A Partnership for Safety: Staff and Family Collaboration in Reducing Never Events Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY July 25, 2016 1
Today s Speakers Linda Hurwitz, BS, MS, RN, NEA-BC, Vice President, Patient Care Services Mazen Maria, BS, MD, FAAP, Associate Director, Pediatric Hospital Medicine Megan Busenbark, BA, MS, Patient/Family Advisor Polly VanderWoude, BS, MHA, Patient/Family Advisor Annmarie Shisler, BSN, RN, Patient/Family Advisor 2
What You ll Learn How to integrate Family Advisory Council (FAC) members into your Performance Improvement work How to create a true partnership between your staff and patient families to increase compliance with safety practices How to develop simple tools designed to reduce never events How to identify benefits and measure outcomes of this partnership 3
Session Overview About Maria Fareri Children s Hospital The Call to Action The Response The Process The Improvements Lessons Learned Next Steps 4
Maria s Story Built in 2004, patient- and familycentered care is at the heart of Maria Fareri Children s Hospital. 5
Maria Fareri Children s Hospital 142-bed children s hospital within a hospital in suburban NYC Tertiary and quaternary academic medical center Level One Trauma Center and Burn Center Serves 7-plus counties in the Tri-State region 6,200 discharges per year NICU, PICU, CTS, multiple medical and surgical sub-specialties 6
Family-Centered Care Statement The Maria Fareri Children s Hospital is committed to family-centered care. We believe that what families and health care professionals can accomplish together is greater than what either can achieve separately. We are dedicated to the whole child, striving to respect the dignity and integrity of the family unit. We hope to assist children and families in achieving their health care goals in a mutually supportive and compassionate environment. 7
MFCH s Family Advisory Council Founded in 2012 18 family members embodying the diversity of the patient population 6 members of MFCH leadership Implements principles from the Institute for Patient- and Family- Centered Care Gives families a voice in performance improvement 8
A Partnership for Safety: The Call to Action 9
Patient Index Case Clinical Presentation A young child about 6 months old was admitted for respiratory illness. Up for several nights, the child and his parents were exhausted. The care team had started IV, fluids and respiratory support. 10
Patient Index Case Safety Concerns Pediatric assessment policy: check IVs hourly; vital signs every 4 hours. Parents refused nurse checking the IV several times because parents wanted patient to rest. The problem was escalated to resident on call; child was left to sleep. Child woke up irritable and in pain. Nurse checked IV site, noted significant IV infiltration. Rapid Response and immediate intervention were required. 11
Patient Index Case The Impact Child had severe IV infiltration of the foot and leg to above the knee. A plastics consult and treatment were required. Ultimately, the leg completely recovered with no long-term effects. The AHA Moments: At this time, we thought that a contract for safety with the family could have set expectations and prevented the IV infiltration and complications. Family Advisory Council suggested we move from contract to partnership. 12
The Wake-Up Call Safety needs to come first at all times even before satisfaction, if it places the patient at risk. Residents in training need to recognize when to escalate vs. making the easier choice, which could have serious consequences. Staff needs guidance on how to balance safety with managing parent expectations and push-back. Nurses said there were limited supports to handle these situations. 13
The Response 14
Pinpoint the Problems Nursing / medical staff identified safety areas where conflict arises with families: Families may refuse vital signs, IV checks because they don t want their child disturbed. Families do not always observe fall precautions. Families do not always adhere to isolation and infection-control practices, specifically hand hygiene and personal protective equipment. When one family does not follow safety steps, many others follow suit. 15
Analyze Why The Problems Exist: A Parent s Perspective Parents are often stressed, tired, confused during admission and don t always absorb information the first time. The hospital environment is foreign to most families. They don t know rules of the road / don t understand hospital policy or safety risks. Families often feel out of control, seek normalcy. Families may be intimidated by the care team and uncomfortable speaking up, even though they want the best care for their child or loved one. 16
Analyze Why The Problems Exist: The Care Team s Perspective Nurses are under pressure to perform their jobs while dealing with parent push-back. The care team lacks clear and consistent messages to help them set expectations for parents and families from the outset of care. A lack of tools makes it harder for the care team to easily communicate specific safety risks, hospital policies / processes designed to deliver the highest-quality care to the child. 17
Our Conclusions We can never assume families understand why nurses and doctors need to take certain precautions that feel foreign or invasive to them. We need to empower families and staff to put safety concerns first. We need to create a true partnership between staff and families, because safety is a two-way street. We need to create 18
A Partnership for Safety 19
Our Cross-Functional Safety Task Force Formed interdisciplinary team of doctors, nurses, administration, child life and social work, patient relations, quality Included inpatients, emergency room, clinical decision unit Engaged members of the Family Advisory Council, as parent / staff conflict was at the heart of the safety issue Brought both advocates and naysayers into the planning process to develop early buy-in to the culture change 20
Safety Task Force Goals Engage staff, patients and parents in both awareness and improvement activities to promote safety and reduce harm. Identify high-risk safety events that can be reduced or eliminated if parents and staff work together with improved methods of communication and understanding. 21
Our Program: Speak up for Safety Speak up for Safety is now the Maria Fareri Children s Hospital roll-out program. This culture change requires a commitment from everyone: Vision and dedication among hospital leadership Cooperation from hospital staff, as well as parents and families A mindset shift for all involved The goal: to create an environment where both staff and families feel comfortable and confident to speak up to reduce never events. 22
