March 28 th, 2013 These presenters have nothing to disclose IHI Expedition Engaging Frontline Teams to Create a Culture of Safety Annette Bartley, RN, MS, MPH Tracy Jacobs, BSN, RN
Today s Host 2 Lizzie Grimm, Project Assistant, Institute for Healthcare Improvement
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Expedition Director 5 Tracy Jacobs, BSN, RN, Director, Institute for Healthcare Improvement (IHI), currently directs IHI's work with Improving Patient Care, a wide-reaching improvement program within the Indian Health System, and the ongoing Achieving Excellence in Primary Care call series. She has worked on several large IHI collaborative improvement projects, including the Transforming Care at the Bedside inpatient-focused initiative and a ten-year collaborative initiative with the Health Resources and Services Administration's Federally Qualified Health Centers focused on improving chronic disease and preventive care services for the nation's underserved populations. Ms. Jacobs has 12 years of experience in health care quality improvement.
Today s Agenda 6 Effective Communication Homework for next session
Our Intent Overall Program Aim Understand the discipline of patient safety and its role in minimizing the incidence and impact of adverse events, and maximizing recovery from them Create a culture of safety amongst frontline healthcare teams that protects all Active participants/homework assignments Applying the theory in practice Sharing the learning
Expedition Objectives 8 At the end of the Expedition each participant will be able to: Describe background and context of patient safety Identify tools which will help to improve communication and teamwork, essential to building culture Apply a range of simple tools and improvement methods for engaging staff in improving patient safety and measuring improvement Identify strategies for managing conflict management, including: appropriate assertion and critical language Describe strategies for involving patients and family members in preventing harm
Schedule of Calls 9 Session 3 Effective Communication Date: Thursday, March 28, 1:00 PM 2:00 PM ET Session 4 Measurement of Adverse Events Date: Thursday, April 11, 1:00 PM 2:00 PM ET Session 5 Tools and Techniques for the Frontline Staff Date: Thursday, April 25, 1:00 PM 2:00 PM ET Session 6 Engaging Patients and Families in Preventing Harm Date: Thursday, May 9, 1:00 PM 2:00 PM ET
Faculty 10 Annette J. Bartley RGN, BA (Hon) MSc, MPH, Programme Director, The Health Foundation's Safer Patient Network, UK, is a registered nurse with over 30 years of health care experience. In 2006 she was awarded a oneyear Health Foundation Quality Improvement Fellowship at the Institute for Healthcare Improvement, during which time she also completed an MPH at Harvard University. Ms. Bartley was faculty lead for the Welsh pilot of Transforming Care at the Bedside (TCAB) and now advises the Welsh Assembly Government as TCAB spreads across Wales. She is a founding member of the Welsh Faculty for Healthcare Improvement and serves as faculty for the IHI TCAB Collaborative, the Wales 1,000 Lives plus Transforming Care programme, the South West Quality and Patient Safety Improvement programme, the National Tissue Viability pressure ulcer prevention pilot programme for Quality Improvement Scotland, and the Kings Fund hospital pathways programme.
