Talk to Me. Teamwork and Communication as Best Practices for Patient Safety. September 29, 2015

Talk to Me Teamwork and Communication as Best Practices for Patient Safety Aileen R. Killen Head of Casualty Risk Consulting Healthcare +1 646 857 0261 aileen.killen@aig.com September 29, 2015 International Forum on Quality and Safety in Healthcare

What is patient safety? Key definitions Freedom from accidental injury (IOM) Discipline in health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events (AHRQ). The avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of health care. These events include errors, deviations, and accidents. Safety emerges from the interaction of components of the system; it does not reside in a person, device or department (NPSF) The absence of preventable harm to a patient during the process of health care (WHO) 2

What makes a team? Characteristics of all teams Two or more individuals Meaningful task interdependence Have a leader Have specialized member roles and responsibilities Intensive communication 3

What is a health care team? Characteristics Posses specialized and complimentary knowledge and skills Know their role and roles of others on the team Make decisions Often function under highworkload conditions Act as a collective unit as a result of interdisciplinary tasks performed by team members World Health Organization (2012) 4

Types of teams found in healthcare World Health Organization Core teams Direct care providers Coordinating teams Provide operational management and resource management for core teams Contingency teams Formed for emergent or specific events Ancillary services Provide services that facilitate patient care Support services and administration Leadership World Health Organization (2012) 5

Key dimensions of effective teams Team leadership Task Coordination and Planning Development and Motivation of team Mutual performance monitoring Understand environment to identify lapses in task assignment or task overload Situational Awareness Backup behavior Understand tasks of other team members to in order to redistribute work or support others Adaptability Respond to changes in the environment Team orientation Take others ideas into account Team goals more important than individual goals Salas, E., Simms, D.E., & Burke, C.S. (2005). 6

Requirements for effective teams Respect and trust in order to debrief and give feedback Good communication skills to accurately convey information Shared mental model (Situational awareness) Be on same page Be in same movie Is your team Team of experts? or An expert team? 7

Teamwork and patient safety What teamwork is Set of interrelated behaviors, cognitions and attitudes Distinct from task work Members anticipate each others needs Collective set of efficacy and teamness Provide back-up behaviors What teamwork is NOT Not automatic response to putting people together You do not need to like all members of your team No need to work with team members on a permanent basis Salas (2008) 8

Teamwork in healthcare What s different? Action teams Conditions change frequently May be assembled ad hoc Have a dynamically changing team membership May work together for short periods of time Consist of specialists Have to integrate different professional cultures Manser, T. (2009) 9

What is communication? World Health Organization (WHO) Transfer of information, idea, feelings Functions of communication in a healthcare system Provides knowledge Establishes relationships Supports leaderships and team co-ordination Model of communication Sender convert an idea into a message using medium (written, verbal) to transmit message to one or more receivers who then translate the message back to the original idea World Health Organization (2009) 10

What is communication? How can it fail? Transmission failures Information not transmitted message is unclear Ambiguity of message Problem with medium Reception failures Information not received Information with sent but misrepresented, ignored, etc. 11

Effective communication Team huddle Knowing the game plan Getting in the huddle Giving signals Listening to the coach Revising the game plan Sitting on the bench 12

And the literature says. What we know about teamwork and communication 13

Key concepts about teamwork and safety From review of the literature (1998-2007) Retrospective analysis of incident and adverse events found communication and teamwork issues to be among the most frequent contributing factors Observational studies and retrospective analysis show that many factors that contribute to incidents or adverse events come from inadequate teamwork and NOT lack of clinical skills Healthcare providers place a great deal of importance on aspects of teamwork such as communication and collaboration Studies identified differences in perceived quality of teamwork between professional groups Studies indicate staff perceptions of teamwork are related to quality and safety of patient care Manser, T. (2009) 14

Patient safety; Hospital risk Perspectives of hospital C-Suite and Risk Managers WHO HOW MANY WHEN HOW Hospital C-Suite Executives and Risk Managers from hospitals representative of the US landscape N=250 Hospital C-Suite Executives N=100 Risk Managers 46% CNO 40% COO Remainder CEO, CMO and CFO Data collection occurred November 13 December 20, 2012 Computer-Assisted Telephone Interviews AIG (2013)

