Confidential & Proprietary A Systematic Framework for Safe & Reliable Surgical Care Allan Frankel,...

Confidential & Proprietary

A Systematic Framework for Safe & Reliable Surgical Care Allan Frankel, MDMichael Leonard, MDMichael Woods, MD


Systematic Framework for Safe & Reliable Care

It’s all about the patient

Leadership

Organizational Fairness

Safety Culture

Effective Teamwork & Communication

Building and Sustaining a Learning System


3*Adapted from Safeskies 2001, “Aviation Safety Culture,” Patrick Hudson, Centre for Safety Science, Leiden University

PATHOLOGICALWho cares as long as we’re not caught Chronically Complacent

REACTIVESafety is important. We do a lot every time we have an accident

CALCULATIVEWe have systems in place to manage

all hazards

PROACTIVEAnticipating and preventing problems before

they occur

GENERATIVESafety is how we do business

around hereConstantly Vigilant

Incr

easing A

wareness

& Tr

ust

Evolution of A Culture of Safety and Reliability

Where are you?


Psychological Safety

Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes.

A shared sense of psychological safety is a critical input to an effective learning system

Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, Vol. 44, No. 2 (Jun., 1999), pp. 350-383 Amy Edmondson


Psychological Safety Is Local

© 2012 Pascal Metrics


Culture of Safety

No one is ever hesitant to voice a concern about a patient

Caregivers - capable, conscientious and playing by the rules – feel comfortable to speak up regarding errors, near misses and adverse events

When people do speak up, they have a high degree of confidence that the organization will act on their concerns and demonstrate such.

There is a cyclic flow of information that leads to analysis, action and feedback - a learning organization – to reinforce well defined behaviors and values

Confidential & Proprietary© 2011 Pascal Metrics Inc.

Benchmarking clinical units

Perceptions of Senior Management

Confidential © 2012 Pascal Metrics, Source: Pascal HealthBench™


0

10

20

30

40

50

60

70

80

90

100

RN rates Physician Physician rates RN

% o

f res

pond

ents

repo

rtin

g ab

ove

adeq

uate

team

wor

k Teamwork in the eye of the beholder: ICU RNs and ICU MDs rate

each other

62 Michigan ICUs 2004Only ICUs with 5 or more physicians reported here (all had 5 or more RNs)


Teamwork Climate Across Michigan ICUs

No BSI 21%

No BSI = 5 months or more w/ zero

The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient

care

No BSI 31% No BSI 44%

Attribution: J. Bryan Sexton


OR

Nu

rse

Su

rgeo

n

Su

pp

ort

Sta

ff

Su

rg T

ech

An

esth

MD

An

esth

Tec

h

< 5

Res

po

nd


Teamwork Climate within OR B



Teamwork Climate item within OR B


Nurse input is well received in this work setting.


Teamwork Climate item within OR B


I have the support I need from others in this work setting to care for patients.


Safety Climate within OR B



Safety Climate item


I would feel safe being treated here as a patient.


Safety Climate item within OR B


I am encouraged by others in this work setting to report any patient safety concerns I may have.


Debriefing Culture Data Locally

- CONFIDENTIAL-

21

Local debrief sessions target improvement at the clinical area level

Sessions empower caregivers to “own the data”

Use the DEBRIEFer tool


Workforce Engagement – 7S Surgical Floor

2009 Percent Favorable 2010 Percent Favorable 2010 Hospital Partner


ICU’s that reflected on their SAQ scores and took action:

• Increased their SAQ scores in 5 of 6 domains

• Achieved a 10.2% decrease in BSI rates

• Achieved a 15.2% decrease in VAP rates

ICU’s that did NOT reflect on their SAQ scores and take action:

• Increased their SAQ scores in 1 of 6 domains

• Achieved a 2.2% decrease in BSI rates

• Achieved a 4.8% increase in VAP rates

Linking Culture and Outcomes:RI ICU Effort to Decrease Infection

Attribution: Margaret Cornell, MS, RN


Effective Teamwork and Communication in Surgical CarePractical tools and behaviors to enhance teamwork and deliver high quality, safe surgical care.


