creating an organizational culture where teamstepps … · creating an organizational culture where...
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Creating an Organizational Culture where TeamSTEPPS can ThriveNellann Nipper, RNC, NNP-BC Joanne Sorensen, DNP, RN, FACHE Joanne Sorensen DNP RN FACHE
Nellann Nipper RNC NNP-BC
Creating an Organizational Culture Where TeamSTEPPS Can Thrive
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• By attending this presentation, the learner will recognize the cultural impact of coupling Crew Resource Management and Just Culture to capitalize on the synergy, value, and need for each.
• By attending this presentation, the learner will participate in Just Culture case reviews.
• By attending this presentation, the learner will explore the impact of simulation training in embedding teamwork and clear communication principles.
Objectives
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1. Background
2. Crew Resource Management and Simulationa. Overview
b. Implementation
3. Just Culture a. Overview
b. Implementation
4. The Need for Both
5. Outcomes
6. Conclusions
Outline
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• 440 Beds
• Level 2 Trauma
• Regional referral center
• Numerous centers of excellence
• Expanding volumes & service lines
• Affiliated with UPMC in June of 2011
• 23 hospital system western Pennsylvania
Facility Overview: UPMC Hamot
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Key Statistics
UPMC Hamot
FY10 FY14 Change
Admissions & Observations 22,400 26,500 18%
Emergency Room Visits 64,000 78,800 23%
Births 830 2,400 189%
Revenue $394M $480M $86M
• Opened January, 2011
• $26 million addition
• 24 bed NICU
• 5 OR Suites with PACU
• 14 Labor suites
• 12 GYN beds & 9 Pediatric beds
• 9 Triage bays
• State of the art Simulation Lab
UPMC Hamot: The Women’s Hospital
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Background
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• 1999 IOM published To Err is Human –98,000 preventable hospital deaths Problem is process – not people
• Gawande cited communication breakdowns as contributing factors in 43% of adverse events in OR cases (Gawande et al 2003)
• Operations on the wrong patient/ wrong body part continue to take place 50 times per week in the US (est from Minnesota DOH 2013)
• Human Factors (73%) and Communication (64%) are 2 of the top 3 causes of sentinel events (Report 2004-2nd QTR 2014)
Background
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Crew Resource Management
1. History in our facility • Emphasis is on cognitive and interpersonal skills needed to manage resources within an organized system
…. not so much with the technical knowledge and skills required to operate equipment
• Training encompasses a wide range of knowledge, skills, and attitudes including
…. communications, situational awareness, problem solving, decision making, and teamwork
• Getting all the disciplines to communicate in a manner which strengthens safety and efficiency
CRM: The Concept
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• Roles:– Role clarity
– Each role creating the team
• Quick team huddle
• Shared mental model
• Situational awareness
• Pre-brief
• Debrief
• Red flags
• Concern statements
• Feedback loops
CRM: The Concept
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910
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Fall 2011: CNO presents CRM concept to leaders
Jan 2012:90 minute kickoff for leaders
May 2012:4 leaders to Nashville for Master TeamSTEPPSTraining
2013:Tools applied and revised
June‐July 2012:Team Training for WH & OR.700 RNs, Surgeons, Anesthesia, STs, PCTs, & HUCs trained
May 2014: 5 more leaders underwent Train the Trainer Education
Dec 2011:Contract signed
April 2012:2‐Day retreat at Sheraton for invested leaders: nurses, surgeons and anesthesia
Sept‐Dec 2012:Tools implemented and edited.
June‐July 2014:Team Training for ED, Trauma, RT, Trauma units. 500 RNs, Surgeons, PCTs, HUCs, and RTs trained.
August 2014:4 Trauma Tools created and implemented.
Project TimelineAugust2012:7 WH & 7 OR Tools createdSIMULATION
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Sept‐Dec 2014:Tools applied & revised
CRM & SIMULATION
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LifeWings® :– Recruiting Physician Champions and Partners
– Creating and Implementing Hardwired Safety ToolsSM
– Sustainability Workshop
– Teamwork Skills Workshops
– Leadership Skills and Implementation Workshop
– Patient Safety System
UPMC Hamot:– 4 hour Teamwork Skills Workshop
– 20 hours Creating and Implementing Hardwired Safety ToolsSM
CRM: LifeWings®
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Women’s Hospital 8 Tools
– L&D Unit Secretary Hand Off
– Triage RN to RN Hand Off
– NICU Unit Secretary/Tech Hand Off
– MBU, NICU, L&D Team Report
– RN Unit to Unit Patient Hand Off Report
CRM: HSTs
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• Rationale: Information missed in hand off report
• Creation of the HST ensured that consistent information was passed on
• Bedside Report-no longer dependent on nurse’s experience, education, or expertise
• This information is essential for patient safety – mother and infant
CRM: RN Unit to Unit Patient Hand Off Report
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L&D to Mother Baby Hand-off Tool
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• Incorporated CRM Team Strategies/Communications into Simulations for the following:
– Shoulder Dystocia
– Postpartum Hemorrhage
– Neonatal Resuscitation including Megacode
– Recognition of Non-Reassuring FHT’s
– Code OB & Maternal Cardiac Arrest
• Staff responses:100% favorable in the follow-up evaluations
CRM: The Simulation Experience
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“Wow, I really learned a lot about working as a team and team communication in a crisis situation”
“Two days after I did the simulation training my patient had a Postpartum Hemorrhage. I remembered everything we covered and you could see a difference in how efficiently everyone took on their role and communicated with each other. I was also more comfortable with telling the physician ‘I need you to see the patient now’.”
