Leonard Plenary ICCH09 PowerPoint

The Path to Safe & Reliable Healthcare

Michael Leonard, MD

Confidential

Profile of Market Leaders• Superior safety / quality and operational

efficiency is their non-negotiable core value• Transparency of clinical data and process• Leadership engagement and accountability -

senior and clinical, just culture• Learning organization - systematic flow of

information and intervention • Culture / risk maps, direct observation• Cultural work - teamwork & communication,

environment of respect• Reliable /resilient processes - robust process

improvement• Measurement and feedback - put it on the wall

Confidential

Team Practice Key Components

© 2008 Pascal Metrics3

LEADERSLeader Attributes

Respect is expected– Non-negotiable

& mutual Psychological safety is

assured– Everyone is fallible– All concerns are

important Excellence is expected

– Determination to fulfill goals

Choose team members– Knowledge

• Clinical• Improvement

– Skills– Attitudes– Behaviors

TEAMSTeam-member Behaviors The game plan is always

known– Brief and re-brief

Communication is clear– Closed loop– SBAR — structured

communication Learning is continuous

– Debriefings

UNITSImprovement

(Improving Improving) Testing is continuous

– Rapid cycle improvement

– Lean– Six sigma– Reliable design Unit structure and

resources support performance improvement

Conflicts are resolved– Critical Language– Crucial Conversation

Situational awareness is maintained

Confidential

Leading With Safety - Thomas Krause• Why do some organizations do well with safety

initiatives while others do poorly or fail?• The most important factor in predicting

success was the quality of leadership and the organizational culture

• Organizations highly successful in safety were also generally successful in operational performance


Confidential

Attributes of the Right Stuff • Behaviors – particularly leadership • Engagement at all levels of the organization• Understand crucial aspects of human

performance• To continuously improve performance and

achieve superior results the organizational culture must change – meaning behavioral change

• They address and align the behaviors of everyone

© 2008 Pascal Metrics5 Krause – Leading with Safety 2005

Confidential

Safety Attitudes Questionnaire:Items Are Grouped Into Six Factors


Factor: Definition Example ItemsJob Satisfaction:

Positivity about the work experience

I like my jobThis hospital is a good place to work

Teamwork Climate:

Perceived quality of collaboration between personnel

Disagreements in this clinical area are appropriately resolved (i.e., what is best for the patient)Our doctors and nurses work together as a well coordinated team

Safety Climate:

Perceptions of a strong and proactive organizational commitment to safety

I would feel safe being treated in this clinical areaMedical errors are handled appropriately in this clinical area

Perceptions of Management:

Approval of managerial action Hospital management supports my daily efforts in this clinical areaHospital management does not knowingly compromise the safety of patients

Stress Recognition:

Acknowledgement of how performance is influenced by stressors

I am less effective at work when fatiguedWhen my workload becomes excessive, my performance is impaired

Working Conditions:

Perceived quality of the work environment and logistical support (staffing, training, etc.)

Trainees in my discipline are adequately supervisedThis hospital deals constructively with problem personnel

0

10

20

30

40

50

60

70

80

90

100

RN rates Physician Physician rates RN

% o

f res

pond

ents

repo

rting

abo

ve a

dequ

ate

team

work 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)

Confidential

Teamwork Climate Across Michigan ICUs


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

Confidential

Teamwork Climate Across Occupations


Confidential

“The physicians and nurses here work together as a well-coordinated team.”


Confidential

“In this clinical area, it is difficult to speak up if I perceive a problem with patient care.”


Confidential

“Disagreements in this clinical area are resolved appropriately (i.e. Not who is right, but what is best for the patient).”


Confidential

“Nurse input is well received in this clinical area.”


Confidential ⓒ 2008 Lotus Forum Inc.

Labor and Delivery Collaboration Map

ⓒ 2008 Lotus Forum Inc.

14

Job Position Response Rate (Returned/Admin)

Age Mean Years (± SD)

Obstetrician 67% (494/739) 45 (9.91)Anesthesiologist 54% (213/401) 44 (7.83)Registered Nurse 77% (1877/2442) 42 (10.71)LVN/OBa 81% (227/280) 42 (10.95)Nurse Manager & Charge Nurse 79% (136/172) 46 (7.56)

Table 1: Labor and Delivery Respondent DemographicsaLVN/OB is licensed vocational nurse/obstetrical technician

OBSTETRICIANS ANESTHESIOLOGISTS

NURSE MANAGERS/CHARGE NURSES

REGISTEREDNURSES

LVN/OBTECHNICIANS

Confidential

Within Hosp #22, which units are the most/least culturally positive?

