Transcript Beard Bloxom - Life Cycle of a Critical Incident2011_03_18

Life Cycle of a Critical Incident
Canadian Patient Safety Officer Course
Cecilia Bloxom, Director of Communications
Paula Beard, Senior Director (Western Region)
What’s going to happen…
Part A: In the Beginning…
Part B: Who’s Asking?
Part C: Can we Talk?
15 minutes
Drink coffee and take a deep breath
Part D: What Happened?
Part E: What are we Going to Do About It?
Part F: Are we Sure we Did Something About It?
Part G: Can we Talk Some More?
Part A
In the beginning there was a patient safety
incident report…
What do we do now?
Assumptions:
– Within your team individuals will play the role of:
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CEO
Attending Physician
Charge Nurse
Patient Safety Officer
Other assignments will be determined based on the
exercise and the group’s decision to add roles
Assumptions
 Staff have made the situation safe for others
 An imminent recurrence has been prevented
 Support has been provided for the family
including the identification of a key family
contact which is the resident’s daughter
Part A: In the Beginning
You have 15 minutes to build a plan with
your team on how to address the critical
incident
1.
2.
3.
Build your plan & let those within your
organization know what role they will play
Report back to your coach
Large team discussion on what went well
and any challenges
Did you?
Notify the…
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Attending Physician
Chief Executive Officer
Nursing Manager
Social Worker
Health Information
Chief of Staff/Medical Managers
Risk Management/Legal Counsel/Insurer
Communications
Other staff as required. If so who?
…about the critical incident
Part B: Who’s Asking?
Effectively communicating after a patient safety
incident
The Media calls…
 DAUGHTER OF THE RESIDENT CALLS THE
LOCAL TELEVISION STATION AFTER BEING
NOTIFIED ABOUT HER MOTHER.
 YOU NOW NEED TO RESPOND TO THE MEDIA
AND THE PUBLIC.
Informing the Media
Assumptions:
– The resident’s daughter has not consented to waive
her or her mother’s privacy
– You have asked for and been given 15 minutes to
get back to the requesting media outlet (local news
at noon are on their way)
– It is 2 days since the critical incident and the
investigation is underway
Informing the Media
In your team –
1. Select a spokesperson and ensure that the person
plays the organizational role (e.g.,
Communications, physician, CEO) as decided by
the group
2. Identify who should assist with developing the
messaging
3. Assist spokesperson to prepare the statement for
the media
4. Your coach will act as the reporter
The Media calls…
POTENTIAL HEADLINES:
 SENIOR WITH DEMENTIA FOUND FROZEN
AFTER WALKING OUT OF SECURE FACILITY
 DAUGHTER WANTS TO KNOW WHY HEALTH
SYSTEM KILLED HER MOTHER.
Responding to the Media…
We know that:
Organizations that appear to be slow in responding
to patient safety incidents and/or perceived to be
consciously “covering them up” are often subject to
intense scrutiny, not only by the public and media,
but also by regulatory bodies or government.
Responding to the Media…
Expectation:
The culture around the disclosure of information on
patient safety incidents is changing.
It is now the expectation, not the exception that
organizations share this information with key
stakeholders and audiences.
Crisis Communications Plan
 Context:
What’s the main issue that needs to be
addressed through communications?
What/whose approvals do you need to proceed
with communications?
Crisis Communications Plan
 Environmental Scan:
What is the current situation, the key issue, the urgency,
seriousness or pressing nature of these issue.
What’s been done to date to address them or identify
what operational response has been approved?
What information are you missing that you need to
proceed?
Who do you need to contact and get involved?
Crisis Communications Plan
 Timing:
How much time do you have?
Clarify if more research and investigation are
required and how long will that take.
Could/should the information-sharing be part of a
larger announcement on broader patient-safety
initiatives being launched by your organization?
In other words, consider the broader patient-safety
initiatives of the organization and how, or if, this
event might reflect or advance them.
Crisis Communications Plan
 Objectives:
What do you want to achieve – i.e. raise
awareness, share information, defuse
controversy, change behaviour? Are your
objectives actionable and measurable?
Crisis Communications Plan
 Stakeholders/Audiences: Who are the
stakeholders, both internal and external, who
are directly affected by this; who are the key
audiences (internal and external) that can
influence outcomes, and/or are involved and
interested in the issue.
Crisis Communications Plan
 Messages: What are you going to say? Address
the 5Ws, with the main focus on “why we are
doing this”, supported by what actions we are
taking/proposing; who will they affect; when will
they occur; where will it take place; and how will
it roll out, change/improve things, etc. When
developing messages, ensure you always consider
your audience. Tailor your messages so the
language is clearly understood by the audience.
Avoid using healthcare jargon or industry-specific
language.
Developing Key Messages
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Keep it short
Make them memorable
Write them towards your target audience
Don’t use acronyms
What’s the what for your
target audience
 Caregivers
“Is someone going to get fired?”
What’s the what for your
target audience
 Other Patients and their families…
“Is this facility safe?”
What’s the what for your
target audience
 Policy makers
“What are you doing to ensure every patient is
safe and this does not happen again?”
What’s the what for your
target audience
 Media
“What’s the story?”
What’s the what for your
target audience
 Media
“Who, what, when, where, why and how?”
Crisis Communications Plan
 Issues Scan:
What are the key issues that need to be
addressed? What issues might create barriers
or controversy; which ones provide
opportunity? How do those issues align by
stakeholder/audience? How are they likely to
be perceived/presented by the public and/or
media – i.e. positive, negative or neutral?
