IHI Expedition Engaging Frontline Teams to Create a Culture of Safety

March 28th, 2013

These presenters have

nothing to disclose

Annette Bartley, RN, MS, MPH Tracy Jacobs, BSN, RN

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Lizzie Grimm, Project Assistant, Institute for

Healthcare Improvement

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Expedition Director

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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

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Effective Communication

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

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

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Schedule of Calls

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

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Faculty

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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 one-year 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 for Action Period

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

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Feedback From Our Volunteers

Nisha

Others

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Overview of Key Learning Points

Patient Safety requires consistent Leadership attention,

focused action and frontline engagement

Don’t crash and burn!

Three key principles -Prevention Detection and Mitigation

Culture eats strategy for lunch

Developing a safety culture within an organization requires

attention to the subcultures within different units and

departments

Teamwork is an essential component of patient safety

Situational awareness/ briefing and debriefing

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Effective Communication

Session Objectives

By the end of this session participants will be able

to:

Appreciate the importance of effective communication in

assuring the provision of safe patient centered care

Describe key factors in effective communication

Describe the impact of behaviors on effective

communication and patient safety

Identify and test structured communication tools

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Importance of Communication

Communication failure has been identified as the leading root cause of sentinel events over the past 10 years (Joint Commission)

Communication failure is a primary contributing factor in almost 80% of more than 6000 root cause analyses of adverse events and close calls (VA Center for Patient Safety)

Focus for to-day communications amongst healthcare professionals

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Investing in Improving Communication

The Joint Commission reports that investing to improve

communication within the healthcare setting can lead to:

Improved safety.

Improved quality of care and patient outcomes.

Decreased length of patient stay.

Improved patient and family satisfaction.

The Joint Commission. The Joint Commission Guide to Improving Staff Communication-Joint

Commission on the Accreditation of Health Care Organizations. 2005

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Effective communication can be supported

by a healthcare organization if they…

Clearly link effective communication and teamwork to patient safety.

Clearly articulates the organization's expectation on how communication will be

carried out.

Fosters a communication process that facilitates continuous improvement in

patient safety and quality of care.

Assesses the current organizational culture of patient safety and identifies areas

for improvement, for example, conducts an assessment of staff perceptions and

current practice in the delivery and management of safe patient care.

Fosters and promotes a work culture that values cooperation, teamwork,

openness, collaboration, honesty and respect for each other and promotes open

and effective communication.

Creates an atmosphere where team members feel safe to speak up about

issues relating to patient care regardless of their position or rank.

Provides resources and identifies appropriate communication strategies to

ensure that information is effectively exchanged between people — depending

on the situation, different communication methods may be required

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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.

http://www.tips4teamwork.com/5-essentials-of-great-teamwork.htm

2. Active Listening

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.

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What factors contribute to communication

failures in healthcare?

Human factors; attitudes, behaviors, morale, memory failures, staff stress and fatigue

Distractions and interruptions.

Shift changes.

Gender, social and cultural differences.

Hierarchy or power distance relationships (e.g. junior staff are reluctant to report or

question senior staff).

Difference in training of doctors, nurses and paraprofessionals.

Time pressures and workload.

Limited ability to multitask even when highly skilled.

Lack of a shared mental model regarding what is to be achieved.

Lack of organization policies and / or protocols.

Organizational culture that discourages open communication.

Lack of defined roles and responsibilities among members of multidisciplinary teams Leonard, M., Graham, S., and Bonacum, D. (2004). The human factor: the critical importance of effective teamwork and communication

in providing safe care. Qual Saf Health Care, 13 Suppl 1: p. i85-90.----------Oandasan, I., Baker, G.R., Barker, K., et al. Teamwork

in Healthcare: Promoting Effective Teamwork in Healthcare in Canada Canadian Health Research Foundation (CHSRF),June 2006.

Viewed 19 October 2009,

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Five Standards of Effective Communication

When trying to generate Improvements in the exchange of information between healthcare professionals, and information should be:

Complete

It answers all questions asked to a level that is satisfactory to

those involved in the exchange of information.

Concise

Wordy expressions are shortened or omitted. It includes only

relevant statements and avoids unnecessary repetition.

