cusp communication & teamwork tools · 7/18/2011 1 welcome to cusp communication & teamwork...

7/18/2011

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Welcome to CUSP Communication & Teamwork Tools

Coaching Call 2

The session will begin shortly.

To access the audio for the session,

Dial: 800-977-8002, Participant code 083842#.

The materials for this coaching call can be downloaded from the CUSP

Communication & Teamwork Tools password-protected web page. Directions

for how to access this web page can be found on each of the coaching call

meeting notices (appointments) sent to you.

The phone lines will be open during the presentation. Please keep your phone

on mute unless you are asking a question. If you do not have a mute function

on your phone, you can press *6 to mute your phone (and *6 again to unmute

if you want to ask a question). PLEASE DO NOT PUT YOUR PHONE ON HOLD!!!

If you experience any problems, please call Marilyn Nichols at the MOCPS office

at 573-636-1014, ext 221 or [email protected].

CUSP Communication &

Teamwork Tools

Pat Posa RN, BSN, MSA Kimberly O’Brien, MHA

System Performance Improvement Leader Project Manager

St. Joseph Mercy Health System Missouri Center for Patient Safety

Ann Arbor, MI Jefferson City, MO

[email protected] [email protected]

Coaching Call 2:Hardwiring Multidisciplinary Rounds with Daily Goals;

Sample HuddlesJuly 19, 2011

Document 1

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Documents/Resources for this Session(All can downloaded from the CUSP Communication & Teamwork Tools password-protected

web site. Detailed instructions are located on each of the coaching call meeting

notices/appointments emailed to you by Kimberly O’Brien)

1. This PowerPoint presentation

2. Monthly Team Leader Checklist

3. Sample Agenda for July CUSP Team Meeting

4. SJMHS Huddle Process

5. Learning from a Defect Tool

6. Video Samples of MDR and Huddles

7. An audio file recording of this session will be posted

on the password-protected web page following the

call

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CUSP Communication & Teamwork ToolsProject Organization

• Monthly coaching calls will be held every third Tuesday of the month, from 12-1pm (beginning on 6/21/2011)

• Six coaching calls

• Coaching calls will be recorded

• Facilitated by Pat Posa, RN, BSN, MSA

• Team leaders will be provided agendas and materials for monthly unit team meetings (can be modified)

• Project deliverables: At end of 6 months, each unit will have implemented multidisciplinary rounds and/or huddles, and solved at least one defect– Submit Case Summary from Learning from a Defect Tool to

MOCPS by November 30, 2011

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Agenda

• Implementing Multidisciplinary Rounds with Daily

Goals

• Structured Huddles: questions and view samples

• Learn from a defect—status of identifying defect

• Identify next steps

• Answer questions

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CUSP Communication & Teamwork Tools

Interventions

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�Multidisciplinary Rounds with Daily Goals

�Structured Huddles

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• A strategy to assemble the patient care team members to

review important patient care and safety issues and improve

collaboration on the overall plan of care for the patient

• Improve communication among care team and family

members regarding the patient’s plan of care

• Goals should be specific and measurable

• Documented where all care team members have access

• Checklist used during rounds prompts caregivers to focus on

what needs to be accomplished that day to safely move the

patient closer to transfer out of the ICU or discharge home

• Measure effectiveness of rounds—team dynamics,

communication, quality measure compliance, LOS

Multidisciplinary Rounds with Daily Goals –

What is it?

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• Should be done in ICUs and all units in hospital

• Hard initiative to implement, especially if you have an open unit

and/or no intensivists or in non-ICU area

– Standardize the structure and process for all units

– Benefits seen even if physician can not attend consistently or at all

– Second rounds should be done in afternoon—include at least

physician and bedside nurse

• Evaluate if goals for day have been met; readjust if necessary

• Identify if patient can be discharged (or transferred ) the next

day and if so, what needs to be accomplished

• Focused first on defining daily goals and recording those either on the

white board in the room or on a sheet of paper

• Then standardize rounds—who should attend and what is discussed

• Implemented checklist or nursing objective card

Multidisciplinary Rounds with Daily GoalsChallenges and Opportunities

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Spectrum of MDR

• Community hospital with all private practice physicians or

hospitalists

– ICU

– Non-ICU

• University affiliated teaching hospital—ICUs with dedicated

intensivists

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Remember purpose of MDR:�A strategy to assemble the patient care team members to review important

patient care and safety issues and improve collaboration on the overall plan

of care for the patient

�Improve communication among care team and family members regarding

the patient’s plan of care

Multidisciplinary Rounds with Daily Goals

Steps to Implementation

1. Commitment by all that MDR with daily goals is a strategy

that will be implemented to improve communication and

patient outcomes

2. CUSP team takes on initiative—identify if there are any

additional team members needed

3. Evaluate current rounding process

These steps you should have completed !!

