Transcript Studer/UAB Presentation 1

TeamSTEPPS
Team Strategies & Tools to Enhance Performance & Patient Safety
TeamSTEPPS
“TieredSTEPPS”: A Commitment to Address
Behaviors that Undermine a Culture of Safety
Gerald B. Hickson, MD
Assistant Vice Chancellor for Health Affairs
Associate Dean for Faculty Affairs
Joseph C. Ross Chair in Medical Education & Administration
Chair, Board of Governors, National Patient Safety Foundation
Center for Patient & Professional Advocacy,
Vanderbilt University School of Medicine
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TEAMSTEPPS 05.2
TeamSTEPPS
Pursuit of Reliability
 Safety Culture
Willingness to report or act…
 Psychological safety
 Trust
 “Behaviors that undermine a culture of
safety” threaten trust, therefore must be
addressed fairly, quickly, and in a
measured way

Hickson, Moore, Pichert, Benegas Jr. Balancing systems and individual accountability in a
safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook
Terrace, IL: Jt Comm Resources;2012:1-36.
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TeamSTEPPS
Case: “Looks a Little Red”
 56 yo homeless man with frostbite to feet
 Initial care in burn unit...to Psych unit. Nurse
and Psych Resident (Dr. PR) concerned...
redness, mild fever, tachycardia?
 Burn Unit resident, Dr. SurgRes, examines...
"on right abx...wounds OK, vitals stable...see
1st thing in A.M. ...call with any concern.”
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TeamSTEPPS
Case: “Looks a Little Red”
 2nd call to Dr. SR, 2 hours later…
 Psych Chief Resident to Dr. SR: "please have
the Burn Fellow come now and examine this
patient."
 Shortly thereafter the phone rings in the
Psych unit…“Let me speak with Dr. PR”
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TEAMSTEPPS 05.2
TeamSTEPPS
Case: “Looks a Little Red”
 Dr. BurnFellow: "is this Dr. PR or whoever the
#%&! is questioning my #%&! resident’s
judgment...”
 Dr. BF continues, “You guys in psych get so
worked up....I bet you consult critical care
every time a patient sneezes..."
 Dr. BF then hangs up...
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TEAMSTEPPS 05.2
TeamSTEPPS
Consider the microsystem where you work…
What % of the time would the professionals report Dr. BF’s
conduct to either a supervisor or through an event reporting
system?
1. 0 – 20%
2. 20 – 40 %
3. 40 – 60%
4. 60 – 80%
5. 80 – 100%
0%
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1
TEAMSTEPPS 05.2
0%
0%
2
3
0%
4
0%
5
10
Countdown
TeamSTEPPS
If reported, what % of the time would a medical
leader have a conversation with Dr. BF?
1.
2.
3.
4.
5.
0%-20%
20%-40%
40%-60%
60%-80%
80%-100%
0%
1
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0%
2
0%
3
0%
4
0%
5
10
TeamSTEPPS
A Few Questions
 From Reason’s “Unsafe Acts” algorithm (1997):




