March 14 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 Introductions Content: Essentials of Teamwork 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 2 Essentials of Teamwork Date: Thursday, March 14, 1:00 PM 2:00 PM ET 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 from Action Period Meet with your team and consider the following: Who makes up your team? Do actually you function as a team? What is your collective purpose? How do you prioritise patient safety issues? Independently ask 5 different members of your team what is their biggest safety concern Collectively agree on one specific safety aim/project for improving patient safety your unit Try testing Safety Briefings (see materials) If you already use them, share your learning 11
Feedback from our volunteers 12 Mary Martha Nisha **Lizzie and Kayla: Please add last names and the organization they represent thanks!!
Essentials of Teamwork
Session Objectives By the end of this session participants will be able to: Describe 5 essentials factors in effective teamwork Appreciate the value of effective teamwork and communication in providing safe patient centered care Identify tools to help individuals speak up reliably when they perceive risk to a patient Describe some simple steps/tools that might help to enhance staff satisfaction and teamwork 14
Why is teamwork so important in healthcare? A healthcare system that supports effective teamwork can improve the quality of patient care, enhance patient safety and reduce workload issues that cause burnout among healthcare professionals. Teamwork in Healthcare: Promoting effective teamwork in healthcare in Canada Ivy Oandasan, G.Ross Baker, et al. 01/06/2006 15
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What does teamwork mean to you? Please use chat facility to share your thoughts With teamwork we can build towards excellence". Stew Leonard.
The View from the top Executive Perceptions vs. Frontline Perceptions: Executives overestimate: Teamwork Climate 4X Safety Climate 2.5X Executive Confidence vs. Executive Accuracy: -Often wrong but rarely in doubt -Currently no incoming data-streams -Halo Effects -Frontline data fills the gap 18
Getting to Goal 19
Video New Zealand Ruby Chant http://www.youtube.com/watch?v=nrkvpi9iusk Insert name of presentation on Master Slide
T.E.A.M. Together Everyone Achieves More Five Principles of Teamwork Edward Davey http://www.tips4teamwork.com/5-essentials-of-great-teamwork.htm
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.
2. Active Listening 23 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.
3. Resolving Conflict 24 People are different and inevitably clashes of personality or other conflicts may arise. The conflict must be resolved and people should use an effective, consistent approach to resolve it.
4. Team Diversity 25 People come from different backgrounds and this can present challenges and opportunities. People have to recognise and understand their own uniqueness and that of others and make allowances.
5. Team Motivation 26 Motivation inspires commitment, innovation and teamwork. Team leaders and members need to be aware of the factors affecting motivation and techniques they can use to enhance and maintain motivation levels.
Criteria for Effective Teamwork Visible and transformational leadership Multiple disciplinary input with active participation of all members - diversity of distinct knowledge and skills needed for patient care Team members share information & coordinate services Good communication Clear purpose (shared vision) Plan of care reflects an integrated set of goals Measurement system & supportive processes/protocols Effective mechanisms to resolve conflict when it arises. Schmitt, Farrell and Heinemann; 1988 27
Barriers to Teamwork Failure to appreciate the value of different roles Power struggles inhibit communication The attitude virus! Frequent staff changes complicate staff learning Conflict and compromise may be caused by predominance of less experienced workers Poor communication Adapted from Opie, 1997 28
Barriers to Safety Trained to be perfect - knowledge and competence are equated with the absence of error Mistakes are seen as episodes of personal failure Catastrophic events are rare- It won t happen to me Assuming safety, not assuring safety Focus on individuals, not complex systems Fix the person and the problem goes away 29
Psychological Safety Recognition that human error is inevitable Complex systems Inherent Human Limitations stress, limited memory capacity, fatigue, & multitasking Safety is often ASSUMED, not ASSURED Familiarity with others is a critical component of effective teamwork: 74% of all commercial aviation accidents happen on the first day of a crew flying together Familiarity trumps fatigue Highlights the importance of predictable patterns of behavior 30
Error Is Inevitable Because of Human Limitations Limited memory capacity 5-7 pieces of information in short term memory Negative effects of stress error rates Tunnel vision Negative influence of fatigue and other physiological factors Cognitive performance after 24 hrs. without sleep equivalent to blood alcohol of.10! Dawson et al, Nature, 1997 Limited ability to multitask cell phones and driving 31
Multitasking, Interruptions, Distractions Humans are poor multi-taskers Drivers on mobile phones have 50% more accidents, 25% of traffic accidents are "distracted drivers *Interruptions and distractions increase error rates Humans need very formal cues to get back on task when interrupted and distracted *Anita L Tucker and Steven J Spear Health Serv Res. 2006 June; 41(3 Pt 1): 643 662. Operational Failures and Interruptions in Hospital Nursing 32
