Transcript Slide 1

RN/MD Collaboration, Where does the CNS fit
in?
Kristi Opper, MS, RN, ACNS-BC
Objectives
• Discuss the background of culture of safety
• Discuss the impact of poor communication on patient
outcomes
• Understand the how the CNS can improve RN/MD
Collaboration
Safety Culture
• The Beginning
• 1999 To Err Is Human Report by IOM
• As many as 98,000 people, die in hospitals each year as a result of
medical errors that could have been prevented
• Most errors were due to system problems, not individual staff
• Hospitals across the nation were encouraged to develop a culture
of safety
• Mandatory reporting of events was started
Definition of a Safety of Culture
• A culture of safety is an atmosphere of mutual trust in
which all staff members can talk freely about safety
problems and how to solve them, without fear of blame or
punishment.
• Essential to improving patient safety in any organization.
Source: http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/
Key features of a Culture of
Safety
• Acknowledgment:
•
High-risk nature of an organization's activities and the
determination to achieve consistently safe operations
• A blame-free environment where individuals are able to report
errors or near misses without fear of reprimand or punishment
• Encouragement of collaboration across ranks and disciplines to
seek solutions to patient safety problems
• Organizational commitment of resources to address safety
concerns
Source:http://www.psnet.ahrq.gov/primer.aspx?primerID=5
The Joint Commission National
Patient Safety Goals:
• Goal 2 – Improve the effectiveness of
communication among caregivers.
• Goal 3 – Improve the safety of using
medications.
• Goal 8 – Accurately and completely
reconcile medications across the
continuum
• Universal Protocol for Preventing Wrong
Site, Wrong Procedure, and Wrong Person
Surgery™
•
Source: http://www.jointcommission.org/NR/rdonlyres/CEE2A577-BC61-4338-8780
43F132729610/0/NPSGChapterOutline_FINAL_HAP_2010.pdf
Kristi Opper, 2011
IOM AIMS:
•
Safe — Avoid injuries to patients from the care that is intended to help them. Safety
must be at the forefront of patient care.
•
Effective — Match care to science; avoid overuse of ineffective care and underuse
of effective care.
•
Patient-Centered — Honor the individual and respect choice. Each patient’s culture,
social context and specific needs deserve respect, and the patient should play an
active role in making decisions about her own care.
•
Timely — Reduce waiting for both patients and those who give care. Prompt
attention benefits both the patient and the caregiver.
•
Efficient — Reduce waste. The health care system should constantly seek to
reduce the waste and the cost of supplies, equipment, space, capital, ideas, time
and opportunities.
•
Equitable — Close racial and ethnic gaps in health status. Race, ethnicity, gender
and income should not prevent anyone from receiving high-quality care.
Author: Marla Fraunfelder
Source: Institute of Medicine
Kristi Opper, 2011
Where are we today
• 5 Million Lives Campaign 2006 – 2008
• Made improvements, we think???
• We still have many deficits resulting in poor patient
outcomes
Complications with a
postoperative patient
• A very complex patient had a vascular surgery
• Over a holiday weekend
• The patient’s abdomen became distended, was having
tarry stools, and the H/H was dropping
• RNs notified the MDs on many occasions of the patient’s
changing status
• Small interventions were done
• Several MDs were covering
• RNs didn’t move up the chain of command
• The patient had a significant change in condition, a code
was called, the patient was transferred to the ICU
Lessons Learned
• RNs reported to be fearful of getting in trouble for moving
up the chain of command
• They didn’t want to call the Rapid Response Team for fear
of getting yelled at
• Residents discussed the lack of hand off communication
between each other
• Resident/RN miscommunication
JCAHO Root Cause of Sentinel Events
All categories, 1995-2004
Kristi Opper, 2011
2010 Culture of Safety Survey
Results
•
•
•
•
•
•
•
There is good cooperation among hospital units that need to work together
Hospital units work well together to provide the best care for patients
Hospital units do not coordinate well with each other
It is often unpleasant to work with staff from other hospital units.