Is the team member intending to cause harm?
Is the team member impaired?
Is the team member knowingly and unreasonably
increasing risk?
Is another team member in the same situation likely
to act in a similar manner?
Reason J.T.: Managing the Risks of Organizational Accidents. Aldershot,
UK: Ashgate Publishing, 1997.
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TEAMSTEPPS 05.2
TeamSTEPPS
Definition of Behaviors That Undermine
A Culture of Safety
Include but are not limited to, words or actions that:
 Prevent or interfere w/an individual’s or group’s work,
academic performance, or ability to achieve intended
outcomes (e.g. intentionally ignoring questions or not returning
phone calls or pages related to matters involving patient care, or
publicly criticizing other members of the team or the institution);
 Create, or have the potential to create, an intimidating, hostile,
offensive, or potentially unsafe work or academic environment (e.g.
verbal abuse, sexual or other harassment, threatening or intimidating
words, or words reasonably interpreted as threatening or intimidating);
 Threaten personal or group safety, aggressive or violent physical
actions; Violate VUMC policies, including conflicts of interest and
compliance.
It’s About Safety
Vanderbilt University and Medical Center Policy #HR-027, 2010
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TEAMSTEPPS 05.2
TeamSTEPPS
The Balance Beam
Competing priorities
Not sure how lack
tools, training
Leaders “blink”
Staff satisfaction
and retention
Reputation
“Can’t change…”
Fear of antagonizing
Do nothing
Patient safety,
clinical outcomes
Liability, risk mgmt
costs
Do something
June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Center for Patient and Professional Advocacy; Hickson GB,
Pichert JW. Disclosure and Apology. National Patient Safety Foundation Stand Up for Patient Safety Resource Guide, 2008; Pichert JW, Hickson GB,
Vincent C: “Communicating About Unexpected Outcomes and Errors.” In Carayon P (Ed.). Handbook of Human Factors and Ergonomics in
Healthcare and Patient Safety, 2007
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TEAMSTEPPS 05.2
TeamSTEPPS
Professionalism and Self-Regulation
• Professionals commit to:
• Technical and cognitive competence
• Professionals also commit to:
• Clear and effective communication
• Modeling respect
• Being available
• “Self awareness”
• Professionalism promotes teamwork
• Professionalism demands self and group
regulation
• You have a critical role
Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In:
Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.
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TEAMSTEPPS 05.2
TeamSTEPPS
Infrastructure for Promoting Reliability &
Professional Accountability (PA)
1. Leadership commitment (will not blink)
2. Goals, a credo, and supportive policies
3. Surveillance tools to capture observations/ data
4. Process to guide graduated interventions
5. Processes for reviewing observations/data
6. Multi-level professional/leader training
7. Resources to address unnecessary variation
8. Resources to help affected staff and patients
Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring and
addressing unprofessional behaviors. Academic Medicine. 2007; Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing
systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed.
Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.
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TeamSTEPPS
“So, is this TeamSTEPPS stuff
required?”
What about:
– Hand hygiene
– Handoffs/documentation
– Time outs
– Arriving on time
– Answering pages
– Refraining from jousting
– Practicing EBM
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TeamSTEPPS
Our organization has Leadership Commitment
to address behaviors that undermine
TeamSTEPPS…
1. Strongly agree
2. Agree
3. Uncertain
4. Disagree
5. Strongly disagree
0%
1
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0%
2
0%
3
0%
4
0%
5
10
TeamSTEPPS
I am committed (act, report) to address
behaviors that undermine safety…
1. Strongly agree
2. Agree
3. Uncertain
4. Disagree
5. Strongly disagree
0%
1
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0%
2
0%
3
0%
4
0%
5
10
TeamSTEPPS
Policies and programs will not work
if behaviors that undermine a culture
of safety go unobserved, unreported
and unaddressed
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TeamSTEPPS
What Are “Surveillance Tools”?
 Risk Event Reporting System
 “Dr. __ entered the room without foaming in…
proceeded to touch area with purulent drainage…I
offered gloves…took and dropped them into trash.”
 Patient Relations Department
 Record pt/family concerns: Father: “Son had surgery
so I asked Dr. XX to explain plan. Dr. XX said, ‘I drew
a picture. If you don't get it, you just don't get it.’“
 Compliance hotline; Equal Opportunity, Affirmative
Action, and Disability Services (EAD)
Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S,
ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.
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Promoting Professionalism Pyramid
Adapted from Hickson
GB, Pichert JW, Webb LE,
Gabbe SG. Acad Med.
Nov 2007. © 2011
Vanderbilt University
Mandated Reviews
No
∆
Level 3 "Disciplinary"
Intervention
Pattern
persists
Apparent
pattern
Single
“unprofessional"
incidents (merit?)
Level 2 “Guided"
Intervention by Authority
Level 1 "Awareness"
Intervention
"Informal" Cup
of Coffee
Intervention
Mandated
Vast majority of professionals - no issues provide feedback on progress
TeamSTEPPS
3 Conversations for Professionals and
Leadership to address unnecessary variation
Authority: EDICTS Conversation
Awareness: An Awareness Intervention
Informal: Cup of Coffee Conversation
and Espresso Conversation
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TeamSTEPPS
But are “awareness”
interventions effective?
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Analyzes existing pt complaint data to
identify unnecessary variation/outlier performance
(Risk):
a) Evidence-based PARS Risk Score
b) Local and/or national comparisons
a. Promote complaint collection
and Service Recovery best
practices*
b. Unsolicited pt/family complaints
collected/recorded by Pt
Relations
c. Transmitted to CPPA
*Hayden et al, 2010; Moore et al,
2006; Pichert et al, 2004
a. Reliably coded*
b. Data aggregated & analyzed**
c. PARS Risk Score***
d. Local & nat’l comparisons****
* Hickson et al, 2002;
** Hickson et al, 2002; 2006;
***Mukherjee et al, 2010;
****Stimson et al, 2010
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TeamSTEPPS
Does it work? PARS® Progress Report
Total # high complaint physicians
Departed after initial intervention
First follow-up in 2012 - 2013
810
59
149
Total with follow-up results
602
Results for those with follow-up data:
Good – Intervention Visits suspended
Good – Anticipate suspension in 2012 - 2013
Some Improvement—still needs tracking
302
93
43
(50%)
(16%)
(7%)
438
127
37
(73%)
(21%)
(6%)
Subtotal
Unimproved/worse
Departed Unimproved
Total with follow-up results
602
Pichert JW, Moore IN, Hickson GB. Professionals promoting professionalism. Jt Comm J Qual Patient
Safe. 2011; 37(10):446.
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TEAMSTEPPS 05.2
This document is confidential and privileged pursuant to the provisions of State Statutes
Malpractice Claims (per 100 MDs) FY1992 – 2011*
**
**TN Certificate of Merit
* Data used with permission, State Volunteer Mutual Insurance Company, a mutual insurer of 10,500 TN
non-VUMC physicians of all specialties, 29% to 33% who practiced in Middle TN during the target date.
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TeamSTEPPS
Infrastructure for Promoting Reliability
& Professional Accountability (PA)
1.
2.
3.
4.
5.
6.
7.
8.
Leadership commitment
Goals, a credo, and supportive policies
Surveillance tools to capture observations/data
Processes for reviewing observations/data
Model to guide graduated interventions
Multi-level professional/leader training
Resources to help address unnecessary variation
Resources to help those affected
Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying,
measuring and addressing unprofessional behaviors. Academic Medicine. 2007. Hickson GB, Moore IN, Pichert JW,
Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to
Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.
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TeamSTEPPS
CPPA Conferences
 Promoting Professional Accountability:
Addressing Behaviors That Undermine A
Culture of Safety
 The How and When of Communicating
Adverse Outcomes and Errors
 For details, please visit our website:
http://www.mc.vanderbilt.edu/centers/cppa/courses.htm
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TeamSTEPPS
Let Us Hear Your Comments, Questions
Now or Later
www.mc.vanderbilt.edu/cppa
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TEAMSTEPPS 05.2