Staff Perceptions of Patient Safety Appropriate Care To Virginians ACT Virginians

Transcription

1 Staff Perceptions of Patient Safety Appropriate Care To Virginians ACT Virginians Edna Rensing, RN, M.S.H.A., CPHQ This material was prepared by the Virginia Health Quality Center, the Medicare Quality Improvement Organization for Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. VHQC/1c/ /445

2 This Session What are we doing here patient safety Culture just or otherwise What is an error anyway Message we send Tools we use Other things that affect patient safety culture Hand offs and transitions SBAR WalkRounds Time and Timeline

3 ACT Virginians ROSC -It s About: Culture of quality improvement and patient safety TOP PRIORITY Hearing all the opportunities to make change before an error happens Patient centered family, friends, neighbors

4 Culture What is an error anyway and can we talk about it? Individual s perception Management perception Policies Literature says Legal Near miss/great save Can t address if not reported

5 If There is an Error Somebody Must Be at Fault Right? Error- not the conclusion but the beginning of the investigation System or the individual Roots of error Execution Planning Violation

6 Just Culture All in the Message Just but Accountable Everybody on the same playing field Set the rules and agree up front Write it down Just Blameless Punitive

7 Why Write the Rules Methodist Hospital in Indiana (9/17/2006) Six premies given wrong dose of Heparin Two died CEO message(9/19/2006) (9/24/2006) As Our part culture of our at Clarian continuing is one investigation that demands into these matters, forthrightness I met this when morning mistakes for are over made, two so hours that we with can learn virtually from all those of the mistakes Methodist and Hospital improve staff our involved systems and with offer the events higher of levels this of past patient care and weekend. While we will continue to investigate safety. matters in great detail, nothing we learned this morning deviates from what we reported yesterday afternoon -- namely, that human and procedural errors account for the administration of....

8 Just Culture All in the Message Some issues Different department, different message Slips Written vs. verbal cues how does it really sound and feel

9 Tools The Nurses Role in Promoting a Culture of Patient Safety - CEU Human Factor on-line training (Patient Safety Center) Human Factor & Just Culture tutorial (free) Blood bank error reporting system ($$) %20a%20just%20culture.pdf A Roadmap to a Just Culture: Enhancing the Safety Environment Algorithm and reporting system ($$)

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12 Collecting Useful Information Error Harm No harm (luck) Save (whew! Planned or unplanned) Cause Individual System Risk level and response

13 What Do You Do With Those Reports Stash in a drawer Collect in a database Set up levels of RISK Trend over time RCA Maybe fix a system fault Just do something with the data or you will lose them

14 Just Culture Group interaction Introduce yourself and area Which part of Just Culture do you think will be difficult to begin? What question do you have for others Give an example of a Just and Unjust response to error you received or have seen

15 Hand Offs and Transitions SBAR Issues and errors Amazing, it s all about communicating and understanding each other - AGAIN

16 What Do We Want? Safety is the Top Priority! Begin with behaviors that improve patient safety. Assertive Communication The Toyota Production System Pull the cord and stop the assembly line.

17 Understand Factors that Affect Communication Education Nurses narrative and descriptive. Physicians problem solve,want only the headlines. Teamwork Nurses: environment not collaborative. Physicians: fairly collaborative. Environmental Impact Interruptions and distractions, can t remember Assertiveness Skills Not everyone has the ability to speak up. The areas mentioned above are not meant to be inclusive of all factors that affect communication.

18 Assertion Cycle. This is a model to guide and improve assertion in the interest of patient safety GET PERSON S ATTENTION REACH DECISION EXPRESS CONCERN PROPOSE ACTION STATE PROBLEM Source: M. Leonard, S Graham, D Bonacum

19 US Navy Nuclear Submarine Service Communication Model SBAR S = Situation B = Background A = Assessment R = Resolution USS Dolphin (AFSS 555) Photographer's Mate 2nd Class Michael D. Kennedy. [ N-5067K-004] May 22, 2002

20 Why SBAR? Provides answers to physicians three main questions What is the problem? What do you need me to do? When do I have to respond? Standardized approach - efficient transfer of key information Helps create an environment to express concerns

21 Successful Clinical Change Requires: Visible Leadership Support Administrative and Clinical Goals and incentives aligned Physician Champion (Role) Educates physicians on the need for having patience during staff s learning curve. Culture change for some physicians. Physicians need to be careful not to alienate staff. Obtain buy in from physicians. Identify distinguishing behaviors that do not support SBAR communication and speak to those physicians.

22 What is the Definition of SBAR? S = Situation What is going on with the patient. A concise statement of the problem. B = Background What is the clinical background information that is pertinent to the situation. A = Assessment What did you find? Analysis and considerations of options. R = Recommendation What action/recommendation is needed to correct the problem. What do you want?