Work for Action Period 11 We would like you to undertake PDSA s Consider testing: Simple ways of acknowledging a job well done The G rrrr board Safety briefings on shift handover Debriefings post incident/ event
Feedback From Our Volunteers 12 Nisha Others
Overview of Key Learning Points 13 Patient Safety requires consistent Leadership attention, focused action and frontline engagement Don t crash and burn! Three key principles -Prevention Detection and Mitigation Culture eats strategy for lunch Developing a safety culture within an organization requires attention to the subcultures within different units and departments Teamwork is an essential component of patient safety Situational awareness/ briefing and debriefing
Effective Communication
Session Objectives By the end of this session participants will be able to: Appreciate the importance of effective communication in assuring the provision of safe patient centered care Describe key factors in effective communication Describe the impact of behaviors on effective communication and patient safety Identify and test structured communication tools 15
Importance of Communication Communication failure has been identified as the leading root cause of sentinel events over the past 10 years (Joint Commission) Communication failure is a primary contributing factor in almost 80% of more than 6000 root cause analyses of adverse events and close calls (VA Center for Patient Safety) Focus for to-day communications amongst healthcare professionals 16
Investing in Improving Communication 17 The Joint Commission reports that investing to improve communication within the healthcare setting can lead to: Improved safety. Improved quality of care and patient outcomes. Decreased length of patient stay. Improved patient and family satisfaction. The Joint Commission. The Joint Commission Guide to Improving Staff Communication-Joint Commission on the Accreditation of Health Care Organizations. 2005
Effective communication can be supported by a healthcare organization if they 18 Clearly link effective communication and teamwork to patient safety. Clearly articulates the organization's expectation on how communication will be carried out. Fosters a communication process that facilitates continuous improvement in patient safety and quality of care. Assesses the current organizational culture of patient safety and identifies areas for improvement, for example, conducts an assessment of staff perceptions and current practice in the delivery and management of safe patient care. Fosters and promotes a work culture that values cooperation, teamwork, openness, collaboration, honesty and respect for each other and promotes open and effective communication. Creates an atmosphere where team members feel safe to speak up about issues relating to patient care regardless of their position or rank. Provides resources and identifies appropriate communication strategies to ensure that information is effectively exchanged between people depending on the situation, different communication methods may be required
1. Communication This is the essence of effective Teamwork. Effective communication provides understanding, interpretation and action. Ineffective communication leads to misunderstanding, misinterpretation, and either inaction or inappropriate action. http://www.tips4teamwork.com/5-essentials-of-great-teamwork.htm
2. Active Listening 20 There are two responsibilities here: That of the sender/transmitter and that of the receiver. The sender must ensure that the message is clear and understood and the receiver must ensure that if the message is not clear that they ask for clarification.
What factors contribute to communication failures in healthcare? 21 Human factors; attitudes, behaviors, morale, memory failures, staff stress and fatigue Distractions and interruptions. Shift changes. Gender, social and cultural differences. Hierarchy or power distance relationships (e.g. junior staff are reluctant to report or question senior staff). Difference in training of doctors, nurses and paraprofessionals. Time pressures and workload. Limited ability to multitask even when highly skilled. Lack of a shared mental model regarding what is to be achieved. Lack of organization policies and / or protocols. Organizational culture that discourages open communication. Lack of defined roles and responsibilities among members of multidisciplinary teams Leonard, M., Graham, S., and Bonacum, D. (2004). The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care, 13 Suppl 1: p. i85-90.----------oandasan, I., Baker, G.R., Barker, K., et al. Teamwork in Healthcare: Promoting Effective Teamwork in Healthcare in Canada Canadian Health Research Foundation (CHSRF),June 2006. Viewed 19 October 2009,
Five Standards of Effective Communication 22 When trying to generate Improvements in the exchange of information between healthcare professionals, and information should be: Complete It answers all questions asked to a level that is satisfactory to those involved in the exchange of information. Concise Wordy expressions are shortened or omitted. It includes only relevant statements and avoids unnecessary repetition. Concrete The words used mean what they say; they are specific and considered. Accurate facts and figures are given. Clear Short, familiar, conversational words are used to construct effective and understandable messages. Accurate The level of language is apt for the occasion; ambiguous jargon is avoided, as are discriminatory or patronizing expressions.
