Transcript Lessons for All from Labor and Delivery

Lessons for All from Labor and
Delivery
Joseph M. Montella, MD
Loraine O’Neill, RN, MPH
Keith Eddleman, MD
Lessons for All from Labor and Delivery:
How leadership and team building make for successful
huddles
Joseph M. Montella, MD
Associate Professor and Director of Quality and Safety
Department of Ob-Gyn
Jefferson Medical College
What makes a good worker?
• Lucy and Ethel wanted to do well, but were intimidated by
management and kept silent about the challenges of the job at hand
• They were obviously understaffed and realized it
• They knew they were “fighting a losing game” but kept on anyway,
and used workarounds to accomplish the task, hoping that the boss
wouldn’t notice and everything would work out fine
• If the boss had listened to their comments about why this was an
impossible task and how it could be made better, they would have
accomplished more
• Perhaps of they worked as a team, they would have been able to
accomplish wrapping the candy
What makes a good team?
•Willingness to work with others and listen to their
opinion with an open mind
•Relinquishing autonomy among the members
•Information exchange as to best practices
•Capitalizing on the strengths of the individual
members to advance the project for the good of the
patient
Team Members and Stakeholders
•Macrosystem
•Mesosystem
•Microsystem
Pardini-Kiely, et.al (2010) Jt Comm J Qual Patient Saf.
36(9):387-98
Systems at Work
System component
Candy Factory
Healthcare Organization
Macrosystem
Owners
C-suite (CMO, CFO, COO,
CEO, CSO)
Mesosystem
Elvira Allman, Manager
Department Chairs and
Administrators
Nursing supervisors and
managers
Microsystem
Lucy and Ethel
Physicians, nurses,
residents, aides, techs
Psychological Safety
•Allows for junior team members to speak up about
their ideas
•Physicians must relinquish autonomy as this is the
only way this will work
Ovretveit, J. et.al. (2009) Journal of Health, Organisation and
Management. 23:581-596.
Model for Improvement
•What are we trying to accomplish?
– Identify the problem
•How will we know if a change is an improvement?
– Systems theory states that a change in one
process may affects others in a positive or
negative way—we need a way to measure
change
•What changes can we make that will result in this
improvement?
Model for Improvement
•Identify the problem--Sign-out was happening in silos: nurse
to nurse, resident to resident, attending to attending. There
was a lack of communication between obstetrics, anesthesia,
neonatology, and nursing on all units which was measured
through Pascal Metrics surveys
•How will we know if a change is an improvement?—Pascal
metric surveys showed low scores on the communication
component of the questionnaire. Raising these scores would
be an improvement
•What changes can we make that will result in this
improvement?—A change in the way information was
exchanged.
Building a Team
•Team members were selected from each of the
three system levels from the various departments
•A desire to be on the team was not the main
criterion—identification of leadership qualities
within those individuals was
•The team started with the problem then created the
SMART goal
SMART Goal
Specific
Measureable
Attainable
Relevant
Time-Bound
Ob Report (Huddle) SMART goal
To improve the level of communication between
members of the obstetrics, anesthesia, nursing, and
neonatology teams so that the communication
portion of the worker satisfaction surveys (PressGaney) will show an improvement by 50% over the
same time period in the last fiscal year within 6
months of starting the program.
Ob Report Tool
Implementation
•Introduced the plan at grand rounds, faculty
meetings, nursing staff meetings
•Piloted the list with two attendings
•Received feedback from attendees at report about
length, missing key information
•Revised form
•Expanded to all attendings
•Needed to change resident morning report time as
this was a barrier to their education.
Success and Sustainability
•Monthly report regarding attendance at twice a day Ob
Report—after 6 months, this report is done 100% of the time
with attendance of at least one person from each of the
clinical areas
•Preliminary survey of staff regarding communication issues
demonstrated a 75% improvement in scores from a survey
administered prior to the implementation of the Ob Report
•Executive walk rounds by members of the mesosystem
(Chairs) and macrosystem (C-suite personnel) have
reinforced to microsystem the importance of their work
•This report is now part of the culture—”It’s the way we do
things around here.”
Conclusions
•A team is only as good as the individuals on it—each member
must be made to feel that their contribution is important for
the success and sustainability of the project. Everyone wants
to do a good job
•Buy-in must start from the most senior levels who must allow
the middle levels and “boots and the ground” the freedom to
recognize problems and create their own solutions
•A SMART goal must be identified for each project so that
success can be measured and sustained
•Even with checklists, huddles and read-backs, when all else
fails to assure that things go smoothly in an emergency
situation, thinking outside the box can create innovative
ideas for safety such as …
TeamSTEPPS National Conference
Wednesday June 12, 2003
Dallas, Tx
Loraine O’Neill, RN, MPH
Director of Quality Initiatives,
Dept of OB/GYN & Reproductive Science
The Mount Sinai Medical Center, New York, NY
 Define
SWOT
 Identify
2 areas to apply this
methodology
 Strengths
 Weaknesses
 Opportunities
 Threats
 Brainstorming
 Silos
 Groups
 Prior
to training
OR
 After training
Implementation planning addresses all phases
FAVORABLE
UNFAVORABLE
STRENGTHS
WEAKNESSES
What are your strengths?
What can you do better than others?
What unique capabilities and
resources do you possess?
What do others perceive as
your strengths?
What are your weaknesses?
What can you improve given the
current situation?
What do your competitors do better
than you?
What do others perceive as your
weaknesses?
OPPORTUNITIES
THREATS
What trends or conditions may
positively impact you?
What opportunities are available to
you?
What trends or conditions may
negatively impact you?
What impact do your weaknesses
have on the threats you identified?
Do you have the necessary resources?
 What
are your strengths?
 What can you do better than others?
 What unique capabilities and
resources do you possess?
 What do others perceive as your
strengths?
 What
are your weaknesses?
 What can you improve given the
current situation?
 What do your competitors do better
than you?
 What do others perceive as your
weaknesses?
 What
trends or conditions may
positively impact you?
 What
opportunities are available
to you?
•What trends or conditions may
negatively
impact you?
•What impact do your weaknesses have
on the
threats you identified?
•Do you have the necessary resources?




