Learn It, Lead It, Live It: Strategies for Creating a Culture of Safety

Kathleen Vollman MSN, RN, CCNS, FCCM, FCNS, FAANClinical Nurse Specialist, Educator, Consultant

ADVANCING NURSING LLC, Northville MIkvollman@comcast.net

©ADVANCING NURISNG LLC 2019

Disclosures for Kathleen Vollman

• Consultant-Michigan Hospital Association Keystone Center

• Subject matter expert for CAUTI and CLABSI, HAPI, C-Diff and Sepsis for CMS/HIIN

• Consultant and speaker bureau:– Sage Products LLC

• Will be addressing an off label use of a 2% CHG pre-op prep cloth

– Eloquest Healthcare– Urology division of Medline

Industries– Baxter Healthcare Advisory

Board

Objectives

• Discuss factors that contributed to quality and safety challenges from a nursing perspective

• Determine strategies to assess organizational and unit culture

• Identify organizational and unit infrastructure necessary to support a quality and safety culture

• Compare and contrast tools and techniques used on the front line to build a quality and safety culture and how to measure improvement

It is Time to Change!!

• HAC refers to a complication for which clinical risk mitigation strategies may reduce (but not necessarily eliminate) the risk of that complication occurring.

• 2017–18, admissions associated with hospital-acquired complications (HACs) cost the public sector $4.1 billion or 8.9% of total hospital expenditure.

Australian Commission on Safety and Quality in Health Care. The state of patient safety and q quality in Australian hospitals 2019. Sydney; ACSQHC, 2019.

HAC’s/HAI’s

Australian Commission on Safety and Quality in Health Care. The state of patient safety and q quality in Australian hospitals 2019. Sydney; ACSQHC, 2019.

HAIs are one of the most common complicationsaffecting hospital patients; they increase the risk of morbidity, mortality & readmission within 12 months

What If!!!

Australian Commission on Safety and Quality in Health Care. The state of patient safety and q quality in Australian hospitals 2019. Sydney; ACSQHC, 2019.

Safety and Quality

• Safety has to do with lack of harm. Quality has to do with efficient, effective, purposeful care that gets the job done at the right time.

• Safety focuses on avoiding bad events. Quality focuses on doing things well.

• Safety makes it less likely that mistakes happen. Quality raises the ceiling, so the overall care experience is a better one.

Understanding The Journey

NursingOrganizations

That’s not the way we do it here!!!

What is a Culture?

Represents a set of shared attitudes, values, goals, practice & behaviors that makes one unit distinct from the next

Pronovost, PJ et al. Clin Chest Med, 2009;30:169-179

Driving Components in a Work Culture

Reasons for Confusion & Disillusionment in Nursing

A narrow definition of health How we define autonomy Nursing’s unique contribution Absence of recognition for basic nursing care

activities

Vollman KM, Stewart KH. AACN Clin Issues. 1996;7(2):315-323.

A 

Narrow

Definition

of 

Health

Medicine’s Health Definition

The absence of disease and measured in terms of morbidity and mortality

Nightingale’s Health Definition

Health is not only to be well but to be able to use what ever power we have.

1st American Nurses Association’s Health Definition

A dynamic state of being in which the development and behavioral potential of an individual is realized to the fullest extent possible.

Social Policy Statement 1980

Lyon’s Health Definition

Health is the dynamic subjective quality of person-environment interaction which is expressed in a person’s composite evaluation of the somatic sense of self and functional ability.

