
known– Brief and re-brief
Communication is clear– Closed loop– SBAR — structured
communication Learning is continuous
– Debriefings
UNITSImprovement
(Improving Improving) Testing is continuous
– Rapid cycle improvement
– Lean– Six sigma– Reliable design Unit structure and
resources support performance improvement
Conflicts are resolved– Critical Language– Crucial Conversation
Situational awareness is maintained
Confidential
Leading With Safety - Thomas Krause• Why do some organizations do well with safety
initiatives while others do poorly or fail?• The most important factor in predicting
success was the quality of leadership and the organizational culture
• Organizations highly successful in safety were also generally successful in operational performance
© 2008 Pascal Metrics4
Confidential
Attributes of the Right Stuff • Behaviors – particularly leadership • Engagement at all levels of the organization• Understand crucial aspects of human
performance• To continuously improve performance and
achieve superior results the organizational culture must change – meaning behavioral change
• They address and align the behaviors of everyone
© 2008 Pascal Metrics5 Krause – Leading with Safety 2005
Confidential
Safety Attitudes Questionnaire:Items Are Grouped Into Six Factors
© 2008 Pascal Metrics6
Factor: Definition Example ItemsJob Satisfaction:
Positivity about the work experience
I like my jobThis hospital is a good place to work
Teamwork Climate:
Perceived quality of collaboration between personnel
Disagreements in this clinical area are appropriately resolved (i.e., what is best for the patient)Our doctors and nurses work together as a well coordinated team
Safety Climate:
Perceptions of a strong and proactive organizational commitment to safety
I would feel safe being treated in this clinical areaMedical errors are handled appropriately in this clinical area
Perceptions of Management:
Approval of managerial action Hospital management supports my daily efforts in this clinical areaHospital management does not knowingly compromise the safety of patients
Stress Recognition:
Acknowledgement of how performance is influenced by stressors
I am less effective at work when fatiguedWhen my workload becomes excessive, my performance is impaired
Working Conditions:
Perceived quality of the work environment and logistical support (staffing, training, etc.)
Trainees in my discipline are adequately supervisedThis hospital deals constructively with problem personnel
0
10
20
30
40
50
60
70
80
90
100
RN rates Physician Physician rates RN
% o
f res
pond
ents
repo
rting
abo
ve a
dequ
ate
team
work Teamwork in the eye of the
beholder: ICU RNs and ICU MDs rate each other
62 Michigan ICUs 2004Only ICUs with 5 or more physicians reported here (all had 5 or more RNs)
Confidential
Teamwork Climate Across Michigan ICUs
© 2008 Pascal Metrics8
No BSI = 5 months or more w/ zero
The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient
care
Confidential
Teamwork Climate Across Occupations
© 2008 Pascal Metrics9
Confidential
“The physicians and nurses here work together as a well-coordinated team.”
© 2008 Pascal Metrics10
Confidential
“In this clinical area, it is difficult to speak up if I perceive a problem with patient care.”
© 2008 Pascal Metrics11
Confidential
“Disagreements in this clinical area are resolved appropriately (i.e. Not who is right, but what is best for the patient).”
© 2008 Pascal Metrics12
Confidential
“Nurse input is well received in this clinical area.”
© 2008 Pascal Metrics13
Confidential ⓒ 2008 Lotus Forum Inc.
Labor and Delivery Collaboration Map
ⓒ 2008 Lotus Forum Inc.
14
Job Position Response Rate (Returned/Admin)
Age Mean Years (± SD)
Obstetrician 67% (494/739) 45 (9.91)Anesthesiologist 54% (213/401) 44 (7.83)Registered Nurse 77% (1877/2442) 42 (10.71)LVN/OBa 81% (227/280) 42 (10.95)Nurse Manager & Charge Nurse 79% (136/172) 46 (7.56)
Table 1: Labor and Delivery Respondent DemographicsaLVN/OB is licensed vocational nurse/obstetrical technician
OBSTETRICIANS ANESTHESIOLOGISTS
NURSE MANAGERS/CHARGE NURSES
REGISTEREDNURSES
LVN/OBTECHNICIANS
Confidential
Within Hosp #22, which units are the most/least culturally positive?
Confidential
Radar Diagram
Confidential
HUMAN FACTORS: Performance in a Complex Environment
17
Confidential
Inherent Human Limitations
* Limited memory capacity – 5-7 pieces of information in short term memory
* Negative effects of stress – error rates * Tunnel vision
* Negative influence of fatigue and other physiological factors
* Limited ability to multitask – cell phones and driving
Confidential © 2008 Pascal Metrics19
Confidential
Structuring the Nursing Work* Big picture or task performance?* Tucker & Spear: med-surg observation, at
least 100 discrete tasks per 8 hour shift:Average 3 minutes / taskNo ability to sequence – juggling, prioritizing
tasksFormally interrupted at least once / hour
Tucker AL, Spear SJ, HSR, June 2006
Confidential
Human Factors: The Foundation of Reliability• Effective team
performance• Structured
communication• Reliable processes• Continuous learning
and improvement
© 2008 Pascal Metrics21
Confidential
Why Communication? Why Teamwork?• The overwhelming majority of
untoward events involve communication failure
• Wrong site surgery — somebody knows there’s a problem but can’t get everyone in the same movie
• The clinical environment has evolved beyond the limitations of individual human performance
© 2008 Pascal Metrics22
Confidential © 2008 Pascal Metrics23 ngerman
Confidential
Christian et al – Patient Safety in the OR
*“Problems in communication and information flow, and workload and competing tasks were found to have measurable impact on team performance and patient safety in all 10 cases”*Information loss – 19 delays, 30 instances of uncertainty among other providers*Circ RN leaves room for something 33 times / case, average of once every 8 minutes *Counts – while closing, 14 % of their time counting
Surgery 2006, 139: 159-173
Confidential
Effective Communication and Teamwork Requires:
© 2008 Pascal Metrics25
Structured Communication
SBAR
Assertion/Critical Language
Key words, the ability to speak up and stop the show
Psychological Safety An environment of respectEffective Leadership Flat hierarchy, sharing the plan,
continuously inviting other team members into the conversation, explicitly asking people to share questions or concerns, using people’s names
Confidential
Effective Communication • Have a plan• The value of a structured process• Hand-offs are dangerous• Structured language/clarity • Who owns the patient?• What are the parameters for increasing
the intensity of care?
