Overcoming the Culture of Silence Why Your Staff Won't Speak Up, Why You Should Care, and What You Can Do About It Capt. Stephen W. Harden
Disclosures of Conflicts of Interest Steve Harden has nothing to disclose. James Conway, IHI
Our systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time. We, as leaders, have a responsibility to put into place systems to support safe practice. James Conway, IHI
Stop-the-Line 80% of patient harm could be stopped by speaking up
1985
2017
Over 200 healthcare organizations in 20 years
A patient s story
Jane 44 5 th Child
No C Section! We ll see.
What Do You Think? If this were an ultra-safe, ultra reliable hospital, what do you expect to happen? What will Rebecca do? What will Dr. K do? If something like this event happened in your hospital, with your version of Rebecca and your version of Dr. K, would Rebecca speak up? How would you rate your culture? 0 10
Safety Climate Survey Results 89% Staff will freely speak up if they see anything that will negatively affect patient care 52% Before After Source: Piedmont Heart Institute
Safety Climate Survey Results 49% (2016 AHRQ Report) Staff feel free to question the decisions or actions of those in more authority 40% Before 71% After Source: Piedmont Heart Institute
Safety Climate Survey Results 94% In this unit we discuss ways to prevent errors from happening again 43% Before After Source: Nebraska Medical Center
Reduction in teamwork/communication errors that contribute to Sentinel Events Percentage of RCAs in which communication and/or teamwork were listed as contributing factors 90% Before TS 2009 40% After TS 2012 Source: Missouri University Hospital
S e l f Others 200% Accountability
200% Accountability We watch out for one another We succeed, and we fail, as a team We reinforce good behaviors We correct perceived problems with patient care in a helpful, respectful manner
How did that happen? ANW story
How did that happen?
How did that happen?
How did I let that happen?
Cross-Check & Assertion Team members actively monitor situation for potential problems and concerns Team members speak up with questions & concerns, and persist until there is a clear resolution
Cross-Check & Assertion Monitor the Situation Acknowledge, Decision, & Thank you Recognize Adverse Situation Communicate with Precise & Standard Comm
Cross-Check and Assertion is NOT Doing someone else s job A critique of your skills Usurping the leader s authority
How to Make an Assertive Statement No response? Assertive Statement No response? Add Check Relay Info
Assertive Statement Get attention Express concern State the problem Call them by name I statement Brief, objective & clear Propose a solution We or Let s
A charge nurse in the cardiac cath lab (Nurse Danner) has received a patient named Morris, but has a patient named Morrison on the schedule. She questions the doctor. Nurse Danner: Doctor, we don t have a patient named Morris on the schedule. I m concerned there might be a mix-up. Doctor: This is our patient. Nurse Danner: Doctor Smith, I need clarity about our patient. We don t have a patient named Morris on the schedule, but we do have a Morrison. Let s check her chart & arm band, and call the floor to see if we have the right patient before we proceed.
Let s Practice! Split up into groups of two Role play making an Assertive Statement from the Case Studies on the screen After each practice session, conduct a debrief What did you do well? What would you like to improve? Here are my comments for you
Stop-the-Line Situation # 1 The labor and delivery charge nurse calls Dr. Ina Minut and reports ruptured membranes, meconium [fetal feces] on vaginal exam, a breech baby on ultrasound, and a fetal heart pattern that shows minimal variability and variable decelerations. Dr. Minut tells the charge nurse, I have another hour in my office and I will be there for a C-Section at 12:15 p.m. Draft an Assertive Statement from the charge nurse to Dr. Minut: Get Attention Express Concern State the problem Propose Solution Dr. Minut, I m concerned that this situation is deteriorating and the patient cannot wait another hour. We need to take action now. 32
Stop-the-Line Situation # 2 The charge nurse, Con (short for Constance) Fuzed, noticed there was an extra bag hanging on the IV pole that wasn t needed, and shouldn t be administered IV. But Con knows the other staff member, Benear Longtime, is one of the most experienced in the department and is unsure if she should speak up and say something. Draft an assertive statement from Con to Benear Longtime: Get Attention Express Concern State the problem Propose Solution Debrief: 1. What did you do well? 2. What would you like to improve? 3. Here are my comments for you.
Stop-the-Line Situation # 3 While rounding on his patient, Dr. Kind notices on the strip that there was an indeterminate tracing an hour ago. Knowing that policy is that every RN is required to communicate, using SBAR, to the patient s provider the patient s status, he asks Nurse Timid why she didn t call him. She responds, I knew you were scheduled to come in and I didn t want to bother you. Draft an Assertive Statement from Dr. Kind to Nurse Timid: Get Attention Express Concern State the problem Propose Solution Debrief: 1. What did you do well? 2. What would you like to improve? 3. Here are my comments for you.
Stop-the-Line Challenge
What is the strongest predictor of clinical excellence? A. The experience (tenure) of the staff B. The educational background of the staff C. Nurse to patient ratio D. Willingness to speak up when a problem with patient care is perceived E. Margin ($$ - payor mix, reimbursement rates, profit line, resources, etc )
7 Critical Steps to Get Your Staff to Speak Up
1. Change your P&P to require cross-check and speaking up
2 Train your staff to speak up
3 Implement an Escalation Policy (and train them how to use it)
4 Implement A Good Catch Program I want to recognize Mary Beck for demonstrating Speaking up in the following manner: Mary spoke up when we failed to follow the pharmacy ordering and verification policy. This allowed us to start A treatment protocol 24 hours sooner than we would have. By doing this, there was a positive impact on the following Key Result Reducing treatment delays Gina Rutland April 30, 2017 Given by: Date
5 & 6 Revise Job Descriptions & Annual Performance Reviews
7. Revise Mentoring & Precepting Programs
3 Stop-the-Line Training Guides
What about Jane and her baby?
"The names of the patients whose lives we save can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would never have been. Don Berwick, MD, MPP Former President and CEO, Institute for Healthcare Improvement Former Administrator of CMS
Thank you