4. Identify gaps between current process and what you want it

to look like

5. Define the standard work of rounds, roles and

responsibilities of each member and develop checklist and

goal process

6. Define metrics to evaluate MDR10

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Current State Assessment

What is the state of rounds on your unit? (summarize

the survey results)

– Describe unit structure (i.e. ICU, non-ICU, open unit, closed unit,

intensivist, hospitalist)

– How often are rounds held?

– Who usually attends rounds?

– What are the roles of each member?

– Where do rounds usually take place?

– Is their a defined structure/process for rounds? If so what is it? Or

does it depend on who is running them?

– How have rounds made a difference during the past year in

improving the performance on your unit?

– What is the major barrier for multidisciplinary round

implementation on your unit?

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Multidisciplinary Rounds with Daily Goals

Steps to Implementation

4. Identify gaps between current process and what you want it

to look like

5. Define the standard work of rounds, roles and

responsibilities of each member and develop checklist and

goal process

6. Define metrics to evaluate MDR

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Future StateWhat Multidisciplinary Rounds should

look like?• Video samples

• Defined and agreed upon purpose and goals

for MDR with Daily Goals

• Consistent time, members, member roles and

structure to rounds

• Defined checklist and daily goal

documentation

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Standardized Work Paradigm

Old Paradigm - I know you’ll be able to figure it out.

Just get it done the best way you can.

New Paradigm - In order to have consistent results

we must do things the same way every time.

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Standard Work System

• Standardized Work is a system for achieving a stable

baseline for a process in order to systematically

improve it.

• Standardized Work Systems are the basis for

Continuous Improvement.

“What you permit, you promote”

“We deserve what we tolerate”

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MDR with DG Action Plan

Task Responsibility Due Date

Obtain executive buy-in

Define members of rounds and their

roles

Define time of day and frequency

Structure of rounds:

•Review of systems (or major issues)

•Define components of checklist

•Time for each patient

Documentation:

•What is documented in medical record

• daily goal—where is it documented?

Define metrics and evaluation process

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Who?• Physician

– Team leader: guide rounds, ensure follow defined process, elicit input from all

members, summarizes define daily goal

• Resident:

– Present patient in system format

– Place orders in computer during rounds

– Document note in chart

• Bedside nurse

– Provide clinical information, current patient status, changes over previous

24hrs, patient or family concerns/issues (if not present on rounds)

• Case manager/social work

– Could function as leader if physician not present

– Oversee discussion of discharge planning

– Define patient/family concerns/issues

• Charge nurse/CNS/CNL

– Function in leader role if designated and physician not present

• Others

– Pharmacist, respiratory therapy, PT/OT, pastoral care, palliative care

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Structure of MDR

• Time of day

• Frequency

• Process for each patient

– Checklist

• Documenting

– Which pieces of rounds?

– Daily goal

• Define daily goal follow up process

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Patient Daily Goals Form(Document 6 of Coaching Call 1 Materials)

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Interdisciplinary Critical Care Plan and Daily Goals – CCU

Relevant System / Discipline Key: “Yes” = issues identified needing to be addressed (list issues) “No” = no issues identified (Information in parentheses is the standard patient goal –

check in daily column whether specific need identified)

Date:

Time: Initials:

Date:

Time: Initials:

Date:

Time: Initials:

Date:

Time: Initials:

Goal(s)

Patient greatest safety issue

Lab work / tests

Tests / Procedures for today

Admit Culture

Hgb Hct

K+ Cr+ CPK Troponin

HgA1C Culture

Hgb Hct

K+ Cr+ CPK Troponin

HgA1C Culture

Hgb Hct

K+ Cr+ CPK Troponin

HgA1C Culture

Hgb Hct

K+ Cr+ CPK Troponin

Neurologic (alert / oriented w/o

deficit)