Staff will freely speak up if they see something that may negatively affect patient
care
Staff feels free to question the decisions or actions of those with more authority
Staff are afraid to ask questions when something does not seem right
Percentile Ranking*
2010 Safety Survey Responses
120%
100%
80%
60%
40%
20%
0%
Froedtert Hospital
Safest Hospitals
Teamwork across
hospital units
Open Communication
Question Category
Kristi Opper, 2011
*AHRQ Database - 885 hospitals
Comments from 2010 Culture of
Safety Survey
• The attitude of safety has to be all inclusive. If the physicians
are not as fully committed as the rest of the staff, I feel that the
weaker practioner can be easily ignored or made to feel
bothersome. Physicians need to communicate more clearly
• We do not have an adequate hand off process & mistakes are
made because of it.
• As a physician, transferring patient care to an ICU nurse is
nearly always an unpleasant task. It is rare to have a
professional exchange. Snide comments, often about matters
out of our control, are the norm and the patient is rarely the
focus. I haven't seen this result in a negative outcome, but feel it
is grossly unprofessional and something that needs to be
addressed.
• Very poor communication between nursing and physicians.
Kristi Opper, 2011
Improving Collaboration
• Lessons learned
•
•
•
•
Patient Outcomes
RN perceptions
Resident perceptions
Observation on the nursing unit
• What other hospitals have done
• Cedars Sinai
• Getting support
Getting Started
• Forming the team:
• The core team was formed by taking volunteers from three surgical
units.
• Two unit managers
• Two CNSs
• One unit educator
• Determining who should be involved:
• The Core Team had to make decisions of who else needed to be
involved.
• We invited a Risk Manager from the Resident Program to join our
team
• We asked for staff RN and Resident volunteers to join our team
• We had support from the Resident Program Director and a Nursing
Director
Getting the MD perspective
• Meeting with the residents
• Core team members met with a group of
selected residents and staff MDs to have an
open discussion about communication issues
• Great Feedback
• Discussion went well
• Opened the communication between the MDs
and Nursing Leadership
• Suggested Interventions
• Residents agreed to be part of the team
Collaboration Team Goals
•
To improve MD/RN communication
• Teamwork across the continuum of care
• Improve MD satisfaction
• Improve RN satisfaction
• Improve patient satisfaction
• Decrease LOS, cost, re-admissions
• Improve overall patient outcomes
Literature Review
• Key findings:
• Just offering a class does not improve Nurses opinion about
collaboration
• Systemic review showed: Little is known about collaboration & how it
contributes to patient outcomes. “Interprofessional collaboration
should be labeled as promising rather than proven”
• Multidisplinary care rounds at the bedside are difficult
• The patient needs to be first
•
Constructive conflict resolution is needed
• Interdisplinary care rounds
• SBAR communication is necessary
• We need to build collegial collaborative practice
Kristi Opper, 2011
Collaboration Team Initiatives
• Unit based teams to improve collaboration
• Paging decision tree
• Photos of staff members on the
communication boards for easier
identification
• Leadership information posted for MDs
Kristi Opper, 2011
Key Initiatives
• Reviewed results from Culture of Safety
Survey
• Bedside Manners Workshop
• SBAR communication staff training
• Is now being introduced during RN
orientation
• house wide training
• Role play RN to MD phone calls
• Currently done with surgical residents
Kristi Opper, 2011
Next Steps
• Team Expansion
• EBP: Team Training in the
Medical/Surgical Setting
• Outreach to the Medical College
Implications for the CNS
• Patient
• Quality Review
• Monitor Outcomes
• Involvement with complex patients
Implications for the CNS
• Staff
• Assessment of the communication environment
• Influence: RNs, Residents, MDs
• Open up lines of communication
• Role Modeling
Implications for the CNS
• Organization
• Collaboration with MCW
• Sit on Service Line Teams
• Teaching Opportunities
• Evidence into practice
• Networking
Questions