Use one word that best described the current
state of communication amongst the groups in
the Dept:
good, OK, open, evolving, succinct,important
and needs improvement
chaotic, minimal, confusing, lengthy,
frustrating, fragmented, lacking and
unprofessional
Words that would most definitely indicate the
need for change





Background:
Methods:
Findings:
Summary:
Next Steps:
Strengths (S):
Weaknesses (W):
Opportunities (O):
Threats/Barriers (T):
Implementation planning addresses all phases
STRENGTHS

Mutual
Support





Leadership


People know

the right thing 
Speak up
User friendly
Group Diversity
New nursing
leadership
Multidisc
collaboration
↑ Situational
awareness &
respect
↑ Patient
assessment





WEAKNESSES
OPPORTUNITIES
Convince staff
Silo culture
(DESC)
 New nurse
managers L&D
MBU
 New MDS
(CUS)
 TeamSTEPPS
training
 New staff
New culture to be 
introduced- must
relearn behaviors

Have silos
More people need
to buy in
Lack of computers
& software that
communicate with
each other
Some barriers to
assignment of
roles
THREATS/BARRIERS





↑

Multidisciplin 
e comm.
↑ level of
staff
comfortablen
ess
Space confined
Staff culture
Familiarity
Physical plant
Staff
Role changing
People not
speaking up or not
being heard
STRENGTHS

Communica 
tion
WEAKNESSES

Part of EMR
Structured
language staff is
knowledgeable 

Situation
Monitoring


Rounds in MBU
EMR (can write
orders
throughout the
house)


Difficult to learn
/lack of
cooperation
Resistant to
change, not
receptive
Neg. attitudes to
change, resistant
OPPORTUNITIES
(SBAR)
 Identify when
to use/dev
criteria
Not all staff
(STEP)
available at the
 Education
same time
needs
Lots of people
resistant to change
THREATS/BARRIERS

Resist to change

Resist change
LEADERSHIP
WHO
WHAT





Nursing Manager
NICU Rep
2 attending
Senior Residents
OB Anesthesia
attending & Resident
Charge nurse is brief



Contest to name the
team
Use scripted rounds






SITUATION
MONITORING
COMMUNICATION
Charge nurse
Attending senior
resident
Would like to have
Anesthesia


Charge RN
2 attending
anesthesiologist
In acuity order
SBAR
Room to room
(acuity 1st)
Scheduled events
& triage
Step process


Ad hoc huddle
Use a script
MUTUAL SUPPORT

RN/MD team
LEADERSHIP
SITUATION
MONITORING
WHEN
(Room
to
Room
proces
s?)