Wellness & IllnessWellness & Illness

Wellness is comfortable somatic sensations accompanied by optimal functional ability whether we have a disease or not

Illness is uncomfortable somatic sensations or a decreased functional ability whether we have a disease or not

Autonomy

Means the self-directed diagnosis & treatment or it is a self determined and controlled action that does not require authorization from another

Confusing Autonomous Scope of Practice

Setting Judgments

AutonomousNursingScope of Practice

MedicalNursingScope of Practice

Florence Nightingale …

An expert in nursing’s autonomous scope of practice

Surveillance & monitoring of patient conditions for early detection of problems

Preventing complications

“I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all of these at the least expense of vital power to the patient”

Notes on Nursing (1860/1969 p. 8)

Florence Nightingale on:

The distinction between disease and illness

“… so deep-rooted and universal is the conviction that to give medicine is to be doing something or RATHER EVERYTHING; to give air, warmth, cleanliness, etc., is to do nothing.”

(emphasis added) Notes on Nursing, (1860/1969, pg. 9)

Self Directed Treatment Categories for Nursing

Hygiene-related activities Nutrition-related activities Elimination-related

activities Comfort-related activities Movement-related

activities Rest/activity relate

activities Learning and

development-related activities

Safety-related activities

Sense of normalcy-related activities

Interaction-related activities

Coping-related activities Physical environment-

related activities Alteration in ADL-related

activities

Recognition & Reprimand Structures within Acute Care Settings

• Recognition• Physiologic assessment • Completing medical treatments in a timely

fashion• Assisting physicians with activities

• Reprimand• Medication administration• Questioning content of medical orders

Behavior that is recognized and reinforced continues

Behavior that is ignored or not reinforced does not continue

Missed Nursing Care

• Any aspect of required patient care that is omitted (either in part or whole) or significantly delayed.

• A predictor of patient outcomes• Measures the process of nursing care

Kalish, R. et al. (2012) Am Jour Med Quality, 26(4), 291-299.

Hospital Variation in Missed Nursing Care

Kalish, R. et al. (2012) Am Jour Med Quality, 26(4), 291-299.

Patient Perceptions of Missed Nursing Care

Kalisch, B et al. (2012). TJC Jour Qual Patient Safety,38(4), 161-167.

Outcomes of Missed Nursing Care: A Systematic Review

• 14 studies connecting missed nursing care with at least 1 patient outcome• Patient Satisfaction ↓ • Lower quality of care reported by nurses with greater missed care • Clinical Outcomes

• Medication errors• CLA-BSI’s• Pneumonia• UTI’s• Pressure Injuries• Falls• Failure to rescue

Recio-Saucedo A, et al. J of Clin Nurs. 2018;27:2248-2259

5 nurse sensitive adverse events in 22 med-surg units added

1300 additional hospital days for 166 patients &

$ 600,000 in excess costs

Tchouaket E. JAN. 2017;73:1696

Reasons for Missed Nursing Care

Kalisch, BJ, et al. American Journal of Medical Quality. 2011; 26(4), 291–299Ball JE, et al. BMJ Quality and Safety 2014 Feb;23(2):116-25.

9.4% variance in missed nursing care

Qualitative Review• Interruptions/multitasking/task

switching• Fatigue & physical exhaustion• Cognitive biases• Lack of patient & family

engagement• Lack of physician resources• Leadership issues• Moral distress & compassion fatigue• Documentation load• Large proportion of new nurses on

unit• ComplacencyPractice environment correlates to missed nursing care

Rationing Care-How we Prioritize

• Highest priority activities for nurses• Those which are likely to have an immediate negative

impact• Administering meds• Medical directed treatments• Procedures-wound dressings, labs

• Lower priority activities for nurses• Those which show no immediate negative harm

• Ambulation• Oral hygiene• Emotional support• Teaching

Bail K, et al. International Journal of Nursing Studies. 2016;63:146-161

Rationing contributes to functional and cognitive decline

Fundamentals of Care Framework

The Fundamentals of Care Framework. Reprinted from Conroy, Feo, Alderman, and Kitson (2016)

• Fundamental care involves actions on the part of the nurse that respect and focus on a persons essential needs to ensure their physical & psychosocial wellbeing.