Four core themes emerged 1 2 3 4 Patient safety and financial sustainability challenge hospital C-Suite and Risk Managers for their time and attention Who is responsible for patient safety and who owns patient safety do not fall within the same role at the hospital. Lack of teamwork, negative culture and poor communication is the number one barrier to ensuring a safe environment for patients. Perceived enhancements to patient safety such as technology, regulation and metrics can have the opposite effect. AIG (2013)

Lack of teamwork, negative culture and communication are seen as the top barrier to patient safety. The culture between the nurses and the physicians. The lack of autonomy the nurses have. The amount of control medical staff have. C-Suite The barriers are the communication with the healthcare team. The handoff from one unit to another and from one physician to another physician or nurse is a hard transition for the patient. Risk Manager Barriers to Improving Patient Safety Lack ofteam work / negative culture and communication Lack ofstaff Financialissues Tim e Resources/equipm ent Training/education O ther N othing D K/Refused 42% 55% 22% 15% 18% 14% 10% 28% * 8% 9% 7% 10% 13% 10% 4% 4% 3% 3% C-suite Risk M anagers *Statistically significant difference between C-Suite and Risk Managers B5. In your own words, what do you feel are the barriers to improving patient safety in your hospital? (split sample; n=125 C-Suite, n=96 Risk Managers) 17

Teamwork and communication problems are at the core of patient safety risk. *Statistically significant difference between C-Suite and Risk Managers B4. Which of the following contribute to patient safety risk? (n=250 C-Suite, n=100 risk managers) 18

Effective communication Patient handover Prospective intervention study in Oxford, UK Using models from Formula 1 and aviation to improve handovers from surgery to ICU Results Mean decrease in technical errors during handovers from 5.42 to 3.15 Mean decrease in omissions 2.09 to 1.07 Duration of handover reduced 10.8 to 9.4 minutes 39% of patients pre-intervention had more than one error in handover; 11.5 % of patients with new protocol Catchpole, KR, De Leval, MR, McEwan, A, Pigott, et al (2007) 19

Operating Room teamwork In the eye of the beholder Survey of 60 hospitals Use of Safety Attitudes Questionnaire Response rate 77.1 % (2,135 / 2,769) Makary, MA, Sexton, JB, Freischlag, JA, Holzmulueller, et al (2006) 20

Differing perceptions From members of the healthcare team CRNA Anesth. Surgeon Nurse Makary, MA, Sexton, JB, Freischlag, JA, Holzmulueller, et al (2006)

Differing perceptions From the view of the surgeon CRNA 87% Anesth 84% Surgeon 85% Nurse 88% Makary, MA, Sexton, JB, Freischlag, JA, Holzmulueller, et al (2006)

Differing perceptions From view of anesthesiologist CRNA 92 % Anesth 96% Surgeon 70% Nurse 89% Makary, MA, Sexton, JB, Freischlag, JA, Holzmulueller, et al (2006)

Differing perceptions From the view of the CRNA CRNA 93% Anesth 75% Surgeon 58% Nurse 76% Makary, MA, Sexton, JB, Freischlag, JA, Holzmulueller, et al (2006)

Differing perceptions From the view of the OR nurse CRNA 68% Anesth 63% Surgeon 48% Nurse 81% Makary, MA, Sexton, JB, Freischlag, JA, Holzmulueller, et al (2006)

Briefings as a communication tool Preoperative briefings and huddles Do not delay operating room start times ( Ali,et al, 2011) 5-10 minute safety briefing between surgeons, anesthesia staff and nursing staff to discuss operating list Great Western Hospital, UK Reduce nonroutine events ( Einav, et al 2010) Reduction (25%) in number of nonroutine events with briefing; increase in number of surgeries with no nonroutine events ( Einav, et al 2010) Haifa Israel Do not take a long time (Berenholtz,et al 2009) 2.9 minutes for briefing 2.5 minutes for debriefing Baltimore, MD, USA Improve compliance with antibiotic and DVT prophylaxis ( Lingard, et al (2011; (Paull, et al 2010) Ontario, Canada USA 26