8:30 a.m. Weekly  8:30 a.m.
8:30 p.m. Weekly & 8:30 p.m.
9:30 a.m. W/E
9:30 p.m. W/E
April 1st
HOW

Implement team 
round
Get message out
to all to get
running
Documentation/S
ign in sheets
Unit see to rally
the group
(paging, etc


Committee
meetings with
Rollout
COMMUNICATION MUTUAL SUPPORT










Color coding on

boards for high

priority

Name tags/
magnetic boards
Interdisciplinary
rounds
Organize functions
on the unit
Text page reminder
Overhead page
Teaching @ Briefs
(more frequent)
Nurse staff
meetings
PA meetings
Peds/OB conference
Policy Revision
UTUBE CLIPS
E-mail

Time

Understanding

Buy In from
Leadership

Logistics

Silos

Take staff meeting or
lunch.

Educate as you go

Present

If you feed them they
will come

Sometimes it has to
be





Pat Kischak, RN
Michael Brodman, MD
David Feldman, MD
Raymond Z. Sandler, MD
Our teams back in NYC








Case presentation of Corrective action plan in
a fictional unit:
Outline how to assembly the local teammembers,meeting schedule, format
Define elements of an overview of
TeamSTEPPS Essentials Course
Explain SWOT
Practice use of SWOT analysis for Leadership
and communication
Create executive summary
Discuss barriers
Q&A




Strengths: Each discipline indicated that communication
amongst their unique group was generally good.
Communication between RN and BAs was identified as good.
The residents noted that the communication with the
attending staff, due to their accessibility, was good.
Weaknesses: Limited multidisciplinary communication. Lack
of structured flow of communication across the Dept and with
those floor teams with admitted patients who remain in the
Dept (due to lack of beds). Lack of coordinated team
formation. Multiple handoffs. Multiple interruptions and
noise therefore vital information can be missed. Minimal
respect between physicians, nurses and support staff . Very
limited use of SBAR. No common language to ensure level of
understanding.
Opportunities: Most felt that the time was right to review
communication –other issues aside such a space and volumeif structured processes were in place. They suggested Team
Rounding.
Threat/Barriers: Change can be difficult. Personalities and
hierarchy could impinge on sustainability. Format of
educational session would be important to ensure success.
RN
L&D


RN POST 
PARTUM 





STRENGTHS
Rounds
Feel free to speak
up or get
assistance from a
colleagues
EMR
Nurse cares for
mom & baby =
consistency in care
Hospt’l purchased
phones
communication
Emergency
beepers
Designated
morning rounds
Access to
Attendings
SBAR already in
place
WEAKNESSES
OPPORTUNITIES
 Lack of advocating  Implement
team STEPPS
for self
 Hand off
communicatio
difficulties
n tools
 Practice
 Phones do not
 Hand-off
(especial
always function
 EMR lose face to
breaks)
face
 Group report
communication
to increase SA
 Need SBAR
coaching/use in
simulation
 Interdisciplinary
communication
gaps
 Variation in use of
debriefs
 Overhead paging
system fails