Confidential

Radar Diagram

Confidential

HUMAN FACTORS: Performance in a Complex Environment

17

Confidential

Inherent Human Limitations

* Limited memory capacity – 5-7 pieces of information in short term memory

* Negative effects of stress – error rates * Tunnel vision

* Negative influence of fatigue and other physiological factors

* Limited ability to multitask – cell phones and driving

Confidential

Structuring the Nursing Work* Big picture or task performance?* Tucker & Spear: med-surg observation, at

least 100 discrete tasks per 8 hour shift:Average 3 minutes / taskNo ability to sequence – juggling, prioritizing

tasksFormally interrupted at least once / hour

Tucker AL, Spear SJ, HSR, June 2006

Confidential

Human Factors: The Foundation of Reliability• Effective team

performance• Structured

communication• Reliable processes• Continuous learning

and improvement


Confidential

Why Communication? Why Teamwork?• The overwhelming majority of

untoward events involve communication failure

• Wrong site surgery — somebody knows there’s a problem but can’t get everyone in the same movie

• The clinical environment has evolved beyond the limitations of individual human performance


Confidential

Christian et al – Patient Safety in the OR

*“Problems in communication and information flow, and workload and competing tasks were found to have measurable impact on team performance and patient safety in all 10 cases”*Information loss – 19 delays, 30 instances of uncertainty among other providers*Circ RN leaves room for something 33 times / case, average of once every 8 minutes *Counts – while closing, 14 % of their time counting

Surgery 2006, 139: 159-173

Confidential

Effective Communication and Teamwork Requires:


Structured Communication

SBAR

Assertion/Critical Language

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

Psychological Safety An environment of respectEffective 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

Confidential

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?


Confidential

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.”


Confidential

“I know the names of all the personnel that I worked with during my last shift”


Confidential

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


Confidential

Confidential

SBAR• Enhances predictability — how we are

going to talk with each other• Crisp — to the point• Promotes critical thinking• Similar in structure to the SOAP model

(subjective/objective/ assessment/plan) that is taught in nursing and medical schools


Confidential35Courtesy Dr. David Morehead

Confidential

Why is Assertion/Critical Language Important?• Because we know 25-40% of nurses

tell us on the Safety Attitude Questionnaire they would be hesitant to speak up if they saw an MD making a mistake

• Often people do not speak up or do so quite indirectly

• Knowing the plan — using SBAR — makes it much easier to speak up


Confidential

AssertionModel to guide and improve assertion in the interest of patient safety


GET PERSON’S GET PERSON’S ATTENTIONATTENTION

EXPRESSEXPRESSCONCERNCONCERN

STATESTATEPROBLEMPROBLEM

PROPOSEPROPOSEACTIONACTION

REACH REACH DECISIONDECISION

Confidential

Confidential

Red Flags: Loss of Situational Awareness• Ambiguity• Reduced/poor communication• Confusion• Trying something new under pressure• Deviating from established norms• Verbal violence• Doesn’t feel right• Fixation/boredom/task saturation• Being rushed/behind schedule


Confidential

How do experts and novices make decisions?

• Experts pattern match against a large mental library of past experience. It is very quick and quite accurate if they continue to seek confirming evidence.

• Novices cannot do this; their library is empty; they have not seen it before. They use a slow, error-prone process.

• Experts need to teach the patterns to novices, even if the answers appear overly obvious — that’s how we help them become expert.


Confidential

Glitch Book• A physical book that is used to document

and help track the solution with:

– Equipment that needs to be fixed or replaced

– Information that got lost– Something that was supposed to happen

for the patient and did not


Confidential

Debriefing• An opportunity for individual, team

and organizational learning• The more specific, the better• What did we do well? What did we

learn? What would we do differently next time?

• Take a minute or two to learn while it is fresh in everyone’s head


Confidential

Effective Debriefing• Be crisp and to the point• Do it while the experience is fresh• Everyone gets a chance to speak• Start with the junior folks —

otherwise they can be overshadowed by the veterans

• Avoid judgment and criticism — this has to be a positive learning experience


Confidential

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

© 2008 Pascal Metrics Inc.46

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

Confidential

Leonard Plenary ICCH09 PowerPoint

Technology

Transcript of Leonard Plenary ICCH09 PowerPoint