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Just Culture
1. Overview2. History in our facility
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Just Culture
• 200,000 people die from medical errors/year (Andel, et al, 2012)
• OVER 130,000 Medicare beneficiaries experienced 1 or more adverse events in hospitals in a single month (HHS, OIC, 2012)
• In 2014, 56% of hospital employees did not report any medical errors over a 12 month period (AHRQ, 2014)
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• James Reason-seminal work 1990’s in human factors and safe environments of care - author of Human Error
• David Marx-thought leader and author of “Whack-a-Mole: The Price We Pay for Expecting Perfection”
• AHRQ Culture of Safety recognizes essentials:
– High risk nature of the work being done
– Determination to achieve consistent safe operations
– A safe and fair environment for reporting error
– Collaboration
– Organizational commitment of resources
A Just Culture Historical Underpinnings
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• Organizational Commitment
• Poor teamwork
• Communication
• Culture of low expectations
• Pronounced authority gradients
Barriers to a Safety Culture
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What is “A Just Culture”?
• An environment of trust and fairness where:
– it is safe to report and learn from mistakes and system flaws to ensure patient safety;
– consistent clarity and distinction exist between human error in unreliable systems and intentional unsafe acts;
– leaders, physicians, and staff work collaboratively to build a thriving healthcare culture.
A Just Culture: Giving Staff a Voice
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Single greatest impediment to error prevention in the medical industry is
“that we punish people for making mistakes”
Lucian Leape, Professor, Harvard School of Public Health
Testimony before Congress on Health Care Quality Improvement
Just Culture
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Punitive culture creates fear, destroys creativity, builds barriers, and DRIVES ERROR UNDERGROUND.
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Just Culture
TOO MANY ABANDON THE “SECOND VICTIMS” OF MEDICAL ERRORS
July 14, 2011 issue
It was with immeasurable sadness that we learned a veteran pediatric nurse had taken her own life in the aftermath of a fatal medication error. The nurse, Kimberly, 50, committed suicide on April 3, 2011, just 7 months after making a mathematical error that led to an overdose of calcium chloride and the subsequent death of a critically ill infant.
The Second Victim
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Institute for Safe Medication Practice accessed on January 2, 2015 at https://www.ismp.org/newsletters/acutecare/articles/20110714.asp
Blame vs. Punitive Cultures
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A Just Culture finds the middle ground between a blame-free culture and an overly punitive culture
BLAME-FREECULTURE
All errors are faults of the ‘system,’ not individuals
PUNITIVECULTURE
All errors are blamed on mistakes made by
individuals
ORGANIZATIONAL CULTURES
Just Culture Model & Simulation
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Product of our current system design and behavioral choices
Manage through changes in:
• Choices• Processes• Procedures• Training• Design• Environment
Human Error
Risky Behavior
Careless Behavior
A Choice: Risk believed insignificant or justified
Manage through :
• Removing incentives for at-risk behaviors
• Creating incentives for healthy behaviors
• Increasing situational awareness
Conscious disregard of substantial and unjustifiable risk
Manage through :
• Remedial action• Punitive action
Console Coach Punish
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1 2 3 4 5 6 7 8 9 10
Nov 2010:Steering Team formed‐Nursing, Physician, Human Resources, and Quality Improvement Specialists
October 2012:Just Culture Workshop for allUPMC Hamot Leaders
Aug‐Sept 2011:Consulted with Michael LeonardDecision Tree created
May 2012: A Just Culture Review Team Toolkit subgroup created
Jan 2011:2 work groups formed—‐Policy/Procedure‐Mgmt Training & Development
January 2012:“A Just Culture Forum” workshop held at UPMC Hamot Quarterly Nursing Shared Governance Retreat
Project TimelineFall 2011:System wide Manager Training, Nursing Grand Rounds, & uLearn module created
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May 2012:UPMC Hamot Nursing Morbidity and Mortality embed “A Just Culture Review”
A Just Culture Initiative at UPMC Hamot
FEB 2011:Hamot joined UPMC
February 2013:Professional Accountability Council (PAC) implements “A Just Culture Review”
October 2014:Labor and Delivery Unit‐specific PAC introduces “A Just Culture” Review process
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September2013:UPMC Hamot Nursing Leaders coach staff using the “Just Culture Decision Tree”
• From philosophy to application– Staff perception of a non-punitive response to
error
– Spread to all levels of the organization
• Reliable consistent application – Leaders are conversant in the topic
– Just Culture Decision Tree is used during incident review
Just Culture: Implementation
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• Assessment of unit-specific culture– Culture is simply,
“…the way we do things around here”.