Red Flags Loss of Situational Awareness Ambiguity Reduced/Poor communication Confusion Trying something new under pressure Deviating from established norms Verbal violence Doesn t feel right Fixation/Boredom/Task saturation Being rushed/behind schedule 33
Fatigue 24 hours without sleep is equivalent to a blood alcohol level of 0.10 a 30% decrease in cognitive processing Nurses are 3 times more likely to make mistakes after 12 hours on the job Junior doctors made 30% more errors in ICU patients when on traditional 24 hour call schedules The best countermeasure for fatigue is teamwork more people in the same movie 34
Psychological Safety Do you know all the names of the personnel you work with? Safety Briefings= Level the playing field Hi, I m. I m sorry I missed your name. I don t have any pride invested here. I just want to get it right, so if you think I am doing anything wrong, please let me know. 35
Communication Styles National Culture Gender Roles (Physician, Nurse, Manager) Nurses: narrative & descriptive Physicians: problem solvers just give me the facts 36
Effective Communication Have a plan Acknowledge that hand-offs are dangerous Recognize the value of a structured process Structured language/clarity Who owns the patient? Criteria for increasing the intensity of care? Use structured communication tools 37
Speaking Up- Critical Assertion CUSS to communicate concern C I m Concerned or I need clarity U Uncomfortable S Stop the line/procedure S Patient Safety is at risk! 38
Safety Briefings/Huddles 39 Can be done standing up At shift handover Used to convey vital safety information Safety first items on the handover Highlights key safety issues Increases awareness
Debriefing - An Opportunity for Individual, Team and Organizational Learning Take a minute or two to learn when it s fresh in everyone s head The more specific, the better What did we do well? What did we learn? What would we do differently next time? 40
Teamwork-Where Do We Begin? 1. Create a sense of urgency 2. Pull together the guiding team 3. Formulate a change vision and strategy 4. Communicate your vision for understanding and buy-in 5. Set aims & use the Model for Improvement 6. Measurement and feedback loop 7. Test one tool on one shift with one team 8. Test and Learn from it/build upon it and refine the process 41
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 Cycles of improvement build a learning organization with continual improvement 42
Keeping an Ear to the Ground Regularly take the pulse of the team Staff will leave Measure sickness, turnover, and vacancy rate Seek staff opinion Empower and actively engage them Groan/Ideas board Insert name of presentation on Master Slide
Little things mean a lot Inspire and motivate Listen & observe Give recognition Appreciate everyone Star of the month Chocolate/ Pizza parties Team building events Make it fun
3 rd March 2011
The Wisdom of Flying Geese Basic Truth #1- Whenever a goose falls out of formation, it suddenly feels the drag and resistance of trying to go it alone and quickly gets back into formation to take advantage of the lifting power of the bird immediately in front. - People who share a common direction and sense of community can get where they are going quicker and easier because they are travelling on the thrust of one another. Basic Truth #2- When the lead goose gets tired, he rotates back in the wing and another goose flies point. If we have as much sense as a goose, we will stay in formation with those who are heading in the same direction as we are. Basic Truth #3- These geese honk from behind to encourage those up front to keep up their speed. It pays to take turns doing hard jobs, with people or with flying geese. Basic Truth #4- Finally, when a goose gets sick, or is wounded by gunshot, and falls out, two geese fall out of formation and follow him down to help and protect him. They stay with him until he is either able to fly or until he is dead, and then they launch out on their own or with another formation until they catch up with their group. We need to be careful what we say when we honk from behind. Final Truth- If we have the sense of a goose, we will stand by each other, protect one another and sometimes make new friends who seem to be going in our direction.
Questions? Hey what s a mountain goat doing way up here in a cloud bank?
Key Take Homes Respect the wisdom of the front line workers Culture is related to clinical and operational outcomes Culture is local work unit culture trumps hospital culture Lots of variability across work units Familiarity improves predictable patterns of behavior (improves performance) Perceptions of teamwork differ by role, whereas perceptions of safety climate are consistent within a work unit Senior leader contact with front-line workers is key to improving perceptions of safety climate Frontline providers have demonstrated a striking ability to improve culture in an relatively short time, when they are leading the effort Answer the question: Are We Safer than Last Year? 48
Repeated Use of the PDSA Cycle Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Hunches Theories Ideas A P S D Very Small Scale Test A P S D Changes That Result in Improvement Implementation of Change Wide-Scale Tests of Change Follow-up Tests
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.
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
Questions? 53 Raise your hand Use the Chat
Summary Content and background to patient safety Essentials of teamwork Effective communication Measurement of adverse events Tools and techniques for the frontline staff Engaging patients and families in preventing harm
Work for Action Period 55 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
Volunteers? 56
Questions? 57 Raise your hand Use the Chat
Expedition Communications 58 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 59 Thursday, March 28, 1:00 PM 2:00 PM ET Session 2 Effective Communication