Learning the Language of Patient Safety Leadership Situation Monitoring Mutual Support Communication 1. Briefs 2. Huddles 3. Debriefs 4. Situational awareness Cross monitoring 5. Task assistance 6. CUSS 7. SBAR 8. Call-outs 9. De-briefing/Check-backs 10. Hand-offs 23
TeamSTEPPS Language Definitions Leadership Situation monitoring Brief: Planned, assign roles, establish expectations, anticipate outcomes Huddle: Gather as needed to discuss critical issues & emerging events Debrief: End of activity, discuss what went well and what we can do better Situation awareness: Know what is going on around you, including cross monitoring your team members Mutual support Task assistance: Ask for and offer support with all team members CUS: When appropriate, use a CUS word: I am C ONCERNED! I am U NCOMFORTABLE! This is a S AFETY ISSUE! S Communication SBAR: Summarize your critical messages in a standard format Situation, Background, Assessment, Recommendation Call-out: Communicate important information and inform team members simultaneously during emergency situations Check-Back: Verbally confirm instructions "closing the loop" Handoff: During transitions in care, clearly transfer both information and accountability make sure to offer opportunity for questions
Communication Styles National Culture Gender Roles (Physician, Nurse, Manager) Nurses: narrative & descriptive Physicians: problem solvers just give me the facts 25
Effective Communication Requires Leadership flat hierarchy sharing the plan continuously inviting other team members into the conversation explicitly asking people to share questions or concerns using people s names Briefing/Debriefing Assertion/Critical Language (key words)- The ability to speak up and stop the show Structured Communication (SBAR) 26
Psychological Safety Environment of Respect A fundamental, non-negotiable respect for every employee, everyday, by everyone Their work is recognized and acknowledged 27
Assertion Speak up and state your information with appropriate persistence until there is a clear resolution 28 What is it? Organized in thought and communication Valued by the entire team Looking for clarification & common understanding What is it not? Aggressive or hostile Ridiculing Confrontational Ambiguous *
How do you communicate? 29 Sterile Bowl Prepping a patient for OR http://www.youtube.com/watch?annotation_id=annotation_8462 05&feature=iv&src_vid=3r4rS0yzQ1M&v=7-a2QBfFQeA
Structured Communication CUSS to communicate concern C I m Concerned or I need clarity U Uncomfortable/Unsafe S Stop the line/procedure S Patient Safety is at risk! 30
Structured Communication: SBAR If the phone goes dead in 10 seconds will the person on the other end know what is needed? Situation State what you are calling about (5-10 second punch line) Background State what you are calling about (including objective date i.e. vitals, labs) Assessment State what you think the problem is (diagnosis not necessary include severity) Recommendation State what you think needs to be done for the patient (get a time frame) 31
Structured Communication S Mr. M has sudden onset of radiating chest pain & shortness of breath B He has a history of MI s, & his obs are 186/76, 180, 24 & he is on 5L of O2 per nasal cannula sats 84% A I think Mr. M might be having an MI R I need you to come evaluate the patient, how soon will you be here? 32
The Difficult Conversation When anticipating a difficult conversation focus on: What needs to happen for us to do the right thing for our patient? Focus on the common goal - high quality, safe care Depersonalize the conversation - focus on the patient Avoid judgment - don t place blame It s not about you & me, it s about the quality & safety of our patient care!