– Leaders collaborate with staff to aggressively address system flaws.
Simulation development by
clinical staff supports
assessment of risk-taking behavior.
Just Culture: Implementation
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Let’s Give It a Try!
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Small Group Application Exercise
• Situation: Patient fell while unattended in the bathroom and suffered a serious injury requiring re-operation.
• Background: A 57-year-old female was admitted and underwent a right knee replacement. She received a nerve block to her right leg for pain control. Post-operatively, the patient was tolerating her therapy and was able to get out of bed with the assistance of a gait belt and walker.
• Assessment: The day after her surgery, the patient was assisted to the bathroom by a PCT, and she requested to sit for a while. She was told to ring the call bell when done and that staff would assist her back to bed. Her husband also was in the room. Five minutes later, her husband ran into the hall and shouted for help because his wife was on the floor. The patient was found on the floor. The patient’s wound had opened during the fall, and there was a large amount of blood on the dressing, floor and the walls of the bathroom. The patient was taken back to the OR for closure of wound. After the fall, the patient was unable to have any further therapy or perform any range of motion. She had an increased length of stay by 4 days.
• Recommendation: ???
Case 1: Evaluate the care by the PCT
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Select the outcome category of this case from the options listed below:......
361 2 3 4 5 6 7 8
0% 0% 0% 0%0%0%0%0%
1. Malicious Behavior
2. Unfit for Duty
3. Human Error
4. Risky Behavior
5. Careless Behavior
6. System Error
7. Human Error + System Error
8. Risky Behavior + System Error
Answer Now
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Example 2: The Truncated Debrief
1. SBAR2. Just Culture
• 48 YO Male
• Presented ED with 1 day hxof RLQ pain
• Abdominal CT
• 19:13 Laparoscopic appendectomy incision
• 19:30 Laparoscopic procedure converted to ‘open’ appy
• Procedure completed
• CRNA begins standardized debrief at procedure end
• Surgeon performs ‘truncated debrief’
S = SITUATION
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• Surgeon departs the room
• Surgeon returns
• OR staff report they are still trying to count sponges– One (1) missing surgical sponge
• Staff ask surgeon “should we get x-ray
• Surgeon responds “no need”
• Patient remains intubated
• Surgical field re-established; patient re-prepped and draped
• Sponge removed without incident
• Surgeon discloses to family
B = BACKGROUND
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• Surgeon admittedly “in a hurry”
• An ED patient needed to be seen
• Beloved and respected trauma surgeon
• Why did the staff not speak up?
• Hinting and Hoping was not effective
A = ASSESSMENT
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R = RECOMENDATION
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• STOP!• I/We have a
concern
• I/We need clarity
• Shout Out
– Pressure is dropping
– My counts are off
– Which toe are we removing
Knowledge Shout Out
P&P CRM
Gut Feeling
Intuition
Question Self
STOP
Skill
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A Just Culture Decision Tree: Finding the Root Cause of Error and Harm
Select the outcome category of this case from the options listed below:...
431 2 3 4 5 6 7 8
0% 0% 0% 0%0%0%0%0%
1. Malicious Behavior
2. Unfit for Duty
3. Human Error
4. Risky Behavior
5. Careless Behavior
6. System Error
7. Human Error + System Error
8. Risky Behavior + System Error
Answer Now
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The Need for Both
…structural components
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Foundational Concepts
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Just CultureCrew
Resource Management
The Need for Both
• Zeal to get it right
• Blame and identifying a person is easier, simpler, and quicker
• Staff view this as not fair and punitive
• Hesitant to report
• Viewed as flavor of the month
• Falls short of establishing:• the identification of coworkers taking risks,
• caregiver accountability for addressing risk-prone processes
The Need for Both: CRM without a Just Culture
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• Lacks strategies to implement systematic changes
• Miss key opportunities: Communication & Teamwork
• Without the HSTs, you lack defined structure and processes
• We do it this way here:
– Depends on tradition and culture instead of well-crafted tools
– Ignores the benefit of standardizing process and communication
• Falls short of establishing infrastructure for reliability
The Need for Both: Just Culture without CRM and Systematic Simulation Practice
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Model developed by: Stephen Harden,
Chairman and CEO of LifeWings Partners LLC
The Results Accelerator
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The Results Pyramid is a Change Accelerator
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A common mistake, working only with the top half of the pyramid...