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25 Practice Situation Mary s patient Henrietta Hobson had her spleen removed this morning. She had a little trouble in the PACU with a low urine output but that seems to be stable right now. They put in a catheter and she is putting out 30 cc/hr. Her blood pressure is low now 75/50, HR-150 and she is a little diaphoretic. Ms. Hobson is a preacher s wife and teaches Sunday school so she needs to be out of the hospital in 5 days. She had a CXR three years ago for a cough and nothing was seen. It just went away. Examining her you see that her abdomen in more distended now than it was 10 minutes ago and there is a bit of seepage bright red on her dressing. Her PPD reads normal she had that test a couple of days ago. She has no know allergies. Last labs (H/H and Glu) were drawn in the PACU and were WNL

26 SBAR Guidelines: Step 1 1. Have all the patient s information available before you contact the physician. Name Medical record number Age Diagnosis Medication list Allergies Vital signs Lab results Advance Directive

27 SBAR Guidelines: Step 2 2. A physical assessment has been conducted Have I seen and assessed the patient myself before calling Review the chart for appropriate physician to call Reviewed the chart for appropriate information

28 SBAR Guidelines: Step 3 3. When calling the physician, follow the SBAR process: (S) Situation: What is the situation you are calling about? Identify self, hospital, patient, patient location in hospital What is going on with the patient. A concise statement of the problem

29 SBAR Guidelines: Step 3 (cont.) (B) Background: What is the clinical background information that is pertinent to the situation The admitting diagnosis and date of admission List of current medications, allergies, IV fluids, etc Most recent vital signs Lab results: provide the date and time test was done and results of previous tests for comparison Advance Directive

30 SBAR Guidelines: Step 3 (cont.) (A)Assessment: What are the clinician s findings What is the analysis and consideration of options Is this problem severe or life threatening

31 SBAR Guidelines: Step 3 (cont.) (R) Recommendation: What action/recommendation is needed to correct the problem What solution can you offer the physician What do you need from the physician to improve the patient s condition

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33 Even used for transferring within the hospital pg 173

34 SBAR POCKET CARD In the interest of Patient Safety and to ensure we are giving complete, accurate information to the physician, please use the following acronym to direct the information we provide: S (the current Situation or problem) B (a little about the patient s Background) A (your Assessment of the patient) R (your Recommendation of what is needed from the physician) 2005 Institute for Healthcare Improvement

35 What do you do if SBAR does not work? It s okay to C.U.S.!

36 C.U.S. (From Aviation United Airlines) We have a serious problem. Stop and listen to me! C = I am Concerned (with my patient s condition) U = I am Uncomfortable (with my patient s condition) S = The Safety (of the patient) is at risk

37 What to do if C.U.S. doesn t work Design policies that guide when not followed Might include: Who to contact (supervisor, physician, medical director) Consulting with Quality Improvement, Risk Management,etc.

38 Hand Offs and Transition Group interaction Can you see a place or time SBAR or CUS would be useful in your institution? Do you see any issues implementing this type of communication style?

39 WalkRounds Senior leaders, using a pre-selected script, to talk with employees Routinely monthly or more frequently visit all departments and all shifts Collect information, track it, do something with it Moves from environmental issues to other safety issues as comfort level increases

40 Change Takes TIME, a whole lot of COMMUNICATION and support from all levels Creating a safety environment is everyone s responsibility

41 Fairy Tales Describe a fairy tale that you experienced Did it work or fail? Why or why not? Was leadership supporting it throughout?

42 It is not by accident that you were chosen to be a leader. It is your destiny. Sensei Chihiro Nakao MAKE SAFETY A TOP PRIORITY

43 References Joint Commission on Accreditation of Healthcare Organizations. Sentinel Events Statistics. Root Causes of Sentinel Events, , Joint Commission on Accreditation of Healthcare Organizations. Sentinel Events Statistics. Settings of Sentinel Events, Available at: Leonard M, Bonacum D, Taggart B Using SBAR to Improve Communication Between Caregivers. Institute for Healthcare Improvement. Leonard M The SBAR Technique: Improving Verbal Communication and Teamwork in Clinical Care. PONL Bulletin. Volume 2, Issue 1. Leonard M, Graham S, Bonacum D The Human Factor: The Critical Importance of Teamwork and Communication in Providing Self Care. Qual Saf Heath Care :i85-i BMJ Publishing Group Ltd. and Institute for Healthcare Improvement.

44 References continued Nunes J Patient Safety Leadership Fellowship Learnings Help Put Theory into Practice. A Newsletter from the National Patient Safety Foundation. Volume 8: Issue 3. Whittington J, Nagamine J SBAR: Application and Critical Success Factors of Implementation. Institute for Healthcare Improvement