Teamwork and Communication for Quality & Safety: It s More Than Checklists James P. Bagian, MD, PE Director Center for Healthcare Engineering and Patient Safety University of Michigan jbagian@med.umich.edu
Overview Problem Background Strategy Interventions
VA 2001-2006
Root Cause Analyses (RCA) Database* ~70% to 80% of RCAs cited COMMUNICATION FAILURE as, at least one of the root causes/contributing factors for an adverse event or close call report. *SPOT Database: VA National Center for Patient Safety, April, 2008 Completed RCAs, Number = 8661.
Assumptions Current OR situation was unacceptable Communication was factor Improvement was possible The risk from intervening was less than the status quo Didn t require absolute evidence base, evaluate on the fly
Communication Skills In medical school and nursing school, the focus is on successful communication with the patient.
Aviation Safety & Crew Resource Management (CRM)
Tenerife March 1977 Pan Am KLM
Fatalities - 583
Crew Resource Management (CRM)* Origin: 1979-80 NASA workshops examining the role of human error in airline crashes Research into aviation accidents in 1970s Definition: Using all available sources information, equipment, and people to achieve safe and efficient operations. Focus: safety, efficiency, and morale of humans working together LOFT: Line Oriented Flight Training Work in flight simulators and measurement of airline crew performance Briefings and Debriefings * Musson D, Helmreich RL. Team training and resource management in health care: Current issues and future directions. Harvard Health Policy Review. 2004; 5(1): 25-35.
CRM Training* Required by FAA and worldwide the way of doing business Aircrew performance measured by materials, organization, individual, and group variables Expanded aviation training from technical focus to human factors dimensions stress, fatigue, communication, shared awareness, and teamwork Outcomes: efficiency, safety, customer satisfaction Airline crew surveys: CRM relevant, useful, and effective in changing attitudes and behavior to improve safety CRM accepted by industry on face validity * Musson D, Helmreich RL. Team training and resource management in health care: Current issues and future directions. Harvard Health Policy Review. 2004; 5(1): 25-35.
Institute of Medicine establish team training programs for personnel in critical care areas using proven methods such as the crew resource management training techniques employed in aviation. Corrigan J, Kohn LT, Donaldson MS. To Err Is Human. Washington, DC: National Academy Press; 2000.
Teamwork
What are the characteristics of a TEAM?
Characteristics of a Powerful Team Common Purpose Excellent Communications Clear Roles Exceptional Results Solid Relationships Accepted Leadership Effective Processes
VHA NCPS Medical Team Training Program 2005-2010 Mean = 74 Attendees Per Learning Session Largest One Day Session = 208 (Baltimore, MD Jan 14, 2010) Largest Facility Attendance = 356 (Dallas, TX December 9-11, 2008) 18
MTT Plan Identify and guide implementation team at site Months Prior Define responsibilities, goals, and tools (e.g., checklist content) Baseline data e.g., SAQ Weeks/Days Prior OR-wide training on communication, briefings and debriefings Implement Follow-up, measure and assist/advise Months
Culture Measurement Survey open to all MDs, RNs, Techs in OR and PACU SAQ (Safety Attitude Questionnaire) Nationally accepted, validated, normed Short (~35 questions) Online Anonymous Shorter and more focused than AHRQ
Briefings Dialogue among principals using concise, relevant information to promote clear and effective communication - Real time - Face-to-face - All team members present - All team members participate
Why Do a Briefing? Establish a platform for common understanding Gives people permission to be frank & honest Gets everyone on the same page Provides a structure for collaborative planning Creates a shared mental model
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Situational Awareness Definition: The continuous perception of self and team in relation to the dynamic environment and the ability to make adjustments. The one most important aid in maintaining Situational Awareness is a common understanding of the briefed plan.
Pre-Op Briefing Entire Surgical Team Attending surgeon Anesthesiologist/CRNA Circulator Scrub nurse/tech Resident, PA, perfusionist, others Guided by checklist OR suite prior to anesthetic induction Does not replace pre-op planning Complements the TIMEOUT
Supporting Long Term Memory Checklists Put knowledge in the world vs. in the head Recognition is better than recall Tool to Guide and Improve Communication Checklist Philosophy Read and Verify checklists Read and Do checklists
Read and Verify
Read and Do
Before Insertion IV Insertion Checklist Patient Identification..CONFIRMED Correct Side CONFIRMED Catheter Size..CONFIRMED Equipment AT BEDSIDE Patient..BRIEFED After Insertion Tourniquet REMOVED Line...FLUSHED Pump.SET (with fluids) Sharps DISPOSED Site..LABELED Documentation.COMPLETE
Checklist-Driven Preoperative Briefing
Checklist-Driven Preoperative Briefing
Post-op Debriefing Entire Surgical Team Attending surgeon Anesthesiologist/CRNA Circulator Scrub nurse/tech Resident, PA, perfusionist, others Guided by checklist What went well? What did not go well? What can we do to improve our processes? What did we learn? Timing when patient is stable before attending leaves (update prior to patient leaving OR) Method to track debrief items and follow-up: Leadership Group
The Checklist is the Tool that Provides the Framework for Communication
Communication Techniques Communication techniques Call out/transparent thinking Directed communication Closed-loop communication / Feedback Read back / Repeat back Teamwork, communication protocols Dynamic Skepticism Assertive statements / wording 3 W s, SBAR, 4 steps
Dynamic Skepticism Attitude of constantly questioning and evaluating the patient care environment Avoid trusting what appears to be obvious Do not assume! Seek facts Verification is NOT a mistrust of others Questioning and verifying is safe practice
Asking the Right Question Any questions? VS What is your biggest concern for today?