1. TeamSTEPPS training
2. Rounding
3. Staff input on checklist
4. Escalation Policy
5. Celebration & Reward
6. Data transparency
7. No retribution policy
0 Telemetry EventsSSI SIR .6 or less
To get different results, we must change the experiences that change the beliefs, that change the daily actions…
R = RECOMENDATION
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Actions
Beliefs
Experiences
I will be supported when I
speak up
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Outcomes
1. Quantitative2. Qualitative
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Outcomes: AHRQ Culture of Safety (COS)
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Communication Openness
Feedback & Communication About Error
Frequency of Event Reporting
Facility Management Support for Safety
Non-punitive Response to Error
Org Learning and Continuous Improvement
Overall Perceptions of Safety
Outcomes: COS
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Outcomes: COS
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Outcomes: COS
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Outcomes: L&D NDNQI
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2012 2013 2012 2013 2012 2013
Recommend Hospital Friend toWork
Orientation Adequate Inservices Adequate
Labor and Delivery 5.06 5.11 4.68 5.5 4.94 4.92
Mean of Hospitals Bedsize 300-399 4.76 4.65 5.03 5 4.66 4.69
3.5
3.7
3.9
4.1
4.3
4.5
4.7
4.9
5.1
5.3
5.5
1 = Strongly Disagree to
6 = Strongly Agree
Recommend Hospital, Unit Orientation, and Inservices
3/3 Exceed Mean Benchmark 2013
Outcomes: NICU NDNQI
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2012 2013 2012 2013 2012 2013 2012 2013 2012 2013
NurseParticipation
Hospital Affairs
NursingFoundations forQuality of Care
Nurse ManagerAbility,
Leadership, andSupport
Staffing andResourceAdequacy
Collegial Nurse-Physician
Relationship
NICU 3.2 3.17 3.41 3.4 3.4 3.44 3.27 2.84 3.35 3.37
Mean of Hospitals Bedsize300-399 2.89 2.87 3.14 3.11 2.92 2.91 2.92 2.91 3.17 3.14
1
1.5
2
2.5
3
3.5
Scale1 = Strongly Disagree
to4 = Strongly Agree
Practice Environment Scale
4/5 Exceed Mean Benchmark 2013
• Significant reduction in episiotomy rates
• Elective inductions reduced to Zero since 2011 (38%)
• Patients receiving > 2 u PRBC fell from 20 to 3 cases between 2011 and 2012
• Top box patient satisfaction scores
Outcomes: Quantitative
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18.0
8.0
5.0
3.0
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
20.0
2011 2012 2013 2014
Pe
rce
nt
Episiotomy Rates 2011-2014 • Senior Professional Nurse Project: Educate L&D staff on the latest AHA interventions for Maternal Cardiac Arrest.
Outcomes: Maternal Cardiac Arrest
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• Incorporated CRM principles in simulation– Pre-brief
– Checklist driven room preparation
– Sterile and standardized communication and processes
– De-brief
Outcomes: Maternal Cardiac Arrest
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.. because that is simply the way we do things around here.
July 1, 2014• OB Alert for ED called for 39
year old woman in full cardiac arrest → 35 1/7 week gestation
Outcomes: Maternal Cardiac Arrest
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“While I do not feel that any amount of teaching could have prepared me for the emotional journey that I experienced both during and after this event, I have to say that both the training and sense of teamwork that UPMC Hamot has provided me with prepared me greatly for this particular situation…On July 1, 2014 I stood by my co-workers in the trauma room of our ED and I felt as though I was as prepared as I ever could be. We functioned as a cohesive unit, a ‘well-oiled machine’.”
July 1, 2014• CPR for 37 minutes ….
Outcomes: Maternal Cardiac Arrest
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“Don’t practice until you get it right,Practice until you can’t get it wrong”
Unknown
ESTELLE
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• Start Smart!
• Where to start?– Service line vs. hot spots
• Strongly consider Role of
Simulation using CRM
• Watch for backsliding
• Be prepared (the value of perseverance
hardiness, and tenacity)
• Maintain momentum
• Engage leaders, staff, and physicians
• Celebrate successes: stories & data
Conclusions
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Nellann Nipper
Women’s Hospital
Nurse Educator
UPMC Hamot
814-877-3371
Joanne Sorensen
Clinical Director
UPMC Hamot
814-877-6875
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