Concrete

The words used mean what they say; they are specific and

considered. Accurate facts and figures are given.

Clear Short, familiar, conversational words are used to construct

effective and understandable messages.

Accurate The level of language is apt for the occasion; ambiguous

jargon is avoided, as are discriminatory or patronizing

expressions.

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Learning the Language of Patient Safety

Communication

7. SBAR 8. Call-outs 9. De-briefing/Check-backs 10. Hand-offs

Leadership 1. Briefs 2. Huddles 3. Debriefs

Situation Monitoring

4. Situational awareness – Cross monitoring

Mutual Support 5. Task assistance 6. CUSS

Leadership •Brief: Planned, assign roles, establish expectations, anticipate outcomes

•Huddle: Gather as needed to discuss critical issues & emerging events •Debrief: End of activity, discuss what went well and what we can do better

Situation monitoring

•Situation awareness: Know what is going on around you, including cross monitoring your team members

Mutual support

•Task assistance: Ask for and offer support with all team members •CUS: When appropriate, use a CUS word: I am ONCERNED! I am NCOMFORTABLE! This is a AFETY ISSUE!

Communication

•SBAR: Summarize your critical messages in a standard format – Situation, Background, Assessment, Recommendation

•Call-out: Communicate important information and inform team members simultaneously during emergency situations

•Check-Back: Verbally confirm instructions – "closing the loop" •Handoff: During transitions in care, clearly transfer both information and accountability – make sure to offer opportunity for questions

CUS S

TeamSTEPPS Language Definitions

Communication Styles

National Culture

Gender

Roles (Physician, Nurse, Manager)

– Nurses: narrative & descriptive

– Physicians: problem solvers “just give

me the facts”

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Effective Communication Requires

Leadership

flat hierarchy

sharing the plan

continuously inviting other team members into the conversation

explicitly asking people to share questions or concerns

using people’s names

Briefing/Debriefing

Assertion/Critical Language (key words)- The ability to speak up and stop the show

Structured Communication (SBAR)

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Psychological Safety…

Environment of Respect

• “A fundamental, non-negotiable respect for

every employee, everyday, by everyone”

• Their work is recognized and acknowledged

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Assertion Speak up and state your information with appropriate persistence until there is

a clear resolution

What is it?

Organized in thought and communication

Valued by the entire team

Looking for clarification & common understanding

What is it not?

• Aggressive or hostile

• Ridiculing

• Confrontational

• Ambiguous

*

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How do you communicate?

• Sterile Bowl

• Prepping a patient for OR

http://www.youtube.com/watch?annotation_id=annotation_8462

05&feature=iv&src_vid=3r4rS0yzQ1M&v=7-a2QBfFQeA

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Structured Communication

• CUSS to communicate concern

• C – “I’m Concerned” or “I need clarity”

• U – Uncomfortable/Unsafe

• S – Stop the line/procedure

• S – Patient Safety is at risk!

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Structured Communication: SBAR

If the phone goes dead in 10 seconds – will the person on the other end know what is needed?

Situation – State what you are calling about (5-10

second punch line)

Background – State what you are calling about (including

objective date i.e. vitals, labs)

Assessment – State what you think the problem is (diagnosis

not necessary – include severity)

Recommendation – State what you think

needs to be done for the patient (get a time frame)

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Structured Communication

S –Mr. M has sudden onset of radiating chest pain & shortness of breath

B – He has a history of MI’s, & his obs are 186/76, 180, 24 & he is on 5L of O2 per nasal cannula sats 84%

A – I think Mr. M might be having an MI

R – I need you to come evaluate the patient, how soon will you be here?

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The Difficult Conversation When anticipating a difficult conversation focus on:

What needs to happen for us to do the right thing

for our patient?

– Focus on the common goal - high quality, safe care

– Depersonalize the conversation - focus on the patient

– Avoid judgment - don’t place blame

It’s not about you & me, it’s about the

quality & safety of our patient care!

