Transcript Teams Preparing to Speak Up and Doing So

Teams Preparing to Speak Up
and Doing So
Jennifer Blaha, MBA
Ronnie McKinnon RN, JD, CPHRM, CPSO, CPPS
Leslie Asdahl, RN, BSN, CNOR
CEDARS-SINAI MEDICAL CENTER
Teams Preparing to Speak Up
Jennifer Blaha, MBA
June 2013
Agenda
Leveraging human factors engineering to
conduct a needs assessment
Gaining physician buy-in
Altering your approach to training
 Study and design of:
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environments
processes
technology
equipment
training
 Identify root causes of
error in vulnerable
systems
 Optimize performance
 Human error is unavoidable
Observing
Your System
to Uncover
Opportunities
 Defective systems allow human errors
to cause harm to patients
 Systems can be improved to prevent
or reduce the consequences of errors
BEFORE a patient is harmed
 Flow disruptions
 Deviations from natural progression
 Provide a window into the system
Flow Disruptions
 86 Trauma Cases Observed
 1,757 flow disruptions
 Average over 20 flow disruptions per case
% of Total Flow Disruptions Observed
Coordination
32%
Communication
20%
Patient Factors
External Interruptions
Communication and
Coordination account
for 52% of observed
flow disruptions
Equipment
Environment
Training
Technical Skills Training
Other
0%
5%
10%
15%
20%
25%
30%
35%
Physician Buy-In
 Conduct a needs assessment and use
data
Physician
Buy-In
 Involve the attendees in content
development
 Involve leadership
 Make every slide relevant to the audience
 Personalize the materials
Personalize the Materials
 Teacher/student relationship: it is extremely
uncomfortable for residents to speak up
Physician
Buy-In
 Safe place to be honest and talk through
experiences
 Real stories of dealing with real situations
will resonate with the attendees
 Coach attending's to be aware of and
responsive to the CUS words and other
escalation techniques
Altering the Approach
Classroom time is not the only way to
get the message across
TeamSTEPPS tools highlighted:
briefing, speaking up
Find a schedule that works
for your attendees
 We used short, one-hour sessions, introducing a related cluster of topics in each session
 Be flexible, the trainees will be more engaged if they have a say in the design
Managed
Conflicts
Crisp Communication
Dynamic and Confident
Leadership
Clear Roles and Responsibilities
Module
TeamSTEPPS Tools
Clear Roles and
Responsibilities
Task assistance,
delegation
Dynamic and
Confident
Leadership
Delegation, resource
management, cross
monitoring, situational
awareness
Crisp
Communication
Briefing, check backs,
debrief
Conflict
Management
Two-challenge rule, CUS,
chain of command
Involve the Right Leadership
 Think about who the trainees would like to meet
 Who would the trainees learn from?
 Our leadership participants showed their vulnerabilities
Physician
Buy-In
Alter Your
Approach
1) Conduct a needs assessment
and use the data
2) Involve physicians in content
development
3) Personalize the messaging
and examples
1) Classroom time is not the only
way to get the message across
2) Find a schedule that works
3) Involve the right leadership
Thank You
Teams Preparing to Speak Up
TeamSTEPPS National Conference
June 12-13 2013
Dallas Texas
Ronnie McKinnon RN, JD, CPHRM, CPSO, CPPS
TeamSTEPPS Master Trainer
Hospital Counsel for Patient Safety, Clinical and Regulatory Affairs
Stony Brook University Hospital and Medical Center
Long Island, New York Teams
Preparing to Speak Up
Getting to the Root of the Root Cause
Deep Dive Process
What we Learned: Staff (RNs, Residents)
“Reluctant to SPEAK UP”
“Reluctant to QUESTION authority”
What we Asked: WHY?
Challenge: Hierarchy
• Hierarchy creates BARRIERS to Safety
• Reluctance to speak up
• Junior members of Team closest to patient
• Best Information  but least vocal
• Good Information  but cut off
• WHY--Hierarchy in Health Care
• Strategy: Find Structured Communication in
which to “SPEAK UP”
• How?TeamSTEPPS®
“CUS” & “2 Challenge Rule”
TeamSTEPPS Deployment
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General Knowledge “Facility” (2010)
Interdisciplinary approach
Change Team selection by Division leaders
Early Lessons Learned:
“Participants showed up; but many “not present” and “not on board”.
“Why am I Here?” “Why do I have to do this?”
“Is this so we get some kind of award?”
“Are the doctors really going to have to do this?”
“You come to my unit and try speaking up to a doctor.”
“Who will back me up if I do this?”