• These needs are met by developing a positive & trusting relationship with the person being care for as well as their families/carers

Feo R, et al. J of Clin Nurs. 2018;27:2285-2299

Reconnect With Our Professional Purpose

“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”

Florence NightingaleNotes on Hospitals: 1859

Advocacy = Safety

Protect The Patient From Bad Things

Happening on Your Watch

Interventional Patient Hygiene

• Hygiene…the science and practice of the establishment and maintenance of health

• Interventional Patient Hygiene….nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies

Incontinence Associated Dermatitis Prevention

Program

INTERVENTIONAL PATIENT HYGIENE(IPH)

Oral Care/ Mobility

VAP/HAP

Catheter Care

CA-UTI CLA-BSI

Skin Care/ Bathing/Mobility

HASISSI

Patient

Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154

Falls

PATIENT

CLEAN GLOVES

CLEAN GLOVES

HAND HYGIENE

HAND HYGIENE

INTERVENTIONAL PATIENT

HYGIENE(IPH):The Physical

Fundamentals of CareOral Care/

Mobility/Comfort

VAP/HAP

Medication Management

CA-UTI CLA-BSI

Skin Care/NutritionBathing/Mobility

SSI

Patient

Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154

PATIENT

CLEAN GLOVES

CLEAN GLOVES

HAND HYGIENE

HAND HYGIENE

VTECatheter Care

Falls

HASI

SSI

Adverse Drug Events/

Medication Errors

Attitude &

Accountability

Factors Impacting theability to Achieve QualityNursing Outcomesat the Point of Care

Achieving the Use of the Evidence

ValueVollman KM. Intensive & Critical Care Nursing, 2013 Oct; 29(5): 250-5

Preventing NV-HAP Through Evidence Based Fundamental

Nursing Care Strategies

Slides courtesy of Barbara Quinn

Why NV-HAP?: DO NO HARM

• HAP 1st most common HAI in U.S.• Increased morbidity 50% are not discharged back home• Increased mortality 18%-29%• Extended LOS 4-9 days• Increased Cost $28K to $109K• 2x likely for readmission <30 day

• Understudied, under-addressed• Focus has been on the other HAP VAP• Surveillance not required….yet

Kollef M.H. et.al. (2005). Chest. 128, 3854-3862ATS, (2005). AmJ Respir Crit Care Med. 171, 388-416.Lynch (2001) Chest. 119, 373S-384S.

Pennsylvania Dept. of Public Health (2010).

Pathogenesis Prevention

Germs in Mouth

• Dental plaque provides microhabitat• Bacteria replicate 5X/24 hrs

Aspirated into Lungs

• Most common route• 50% of healthy adults micro-aspirate

in sleep

Weak Defenses

• Poor cough• Immunosuppressed• Multiple co-morbidities

NV‐HAP SMCS Research Findings: 2010

Incidence:• 115 adults• 62% non-ICU• 50% surgical• Average age 66• Common comorbidities: CAD, COPD, DM, GERD

• Common Risk Factors: Dependent for ADLs (80%) CNS depressant meds (79%)

Quinn, B. et al. Journal of Nursing Scholarship, 2014. 46(1):11-19

Cost:• $4.6 million• 23 lives• Mean Extended LOS 9 days• 1035 extra days

SMCS HAP Prevention Plan

Phase 1: Oral Care

• Formation of new quality team: Hospital-Acquired Pneumonia Prevention Initiative (HAPPI)

• New oral care protocol to include non-ventilated patients

• New oral care products and equipment for all patients

• Staff education and in-services on products

• Ongoing monitoring and measurement– Monthly audits

Quinn B, et al. J of Nursing Scholarship, 2014, 46(1):11-19

Protocol – Plain & Simple

Patient Type Tools Procedure FrequencySelf Care / Assist

Brush, paste, rinse, moisturizer

Provide toolsBrush 1-2 minutesRinse

4 X / day

Dependent / Aspiration Risk

Suctiontoothbrush kit (4)

Package instructions 4 X / day

Dependent / Vent

ICU Suction toothbrush kit (6)

