10/24/2013. Creating A Culture Of Safety Through Disrupting Healthcare Education

Transcription

1 Creating A Culture Of Safety Through Disrupting Healthcare Education Kathleen Gallo PhD, MBA, RN, FAAN Senior Vice President & Chief Learning Officer North Shore LIJ Health System 1

2 The study by the independent Institute of Medicine estimated that, in hospitals alone, mistakes from drug mix ups to surgical errors to misdiagnoses kill as many as 98,000 people yearly. In addressing basic safety, it said, health care is at least a decade behind other highrisk industries. In The News What should have been a blessed time for actor Dennis Quaid and his wife, Kimberly Buffington, turned into a time of anguish and anxiety, after their newborn twins nearly died from an accidental overdose of a blood thinning drug. 6 2

3 The Journal News, August 27, 2005 A patient at Phelps Memorial Hospital Center had an operationthisweekonthewrongareaofhisbody,in the second local case of so called wrong site surgery in two months. Dana Carvey's Medical Nightmare Doctor says he made an honest mistake Two months after the bypass symptoms returned As Dana Carvey tells it, it, he he was was lying lying on on a hospital a gurney in May of hospital 1998, after gurney undergoing May aof diagnostic 1998, after angiogram at Cedars Sinai undergoing Medical Center a diagnostic in Los Angeles... angiogram at Cedars- Sinai Medical Center in Los Angeles, awaiting word They on bypassed the effect the wrong of a double-bypass artery, the cardiologist operation said. performed You re hilarious, two months Carvey before. recalls That's saying, when but Dr. let me be the Neal comedian. Eigler Seriously, gave him doctor, the news. what happened? They bypassed the wrong artery. 3

4 How Hazardous Is Healthcare? 4

5 583 People Killed Because. Of the old style pecking order that led to excessive deference to a captain and the implicit assumption that a human captain could be perfect, clearly had to be abolished John Nance 2008, Why Hospitals Should Fly 5

6 Steve Irwin February 22, 1962 September 4, 2006 Crew Resource Management (CRM) Organized in 1979 to address the impact of human errors on the safety of Commercial Aviation Designed to train flight crews to acknowledge their human fallibility and measure their leadership abilities by how effectively they are able to use the capabilities, or resources, of their team in an atmosphere of free flowing communication CRM operates on simple behavioral premises that are easily grasped, yet must be practiced and repeatedly reinforced in order to become ingrained 6

7 Crew Resource Management Cont d Often the greatest hurdle is getting health care providers, who are accustomed to traditional medical hierarchy, to recognize that incorporating improved team structure can make their jobs simpler, safer, and ultimately more satisfying A key step is shifting the focus away from regarding personal responsibility as the sole means of error prevention to everyone is responsible for a good outcome CRM MedTeams TeamSTEPPS US Airways Flight 1549 Landing on the Hudson Flight Time: 4 minutes 15:26 15: Survived Because. There was no hierarchy gradient in the cockpit Role clarity was present Communication flowed freely The captain knew he was imperfect 7

8 Sully is clear for takeoff Chesley Burnett Sullenberger III Known for: Captain of US Airways Flight 1549 Famous flights: US Airways Flight 1549 which he successfully ditched in the Hudson River. Awards: Master's Medal from the Guild of Air Pilots and Air Navigators, Key to the City from The City of New York, Jabara Award for Airmanship from the USAF Academy The requirements for returning include ground school, simulator training and flying with a captain from the training department Human factors can be encompassed in three aspects of the health care profession: The individual involving their interrelationships with others, The job including the tools and equipment they use in the workplace, and the organization or environment in which they work 8

9 So Why Does Healthcare Need To Learn About Human Factors? To anticipate errors before they occur To encourage teamwork communication and reliable design To help systems become more error resistant To select the best error reduction strategies To focus on preventing future errors by designing safety into the system To create an environment of psychological safety where everyone and anyone feels comfortable to raise a concern including the patient/family Human factors engineering focuses on how systems work in actual practice, with real and fallible human beings at the controls, an attempts to design systems that optimize safety and minimize the risk of error in complex environments Teams Rule In complex problems, team performance will exceed the expected sum of all single actions Mutual monitoring can help to notice individual errors Shared workload can help to prevent the overstrain of an individual, and make sure that all tasks planned can be executed in a timely manner Mutual support and encouragement can enable team members to master even the most difficult situations Successful team performance results in low error, high quality patient care and high satisfaction of the healthcare provides 9