SBAR
coaching
 Noon huddle
 Education on
escalation
policy
 Empower
Chief
Residents &
Attendings
THREATS/BARRIERS
 Volume
 Lack of Follow-up
 Volume
 Physical Layout
 Hierarchy privates
STRENGTHS
PAs/
CNMs
NICU
ANES
WEAKNESSES
OPPORTUNITIES
THREATS/BARRIERS
 Attitude
 Create
 Easy to huddle
 Hierarchy
 Small/carrying cell
moraleResistance
phones provides  Need ownership
boosting
for increase
of patient –
opportunities
provider may not
(outside work
communication
be available
environment)
 Communicates
 Leadership
 Facilitate
 Perception of middecisions made
communicatio
status well
line leaders
without input
n flow up and
from staff
down
 Communication
between staff and
leaders
 Training and  Hand-offs
 Familiarity
education
 Feedback
RN
STRENGTHS
WEAKNESSES
 Work well in
emergencies
 Skill/Knowledg
e
 Comradery &
cooperation
 Resources
 Inconsistent
communication
 ‘I’ first vs. ‘We’ first
 Communicatio 
n
 Professionalis 
m
ANES
 Patient safety
initiative
 Senior staff
 Buy In
 Leadership
SAFETY




 Improved
communication
 Education
 Resolution w/
empowering MD
 Safety team
allocate resource
Silo Communication  Improve
communication
(Hands-Off)
Resistance to
with team re: DR
changes
plans
 Medical team hand
off
Staffing Resources  Simulation
Communication Interdisciplinary
Multidisciplinary
meetings
Time-Out process
 Improved
weak
communication
MD apathy toward  Standardization of
changes
issue identified
 Silo Hands-offs
 Communication
with Attending
NICU
OPPORTUNITIES
THREATS/BARRIERS
 Hierarchy
culture
 Compliancy
 Communicatio
n structure
 Consistency
/Resistance
 Time
 Personalities
 Culture
 Staffing
 Broad scope of
issue
 Skepticism
EMBEDDING TEAM STEPPS
`````````````````````
Keith A. Eddleman, MD
Professor
Director of Obstetrics
Department Ob/Gyn and Reproductive Medicine
Icahn School of Medicine at Mount Sinai
New York, New York
OBJECTIVES
▶
Describe the elements of Team STEPPS as it
relates to a patient’s experience.
▶
Describe the process of embedding
Team STEPPS into our obstetrical service.
Labor & Delivery
Mini-Hospital:
▶
Triage
▶
Delivery.. PACU
▶
ICU
▶
O/R
Outcomes of Team Competencies
▶
Knowledge
– Shared Mental Model
▶
Attitudes
– Mutual Trust
– Team Orientation
▶
Performance
– Adaptability
– Accuracy
– Productivity
– Efficiency
– Safety
48
Barriers to Team Effectiveness
BARRIERS
 Inconsistency in Team














Membership
Lack of Time
Lack of Information Sharing
Hierarchy
Defensiveness
Conventional Thinking
Complacency
Varying Communication Styles
Conflict
Lack of Coordination and FollowUp with Co-Workers
Distractions
Fatigue
Workload
Misinterpretation of Cues
Lack of Role Clarity
TOOLS and
STRATEGIES
OUTCOMES
Brief
Huddle
Debrief
STEP
Cross Monitoring
Feedback
Advocacy and Assertion
Two-Challenge Rule
CUS
DESC Script
Collaboration
SBAR
Call-Out
Check-Back
Handoff
 Shared Mental Model
49
 Adaptability
 Team Orientation
 Mutual Trust
 Team Performance
 Patient Safety!!
Patient to Physician
Scenario
Rear ended! LIE!
Home from a party!
Bag deployed! Side and front!
”wet” down below!
Neck hurts!
Speeding teenagers!
Baby moving?!
Scared
Attending to Resident
Mount Sinai / Presentation Slide / December 5, 2012
52
Information Exchange Strategy
(SBAR)
▶
Situation
▶
Background
▶
Assessment
▶
Recommendation
53
Process
▶
How did we do it...?
▶
Every attending (67) attended a communication
workshop approx 10 at a time
▶
Scenarios and training
Barriers to Team Effectiveness
BARRIERS
TOOLS and
STRATEGIES
 Inconsistency in Team














Membership
Lack of Time
Lack of Information Sharing
Hierarchy
Defensiveness
Conventional Thinking
Complacency
Varying Communication Styles
Conflict
Lack of Coordination and FollowUp with Co-Workers