Package instructions 6 X / day

Dentures Tools +CleanserAdhesive

Remove dentures & soakBrush gums, mouthRinse

4X / day

NV-HAP Incidence 50 % Decrease from Baseline

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Month/Year

Control chart for NV-HAP January 2010 to December 2013

UCL

LCL

Average

Oral CareBaseline

Return on Investment

60 NV-HAP avoided Jan 1 – Dec. 31 2013 $2,400,000 cost avoided- 117,600 cost increase for supplies $2,282,400 return on investment

•8 lives saved

NV-HAP 70% from baseline!

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Control chart for non-ventilator HAP January 2010 to December 2014

UCL

LCL

Mean

Oral care for all adult pts

Started oral care prior to surgery

Quinn B, Presented at AACN NTI, Houston, Tx, 2017

Pharmacy starts PPI protocol

NGT standards revised

Baseline

Documentation

Mandatory Education for Nurse Assistants

Driving Components in a Work Culture

Number 1 Respected Profession

So Why Don’t We Feel Respected?

NursingGallup Poll: 82% Honesty & Ethical Rating

Reclaiming Professional Respect

What Behaviors or Communications Make You Feel the Recipient of Respect?

Work EnvironmentQuality of Care You Provide to Patient & Families

Feeling of Respect or Not being Respected Bournes DA, et al. Nursing Science Quarterly, 2009;22(1):47-56

• Respected• Feeling listen to• Feeling revered for their

knowledge• Feeling trusted• Feel part of the group• Being acknowledged• Sense of belonging/contributing• Persons look out for each other

and their support• Fairness• Free to speak• Opportunities to excel

• Not Being Respected• Disregarded• Not revered• Not trusted• Not supported• Not recognized• Closed conversation• Speaking in a tone that is

demeaning• Ideas and opinions not

considered a value priority• Unsafe, guarded,

pressured, put down

Respect

Self Respect

Self Respect

Internal Dialogue External Dialogue

Culture of Respect

• Develop effective methods for responding to episodes of disrespectful behavior

• Initiating cultural changes needed to prevent the episodes

• Disrespectful behavior must be addressed consistently and transparently

• Organization set up a code of conduct and it must be enforced

• Culture of respect requires building a shared vision

Leape LL, et al. Academic Medicine, 2012;87(7):853-858

The Road to Respect

I spoke.You listened.I felt valued and honored.You shared your opinion.I trusted your wisdom.The circle of respect was complete.We saw in each other’s eyes are common humanity.Now, moving to a zone of mutual affirmation, we felt safe to trust and learn and nurture in the give-and-take of life.

Yasmin Morais 2006

Culture Assessment is Critical

Assessment of Safety & Work Culture-Organization & Unit

• SAQ (Safety Attitudes Questionnaire)• Teamwork• Safety• Working conditions• Job satisfaction• Stress recognition• Perception of upper management• Perception of unit management

Strive for 80%, if > 60% SAQ scores correlates to decreases in clinical outcomes

AACN Healthy Work Environment Assessment tool-Unit Level

• Skilled communication• True collaboration• Effective decision making• Appropriate staffing• Meaningful recognition• Authentic leadership

Unit Culture Assessment

Tweeners

PositronsNegatoids

If you Permit it you Promote it

Understanding The Journey

Nursing Organizations

Health Care QualityDonabedian Framework

STRUCTURE PROCESS OUTCOME

Having the right things in place

Doing the right things

Having the right things happen

Quality of care is represented by an entire systemic integration from structure to process and to outcome,

but not by one or the other independently

Organizational & Unit Structures that Supported the Empowerment

Shared Governance Model

Continuous Quality Improvement Model

Professional Practice Model/Clinical Ladder

Unit Based Leadership Model

Educational Support

Foundational Principles to Maximize Staff Empowerment

• The Unit is the center of a shared governance model..the locus of control is at the point of service