Engagement Physicians in Quality and Safety Challenges: Doctors are busy They ve been trained as individual experts They are very goal oriented and want to see results Traditionally, we haven t taught them about human factors, teamwork and system error a different way of thinking 34
Doctors & Nurses Nurses are trained to be narrative and descriptive Doctors are trained to be problem solvers what do you want me to do? just give me the headlines Complicating factors: gender, national culture, the pecking order, prior relationship Perceptions of teamwork depend on your point of view 35
What is TeamSTEPPS TM? TeamSTEPPS is an evidence-basedteamwork system based on 20 years experience and lessons learned from High-Reliability Organizations (HROs) designed to improve: Quality Safety Efficiency of health care Practical and adaptable Provides ready-to-use materials for training and ongoing teamwork 36
Why Use TeamSTEPPS? Goal: Produce highly effective medical teams that optimize the use of information, people and resources to achieve the best clinical outcomes Teams of individuals who communicate effectively and back each other up dramatically reduce the consequences of human error Team skills are not innate; they must be trained 37
Teams STEPPS- What Teams Learn? 38
Crew Resource Management United Airlines was the first airline to provide CRM training for its cockpit crews, in 1981. CRM can be defined as a management system which makes optimum use of all available resources - equipment, procedures and people - to promote safety and enhance the efficiency of operations. CRM although first established in the civil aviation industry as cockpit resource management has been adopted and adapted by many other industries, some of which are the commercial maritime shipping industry using a form called "Maritime Resource Management (MRM)". CRM training encompasses a wide range of knowledge, skills and attitudes including communications, situational awareness, problem solving, decision making, and teamwork; together with all the attendant sub-disciplines which each of these areas entails. Focus on teamwork, communication, flattening hierarchy, managing error, situational awareness, decision making Non-punitive reporting of near misses, 500,00 reports over 15 years Very open culture with regard to error and safety 39
High Reliability 40 Preoccupation with failure When someone raises a concern, the problem exists until proven otherwise Reluctance to simplify Errors and close calls are reflections of deeper system flaws Commitment to resilience Knowing there will be problems and flaws, the job will get done Deference to expertise The person most qualified does the job Sensitivity to operations Flexing resources to deal with demand or workload
Focus on the Common Goal Anchor the work where we have common agreement Avoid judgment and 1st person / 2nd person dialogue Basic tenet of negotiation theory it is much easier to have the 3rd person conversation when discussing how to do the work 41
Understanding Culture is Essential What are your social metrics? How do people perceive teamwork in the environment are staff hesitant to speak up? Safety climate? Do staff believe their concerns would be acted upon? What is their level of threat awareness? High workload, fatigue, multi-tasking? 42
Putting the Pieces Together Culture respect-recognition and the tools to do the job Leadership, at every level A safety culture, teamwork, joy Reliable Processes embed teamwork practices in these Effective communication Cycles of Improvement build a learning organization with continual improvement 43
What will you test by next Tuesday? 44 Elevator speech SBAR ISBARD- Introduction and discussion CUSS Safety Huddle Briefings /Debriefings Safety Cross
Data for Improvement Using Data to understand progress toward the team s aim Using Data to answer the questions posed on in the plan for each PDSA cycle The Improvement Guide, API
PDSA Cycle No 1 : Worksheet for Testing Change Aim: (Overall goal you would like to reach) Every goal will require multiple smaller tests of change Describe your first (or next) test of change Person Responsible When to be done Where to be done Plan List the tasks needed to set up this test of change Person Responsible When to be done Where to be done Predict what will happen when the test is carried out Measures to determine if prediction succeeds
Do: Study: What happened? What did you learn? What surprised you? Act: What will you differently as a result of your test? What will your next test be? When will it be? Repeat the cycle Test over a wide variety of conditions, different patients, different staff, days, nights, secondary care/primary care. Measure, collect enough data to tell you if your test was a success. Keep testing until the changes you are making result in improvements.
The Blue Angels http://www.youtube.com/watch?v=mr0_sk1k8xy
Homework for the Next Action Period 49 The elevator speech Imagine you have just walked into the elevator with your chief executive officer You want to share you patient safety project with them and seek his /her support Succinctly describe your patient safety project within 2 minutes Incorporate the overall purpose of what you are doing, the key aims and objectives, and details of the actions. Seek support for what you need Practice to ensure you share the key message make the maximum impact in a short
Homework (cont) 50 Meet as a team and consider how you currently measure adverse events /harm in your unit/ department/ organization. What tools do you use? Who collects the data? Who analyses the data? How timely is feedback? Who develops any required action plans? Is the data locally owned?
Questions? 51 Raise your hand Use the Chat
Volunteers? 52
Questions? 53 Raise your hand Use the Chat
Expedition Communications 54 Listserv for session communications: SafetyExpedition@ls.ihi.org To add colleagues, email us at info@ihi.org Pose questions, share resources, discuss barriers or successes
Next Session 55 Session 4 Measurement of Adverse Events Date: Thursday, April 11, 1:00 PM 2:00 PM ET