Risky talk: How conversations advance safety cultures

Transcription

1 Risky talk: How conversations advance safety cultures IHI 2016 Presenters: Joanne Zee, Clinical Director Brenda Kenefick, Director, Lean Process Improvement University Health Network

2 What do you do In the MOMENT. When you see a behavior, what would you do? SPEAK DON T SPEAK SPEAK LATER

3 Situation 1 A pharmacist sees a patient spill water in the hallway and the pharmacist stops to clean it up.

4 Situation 2 There is a new physiotherapist in an inpatient unit. When a bed alarm sounds they do not react.

5 Situation 3 A patient is ready for discharge and the ward clerk leaves their chart on a table where other people can view it.

6 Situation 4 You work in an open concept office and your coworkers are talking loudly about specific patient concerns.

7 Situation 5 A senior hospital leader is obviously sick, coughing and sneezing at a meeting

8 Situation 6 You notice a doctor did not wash her hands before entering a patient room.

9 Situation 7 A nurse goes to use a piece of equipment, it must be broken because she walks away and uses another one.

10 Situation 8 You are a nurse filling in at a busy clinic and you notice another nurse does not follow medication administration best practices.

11 Situation 9 All surgical sites must be marked with an X. The surgeon is preparing to cut, knife in hand, and you clearly see there is no X.

12 Situation 10 You are a manager and you see one of your nurses organizing a clean supply room.

13 Situation 11 You are a student and the nurse you are shadowing tells you never to do a procedure the way she is about to do it, because she knows it s the wrong way.

14 Situation 12 You are a housekeeper and you found a needle in the garbage next to the sharp bin

15 Situation 13 You are standing beside your manager, you both see something wrong and s/he does not say anything.

16 How would you react? A. Speak up every time B. Speak up most times C. Speak up some times

17 Brenda Kenefick Lean Process Improvement Leader Experience in trucking, courier, heavy equipment manufacturing, consumer packaged goods +++ Worked in North America, Europe, Great Britain, South Africa, Australia, New Zealand Joined Healthcare 7 years ago Operational Leader

18 Learning Objectives: 1. Learn to build your personal credibility by speaking up. 2. Develop your threshold intuition know when to voice a concern and when to stay quiet. 3. Protect your professional relationships by speaking about the process.

19 Joanne Zee Pharmacy Technician Physiotherapist Clinical Manager Private Clinic Acute and Rehab Hospital Patient Safety & Quality Improvement Research Teaching Clinical Director

20 University Health Network 1,365 Beds 446,000 Inpatient Days 1,110,000 Ambulatory Care Visits 115,000 Emergency Room Visits Translation services in 92 languages 4 Sites in downtown Toronto 14,300 employees, 770 MDs Patient Care, Research, Education

21 How we came to be here To speak or not to speak: A process improvement coach s dilemma

22 What factors impact your decision to speak or not speak As a group, list the factors that affect your decision to speak or not speak

23 Group exercise 2 minutes Table introductions 11 minutes Talk about questions that go through your mind 2 minutes - Report back

24 DEBRIEF

25 Acknowledging the contribution of Melanie Vicente RN, for her research with UHN ICU nurses. "Silence Kills: What Breaks Down At The Critical Point In Communication That Leads Nurses To Be Silenced". Here s what we ve seen What happened to the last guy? Will I look stupid? She is more senior / junior - it matters? Does s/he know more than me? Is this career limiting?

26 Here s what we ve seen How well do I know this person? Will it affect my relationship with them in the future? Will I get a reputation for being a pain? If I need this person s help in the future, will I get it?

27 Here s what we ve seen Should I point out that s no longer best practice? Will my manager support me? My manager never speaks up, why should I?

28 Here s what we ve seen What s the risk level to the patient? Should I say something in public or in private? What mood am I in, what mood are they in?

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30 What s your threshold? General lowlevel daily risks Gut Check When will you speak? Don t know of anyone ever getting hurt High Personal Risk I will get hurt

31 Culture is not the elephant in the room Culture is what you choose to do today

32 How we measure it UHN has used the Hospital Survey on Patient Safety Culture* 8 times since 2006

33 Safety Culture Survey A. Staff speak up when they see a safety risk B. My manager notices when I follow safety procedures properly C. My manager overlooks reoccuring patient safety problems D. My colleagues support each other E. My colleagues respect each other F. Staff feel free to question people with more authority G. Staff feel like their mistakes are held against them H. People are afraid to write incident reports I. Management creates a safety culture J. The actions of hospital management show that patient safety is a top priority K. Hospital management is only interested in safety after something bad happens Adapted with permission from:

34 Group Exercise 2 13 minutes Discuss how speaking impacts: A. Safety culture B. Personal credibility 2 Minutes Reflections

35 DEBRIEF

36 Culture change In the Moment Safety Culture Safety Huddles Thank you Silence Kills Low engagement Time

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38 Toronto Rehabilitation - Results so far 5 Toronto Rehab sites Everyone, Every day New Huddle Format Introduced Monthly safety concerns at Toronto Rehab 1286 Issues raised to date Oct. 13, 2015 to Nov. 4, August September October Number of Safety Incidents Raised 9 MINUTES Average Leadership Daily Safety Huddle call September 5 October Unit huddles 6 Director huddles Fall Adverse Medication Events Behavior Staff Other Number of Good Catches Identified October 2015-October Executive huddle 100% huddle compliance among clinical teams

39 Scenarios round 2

40 Situation 1 A pharmacist sees a patient spill water in the hallway and the pharmacist stops to clean it up.

41 Situation 2 There is a new physiotherapist in an inpatient unit. When a bed alarm sounds they do not react.

42 Situation 3 A patient is ready for discharge and the ward clerk leaves their chart on a table where other people can view it.

43 Situation 4 You work in an open concept office and your coworkers are talking loudly about specific patient concerns.

44 Situation 5 A senior hospital leader is obviously sick, coughing and sneezing at a meeting

45 Situation 6 You notice a doctor did not wash her hands before entering a patient room.

46 Situation 7 A nurse goes to use a piece of equipment, it must be broken because she walks away and uses another one.

47 Situation 8 You are a nurse filling in at a busy clinic and you notice another nurse does not follow medication administration best practices.

48 Situation 9 All surgical sites must be marked with an X. The surgeon is preparing to cut, knife in hand, and you clearly see there is no X.

49 Situation 10 You are a manager and you see one of your nurses organizing a clean supply room.

50 Situation 11 You are a student and the nurse you are shadowing tells you never to do a procedure the way she is about to do it, because she knows it s the wrong way.

51 Situation 12 You are a housekeeper and you found a needle in the garbage next to the sharp bin

52 Situation 13 You are standing beside your manager, you both see something wrong and s/he does not say anything.

53 How would you react NOW? A. Speak up every time B. Speak up most times C. Speak up some times

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