� Yes � LOC � No � Seizure Precautions




Cardiovascular LVEF Measurement:ECHO____________

Coronary Cath ____________

ICD / PPM

� Yes Rhythm

� No Vasopressors Antiarrythmic

� Need for anticoagulation

� Yes Rhythm



� Yes Rhythm



� Yes Rhythm



Respiratory / vent management Date Intubated

Date Extubated

Reintubation required

Combivent / Nebs

ARDS: Low TV management

� Yes O2 SpO2

� No � HOB �� 30O

� Smoking cessation Vent � Yes � No � RSBI

� Daily weaning trial completed

� Sedation vacation MAS score � Oral care every 2 hours

� Yes O2 SpO2

� No � HOB �� 30O




� Yes O2 SpO2

� No � HOB �� 30O




� Yes O2 SpO2

� No � HOB �� 30O




Renal / Fluid Status Baseline Cr

Output goals

Recognize Daily weight gain / loss

� Yes Dialysis � Yes � No

� No

Ready to DC urinary catheter � Yes � No


� No



� No



� No


GI / Nutrition Baseline Prealbumin

Enteral tube feeding protocol Supplements/speech evaluation

Document malnutrition

Bowel management

� Yes � Stress bleeding prophylaxis

� No � Tolerating present nutrition

� Diet

� Tolerating TF � Goal Rate

� Last BM



� Diet


� Last BM



� Diet


� Last BM



� Diet


� Last BM

Endocrine Glucose control: Goal 80 – 120, if intubated,

blood sugar every 6 hours. If blood sugar

121 – 149, initiate diabetic management orders. Hypoglycemia protocol utilized

� Yes � Insulin gtt

� No � SSI

� Glucose 80 – 110 mg/dL � Steroids


� No � SSI



� No � SSI



� No � SSI


Pain / Sedation medications Goal to remain calm and pain managed at

acceptable level

� Yes � Sedation protocol utilized

� No � Treatment







6492-016-W-2s-3 (Rev. 02-07-05

Daily Goal Sheet

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(Information in parentheses is the standard patient goal –

check in daily column whether specific need identified)

Date: Initials: Date: Initials: Date: Initials: Date: Initials:

Activity – Skin – Mobility (Adequate activity progression, no skin

breakdown)

“If Braden < 18 at risk for skin breakdown”

� Yes � No � PT consult � ROM

� DVT prophylaxis � Consult ET RN

� Dressing, wound, incision

� Pressure ulcer prevention standard � Impaired skin management standard













VAD

� Yes Temp

� No � Readiness to DC

Arterial Line Day # ER/Elective

Central Line Day # ER/Elective

Peripheral IV Day # ER/Elective

� Yes Temp





� Yes Temp





� Yes Temp





Safety / Restraints � Yes

� No

� Assess need every 2 hours

� Order obtained

� Yes

� No


� Order obtained

� Yes

� No


� Order obtained

� Yes

� No


� Order obtained

Family – Psychosocial – Spiritual (No ethical concerns, e.g., end of life issues,

financial issues)

Spokesperson

� DPOA � Living Will

� Yes Code Status

� No

� Family Conf. (LOS>3 Days)

Plan of care reviewed with pt/family

� Yes � No

� Financial Services Consult

� Social Services Consult

� Yes Code Status

� No



� Yes � No



� Yes Code Status

� No



� Yes � No



� Yes Code Status

� No



� Yes � No



Discharge / Transfer Plans Long term discharge goal

� Yes � No

Ready to discharge from CCU?

� Yes � No

ECF Planning � Yes � No


� Yes � No


� Yes � No



� Yes � No


� Yes � No



� Yes � No


� Yes � No



Medication Review (no concerns re: IV

to PO, home med, renal adjustments, sedation

requirements, new allergies, adverse reaction,

unnecessary medications)

� Yes � No

Can any be discontinued?

IV to PO

� Yes � No


IV to PO

� Yes � No


IV to PO

� Yes � No


IV to PO

Other patient specific issues /

Other needed consults

AMI / ACS Indicators Cardiac Cath

ACE for EF < 40%

� Yes Plavix

� No Aspirin

Beta Blocker

ACE / ARB

Lipid lower

� Yes Plavix

� No Aspirin

Beta Blocker

ACE / ARB

Lipid lower

� Yes Plavix

� No Aspirin

Beta Blocker

ACE / ARB

Lipid lower

� Yes Plavix

� No Aspirin

Beta Blocker

ACE / ARB

Lipid lower

CHF Indicators ACE for EF < 40%

� Yes ACE

� No ARB

� Yes ACE

� No ARB

� Yes ACE

� No ARB

� Yes ACE

� No ARB

RN Signature Date:

Time: Date:

Time: Date:

Time: Date:

Time:

Intensivist Signature Date:

Time: Date:

Time: Date:

Time: Date:

Time: � Physician � PCM � RN � Physician � PCM � RN � Physician � PCM � RN � Physician � PCM � RN