Engagement Physicians in Quality and

Safety

Challenges:

Doctors are busy

They’ve been trained as individual experts

They are very goal oriented and want to see results

Traditionally, we haven’t taught them about human

factors, teamwork and system error – a different way of

thinking

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Doctors & Nurses

Nurses are trained to be narrative and descriptive

Doctors are trained to be problem solvers

– “what do you want me to do?”

– “just give me the headlines”

Complicating factors: gender, national culture, the

pecking order, prior relationship

Perceptions of teamwork depend on your point of view

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What is TeamSTEPPSTM?

TeamSTEPPS is an evidence-basedteamwork system

based on 20 years experience and lessons learned from

High-Reliability Organizations (HROs) designed to

improve:

– Quality

– Safety

– Efficiency of health care

Practical and adaptable

Provides ready-to-use materials for training and ongoing

teamwork

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Why Use TeamSTEPPS?

Goal: Produce highly effective medical teams that

optimize the use of information, people and resources to

achieve the best clinical outcomes

Teams of individuals who communicate effectively and

back each other up dramatically reduce the

consequences of human error

Team skills are not innate; they must be trained

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Teams STEPPS- What Teams Learn?

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Crew Resource Management United Airlines was the first airline to provide CRM training for its cockpit crews,

in 1981.

CRM can be defined as a management system which makes optimum use of all

available resources - equipment, procedures and people - to promote safety and

enhance the efficiency of operations. CRM although first established in the civil

aviation industry as cockpit resource management has been adopted and

adapted by many other industries, some of which are the commercial maritime

shipping industry using a form called "Maritime Resource Management (MRM)".

CRM training encompasses a wide range of knowledge, skills and attitudes

including communications, situational awareness, problem solving, decision

making, and teamwork; together with all the attendant sub-disciplines which

each of these areas entails.

Focus on teamwork, communication, flattening hierarchy, managing error,

situational awareness, decision making

Non-punitive reporting of near misses, 500,00 reports over 15 years

Very open culture with regard to error and safety

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High Reliability

• Preoccupation with failure – When someone raises a

concern, the problem exists until proven otherwise

• Reluctance to simplify – Errors and close calls are

reflections of deeper system flaws

• Commitment to resilience – Knowing there will be

problems and flaws, the job will get done

• Deference to expertise – The person most qualified does

the job

• Sensitivity to operations – Flexing resources to deal with

demand or workload

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Focus on the Common Goal

Anchor the work where we have common agreement

Avoid judgment and 1st person / 2nd person dialogue

Basic tenet of negotiation theory – it is much easier to

have the 3rd person conversation when discussing how

to do the work

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Understanding Culture is Essential

What are your social metrics?

How do people perceive teamwork in the

environment – are staff hesitant to speak up?

Safety climate? Do staff believe their

concerns would be acted upon?

What is their level of threat awareness? High

workload, fatigue, multi-tasking?

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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

Effective communication

Cycles of Improvement – build a learning organization with continual improvement

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What will you test by next Tuesday?

Elevator speech

SBAR

ISBARD- Introduction and discussion

CUSS

Safety Huddle

Briefings /Debriefings

Safety Cross

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The Improvement Guide, API

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

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

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.

Do:

Study: What happened?

What did you learn?

What surprised you?

The Blue Angels

http://www.youtube.com/watch?v=mR0_SK1K8xY

Homework for the Next Action Period

The elevator speech

Imagine you have just walked into the elevator with your chief

executive officer

You want to share you patient safety project with them and

seek his /her support

Succinctly describe your patient safety project within 2 minutes

Incorporate the overall purpose of what you are doing, the key

aims and objectives, and details of the actions.

Seek support for what you need

Practice – to ensure you share the key message make the

maximum impact in a short

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Homework (cont)

Meet as a team and consider how you currently measure

adverse events /harm in your unit/ department/

organization.

What tools do you use?

Who collects the data?

Who analyses the data?

How timely is feedback?

Who develops any required action plans?

Is the data locally owned?

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Questions?

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Volunteers?

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Questions?

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Raise your hand

Use the Chat

Expedition Communications

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

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Next Session

Session 4 –

Measurement of Adverse Events

Date: Thursday, April 11, 1:00 PM – 2:00 PM ET

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