10 Perhaps The root of the problem may lie more in education than practice Important Part of the Solution Use simulation whenever possible for healthcare education Train in teams, those who are expected to work in teams Create new and realistic methods of learning without putting patients at risk 10

11 Interprofessional Education (IPE) Interprofessional education occurs when learners from the health professions and related disciplines learn together about the concepts of health care and the provision of healthcare services toward improving the effectiveness and quality of healthcare Essential Elements: Collaboration Respectful communication Reflection Application of knowledge and skills Experience in interprofessional teams Mutual understanding of roles Interprofessional Education (IPE) Why Increased incidence of preventable errors (IOM) How care is delivered is as important as what care is delivered Effective clinical teams are essential to the delivery of care that is patient centered, safe and efficient Train in teams those that work in teams Limitations of Traditional Training Variable clinical experience amongst individuals during training Limited experience of managing rare events Ethical considerations of using patients for learning Current environment difficult to discuss and learn from mistakes Limited opportunities to acquire proficiency of skills in procedures Focus is on individual learning of skills and knowledge during training Variation in educational preparation of team members 11

12 Deliberate Practice Activities that are specifically designed to improve the current level of performance Repeated application with use of knowledge over extended periods of time leads to remarkably good retention However. The lack of adequate feedback make efficient learning impossible. Mere repetition does not automatically improve performance K. Anders Ericsson PSI Mission The Patient Safety Institute, through education, collaboration, research and interprofessional simulation, assists members of the patient care team in achieving excellence in the delivery of quality and safe patient care. The Patient Safety Institute promotes a culture dedicated to caring, excellence, innovation, integrity, teamwork and improving the health of the community. PSI Vision The Patient Safety Institute will be an internationally recognized leader in interprofessional simulation and a model provider of clinical education, promoting the practice of safe and effective patient care. 12

13 The Patient Safety Institute ACLS Provider Online Course and Skills Testing Associate Fellow Course BLS Provider Online Course and Skills Testing Internal Medicine Residency Program Pediatric Clinical Interventions Session Pediatric Fundamental Critical Care Course Pediatric Procedure Course OB Emergency Drills PALS Instructor Course PALS Provider Online Course Pararescue Critical Care Course Pediatric Clinical Scenarios Pediatric Communication Course Southside Family Medicine Trauma Nursing Core Course Hofstra North Shore LIJ School of Medicine West Campus PSI Interprofessional Education Basic Obstetrics Behavioral Health Clinical Skills Program Behavioral Health Medical Emergency Simulation Program Cardiothoracic Surgical Team Emergency Medicine Pediatric Emergency Medicine Mock Codes PSI Nurse Fellowships Neonatology Resuscitation Pediatric Acute Care Assessment and Stabilization Perioperative Core Orientation Taming Sepsis Education for Nurses Perinatal Teams Simulation Instructor Course The William Randolph Hearst and Rhonda N. Gilbert Critical Care Nurse Fellowship Program The Emergency Department Nurse Fellowship Program The Pediatric Nurse Fellowship Program The Pediatric Hematology/Oncology Nurse Fellowship Program Course Development Process: A Team Approach Initial Contact Committing to the Partnership Developing the Program Finalize Program Design and Logistics Deliver Program Post-Program Review and Follow Up Planning meeting Faculty attends Simulation Instructor Course Design program according to established objectives Program agenda Faculty and participants execute the learning experience Post-program surveys completed by participants Establish program objectives Confirm program timeline Prepare scenario template for each scenario that is part of the program Distribute prework to participants Combine pre- and post-program learning, action learning, teaching methodologies, and delivery principles Debrief with faculty and PSI staff Share PSI s approach, experience, capabilities Conduct practice session to ensure scenarios meet learning objectives Take key learning from the delivery process into the redesign process 13

14 Patient Safety Institute Perinatal Delivery Patient Safety Institute Lithotripsy Unit North Shore University Hospital 14

15 Debrief Rooms Kolb Learning Cycle 15

16 What We Know For Sure No matter how sophisticated the technology, if humans are involved, errors will occur The brightest and best make errors Culture is directly related to the safety record The safety net is The Team not the individual Teamwork allows larger and more complicated tasks to be accomplished safely and effectively Teamwork Trumps Autonomy and Is Essential to a Culture of Safety 46 Trying harder will not work. Changing systems will IOM in Crossing the Quality Chasm Disruptive Innovation Interprofessional educational models are essential to develop and maintain interdisciplinary teams thereby advancing teamwork and improving patient safety 48 16

17 Innovation The Light Bulb was not a Continuous Improvement of the Candle Ronald Harden Train in teams those that work in teams! 17