Transcript Document

ValleyCare
™
The Impact of
Medical Errors
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ValleyCare
™
Diane Brack
Two Boeing 747s, operated by KLM and Pan Am, collide due to
breakdowns in communication and safety checks.
Number of people killed: 583
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ValleyCare
™
This plane flew in a holding pattern for 77 minutes while awaiting landing
clearance at JFK and crashed due to a failure to communicate the urgency
of fuel situation.
Number of people killed: 73
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ValleyCare
™
As many as
98,000 deaths
occur as a result of
medical errors
each year
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ValleyCare
™
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That’s the same as a 747 jet
falling out of the sky
EVERYDAY
for a YEAR!!!
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ValleyCare
™
More Americans die
from medical errors than
from breast cancer,
AIDS, or car accidents
combined
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ValleyCare
™
22,980 Obstetrical adverse
events every year are
caused by
medical error
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ValleyCare
™
Cost associated
with medical
errors is
$8–29 billion
annually
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ValleyCare
™
Failures in
Communication
are the leading
contributor to
sentinel events.
~The Joint Commision
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ValleyCare
™
Communication Failures contribute
to 72% of Root Cause Analysis of
sentinel events in perinatal units
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ValleyCare
™
The solution?
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ValleyCare
™
™
Strategies and Tools
to Enhance
Performance
and Patient Safety
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ValleyCare
™
CHAIN EXERCISE
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ValleyCare
™
Using the materials in front of
you, create a paper chain with
the most links. You may only use
your non-dominant hand. You
have 2 minutes to create this
chain.
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ValleyCare
™
Objectives
 Road To TeamSTEPPS
 TeamSTEPPS Concepts and Tools
 Impact on Culture of Safety
 The Journey Continues…
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ValleyCare
™
The Road to TeamSTEPPS…
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ValleyCare
™
The Components of a
Patient Safety Program
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ValleyCare
™
Introduction
Evolution of TeamSTEPPS
Curriculum Contributors
• Department of Defense
• Agency for Healthcare
Research and Quality
• Research Organizations
• Healthcare Foundations
• Private Companies
• Universities
• Medical and Business
Schools
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• Hospitals—Military and
Civilian, Teaching and
Community-Based
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• Subject Matter Experts in
Teamwork, Human
Factors, and Crew
Resource Management
(CRM)
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ValleyCare
™
Institute of Medicine Report
“To Err is Human” (1999)
Impact of Error:

44,000–98,000 annual deaths
occur as a result of errors

Medical errors are the leading
cause, followed by surgical
mistakes and complications

More Americans die from medical
errors than from breast cancer,
AIDS, or car accidents

7% of hospital patients experience
a serious medication error
Cost associated with medical errors
is $8–29 billion annually.
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ValleyCare
™
JCAHO Sentinel Events
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ValleyCare
™
OR Teamwork Climate and Postoperative Sepsis Rates
Avg. Length of Stay (days)
Length of ICU Stay After Team Training
(per 1000 discharges)
2.4
18
2.2
16
50
2
1.8
14
%
Group Mean
12
Re
du
cti
on
AHRQ National Average
10
1.6
8
1.4
6
Low Teamwork
Climate
Mid Teamwork
Climate
4
1.2
High Teamwork
Climate
2
1
June
July
August
Sept
Oct
Nov
Dec
Jan
Feb
March
April
May
(Pronovost, 2003)
Johns Hopkins
Journal of Critical Care Medicine
0
Teamwork Climate Based on Safety Attitudes Questionnaire
(Sexton, 2006)
Johns Hopkins
Adverse Outcomes
Low

