Session #3: Weaving Together the Critical Components of a Strong and Comprehensive Patient Safety Program

Transcription

1 Session #3: Weaving Together the Critical Components of a Strong and Comprehensive Patient Safety Program Panelists: Chelsie Bakken, MBA, R.N. and Melissa Jones, R.N. Facilitator: Martin J. Hatlie, J.D. Thursday, Oct. 25, a.m. Minnesota Ballroom Sponsored by:

2 Chelsie Bakken, MBA, BSN, B.S., R.N. Chelsie Bakken is the manager of patient safety for CentraCare Health St. Cloud Hospital. Her professional experience in psychology and nursing are a strong combination for the work of a patient safety professional. Chelsie leads a program that utilizes innovative, evidence-based strategies to reduce patient harm and increase patient safety. She has presented both locally, on the subject of caregiver resilience/wellbeing and patient safety culture, as well as nationally, on safety event reporting. Melissa Jones MHA, BSN, R.N. Melissa Jones serves CentraCare St. Cloud as senior performance improvement clinical consultant for patient experience/patient safety and is a motivated advocate for patient safety improvements. Her career in surgery and quality-based leadership gives Melissa an empathetic heart to the challenges faced daily by caregivers. With experienced perspective, Melissa effects quality attainment alongside resilience improvement for those in operational health care. Melissa values evidence-based analytical approaches to complicated issues leading to practical team-generated solutions. A published co-author in Diagnosis and a presenter at Diagnostic Error in Medicine International Conference, Melissa is a respected contributor regarding patient experience and safety. Martin J Hatlie, J.D. Marty Hatlie is co-director of the MedStar Institute for Quality and Safety, which integrates open and honest communication strategies, patient and family engagement, research and high reliability organization methods into quality and safety improvement. He also serves as president and CEO for Project Patient Care, a Chicago-based safety and quality improvement coalition dedicated to using the voice of the patient to improve care. He is active in federal health system transformation work as a consultant on several projects funded by Centers for Medicare and Medicaid Services, Agency for Healthcare Research & Quality and the Patient Centered Outcomes Research Institute.

3 Weaving Together the Critical Components of a Strong and Comprehensive Patient Safety Program using Communication & Optimal Resolution (CANDOR) CentraCare Health Presenters Chelsie Bakken, MBA, BSN, RN, CPPS, Manager, Patient Safety Melissa Jones MHA, BSN, RN,Sr. Performance Improvement Clinical Consultant Session Facilitator Martin J Hatlie, JD, Co-Director, MedStar Institute for Quality and Safety Sponsored by the MMIC Group 1

4 What is CANDOR? CANDOR (CommunicationandOptimalResolution) is the acronym associated with a dynamic new toolkit published in May 2016 by the Agency for Healthcare Research and Quality (AHRQ). developed to accelerate redesign of traditional deny and defend responses to patient safety events. 2

5 1 Identification of CANDOR Event 2 CANDOR System Activation 3 Response and Communication 4 Investigation and Analysis Event Review 5 Resolution Why CANDOR? Why Now? 3

6 The Problem Makary and Daniel BMJ 2016; 352:i2139 What Do Patients Want After a Harm Event? The truth What is it? The facts What are they? Emotional first aid Empathy and compassion Recognition and validation of emotions Non-abandonment Accountability, including apology if the standard of care was breached Compensation and/or some other meaningful response? Learning and future prevention Module 1 8 4

7 Making Matters Worse Impact of The Wall swallowed up life demanded constant attention and study multiplied attention and strain generated pattern of broken sleep felt integrity as a person and physician had been damaged and might be permanently lost 5

8 The Unkind Acts Cascade: Collateral Damage of The Wall of Silence Agency for Healthcare Research and Quality Patient Safety Net: 2016 October 16,

9 The Paradigm Shift Reporting Communication Event Review Care for the Caregiver Resolution from delayed to immediate from delay, deny and defend to immediate and ongoing from shame, blame, and train to human factors process redesign from suffering in isolation to immediate and ongoing support from having to fight for it to early offer Why CANDOR at CentraCare? Harm events at CentraCare Stresses of system expansion Gaps in some processes The need to braid 7

10 CANDOR is a CRP CRP = Communication and Resolution Program CRPs seek to normalize compassionate honesty CANDOR: Braided together CentraCare work already started: Patient Experience Resilience Safety Just Culture Our goal: To implement CANDOR as CentraCare s Comprehensive, Principled, Systematic Approach to the Prevention and Response to Patient Harm CANDOR Gap Analysis -- Pre-Site Visit Review of important documents, including recent survey results Facilitated focus groups of key different stakeholders Areas of discussion include: High Reliability Domains: Culture, Leadership, Improvement National Quality Forum Safe Practices: Leadership: Safe Practice 1 Culture: Safe Practice 2 Identification and mitigation of risks and hazards, including event reporting and analysis: Safe Practice 4 Informed consent; Safe Practice 5 Communication, disclosure, and resolution following harm: Safe Practice 7 Caring for caregivers: Safe Practice 8 8

11 The On Site Component: Stakeholder Meetings Hospital Leadership Medical Staff Leadership Hospital Clinic Safety/Risk/Quality Claims Legal Patient Experience Unit Managers Patient & Family Advisory Council Board of Directors Frontline Clinical, e.g. Nursing, Pharmacy Non-Clinical Hospital, e.g. Transporters. Watchers, IT Non-Clinical Ambulatory, e.g. Front Desk Staff Marketing/Communications Planning CANDOR Gap Analysis Report creation: Specific results for several hundred questions posed to stakeholders Identification of common themes Assessment of readiness High Reliability assessment SWOT analysis Recommendations for Next Steps Usually reported to a trusted leader or leadership team At CentraCare, our leadership chose to share the results at an open meeting with anyone in our staff community interested in hearing them. 9

12 What We Heard To be free to tell the patients what really went wrong. Build on partnership with providers as they are engaged to develop the future. Improve relationships across the system, better but room for improvement. We need to be in action sooner communicating with patients and staff. If ever hour passing is a new harm, we can do better. Themes Rapid growth has exceeded capacity to manage work and is fueling burnout. Uneven responses in caring for staff when things go wrong. Inability to recruit a critical mass of physicians to the CANDOR process. Ongoing burnout from change fatigue and the growing exposure to incivility in the workplace. Implementation Steering Committee Four Workgroups Disclosure Care for the Caregiver Resolution Discovery & Learning Policy review to consider shift from focus on error to harm Define CANDOR event 10

13 Challenges and Strengths Our Challenges Discomfort Fear of transparency Worry about the unknown We re already doing this Focus on Resolution as financial Provider engagement Our Strengths Leadership very committed Strong support from legal and claims MMIC partnership We re Seeing Change Already Leadership very engaged Peeling the Onion on Discomfort/Fear/Worry Our disclosure process different after a recent harm event Process mapping that is expediting our resolution and learning processes A strong partnership between Patient Safety and Patient Experience. Much more thought & discussion about emotional harm. 11

14 Questions? Comments? Thank you Chelsie Baaken: Melissa Jones: 12