TeamSTEPPS Trainers’ Huddle
• We Identified Structure was not enough
• Flatten the hierarchy & empower staff to
speak
up in an environment and culture of:
“Psychological Safety”
Challenge: Hierarchy and
Fear Speaking Up
Goal: Create “Psychological Safety”
How:
Make these concepts more tangible to
improve
staff engagement
 “CUS” PLUS “Bump IT UP” Policy
 Physician Engagement
“Making it Tangible”
“The Landing on the Hudson”
Crew Resource Management
How Aviation CRM improved safety
Communication
+ Teamwork =
SAFETY
Karl, R. MD., “Briefings, Checklists, Geese and Surgical Safety” Ann Surg Oncol (2010) 17:8-11
CUS +“Bump it Up Policy”
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Crew Resource Management Principles*
Scope Hospital Wide*
Responsibility/Expectation to “Bump IT UP”*
Escalation Chain of Command in flowchart*
Empowers all staff with steps to take*
Describes CUS Model for Communication*
Collegial and Respectful* [“we are already assertive”]
Rapid Response Team Code Trigger*
*Expressly Stated in policy
“BUMP IT UP Policy”
Expectations are Empowering
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Structure
Expectations
Leadership Support
Hospital Wide
Collegiality vs Conflict
Communications Plan
Escalation Plan
Clear Known points
Physician Engagement
*
Hints:
 Customize
 Explain the
Penguins
 Bring Data*
The Strategy:
 Medical Staff Briefings & Find Early Adopters
 Graduate Medical Education Program Directors
 Chairs and Directors of Each Department
 Chief Medical Officer*
Catchpole, K., de Leval M., McEwan, A., et al., Patient handover from surgery to intensive care: using Formula 1 pit-stop and
aviation models to improve safety and quality. Pediatric Anesthesia 2007;17:470-478
THE TURNING POINT
The Chief Medical Officer
New to His Role as CMO
OB/GYN Attending
Prior Navy Officer
Patient Safety Advocate
Good Collegial Working
Relationship************
Assisted enlisting other motivated medical staff
CMO ACTIVELY ENGAGED
Attended a TeamSTEPPS Training
Showed up (when possible)at Training even
if for 5 minutes and delivered:
“inspiration and encouragement”
“ We are a TEAM” message
“high level support” for “Bumping it Up”*
* If you bump it up and get nowhere—I have informed nursing leadership that they should call me at home.
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“Change Brings Opportunity”
CMO promoted to Chair of OB/GYN
New CMO being Recruited
Cultivate TeamSTEPPS in new CMO
OB/GYN Chair (former CMO)
INTERDEPARTMENTAL
L&D And NICU
Strategies/Policies To Help Individuals
Feel Empowered To ‘Stop The Line.’
Leslie Asdahl, RN, BSN, CNOR
North Shore - LIJ Health System
North Shore Hospital
Manhasset, NY
Leslie Asdahl RN, BSN, CNOR
• Perioperative Services
• Co-Chairman Collaborative Care Council,
Operating room
– Interdisciplinary council comprised of medical and nursing
personnel on each unit working together to resolve issues that
directly affect pt. safety.
Collaborative Care Model
EXCELLENCE CARING
HONORING THE
COLLABORATION
HUMAN SPIRIT
PROFESSIONALISM
LEADERSHIP SAFETY
Health Care Team
PATIENTS
COME
FIRST
Practice Environment
(Structure)
Health Care Team
Care Delivery Model
(Process)
Outcomes
Patient Experience
Financial Performance
Quality
Copyright 2008 © North Shore -Long Island Jewish Health System Inc.
TEAMSTEPPS
TEAM STEPPS®/ Collaborative Care
Councils
• 2009 Implemented Team Stepps®
• Collaborative Care Councils
– Interdisciplinary Front Line Team
• Collaborative Care Model: Part of our Organization
– Surgical Safety Checklist
• Brief/Huddle/Debrief
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SURGICAL SAFETY CHECKLIST
The circulating nurse/clinical team member completes this form and alerts the team if any element is omitted
PRIOR TO SEDATION / INDUCTION
SIGN-IN / BRIEFING
IMMEDIATELY PRIOR TO PROCEDURE / INCISIONPRIOR TO PROVIDER LEAVING PROCEDURE
ROOMSIGN-OUT / DEBRIEFING
TIME OUT / HUDDLE
REGISTERED NURSE
COMPLETED PRIOR TO SEDATION
PATIENT / ANESTHESIA / REGISTERED NURSE
Confirm with patient:
 Name, date of birth
 Procedure and if applicable:
 Site / Side / Level
 Laterality Right____ Left____
 Allergies
All consents are present, accurate, signed.