• Staff need mentoring and leadership coaching• Shared leadership means the clinical and administrative

lead of the unit are part of the unit practice/governance council

• Defined accountability of all members• Sufficient time in meetings to formulate ideas and plan

work (unit meeting 4hrs)

Example Structure:Unit Based Accountability Teams

• Every patient care unit in hospital or group practice• Composition: Medical Director, Nurse manager, Clinical

Nurse Specialist, System Performance Improvement Leader

• Responsibilities:• Establish clinical/quality goals for unit• Responsible for unit outcomes---unit dashboard

• Clinical and operation measures• Quality• Patient Safety and safety culture• Patient satisfaction• Employee satisfaction

One of the reasons people don’t achieve their dreams is that they desire to change

their results without changing their thinking

John C. Maxwell

A Large Part of Your Success in Driving Change Occurs Around the

Ability to Lead or Influence

Leadership in Driving Change• The essence of leadership is influence over

others. But, influence is not unidirectional.• You do not need a formal title to be a leader• Understanding power relationships and

influence strategies in organizations is essential to drive change and effective team work

http://accurate.clemson.edu/becker//prtm320/notes/power320.pdf

“If your actions inspire others to dream more, learn more, do more, and become more, you are a

Leader”

John Quincy Adams

Understanding How You Influence

Legitimate Power– Authoritative

power derived from a job, position, or status and held as belonging to the person in such a position.

Expert Power– Based on a

person’s expertise, competence, and information in a certain area.

Power is the engine that drives the ability to influence

Referent Power― Based on a

high level of identification with, admiration of, or respect for the power holder/leader.

Potential Reactions to Individual Sources of Power

• Coercive Power

• Reward Power

• Legitimate Power

• Expert Power

• Referent Power

Resistance

Compliance

Commitment

“Setting an Example is Not the Main Means of Influencing Others….It

is the Only Means”Albert Einstein

The Most Powerful Force of Human Behavior is Social Influence

Changing the Routine

• Implementation science: study of methods to promote uptake of clinical research findings and make them the new routine• Identification of need• Team Assembly• Tools & Methods• Implementation• Measuring success

Murphy DM, et al. APIC. 2012;40:296-303Babine RL, et al. J of Nursing Management, 2016;24:39-49

Models/Frameworks Used to Guide Change

Iowa Model

John Hopkins Translating Evidence into Practice Model

Process = Strategies for Creating a Safety Culture

CUSP

Huddles

Crucial Conversations

PDCA

Multidisciplinary Rounds

Learn From a Defect

Comprehensive Unit-Based Patient Safety Program (CUSP)

• Assess culture of safety (SAQ & AHRQ)• Educate staff on science of safety

http://www.safetyresearch.jhu.eduhouse staff orientation

• Identify defects• Learn from one defect per quarter• Assign executive to adopt unit• Implement team/communication tools• Reassess culture annually

www.aone.org/hret/programs/cusp.html

CUSP in Partnership with Technical Interventions for Improvement

• CUSP + VAP• CUSP + CAUTI• CUSP + CLA-BSI

HAI Progress Reports 2014-2016↓ VAP’s by 32%↓ CLABSI by 31%↓ VTE by 21%↓ ADE by 15%↓ C. difficile by 11%

Patient Advocacy/Safety Related to Clinical Practice

• Nurses knowledge of the Evidence based care• Ability to deliver the care to the right patient at the right time,

every time it is needed• The ability to communicate patient concerns in a concise,

data driven manner and take appropriate action• Understanding the chain of command when faced with

resistance and that we are the patients voice

What Supports Our Ability to Advocate & Use the Evidence?

• Leadership support• Evidence-based knowledge• Experience• Effective communication• Respectful communication and being respected

• Goes both ways• If we as nurse don’t know or believe something different than

the doctors order what should we do?• Understanding that it’s worth it!!!!!

George Bernard Shaw

“Our lives begin to end the day we become silent

about things that matter”

Martin Luther King Jr.