High
Indemnity Experience
Pre-Teamwork Training
Post-Teamwork Training
25
20
50%
Reduction
20
15
50%
Reduction
11
10
5
0
Malpractice Claims, Suits, and Observations
(Mann, 2006)
Beth Israel Deaconess Medical Center
Contemporary OB/GYN
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ValleyCare
™
TeamSTEPPS Key Principles
 Team Structure
 Leadership
 Situation Monitoring
 Mutual Support
 Communication
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ValleyCare
™
Paradigm Shift to Team System
Approach
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Single focus (clinical skills)
Dual focus (clinical and team skills)
Individual performance
Team performance
Under-informed decision-making
Informed decision-making
Loose concept of teamwork
Clear understanding of teamwork
Unbalanced workload
Managed workload
Having information
Sharing information
Self-advocacy
Mutual support
Self-improvement
Team improvement
Individual efficiency
Team efficiency
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ValleyCare
™
High-Performing Teams
Teams that perform well:
 Hold shared mental models
 Have clear, valued, and shared vision
 Have strong team leadership
 Engage in a regular discipline of feedback
 Develop a strong sense of collective trust and confidence
 Optimize resources
 Have clear roles and responsibilities
 Create mechanisms to cooperate and coordinate
 Manage and optimize performance outcomes
(Salas et al. 2004)
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ValleyCare
™
Why Teamwork?
“High-performance teams
create a safety net for your
healthcare organization as
you promote a culture of
safety."
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ValleyCare
™
Effective Team Leaders
 Organize the team
 Articulate clear goals
 Make decisions through collective input of
members
 Empower members to speak up and
challenge, when appropriate
 Actively promote and facilitate good teamwork
 Skillful at conflict resolution
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ValleyCare
™
A Continuous Process
Situation
Monitoring
(Individual Skill)
Situation
Awareness
(Individual
Outcome)
Shared
Mental Model
(Team Outcome)
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ValleyCare
™
Cross Monitoring
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ValleyCare
™
Shared Mental Model?
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ValleyCare
™
What Do You See?
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ValleyCare
™
Task Assistance
Team members foster a climate in which it
is expected that assistance will be actively
sought and offered as a method for reducing
the occurrence of error.
“In support of patient safety,
it’s expected!”
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ValleyCare
™
Characteristics of Effective Feedback
Good Feedback is—

TIMELY

RESPECTFUL

SPECIFIC

DIRECTED toward improvement

Helps prevent the same problem
from occurring in the future

CONSIDERATE

FIRST HAND encouraged
“Feedback is where the learning occurs.”
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ValleyCare
™
CHAIN EXERCISE
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ValleyCare
™
Using the materials in front of you,
create a paper chain with the
most links. You may only use
your non-dominant hand AND
you cannot speak.
You have 2 minutes to create this
chain.
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™
Strategies and Tools
to Enhance Performance
and Patient Safety
TOOLS
ValleyCare
™
Leadership Tools
™
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ValleyCare
™
Briefing Checklist
TOPIC
Who is on core team?
All members understand
and agree upon goals?
Roles and responsibilities
understood?
Plan of care?
Staff availability?
Workload?
Available resources?
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ValleyCare
™
Debrief Checklist
TOPIC
Communication clear?
Roles and responsibilities
understood?
Situation awareness
maintained?
Workload distribution?
Did we ask for or offer
assistance?
Were errors made or
avoided?
What went well, what
should change, what
can improve?
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MUTUAL SUPPORT
Conflict Resolution Tools
™
ValleyCare
™
Two-Challenge Rule
Invoked when an initial assertion is ignored…
 It is your responsibility to assertively voice your
concern at least two times to ensure that it has
been heard
 “Empower any member of the team to “stop the line” if
he or she senses or discovers an essential safety
breach.”
 If the outcome is still not acceptable:


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Take a stronger course of action
Use supervisor or chain of command
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ValleyCare
™
Please Use CUS Words
but only when appropriate!
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Communication
Tools
Assumptions
Fatigue
Distractions
HIPAA
™
ValleyCare
™
R-SBAR

“I am concerned about………”

“I need you to come in now because….”

Situation―What is going on with the patient?

Background―What is the clinical background or
context?

Assessment―What do I think the problem is?