Distractions
Fatigue
Workload
Misinterpretation of Cues
Lack of Role Clarity
SBAR
OUTCOMES
 Shared Mental Model
 Adaptability
 Team Orientation
 Mutual Trust
 Team Performance
 Patient Safety!!
55
Initial Fetal Heart Tracing – Category I
Category I
▶
Baseline 110 – 160 beats per minute
▶
Moderate variability
▶
No variable or late declerations
▶
Early decelerations may be present
▶
Accelerationss may be present or absent
Resident to Attending
Barriers to Team Effectiveness
BARRIERS
 Inconsistency in Team














Membership
Lack of Time
Lack of Information Sharing
Hierarchy
Defensiveness
Conventional Thinking
Complacency
Varying Communication Styles
Conflict
Lack of Coordination and FollowUp with Co-Workers
Distractions
Fatigue
Workload
Misinterpretation of Cues
Lack of Role Clarity
TOOLS and
STRATEGIES
SBAR
Check-Back
Handoff
OUTCOMES
 Shared Mental Model
 Adaptability
 Team Orientation
 Mutual Trust
 Team Performance
 Patient Safety!!
59
EFM WORKSHOP
▶
Nurses (104) and MDs (67) in groups of 10
▶
The nomenclature of NICHD taught with scenarios
▶
Briefs, Huddles and Debriefs
Barriers to Team Effectiveness
BARRIERS
 Inconsistency in Team














Membership
Lack of Time
Lack of Information Sharing
Hierarchy
Defensiveness
Conventional Thinking
Complacency
Varying Communication Styles
Conflict
Lack of Coordination and FollowUp with Co-Workers
Distractions
Fatigue
Workload
Misinterpretation of Cues
Lack of Role Clarity
TOOLS and
STRATEGIES
SBAR
Check-Back
Handoff
Brief
Huddle
Debrief
OUTCOMES
 Shared Mental Model
 Adaptability
 Team Orientation
 Mutual Trust
 Team Performance
 Patient Safety!!
61
10:00 –
11:41
TOOLS FOR CONFLICT RESOLUTION
▶
TWO-CHALLENGE RULE
– SAME PERSON/DIFFERENT PERSON
– INVOKES CHAIN OF COMMAND
▶
CUS: ANOTHER FRAMEWORK FOR CONFLICT RESOLUTION
– CONCERNED
– UNCOMFORTABLE
– THIS IS A PATIENT SAFETY ISSUE
▶
DESC-IF CONFLICT HAS BECOME PERSONAL IN NATURE (HOSTILE,
HARRASSING)
–
–
–
–
DESCRIBE THE SPECIFIC SITUATION
EXPRESS YOUR CONCERNS ABOUT THE ACTIONS
SUGGEST OTHER ALTERNATIVES
CONSEQUENCES SHOULD BE STATED
Mount Sinai / Presentation Slide / December 5, 2012
64
Nurse Intervention
▶
Situation Awareness, Advocacy, Escalation
▶
CUS.. Clarity
▶
Weekly meetings , nurse manager/perinatal safety officer
scenarios and vignettes
constantly reinforcing Team STEPPS.
▶
Mutual Support .Feedback, Cross monitoring etc ongoing
Barriers to Team Effectiveness
BARRIERS
 Inconsistency in Team














Membership
Lack of Time
Lack of Information Sharing
Hierarchy
Defensiveness
Conventional Thinking
Complacency
Varying Communication Styles
Conflict
Lack of Coordination and FollowUp with Co-Workers
Distractions
Fatigue
Workload
Misinterpretation of Cues
Lack of Role Clarity
TOOLS and
STRATEGIES
OUTCOMES
SBAR
Check-Back
Handoff
Brief
Huddle
Debrief
Feedback
Advocacy and Assertion
CUS
Collaboration
 Shared Mental Model
66
 Adaptability
 Team Orientation
 Mutual Trust
 Team Performance
 Patient Safety!!
13:15 6cm dilated, Tachy
HUDDLE
▶
Attending, resident, nurse, charge nurse,
anesthesiologist
13:50 –
Pre-op assessment
▶
Brief, huddle debrief
The Mount Sinai Hospital
One Gustave L. Levy Place
New York, NY 10029
SURGICAL SAFETY CHECKLIST
Pre –Procedure Verification
Before Leaving Holding (RN, Anesthesia, Surgeon)
Has the patient confirmed his/her identity, site, procedure and consent with each team member using name and
DOB?
 Yes
Was the consent verified against the schedule?
 Yes
Is the site/side correctly identified and marked with the surgeon’s initials?
 Yes
Silver armband required?
 Yes
 Not applicable
H&P completed within 30 days, 24 hour surgical confirmation present, signed, timed, dated and dictation
number?
 Yes