Crisis Communications Plan
 Strategy:
How high or low-profile do you want your
“notification” to be?
How wide a circle of audiences/stakeholders
should it include? Should public outreach and
communication be proactive or reactive?
Consider the need to notify audiences in stages
as the notification group is broadened,
depending on the issue..
Crisis Communications Plan
 Tactics:
Your strategy will help define the scope of
your tactics – e.g. a high-profile and proactive
strategy obviously dictates more outreach, a
wider range of information channels and
communication products, and potentially a
greater involvement by more members of your
organization.
Crisis Communications Plan
Key considerations include:
 What is your pre-announcement plan to talk to and/or
precondition key stakeholders and audiences?
 What is your plan surrounding the actual announcement?
 How do you propose to follow up, sustain and adjust your
messaging over time?
 What communications vehicles/channels are you proposing
to distribute the information – i.e. face-to-face, print, webbased, digital, etc.?
 How do you propose to target specific key stakeholders and
audiences?
Crisis Communications Plan
Roles and Responsibilities: Who needs to develop
and deliver the tactical outputs – be specific. For
example:
 What’s the role for your CEO, if any?
 Who are your other key spokespeople?
 Who else besides communications needs to be
involved – e.g. board members, professional staff,
Legal, HR, Finance, partners, volunteers, etc.?
Part C: Can we Talk?
In your team –
1. Identify a key contact for the family
2. Discuss if, when and how you would like to
meet with the family
3. Decide what you will discuss with the family
4. Invite the resident’s daughter in to have the
discussion (your coach)
Did you?
 Utilize a process agreed upon by your team
 Provide as many known facts as possible
 Not speculate about the cause
 Consider providing information regarding the
organizational response
 Identify a process for staying in contact and following
up
Take a Deep Breath…
It’s coffee time!
Please be back in your teams in 15 minutes
Part D: What Happened?
In your team:
1. Decide how you are going to investigate what
happened
2. List the steps you will take
3. Have a discussion based on the time line you
will be provided by your coach about what
your team believes is the contributing factors
to the critical incident
Did you?
Quarantine and review articles related to the event
– Devices
• To ensure defective devices are removed from service
• Repair/return to manufacturer (serial numbers may be needed)
– Tour the Location
– Drugs/solutions and associated packaging
• For analysis
– Physically examine drugs/devices involved in an event
– Health record
Did you?
Interview staff and others as appropriate (including
the family)
– As soon as possible after the event
– One person at a time
– Interview all staff involved in the event as well as the
family as appropriate.
– Use a cooperative approach
When interviewing did you?
• Ask individuals to “tell their story” and “re-enact”
event. If possible, do not interrupt.
• Use open-ended questions
• Stay on track
• Record interview in a comfortable way
• Thank people for helping to provide
understanding of event
Did you?
Conduct a literature review to:
• Determine leading practices and relevant evidence
based guidelines
• Review standards of practice
• Any intervention, elimination or prevention
strategies that has been previously tried for this
type of incident
Did you?
Review the incident as a team:
– Multi-disciplinary
– Those with direct knowledge of the event processes
– Those responsible for change
Use a different method?
How did you arrive at the root causes
 Use diagramming?
 Are you sure your findings contributed to the
critical incident?
 How will you ensure there is an organizational
memory of the critical incident?
Part E – What are we going
to do about it?
Using your contributing factors from
Part D, develop an action plan for the
organization
Hint: Ensure they encourage system level
changes which, if implemented, will have
lasting effects on safety
Did your changes…
Receive leadership endorsement?
Consider a hierarchy of effectiveness?
1.
2.
3.
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6.
7.
Forcing functions and constraints
Automation / computerization
Simplification / standardization
Reminders, checklists, double checks
Rules and policies
Education
Information
Part F: Are we Sure we Did
Something About it? 30 minutes
The team will need to:
1.
Develop a measurement plan.
2.
Provide a 5 minute report to the Board
Quality Committee (your coach)
Did you?
 Assign actions to specific individuals
 Specify timelines
 Consider:
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Potential impact on individual units/staff
Barriers to implementation
Cost of implementation
Likelihood of causing additional adverse events
“Pilot-testing”
Did you?
 Assess current status to determine if actions
were effective
 Monitor to ensure changes are maintained
 Provide feedback to staff about impact of
patient safety efforts
Did you?
 Measure effectiveness of the action not [just]
completion of the action
– e.g. measure that falls assessment occurs for x% of new
patients admitted, NOT the number of staff trained to do
falls assessment
 Ensure the measures were quantifiable with defined
numerator and denominator (if appropriate)
How do you know when you are
done?
When is measurement complete?
How will you know if the improvement is successful?
1. Repeated measurement (e.g. audit) demonstrates sustained
change
2. When the new process is routine
3. When new employees demonstrate proper procedure after
orientation
Who else needs to know?
 Consider communicating the information learned to
those who could also benefit from the information
1. Within the organization
2. Outside the organization
3. “Incidental findings”
Part G – Let’s talk some more
15 minutes
As a team consider what you can tell the
resident’s daughter about what you know now.
When you are clear about what information
and who will provide it to the resident’s
daughter ask her to have another conversation
with you.
Team Debrief
1. How much can you plan for and how much
flexibility do you need when designing an
organizational plan for addressing critical
incidents?
2. If the original close call was reported to the
organization how would the plan and the
organizational response change?
3. What is the most important action or decision
you will change or adapt after today’s exercise?