Recommendation―What would I recommend?
Remember to introduce yourself…
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ValleyCare
™
Check-Back is…
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ValleyCare
™
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
Follow-Up with Co-Workers
Distractions
Fatigue
Workload
Misinterpretation of Cues
Lack of Role Clarity
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TOOLS and
STRATEGIES
Brief
Huddle
Debrief
STEP
Cross Monitoring
Feedback
Advocacy and Assertion
Two-Challenge Rule
CUS
Collaboration
SBAR
Call-Out
Check-Back
Handoff
TEAMSTEPPS 05.2
OUTCOMES
 Shared Mental Model
 Adaptability
 Team Orientation
 Mutual Trust
 Team Performance
 Patient Safety!!
45
ValleyCare
™
Perinatal Safety Program
■ Mandatory Team STEPPS Training
■ Mandatory Simulation Training
■ Implementation of Laborist Program
■ Leadership Rounds
■ Quality Initiatives
● Intradepartmental Performance
Improvement
● Peer Review
● Case Conferences
■ Mandatory Debriefing
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ValleyCare
™
Team STEPPS
Team Assessment Questionnaire
“The team is a safety net for patients.”
Pre Team STEPPS training
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TEAMSTEPPS 05.2
Post Team STEPPS training
47
ValleyCare
™
Hospital Survey on Patient Safety Culture 2011
Composite Report - MCH
Patient Safety Culture
Composites
Average % Positive
2009 AHRQ
n=196,462
2011 AHRQ
n=472,397
2009
ValleyCare
n=600
2011
ValleyCare
n=593
2009 MC
n=68
2011 MC
N=41
1. Teamwork Within Units
79%
80%
85%
82%
90%
92%
2. Supervisor/Manager Expectations &
Actions Promoting Patient Safety
75%
75%
76%
76%
85%
89%
3. Organizational Learning—Continuous
Improvement
71%
72%
76%
78%
90%
86%
4. Management Support for Patient Safety
70%
72%
74%
78%
78%
89%
5. Overall Perceptions of Patient Safety
64%
66%
62%
69%
71%
73%
6. Feedback & Communication About
Error
63%
64%
62%
67%
72%
76%
7. Communication Openness
62%
62%
59%
62%
66%
66%
8. Frequency of Events Reported
60%
63%
57%
60%
60%
72%
9. Teamwork Across Units
57%
58%
60%
64%
69%
71%
10. Staffing
55%
57%
49%
57%
64%
57%
11. Handoffs & Transitions
44%
45%
42%
45%
54%
56%
12. Nonpunitive Response to Error
44%
44%
35%
39%
41%
50%
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ValleyCare
™
Patient Safety Culture Grade
Excellent
MCH
3.33
Very Good
ValleyCare
3.03
AHRQ
2.99
Excellence
Acceptable
Acceptable
Unacceptable
MCH
ValleyCare
2011
AHRQ 2011
Poor
Failing
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ValleyCare
™
Hospital Survey on Patient Safety Culture 2011
Item Level Report - MCH
2009
AHRQ
Averag
e
Percent
Positiv
e
(n=196,
462)
2011
AHRQ
Averag
e
Percent
Positiv
e
(n=472,
397)
2009
ValleyC
are
Averag
e
Percent
Positiv
e
(n=600)
2011
ValleyC
are
Averag
e
Percent
Positiv
e
(n=593)
2009
MCH
Averag
e
Percent
Positiv
e
(n=68)
2011
MCH
Averag
e
Percent
Positiv
e
(n=41)
1. People support one another in this unit. (A1)
85%
86%
93%
89%
97%
100%
2. When a lot of work needs to be done quickly,
we work together as a team to get the work
done. (A3)
86%
86%
90%
88%
96%
98%
3. In this unit, people treat each other with
respect. (A4)
78%
78%
86%
81%
93%
90%
4. When one area in this unit gets really busy,
others help out. (A11)
68%
69%
72%
73%
76%
80%
TEAMWORK WITHIN UNITS
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ValleyCare
™
COMMUNICATION OPENNESS
1. Staff will freely speak up if they see
something that may negatively affect
patient care. (C2)
76%
76%
76%
80%
84%
83%
2. Staff feel free to question the decisions or
actions of those with more authority. (C4)
47%
47%
43%
44%
52%
53%
3. Staff are NOT afraid to ask questions when
something does not seem right. (C6)
63%
63%
59%
61%
62%
61%
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ValleyCare
™
TEAMWORK ACROSS UNITS
1. Hospital units coordinate well with each
other. (F2)
45%
46%
44%
51%
49%
59%
2. There is good cooperation among
hospital units that need to work together.
(F4)
58%
59%
63%
67%
78%
71%
3. It is often pleasant to work with staff from
other hospital units. (F6)
58%
59%
63%
62%
69%
76%
4. Hospital units work well together to
provide the best care for patients. (F10)
67%
68%
69%
77%
78%
80%
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ValleyCare
™
ValleyCare’s Key Success Factors
 Strong Need for Team Approach Identified
 Support From Senior Administration
 Support From Department Leadership
 Support From Physician Champions
 Support From Ancillary Department Leadership
 Support From Staff
 Staff Buy In
 Strength in Numbers-Multidisciplinary Core Team
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ValleyCare
™
The Journey Continues…
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