Effective Communication and Teamwork Requires:

• Structured Communication

• Assertion/Critical Language

• Psychological Safety

• Effective Leadership

• SBAR (Situation-Behavior-Assessment-Recommendation), structured handoffs,

• Key words, CUS, the ability to speak up and stop the show, STAR (stop, think, act & review)

• An environment of respect

• 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

Manser T. Acta Anaesthesiol Scand, 2009;53:143-151

Communication Training

Communication Strategies

• Tools to help structure communication for Safety• CUS Words: I am Concerned, I am

Uncomfortable, This is not Safe• ARCC:

• Ask a question to gently prompt the other person of a potential safety issue.

• Request a change to make the person fully aware of the risk.

• Voice a concern if the person is resistant.• Finally, use the chain of command if

Tools and Strategies to Improve Communication and Teamwork

• Huddles• Learn from a defect• Daily rounds/goals• Pre-procedure briefing• Morning Briefing

Huddles• Enable teams to have frequent but short briefings

so that they can stay informed, review work, make plans, and move ahead rapidly.

• Allow fuller participation of front-line staff and bedside caregivers, who often find it impossible to get away for the conventional hour-long improvement team meetings.

• They keep momentum going, as teams are able to meet more frequently.

Metrics Don’t Change Until You Have Been Successful

Learn from a Defect Tool• Designed to rigorously

analyze the various components and conditions that contributed to an adverse event and is likely to be successful in the elimination of future occurrences.

• Tool can serve to organize factors that may have contributed to the defect and provides a logical approach to breaking down faulty system issues.

Huddle Issues Requiring In-Depth Review Gets the Full Drill Down

Multidisciplinary/Interdisciplinary Rounds with Daily Goals

• Purpose: Improve communication among care team and family members regarding the patient’s plan of care• Goals should be specific and measurable• Documented where all care team members have access• Checklist used during rounds prompts caregivers to focus

on what needs to be accomplished that day to safely move the patient closer to transfer out of the ICU

• Use of checklists result in knowledge of the plan of care among clinicians, a culture of teamwork & safety and clinical, financial and service outcomes

• Evidence of reduced mortality in ICU’s that use daily multidisciplinary rounds (Kim MM. et al Arch Intern Med. 2010;170(4):369-376)

Halm MA. AJCC, 2008;17:577-580

RN Starts Round with Vital SignsThen Integrates The Checklist

The Silent Treatment, April 20

Helpful Hints to an Empowered Practice

• Encourage staff to be a part of unit governance council or on projects or task forces to solve clinical issues with the evidence

• Start up a journal club or participate…help them learn to read evidence

• Strategies to impact value of practice

It Takes a Village

Measurement is Key

Nurse Sensitive Care Indicators

• Death among surgical patients with treatable serious complication

• Pressure ulcer prevalence• Falls prevalence• Falls with injury• Restraint prevalence (vest

& limb only• UTI rate/ICU• Blood stream infections

(BSI) from invasive catheters (ICU and high risk nursery)

• Ventilator-associated pneumonia (VAP and high risk nursery)

• Smoking cessation for AMI

• Smoking cessation counseling for heart failure and pneumonia

• Skill mix• Nursing care hours per

day• Voluntary turnover• Nursing Environment

IndexNursing Quality Forum 2004

Additional Measures

• Non-ventilator hospital acquired pneumonia• Employee satisfaction• Retention of qualified experience staff• Staff Empowerment

• Culture and healthy work environment tools• Participation in process improvement & committees• Presentations-posters and podiums• Actively engaged in problem solving

“Quality is never an accident. It represents the wise choice of many

alternatives.”

Willa Foster

Health Care Quality Outcomes

Positive Patient

Outcomes

Satisfied Patients & Families

Positive Safety Culture

Engaged & Satisfied

Employees

Cost Efficient Care

Evidence Based Care

Accountable Leadership