Effective Communication and Teamwork Requires:

Structured Communication

Briefing, Checklist, SBAR, Debriefing

Assertion/Critical Language

Key words, the ability to speak up and stop the show

Psychological Safety An environment of respect

Effective Leadership Flat hierarchy, sharing the plan, continuously inviting other team members into the conversation, explicitly asking people to share questions or concerns, using people’s names


Effective Communication

Have a plan

The value of a structured process

Hand-offs are dangerous

Structured language/clarity

Who owns the patient?

What are the parameters for increasing the intensity of care?

27


Briefings

Share the game plan

Set the stage — psychological safety

Norms of conduct

Disavow perfection – a little humility goes a long way

Engage every participant using eye contact and people’s names

Explicitly ask for input about concerns or issues

Provide information and talk about next steps

Seek useful information

Update as needed — build into procedure

28


Setting the Stage

Vascular surgeon doing new, complicated procedure – endovascular aortic stent — in CV lab:

“I don’t have any pride invested here. I just want to get this right, so if you think of anything helpful or see me doing anything wrong, please let me know.”

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Confidential & Proprietary32

Confidential & Proprietary 33

VA Surgical Teamwork

18% reduction in mortality

Significant improvement in safety culture scores, surgical process measures – DVT, antibiotic administration On time OR starts – went from 38% to 60%

25% reduction nursing turnover

Circulating nurses left the room less

144 serious events prevented, 11 million dollars


WHO Surgical Checklist

34


Debriefing – the link between teamwork and improvement

What went well?

What did we learn?

What do want to differently tomorrow?

36


Building a Learning System

37


Acute Medicines Unit WorkstreamNinewells Hospital, Dundee, ScotlandArun Chaudhur, Medical Director

O2 PrescribingDVT PrescribingCompliance

SNAP-CAP ABX PrescribingCompliance

Bld CultureContamination

Pressure UlcerPrevention Bundle

Compliance with Med. Reconciliation

Early WarningScores Bundle

Hand Hygiene

?

?


Arun Chaudhur, Medical Director


Annotations

1: Marked beds at 30 degree angle2: Fact Sheet for staff education3: Poster with weekly data feedback4: Vent bundle posted in all vent patient rooms5: Began initial trials of Daily goal sheet and pre-extubation sheet6: Initiated Powerpoint education for RT/RN7: Initiated Clinical Pharm rounds8: 1st test of multidisciplinary rounds9: Expanded use of Pre-extubation sheet

ICU Percent of Patients Receiving all Four Aspects Of Ventilator Bundle

10: Staff education on Goal sheet; mini inservices on unit on SBT and Pre-extubation sheet11: Incorporated Goal Sheet into Multidisciplinary Rounds12: Impact Extravaganza (staff/MD education)13: Expanded multidisciplinary rounds to include additional disciplines14: Check compliance on night shift past 2 weeks15: New sign at HOB,16: One on one follow up by Nursing & RT managers on collaboratiion in weaning process


The Importance of Reducing Variation and Avoiding Avoidable Harm


Avoiding Avoidable Harm is Key for Success

Never Events – retained surgical objects, transfusion injury, etc.

Healthcare Associated Infections

The current rate of adverse and avoidable harm is unacceptable

Quality and safety will have progressively more financial impact – more metrics


No Preventable mortality – HSMR, sepsis, rapid response, etc.

No preventable harm – Triggers, AE – Baylor 30% patients with positive trigger / 6% patients adversely affected or increased LOS

- North Carolina study – 10 hospitals, 25% patients experienced harm – 60% “avoidable”

- Health Affairs – 1/3 patients experienced avoidable harm, 2/3 “avoidable”

No preventable risk

Evolution of Risk Mitigation


ADE Detection at LDS Hospital

*Total - 731

Computerized Surveillance*

90 (12%)641 (88%)9

Enhanced ReportingAutomated DetectionTraditional

Confidential & Proprietary A Systematic Framework for Safe & Reliable Surgical Care Allan Frankel,...

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