RN/Clinical Team Member Signature:
________________________
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Confirm availability of responsible practitioner or
practitioners.
Confirm discussion among team members: Practitioner,
Anesthesia / Sedation Provider, Registered Nurse
RN confirms any special equipment / supplies / implants are
present
Anesthesia confirms machine and medication check
complete
Anesthesia confirms review for anesthesia risk alert
categories:
 Any difficult airway or aspiration risk
 ASA 4 or 5
 BMI > 40
 Surgery on head or face
 Sickle Cell Disease
Ready for the time out?
Assure that all team members introduce themselves.
Announces “sterility confirmed”.
REGISTERED NURSE CONFIRMS WITH
TEAM
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What is the name of the procedure and
wound class to be recorded?
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Has the team reconciled all specimens
(number of specimens, proper labeling, and
pathology form completed by the surgical
team)?
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Confirm with team members any equipment,
instrument and / or supply issues that need
to be addressed.
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Instrument, sponge and needle counts done
per policy.
PRACTITIONER
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Time: ____________
COMPLETED PRIOR TO INDUCTION
ANESTHESIA / REGISTERED NURSE /
PRACTITIONER
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Verify patient name, date of birth and Medical Record No.
Confirm procedure on the consent is the correct procedure.
Verify position.
Confirm pre / intra / post-procedure DVT prophylaxis
Verify need for fluids or irrigation.
Review anticipated exceptions to usual procedure, estimated
procedure duration, and anticipated blood loss.
Confirm for high risk site-specific procedures that relevant
images were reviewed together by two (2) appropriately
credentialed practitioners and documented.
“I verify that all relevant diagnostic and / or imaging studies are
available and correctly oriented and labeled.”
Confirm that all supplies, equipment and implants I expect to
need are present.
CONFIRMING TEAM MEMBER
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Confirm site / side / level is marked and is visible.
Team member announces “confirmed” (available
diagnostic / imaging studies have the correct name and
orientation).
ANESTHESIA / SEDATION PROVIDER
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“Procedure confirmed by consent” making sure that the
consent matches description of procedure just given by
provider.
Allergies
Anesthesia / sedation provider specifies safety
precautions to be considered based on history or
medication use.
Discussion of antibiotic administration status.
Need for and availability of blood products.
Anticipated post-procedure disposition of patient.
REGISTERED NURSE
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Does anyone have any patient-specific concerns
that have not been addressed?
“We have independently and collectively identified
the patient by name and birth date and have
resolved any discrepancies.”
Team announces “confirmed”.
ANESTHESIA / PRACTITIONER
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Confirm estimated blood loss.
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Confirm disposition of the patient and any
key concerns for recovery and management
of the patient
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CUS/Hard Stops
• Adverse Events –
– Can be prevented by implementing “CUS”
– All team members empowered to call a “Hard Stop”
• Culture of the OR
– New staff intimidated
– Surgeon/hierarchy
• Root Cause Analysis
– Corrective Actions – Medical/ Nursing Leadership
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Role playing / “Hard Stop” Simulation
Escalation Policy/ Escalation Pyramid
High risk Equipment List-privileges/training
Escalation Through Chain Of
Command Policy and Procedure
At the time that a concern, safety
or quality issue is identified,
nursing staff must immediately
contact management utilizing
communication devices ie:
Vocera, telephone, or Spectralink
phone.
Management/charge will follow
the escalation pyramid in
notifying the appropriate service
line as needed.
If necessary, consultation with
the appropriate service line
chairman/designee occurs.
Activity will not commence until
the team is in agreement that
patient safety and/or quality
issue is resolved and patient care
has not been jeopardized.
Escalation Through Chain Of
Command Policy and Procedure
• Utilizing TEAM STEPP's®, a team
work approach, is a key initiative
in patient safety. Implementing
these skills in the perioperative
setting can mitigate medical
errors. For any team member
who expresses a concern, is
uncomfortable in a situation,
and/or identifies a safety issue,
requires all activities to be
immediately suspended “hard
stop”.
• The chain of command for
escalation is a systematic
approach for addressing patient
care concerns, safety or quality
issues in the perioperative
setting. The chain of command
includes OR management,
medical/anesthesia leadership
and administration. Refer to the
Perioperative Service Policy and
Procedure manual for “Chain of
Command”.
Escalation Through Chain Of
Command Policy and Procedure
• Anesthesia Escalation: To define the chain of command to be followed for
reporting unresolved clinical and administrative issues in the Department
of Anesthesiology (see escalation pyramid)