Positive Rounding in Health Care Work Settings J. Bryan Sexton, PhD Kathryn C. Adair, PhD
Introduction & Overview J. Bryan Sexton, PhD Associate Professor, Department of Psychiatry Director of Patient Safety Center, Duke University Health System Kathryn C. Adair, PhD Associate in Research Patient Safety Center, Duke University Health System
Goal and Rules of Engagement Goal: To understand why, when, and how to start a Positive Rounding practice or program How: Through empirical evidence on positive rounding, safety, teamwork and burnout, in tandem with activities and practice Cell phones set phasers on stun Pee Eat Share Environment of Respect Use protected time to practice Engage in activities Will use phone/laptop / IPad for activities Page 4
Overview Analogy what you notice What is traditional Safety Rounding? Burnout: Prevalence, Severity, Links to Outcomes Psychology of Burnout What is Positive Rounding? What s the evidence? Logistics: When, Where, and How Navigating the Interpersonal Dynamics Implementation Session: 8-11:30am Break 10-10:30am
Analogy: Noticing something about the world Commenting on it briefly through your mobile phone Seeing what other people commented on
Anyone currently doing Patient Safety Walkrounds/Leadeship WalkRounds?
Executive Partnerships Clinical Area Unit Based Safety Officer Executive Hospital Quality Council/Patient Safety Committee
Executive Partnerships Clinical Area Unit Based Safety Officer Linked Executive Hospital Quality Council/Patient Safety Committee
Traditional Patient Safety Rounding Frame: So how are we going to kill the next patient around here?
WalkRounds Questions Does your work setting use Patient Safety Leadership WalkRounds to discuss with senior leaders any issues that could harm patients or undermine the safe delivery of care? Yes No Not Sure Did you receive feedback about patient safety risks that were reduced as a result of WalkRounds? Yes No Not Sure
WalkRounds Questions Did you receive feedback about patient safety risks that were reduced as a result of WalkRounds? Yes No Not Sure 26% 35% 39%
Positive Rounding Frame: What are three things that are going well around here, and one thing that could be better?
Positive Rounding at Duke: How did we transition from rounding on safety concerns to celebration?
Duke Health System 2016 Safety Culture Survey SCORE (Sexton et al., 2017) Positive Rounding Question: Did leaders ask for information about what is going well in this work setting (e.g., people who deserve special recognition for going above and beyond, celebration of successes, etc.)?: Yes / No / Not Sure Yes: No: Not Sure:
Mean of the clinical area scores Learning Env, 40 Local Leadership, 31 Teamwork Climate, 39 Safety Climate, 38 Learning Env, 76 Local Leadership, 66 Teamwork Climate, 71 Burnout (My Burnout), 36 Burnout Climate, 53 Safety Climate, 75 Burnout (My Burnout), 61 Burnout Climate, 76 Work Life Balance, 67 Work Life Balance, 50 100 90 80 70 60 t=40.33, p<.001 Safety Culture Domains by Positive Rounds t=37.24, p<.001 t=34.10, p<.001 t=41.17, p<.001 t=-25.09, p<.001 PosRd Yes (n=6585) PosRd No (n=2212) t=-24.15, p<.001 t=18.76, p<.001 50 40 30 20 10 0
After controlling for pt severity and nurse and hospital characteristics, only nurse burnout was associated with the clinical outcomes
Impact on critical care nurses Half are emotionally exhausted (burned out) 2 out of 3 have difficulty sleeping 1 out of 4 are clinically depressed Sexton, et al. (2009). Palliative Care.
Am I burned out?
Am I burned out? You try to be everything to everyone You get to the end of a hard day at work, and feel like you have not made a meaningful difference You feel like the work you are doing is not recognized You identify so strongly with work that you lack a reasonable balance between work and your personal life Your job varies between monotony and chaos You feel you have little or no control over your work You work in healthcare
Percent Negative- % Reporting Burnout 100 90 Burnout Climate across MI work settings 2015 80 70 60 50 40 30 20 10 0
Part in Decision Making.61 Learning Environ.62 Burnout Climate.79 Local Leadershi p.59 Teamwork Climate.58 Workload.56? Safety Climate.64 Advancement.28 Job Uncertainty.33 Intentions to Leave.44 Growth Opportunities.54 Work-Life Balance.50
Part in Decision Making.61 Learning Environ.62 Burnout Climate.79 Local Leadershi p.59 Teamwork Climate.58 Workload.56 Personal Burnout Safety Climate.64 Advancement.28 Work-Life Balance.50 Job Uncertainty.33 Intentions to Leave.44 Growth Opportunities.54
Percent Positive - % Reporting Good Climate 100 90 80 Burnout Climate vs My Burnout across MI work settings 2015 Burnout Climate My Burnout 70 60 50 40 30 20 10 0
Percent Reporting Emotional Exhaustion in self vs. work setting 100 90 80 Burnout Climate vs My Burnout across DUHS work settings 2016 Burnout Climate My Burnout 70 60 50 40 30 20 10 0
My Burnout better predictor of Work Life Balance Safety Climate Advancement Growth Opportunities Burnout Climate better predictor of Learning Environment Teamwork Climate Psychological Safety (for physicians)
Burnout is associated with: Infections Cimiotti, Aiken, Sloane and Wu. Am J Infect Control. 2012 Aug;40(6):486 90. Lower Patient Satisfaction Aiken et al. BMJ 2012;344: e1717 Vahey, Aiken et al. Med Care. 2004 February; 42(2 Suppl): II57 II66. Medication Errors Fahrenkopf et al. BMJ. 2008 Mar 1;336(7642):488 91. Higher Standardized Mortality Ratios Welp, Meier & Manser. Front Psychol. 2015 Jan 22;5:1573.
Are they burned out? A brief tour of prevalence Page 39
Burnout is common among physicians in the United States, with an estimated 30% to 40% experiencing burnout.
Results 24 (20%) of the participating residents met the criteria for depression and 92 (74%) met the criteria for burnout. Active surveillance yielded 45 errors made by participants. Depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed: 1.55 (95% confidence interval 0.57 to 4.22) compared with 0.25 (0.14 to 0.46, P<0.001)
a person s future level of cognitive vulnerability was significantly affected by his or her roommate s baseline level of cognitive vulnerability (and vice versa)
Burnout by Specialty Emergency medicine General internal medicine Neurology Family medicine Otolaryngology Orthopedic surgery Anesthesiology Obstetrics and gynecology Radiology Physical medicine and rehabilitation Mean burnout Mean burnout among among all all physicians participating General surgery Internal medicine subspecialty Ophthalmology General surgery subspecialty Urology Psychiatry Neurosurgery Pediatric subspecialty Other Radiation oncology Pathology General pediatrics Dermatology Preventive medicine, occupational medicine, or environmental medicine % Reporting Burnout 0 10 20 30 40 50 60 70 Arch Intern Med. Published online August 20, 2012. doi:10.1001/archinternmed.2012.3199