Storytelling: A Powerful Tool in a Hospital s Culture of Safety Stephanie Bailey, M.P.H. Director of Accreditation & Patient Safety, John Muir Health Michael Leonard, MD Co-Chief Medical Officer, Pascal Metrics Adjunct Professor of Medicine, Duke University
Objectives Understand the power of telling patient stories to engage clinicians in clinical improvement. Appreciate that medical care is a profound social process, and this is the primary means that patients and their families interpret medical care. Learn the elements of an effective story that make it personal to the listener. Know how to use storytelling to drive effective learning in a healthcare system. 2
John Muir Medical Centers John Muir Medical Center - Walnut Creek 572 Licensed beds Designated Level II Trauma Center for Contra Costa County Level III Neonatal ICU Also known for Neurosurgery, Orthopedics, High Risk OB, Rehab Annually 17,500 Discharges; 46,000 Emergency Room Visits John Muir Medical Center Concord 309 Licensed Beds Cardiovascular Institute Also known for Cancer Care Annually 9,600 Discharges; 46,000 Emergency Room Visits John Muir Behavioral Health Center 73 Licensed Beds Behavioral Health Services Chemical Dependency Programs 3
May 17, 2012: The Ethics of Improvement it is unethical to allow a patient to be injured, and it is doubly unethical to allow another patient to be injured in the same way Don Berwick, MD health care professionals have a duty to improve the systems in which they work, and health care leaders have a duty to facilitate that improvement 4
Patient Stories Engage the Voice of the Patient
The Story Book is a celebration of Great Catches by John Muir Health staff and a sharing of Patient Stories. As a learning organization, telling these stories is intended to generate dialogue among frontline caregivers who may be able to prevent a similar occurrence. 6
Great Catch Program Honors those who intercept an error before it reaches a patient and those who take extraordinary action to protect a patient or visitor from a potentially unsafe situation 7
Physician Network Behavioral Health Q1 2012 Great Catch Awards Walnut Creek Concord 8
One Patient s Story Published Monthly 48 Publications So Far
The naming of our patient stories
Story elements The Case of the Summary of Event Why Did The Event Happen How You Can Prevent This How You Can Support The Culture of Safety 11
The Case of the Meal Tray Mix-Up Summary of Event A patient had an NPO order because he was at high risk for choking on food by mouth. The patient had been scheduled for a procedure one day and it was cancelled. On the day of the cancelled procedure, a nursing assistant was passing out lunch time meal trays. Having knowledge that the patient s procedure was cancelled, s/he asked the RN if it was okay to give the patient the lunch tray. The RN said it was okay. Upon discovering that her father was eating a meal, the daughter, knowing that her father was at risk for aspiration, expressed concern. Upon investigation by Nutrition Services, it was discovered that the meal consumed by the patient was intended for a different patient on the unit. 12
The Case of the Meal Tray Mix-Up Why Did This Event Happen? Two patient identifiers were not used when delivering the meal tray. The nursing assistant and RN incorrectly assumed that the patient s NPO status was related to the scheduled procedure [which was cancelled] and were unaware that the NPO order was related to aspiration risk. 13
The Case of the Meal Tray Mix-Up How You Can Prevent This Always compare two patient ID s on the patient s wristband with two patient IDs on the menu ticket when delivering meal trays to inpatients. 14
The Case of the Meal Tray Mix-Up How You Can Support the Culture of Safety Advocate for patient safety! Speak up if a safety procedure is not being followed Document events that pose a risk to patient safety or cause harm as a MIDAS Patient Safety Alert/RDE -- if warranted, notify your supervisor and Risk Manager. For general [not case specific] safety concerns, submit a Culture of Safety Report available through the Quality Management intranet page. 15
Lessons Learned & Challenges Senior Leadership comfort level with openly sharing stories Key: Emphasize transparency, learning from errors, preventing harm Distribution logistics Key: Distribute to all staff directly Stories based on actual entity events Key: Avoid temptation to use stories from outside Personalize the stories Key: Reader should feel that could happen to me 17
Contact: Stephanie Bailey Director of Accreditation & Patient Safety 925-674-2372 stephanie.bailey@johnmuirhealth.com 18