Clarity Communication should be Specific Direct Concise DO NOT Hint and Hope
Hint and Hope Communication Boy that grass is really getting tall out there!
Hint and Hope Communication August 2, 1985 137 Fatalities There s Lightning Coming out of that one
3 W s 1. What I see 2. What I m concerned about 3. What I want
Situation What is the problem? Background Brief background information Assessment SBAR R What is your assessment of the patient? Recommendations What do you recommend? Response Close the loop
Assertive Statements Direct and clearly communicated statements that facilitate patient advocacy in decision-making. Not a license to be rude Use I statements, rather than You statements I statements describe your experience rather than another s shortcomings Give people options
Assertive Communication Standardized Communication Tools 4 Step Assertive Communication Tool 1. Get Attention - State name/position - Strip away title 2. State concern - Preface with I m uncomfortable 3. Offer Alternative -. 4. Pose question - to get resolution Assertiveness with Respect
When all else fails? Chain of Command
STEP BACK Engage Team Use Chain of Command TAKE ACTION 4 Step Assertive Tool 1. Get Attention 2. State Concern I m uncomfortable with 3.Offer Solution 4.Pose Question 3 W s 1. What I see 2. What I m concerned about 3. What I want OR SBARR 1. Specific 2. Direct 3. Concise Avoid Hint and Hope
Results
** Are they working in the same OR? Carney, et al, Differences in Nurse and Surgeon Perceptions of Teamwork. AORN J. 2010Jun;91(6):722-9
Medical Team Training Safety Attitudes Questionnaire In this clinical area, it is easy to speak up. * * I would feel safe being a patient here. * P < 0.05 paired, Students t-test N = 3138 Questionnaires
% Turnover Per Year Nursing Turnover Operating Room 10 P = 0.02 8 6 4 2 0 Pre Post 45 Operating Rooms and 35 Intensive Care Units Pre = 12 Months Prior to Learning Session Post = 12 Months Following Learning Session
Leadership Participation Matters
Diiference between Max and Min response (by role ave.) Team Consensus: Disparity between Physicians and Nurses (Small numbers are be er) 1.8 1.6 1.4 1.2 1.0 0.8 0.6 2011 disparity 2012 disparity 0.4 0.2 0.0 Team Climate Safety Climate Job Sa sfac on Stress Recogni on Percep on of managemnent Working Condi ons SAQ Dimension
% consensus Positive Consensus, Before and After MTT 60% 50% 40% 30% PreMTT PostMTT 20% 10% 0% Team Climate Safety Climate Job Satisfaction Stress Recognition Perception of management SAQ Dimension Working Conditions
Improved Results after One Year
MTT Facility Level Impact 67% High Impact on OR Staff 73% High Impact on OR Patients 69% of OR Teams Improved Teamwork 66% of OR Teams Report Improved Efficiency Eqpt Util (61%), Starts (35%), Duration (19%) Safety Attitudes Questionnaire (SAQ) Significant Improvement (p<0.001): Working Conditions, Perception of Mgmt, Job Satisfaction, Safety Climate, & Teamwork
Neily et al. Assoc. Between MTT and Surg Mortality. JAMA. 2010;304(15):1693-1700.
MTT Impact - VA N=108; 74 MTT, 34 Control MTT 50% greater decrease in mortality & morbidity than Control, 18% & 17% respectively Dose-response 0.5 deaths/1000 procedures less per quarter p=0.001 0.6 deaths/1000 procedures per increase in briefing/debriefing p=0.001 70% reduction in reported OR related harm
Debriefings Provide near real-time feedback Must be prepared to handle reports Prioritization Action Feedback must prompt to prevent cynicism The engine for continuous improvement
Obstacles to Performing the Debrief - Summary Transparency and Feedback are the key
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 60% 44% 75% 100% Debrief Participation For the week of Dec. 23 100% 73% 60% 36% 27% 0% 20% Increase from last week No change from last week Decrease from last week 55% 47% 71% 17% Trauma Burn(12) Oncology(7) Minimally Invasive(15) Urology(11) Gynecology(10) Colorectal(0) Hepatobiliary(5) Transplant(1) Endocrine(11) Orthopaedics(14) Ophthalmology(1) Plastics(26) Neuro(16) Otolaryngology(18) Oral(10) Service (#Cases) Pod 1 Pod 2 Pod 3
Observational Data
MTT Summary Systems Approach Surgical issues must be dealt with in the extended peri-operative period, not solely in the OR Entire System of care must be Examined and Engineered with desired results in mind avoid unintended consequences Team Training start in initial training & sustain More than SBAR Leadership Must Be Involved Checklist-guided briefings and debriefings Can t rely on individuals being careful (vigilant) Compliance Trust But Verify Consequences for Deliberate Non-Compliance
Beyond the Operating Room
Creating a Text here Shared Mental Model Slide Title
If patients know what to expect they are more likely to identify and question an unexpected or unplanned event
Providers Orders extracted from the electronic medical record Limited to current date Printed for each patient
Straightforward Implementation Nurses Review the Daily Plan with patients to: Identify potential errors Explain the day s activity Encourage questions Provide patient education
17.6% of the nurses found at least one error as the result of The Daily Plan
Improves the patient satisfaction Strengthens communication Provides patient education Facilitates continuity of care
Conclusions Need to Provide Recurrent Teamwork Training Not One and Done for OR and Floor Data show that people more likely to be on the on same page post implementation MTT process (Debriefing) highlights issues that need attention Must continue to improve system in place to deal with debrief comments Avoid BLACK HOLE EFFECT Ongoing Process Requires Leadership
Resistance Move From: Pro forma Compliance