International Experiences Strategies from around the globe 27

An effective approach to patient safety National University Hospital Singapore Program developed to respond to areas identified as needing improvement in culture surveys over several year Teamwork across hospital units Handover Based on ideal communication and teamwork of Formula 1 car racing pit crew Mind your Ps - 4 P s Presider : leadership Player: role of each member Process: vital steps Purpose: common goal Mujumdar,S. & Santos, D (2014) 28

An effective approach to patient safety National University Hospital Singapore Need effective communication of the 4 Ps to execute the patient safety task at hand What else gets in the way? Number of lines of communication in complex patient care scenarios Mode of communication oral, written, electronic Cultural factors Nurses are narrative and descriptive Physicians prefer brevity Strategies Practice, Practice, Practice Assertion Empathy SBAR TeamSTEPPS 29

Keeping patients safe New South Wales, Australia Between the Flags program in NSW Public Hospitals (2010) Over 200 facilities Role of High reliability teams in responding to clinical deterioration Based on work in 1980 s in UK to identify patients who were deteriorating Vital signs thresholds Criteria for escalation Evaluation under way Also role of culture on implementation of program (with University of NSW) www.cec.health.nsw.gov.au/programs/between-the-flags 30

Overcoming barriers to effective communication University of Auckland, New Zealand Doing what we already know how to do Create conditions that prompt, reward and facilitate appropriate behaviors 7 step plan Overcoming educational barriers 1. Teach effective communication strategies e.g. SBAR 2. Train teams together 3. Train teams using simulation Overcoming psychological barriers 4. Define inclusive teams 5. Create democratic teams Overcoming organizational barriers 6. Support teamwork with protocols and procedures 7. Develop an organizational culture supporting healthcare teams Weller, J., Boyd, M., & Cumin, D. (2014) 31

Strategies to improve communication University of Mandurah, Western Australia Means to reduce the authority gradient Among different professional groups Among senior and junior staff in the same professional groups Reluctance to speak up often related to previous rudeness or intimidation Overcome ineffective communication due to differences in communication styles Strategies Team Briefings and debriefings You cant debrief it you did not brief (ark) Huddles Structured Communication Tools SBAR CUS Memory Joggers (checklists) Gluyas (2015) 32

Building teamwork and trust University of Manitoba, Canada A different methodology to study handoffs Use of philosophy and methodology of Appreciative Inquiry (AI) Change management technique that looks at what works well Positive cousin of root cause analysis Because most handoffs go well Structured interviews with 29 nurses, 5 ward clerks, 2 home health coordinators, 9 allied health clinicians, 2 patients, 1 family member Key Themes Identified situational variables necessary for perfect transfer Mode and transfer related communication Important factors with patient and family Clarke, D., Werestiuk, K., Schoffner, A., Gerard, J., et al (2012) 33

So what does it all mean? What do we all need to do? 34

Patient Safety How to be safe Know thy self Picture here What kind of clinician am I? Do I take shortcuts Be mindful Do I have it right? What is the worst it could be? Develop Internal Alarms Know when you are drifting What is drift? Gradually downgrade the significance of risk until it is accepted as normal part of work 35

Patient Safety How to be safe Know thy Colleagues Teamwork Who is on your team? Do your know their names? Formal leaders Board C-suite Informal leaders Patients 36

Team Training It takes practice, practice, practice TeamSTEPPS Developed by Agency for Healthcare Research and Quality Incorporated by WHO in Patient Safety Curriculum Strategies & Tools to Enhance Performance and Patient Safety Key Principles Team Structure Leadership Situation Monitoring Mutual Support Communication www.ahrq.gov/health-care-information/topics/topic-teamstepps 37

TeamSTEPPS Leadership Organize and lead team events Brief Huddle Debrief Effective Leadership Flat hierarchy Share the plan Invite others into the conversation Explicitly ask people to share questions and concerns www.ahrq.gov/health-care-information/topics/topic-teamstepps 38