The Process 23
Where We Started Called other hospitals to learn from them Colorado Children s Hospital Lurie Children s Hospital Northwestern Memorial Healthcare Decided on the risk focus to personalize the safety measures to the patient and family. Created messaging that was engaging but not too soft similar to being on an airplane. The captain has turned on the seat belt sign. 24
Our Guiding Principles for Improvements Parents are not visitors. They are part of the care team for their child. As such, families have a responsibility, along with the staff, to prevent harm. Patients and families expect specific care from staff. Staff expect specific behavior from families. 25
The Improvements 26
Improvement Strategies Agree on a scope of topics / safety risks. Develop tools for staff, patients and families to understand safety risks. Ensure that tools are family-friendly. Spanish and English versions Reviewed for literacy 27
Improvement Strategies Identify ways to communicate safety information to patients, families. Build consistent message for care teams. Make the process EASY for teams to implement. Determine how success would be measured. Develop a unifying, memorable theme for the improvements. 28
Identify Risk Events Start with an overview card explaining risk. Infection Wrong patient identification Pressure ulcers Infiltration of intravenous lines Central venous line infection Change in condition Injury from falls Change in condition Safe sleep Post-operative surgical site infection Bleeding risks 29
Cards Signs Video Develop Tools Your child is at risk cards with safety information are given to and discussed with families. Laminated cards also will hang in each patient room for easy access. Speak up for Safety signs are posted on the wall in all patient rooms. Signs serve as a constant, visible reminder to staff and families confidence and courage to speak up for safety. Welcome video will serve as introduction to the Partnership for Safety. The video is in process, with funding from the Torch Foundation. 30
Create Risk Cards Each patient family is given 4 standard cards of risk prevention. Change in condition Falls Patient ID Infection After risk assessment, other cards are shared, discussed with family as needed. 31
Safety Cards 32
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Roll Out to Staff All attending MDs were educated in monthly staff meeting. Family Advisory Council was part of the education. RN staff had 1:1 education on the unit and in annual competency days. Resident staff were trained at their noon conference. 35
Empowerment Our simple tools empower staff to enforce safety rules and empower patients and families to Speak up for Safety. Our clear process makes it easier for staff to communicate important safety information to parents even under stressful circumstances built around the same, consistent messages. 36
Measure of Success Success is measured through collecting data before and after the implementation of this initiative. The risk areas are shared in dashboards to monitor success. 37
Dashboard 38
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Lessons Learned We must have buy-in from staff in all areas. There will always be resistors. Education of all disciplines takes time and coordination. Refined messages improve communication time. Initially, some nurses spent up to 45 min reviewing cards in detail with families. We refined the communication and cut it to 5 minutes. Multiple methods of communication improve outcomes (cards, video, languages). Scripting specific messages would have helped. 40
Early Feedback A parent reported a mistake in a medication order. The nurse immediately checked and found the Mom to be correct. The RN got the MD order changed, and the correct medication was given. The nurses now feel like they have something to back them up. RN The residents are on board. Now we all will have the same message. Resident 41
Tips from a Parent s Perspective Set expectations around care and safety processes right from the start. Let parents know the policy and processes you need to follow to deliver the best care for their child in the safest environment possible. Explain each step of care, every step of the way. While your work is routine for you, it is anything but routine for tiny patients and their stressed-out families. Shift the focus of your communications. When parents push back, DON T say, I need to do my job. DO say, Your child needs this. 42
Next Steps Continue transforming the culture with Speak up for Safety program. Complete the production of our Welcome video introducing our Partnership for Safety and concept of risk. Measure never events and continually improve our processes to prevent harm. Leverage hallway or elevator flat screens to scroll safety messages, putting the message on the website and in app. Celebrate and promote successes to drive continued results. 43
Questions 44
Contact Information Linda Hurwitz, VP Patient Care Services. Linda.hurwitz@wmchealth.org Mazen Maria, MD, Hospitalist. Mazen.maria@wmchealth.org Megan Busenbark, Patient/Family Advisor. megan.mcdonnell@encorecomm.com Polly VanderWoude, Patient/Family Advisor. polly_oneil@yahoo.com Annmarie Shisler, Patient/Family Advisor. MarkShis@comcast.net 45
References Partnering With Parents to Reduce Preventable Harm - From Board to Bedside Daniel Hyman, MD, MMM, Amy Jacqumard, Children's Hospital Colorado Presented at the Children s Hospital Association 2015 Quality Conference, San Francisco, CA Help Family Members Improve Hand Hygiene Compliance: An educational initiative can help improve parent hand hygiene compliance. Celeste Chandonnet, R.N., B.S.N., CCRN, CIC, Children s Hospitals Today, April 25, 2016 46
References The Nicklaus Children's Hospital Humpty Dumpty Falls Prevention Program : Preventing Falls in Children Across the Globe; Jackie Gonzalez DNP, ARNI, MBA, NEA-BC, FAAN1, Deborah Hill-Rodriguez, MSN, ARNI, PCNS-BC2, Laura M. Hernandez, DNP, ARNP, CPN, FNP-C3, Jessica R. Williams PhD, MPH, APHN-BC4, Jennifer A. Cordo, MSN, ARNP NE- BC5, June 2016, Volume 14, Issue 3, Pages 212 218 What Zero Looks Like: Eliminating Hospital-Acquired Infections, The Institute of Health Care Improvement. http://www.ihi.org/resources/pages/improvementstories/whatzerolookslikeeliminatingh ospitalacquiredinfections.aspx 47
References Eight Recommendations to Drastically Improve Patient Safety The National Patient Safety Foundation revisits 'To Err is Human' and renews the call to action for safer care. Hospital and Health Networks, December 14, 2015 Jon Asplund Communicating With Patients http://www.aha.org/advocacy-issues/communicatingpts/index.shtml 48