© 2008 Pascal Metrics26
Confidential © 2008 Pascal Metrics27 ob money
Confidential
Setting the Stage• Vascular surgeon doing new, complicated
procedure – endovascular aortic stent — in CV lab:
“I don’t have any pride invested here. I just want to get this right, so if you think of anything helpful or see me doing anything wrong, please let me know.”
© 2008 Pascal Metrics28
Confidential © 2008 Pascal Metrics29
Confidential
“I know the names of all the personnel that I worked with during my last shift”
© 2008 Pascal Metrics30
Confidential
Briefings• Share the game plan• Set the stage — psychological safety• Norms of conduct• Disavow perfection – a little humility goes a long way• Engage every participant using eye contact and
people’s names• Explicitly ask for input about concerns or issues • Provide information and talk about next steps• Seek useful information• Update as needed — build into procedure
© 2008 Pascal Metrics31
Confidential
Confidential © 2008 Pascal Metrics33
Confidential
SBAR• Enhances predictability — how we are
going to talk with each other• Crisp — to the point• Promotes critical thinking• Similar in structure to the SOAP model
(subjective/objective/ assessment/plan) that is taught in nursing and medical schools
© 2008 Pascal Metrics34
Confidential35Courtesy Dr. David Morehead
Confidential
Why is Assertion/Critical Language Important?• Because we know 25-40% of nurses
tell us on the Safety Attitude Questionnaire they would be hesitant to speak up if they saw an MD making a mistake
• Often people do not speak up or do so quite indirectly
• Knowing the plan — using SBAR — makes it much easier to speak up
© 2008 Pascal Metrics36
Confidential
AssertionModel to guide and improve assertion in the interest of patient safety
© 2008 Pascal Metrics37
GET PERSON’S GET PERSON’S ATTENTIONATTENTION
EXPRESSEXPRESSCONCERNCONCERN
STATESTATEPROBLEMPROBLEM
PROPOSEPROPOSEACTIONACTION
REACH REACH DECISIONDECISION
Confidential
Confidential
Confidential
Confidential
Red Flags: Loss of Situational Awareness• Ambiguity• Reduced/poor communication• Confusion• Trying something new under pressure• Deviating from established norms• Verbal violence• Doesn’t feel right• Fixation/boredom/task saturation• Being rushed/behind schedule
© 2008 Pascal Metrics41
Confidential
How do experts and novices make decisions?
• Experts pattern match against a large mental library of past experience. It is very quick and quite accurate if they continue to seek confirming evidence.
• Novices cannot do this; their library is empty; they have not seen it before. They use a slow, error-prone process.
• Experts need to teach the patterns to novices, even if the answers appear overly obvious — that’s how we help them become expert.
© 2008 Pascal Metrics42
Confidential
Glitch Book• A physical book that is used to document
and help track the solution with:
– Equipment that needs to be fixed or replaced
– Information that got lost– Something that was supposed to happen
for the patient and did not
© 2008 Pascal Metrics43
Confidential
Debriefing• An opportunity for individual, team
and organizational learning• The more specific, the better• What did we do well? What did we
learn? What would we do differently next time?
• Take a minute or two to learn while it is fresh in everyone’s head
© 2008 Pascal Metrics44
Confidential
Effective Debriefing• Be crisp and to the point• Do it while the experience is fresh• Everyone gets a chance to speak• Start with the junior folks —
otherwise they can be overshadowed by the veterans
• Avoid judgment and criticism — this has to be a positive learning experience
© 2008 Pascal Metrics45
Confidential
Annotations
1: Marked beds at 30 degree angle2: Fact Sheet for staff education3: Poster with weekly data feedback4: Vent bundle posted in all vent patient rooms5: Began initial trials of Daily goal sheet and pre-extubation sheet6: Initiated Powerpoint education for RT/RN7: Initiated Clinical Pharm rounds8: 1st test of multidisciplinary rounds9: Expanded use of Pre-extubation sheet
ICU Percent of Patients Receiving all Four Aspects Of Ventilator Bundle
© 2008 Pascal Metrics Inc.46
10: Staff education on Goal sheet; mini inservices on unit on SBT and Pre-extubation sheet11: Incorporated Goal Sheet into Multidisciplinary Rounds12: Impact Extravaganza (staff/MD education)13: Expanded multidisciplinary rounds to include additional disciplines14: Check compliance on night shift past 2 weeks15: New sign at HOB,16: One on one follow up by Nursing & RT managers on collaboratiion in weaning process
Confidential