TeamSTEPPS Situation Monitoring Continually scanning and assessing the environment to maintain situational awareness Ensure all team members are on the same page and have each others back Loss of Situational Awareness Trying to do something new under pressure Doesn t feel right Boredom Being rushed being behind schedule www.ahrq.gov/health-care-information/topics/topic-teamstepps 39

TeamSTEPPS Mutual Support Foster climate where it is expected that assistance will be actively sought and offered Go from I am not sure but this must be right to I will assume this is not right until I get proof otherwise Provide feedback to improve team performance Timely, respectful, specific, directed towards improvement, considerate Advocate for the patient when team member viewpoint do not agree with decision maker Assert a correction action Two- Challenge Rule Stop the line It s okay to CUS www.ahrq.gov/health-care-information/topics/topic-teamstepps 40

TeamSTEPPS Communication SBAR Situation Background Assessment Recommendation Call Outs for critical information Informs all at same time in emergency Airway status? Airway clear Closed- Loop Communication Critical Language Handoff www.ahrq.gov/health-care-information/topics/topic-teamstepps 41

Final Thoughts 42

Discussion Questions, please! 43

References AIG (2013). Patient Safety; Hospital Risk Perspectives of Hospital C-suite and Risk Managers. Ali, M., Osborne, A., Bethune, R., & Pullyblank, A. (2011). Preoperative surgical briefings do not delay operating room start times and are popular with surgical team members. Journal of Patient Safety, 7 (3): 139-43. Berenholtz, B.M., Shumacher, K., Hayanga, A.J., Simon, M. Goeschel, C., Pronovost, P.J., Shanley, C.J., & Welsh, R.j. (2009). Implementing standardized operating room briefings and debriefings at a large regional medical center. Joint Commission Journal of Quality and Patient Safety, 35 (8): 391-7. Cathchpole, K.R., De Leval, M.R.. McEwan, A., Pigott, N., Elliot, M.J., McQuillan, A., MacDonald, C., & Goldman, A.J. (2007). Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Pediatric Anesthesia, 17: 470-478. 44

References Einav, Y. Gopher, D. Kara, I. Ben-Yosef, O. Lawn, M., Laufer, N. Lievergall, M. Donchin, Y. (2010). Preoperative Briefing in the operating room: shared cognition, teamwork and patient safety. Chest. 137 (2): 443-9. Lingard, l., Reghr, G. Cartmill, C. Orser, B. Espin, S., Bohen, J., Reznick, R. Baker, R. Rotstein, L., & Doran, D. (2011). BMJ Quality and Safety, 20 (6): 475-82. Makary, MA, Sexton, JB, Freischlag, JA, Holzmulueller, et al (2006). Operating Room Teamwork among Physicians and Nurses: Teamwork is in the Eye of the Beholder. Journal of the American of Surgeons, 202 (5), 746-752. Manser, T. (2009) Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiologica Scandinavica, 53, 143-151. 45

References Mujumdar, S. & Santos, D. (2014). Teamwork and communication: An effective approach to patient safety. World Hospitals and Health Services, 50 (1), 19-22. Salas, E., Sims, D, Klein, C. & Burke, C.S. (2003). Can Teamwork enhance safety?. Risk Management Foundation Forum, 5-9. Salas, E., Simms, D.E., & Burke, C.S. (2005). Is there a Big Five in teamwork? Small Group Research, 36, 555-99. Weller, J., Boyd, M., & Cumin, D. (2014) Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare. Postgraduate Medicine Journal,90,149-154 46

References Websites www.ahrq.gov/health-care-information/topics/topic-teamstepps www.cec.health.nsw.gov.au/programs/between-the-flags World Health Organization (2009). Human Factors in patient safety: review of topic and tools. Report for methods and measures working group of WHO patient safety. Retrieved from www.who.int/patientsafety/research/methods_measures/human_factors/hum an_factors_review.pdf World Health Organization (2012). Being a team player. To Err is Human Course, 1-5. Retrieved from www.who.int/patientsafety/education/curriculum/course4_handout.pdf 47

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