� Pharmacy � RT � SS � Pharmacy � RT � SS � Pharmacy � RT � SS � Pharmacy � RT � SS

� PT � Dietary � Chaplain � PT � Dietary � Chaplain � PT � Dietary � Chaplain � PT � Dietary � Chaplain

� Palliative Care � Other � Palliative Care � Other � Palliative Care � Other � Palliative Care � Other

Daily Goal Sheet (continued)

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Nursing Card(see Document 7 of the Coaching Call 1 materials – SJMHS Interdisciplinary Rounds

Checklist)

VAP

Delirium

Sepsis

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• http://www.youtube.com/watch?v=PKN8a8bL

rSI&feature=email

• Remember . . . This is an example of MDR with

DG with a physician present during rounding.

There are also models of effective rounding

without a physician present, as discussed in

Coaching Call 1

Video Example: MDR with Daily Goals at Kaiser Permanente

(on YouTube)

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• Enable teams to have frequent but short briefings so that they

can stay informed, review work, make plans, and move ahead

rapidly.

• Allow fuller participation of front-line staff and bedside

caregivers, who often find it impossible to get away for the

conventional hour-long improvement team meetings.

• They keep momentum going, as teams are able to meet more

frequently.

Structured Huddles

Use this strategy to begin to recovery immediately

from defects---IE: falls, sepsis and daily to focus on

unit outcomes

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Huddles

• View sample videos

• What questions do you have?

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Components

Metric 1: Quality/Safety

Metric 2: Patient Satisfaction

Metric 3: Operations

Daily Critical Communications

Information

Ideas in Motion

How to do it?

•Beginning or mid shift

•5 minutes

•Lead by member of unit

leadership team

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SICU Huddle Board

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General Surgery Huddle Board

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MICU Huddle Board

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MICU Huddle Board Location

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Example Videos: Structured Huddles(all videos are also located on the password-protected web page for this project)

Download Viewing Option (the download/buffering time is lengthy – approx 5-7 minutes)

• Video Example of Structured Huddles

– Non ICU:

http://www.mocps.org/wp-

content/uploads/2011/07/Huddle%2

0on%208.wmv

• Video Example 1 of Structured

Huddles – ICU:


content/uploads/2011/07/Huddle%2

0on%20SICU.wmv


Huddles – ICU:


content/uploads/2011/07/Huddlevid

eo.mp4

YouTube Viewing Option

• Video Example of Structured Huddles

– Non ICU:

http://www.youtube.com/watch?v=6

0Ru5eDWleo


Huddles – ICU:

http://www.youtube.com/watch?v=3

lnS5QAAf6M


Huddles – ICU:

http://www.youtube.com/watch?v=B

ZE3HI7X_34

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Structured Huddles Action PlanTask Responsibility Due Date

Obtain executive buy-in

Order Huddle board

Select Huddle metrics for first board:

operational, quality/safety and patient

satisfaction

Define huddle process:

•Define time of day and frequency

•Who will lead huddle

•Expectations of staff—who will attend

•Create agenda (in first huddles include

overview of purpose of huddles and huddle

process)

Hang huddle board and fill in metrics

Identify when huddles will begin

Define process for changing huddle metrics

Create evaluation process: how will I know

if huddles are successful?

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Identifying a Defect

� AHRQ HSOPS results

� Staff safety assessment—how will the next patient be

harmed?

� Non-compliance with a core measure

� Event/incident reports

� Issues identified on Executive patient safety rounds

Have you identified a defect? If not, where are you

stuck?

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Learning from Defects Tool

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CUSP Communication & Teamwork ToolsNext Steps

• Multidisciplinary Rounds– Ask CUSP team to view sample videos

– Complete action plan (slide 16)

• Learning from a Defect– Identify next defect to solve (if haven’t done it yet)

– Begin/complete through LFD steps

• Structured Huddles– Show sample videos to unit leadership and CUSP team, gather questions

– Complete action plan (slide 27)

• CUSP Team Agenda (see Document 3 of Coaching Call Materials)– Choose next defect to take through the Learning from a Defect Tool or begin LFD process

– Show videos of MDR to CUSP team; Complete MDR with DG action plan

– Show videos of structured huddles; Complete Structured Huddles action plan

– Ensure that concepts of Multidisciplinary Rounds and Structured Huddles are vetted by

executive sponsor for unit and VPMA/CMO

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We Are On a Continuous Journey

• We have toolkits, manuals, websites, and monthly calls to

learn from and with each other.

• Your job is to join the calls, share with us your successes

and more importantly the barriers you face.

• Commit to the premise that harm is untenable.

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Questions?

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