Radiologic and diagnostic test available and labeled with patient name, DOB & Laterality (if applicable)
 Yes
 Not applicable
Does the patient have any known allergies and allergy band?
 Yes  No
Blood products required?
 Yes
 No
Blood type and Screen Blood Ordered Blood Available
Are the correct implant(s)/Special equipment available (if applicable or requested)?
 Yes
 Not applicable  Not requested
Intra-Operative
OR Team Huddle(RN, ST, Anes, Attending)
Have all team members introduced themselves by name, role and confirm the patient name, procedure, allergy and where
the incision will be made?
 Yes
Has antibiotic prophylaxis been given within the last 60 minutes?
 Yes
 Not applicable
DVT prophylaxis?
 Yes
 Not applicable
Patient pressure points reviewed to minimize potential for pressure ulcer injury
TIME OUT
RN, Anesthesia, Surgeon, Surgical Technologist
RN initiates and states planned procedure from consent.
 Yes
 Surgeon confirms the procedure and estimates the time to perform the procedure?
 Verifies Image and confirms laterality/site markers with Surgical Team
 Surgeon reviews with the team the risk of blood loss > 500ml (7ml/kg in children)
Anesthesia and the surgeon confirm what are the triggers for blood transfusion?
 Patient position is confirmed for type of procedure
 Anesthesia states any airway specific concerns and addresses airway fire safety?
Are there any safety (fire safety), equipment, supplies, instrument or implant (if applicable) concerns?
 Yes  No
Surgical instrumentation sterility confirmed?  Yes
Surgical Technologist verifies site mark is visible for all team members and patient is in the correct position  Yes  Not
applicable
1409 8cm dilated30 min
Terbutaline given 1422
Pause for the gauze tools
Post Procedure
Debriefing (RN, ST, Anesthesia, Attending)
Circulating Nurse verbally confirms with attending surgeon:
 Post operative diagnosis
 Name of the procedure performed
Specimen(s) identified, reviewed, solution confirmed and form signed by attending surgeon?
 Yes
 Not applicable
Completion of Surgicount™, manual count verified, and final count reported to surgeon prior to skin closure
 Yes and correct
Surgeon performs wound sweep (if applicable).
 Yes and correct
 Not applicable
Surgical instrument accounted for and intact  Yes
Reconciled correct count stated by RN
 Yes
Were there any equipment, instrument or supply opportunities for improvement to be addressed?
 Yes
 No
What are the key concerns for recovery and disposition of patient?
 Yes
 No
What are the key concerns for recovery and disposition of patient?
 Yes
 No
What are the key concerns for recovery and disposition of patient?
 Yes
 No
Back into PACU
HAND OFF
Physician decision making
▶
TASK FIXATION
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DESC
STANDARDIZATION DRILLS
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Shoulder:
▶
huddles, briefs, debriefs, call out, read back
▶
Hemorrhage:
▶
huddles, briefs, debriefs, call out, read back
Team Effectiveness
BARRIERS
 Inconsistency in Team
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Membership
Lack of Time
Lack of Information Sharing
Hierarchy
Defensiveness
Conventional Thinking
Complacency
Varying Communication Styles
Conflict
Lack of Coordination and FollowUp with Co-Workers
Distractions
Fatigue
Workload
Misinterpretation of Cues
Lack of Role Clarity
TOOLS and
STRATEGIES
OUTCOMES
Brief
Huddle
Debrief
STEP
Cross Monitoring
Feedback
Advocacy and Assertion
Two-Challenge Rule
CUS
DESC Script
Collaboration
SBAR
Call-Out
Check-Back
Handoff
 Shared Mental Model
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 Adaptability
 Team Orientation
 Mutual Trust
 Team Performance
 Patient Safety!!