Changing Work Cultures to Improve Patient Safety in the ICU by gyvwpsjkko

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									Changing Work Cultures to Improve
    Patient Safety in the ICU

           Kathleen M. Vollman MSN, RN, CCNS, FCCM
           Clinical Nurse Specialist/Educator/Consultant
                       ADVANCING NURSING
                      kvollman@comcast.net
                        Northville, Michigan
          It is Time to Change!!

• 44,00 to 98,000 preventable death in hospitals
  related to medical errors annually (IOM report,
  1999)
• 92,888 deaths directly attributable to safety
  indicators between 2005-2007 (HealthGrades
  2009)
• $50 billion in total costs
• 5th leading cause of death in US-more than
  AIDS, breast cancer, MVAs
               Quality & Safety Drivers
Institute for Medicine
•   IOM report
•   Crossing the Quality Chasm
•   Transforming the work culture
Evidence based practice movement
Quality organizations
      •   Australian Patient Safety Foundation (1989)/Safety &Quality
          Council (2000)/New Zealand part of Quality Network
      •   Patient Safety First Campaign/NPSA/NICE/UK
      •   IHI/VHA:100,000 lives campaign /5 million lives campaign
      •   Best Care Always: www.bestcare.org.sa
      •   Clean Care is Safer Care/WHO
Regulatory agencies:
      •   Create & maintain a safety culture
Public transparency
Professional Nursing: Back to the Basics
Economics
          Keystone Project

• Statewide initiative-75 Hospitals, 127 ICUs
• In Collaboration with Johns Hopkins’ Quality
  and Research Institute
• Reduce errors and improve patient outcomes
  in ICUs
• Combination of evidence based medicine and
  quality improvement
• 5 interventions implemented over a 2 year
  Grant funded period
• Still going strong after 5 years!!!!
                    Keystone: ICU

  Science of Safety
  BSI
  VAP
  Daily Goals
  Sepsis
  Oral Care
  Palliative Care

        Partnership between Johns Hopkins University and MHA
Initiated with AHRQ Matching Grant Sustained with participant fees in
                           2005 and 2006
        The “Secret Recipe”
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
What is a Culture?

                   That’s not the way
                     we do it here!!!



                      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
Assessment of Safety & Work Culture
  • 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
Assess Culture of Safety and Teamwork


I would feel safe being treated here as a patient?

1.Strongly agree
2.Agree
3.Disagree
4.Strongly disagree
Assess Culture of Safety and Teamwork

I am encouraged by my colleagues to report any
patient safety concerns I may have.

1.Strongly agree
2.Agree
3.Disagree
4.Strongly disagree
Assess Culture of Safety and Teamwork


 Nurse input is well received in this clinical area.

 1.   Strongly agree
 2.   Agree
 3.   Disagree
 4.   Strongly disagree
Assess Culture of Safety and Teamwork

 Disagreements in this clinical area are resolved
 appropriately (IE: not who is right, but what is
 best for the patient)

 1.Strongly agree
 2.Agree
 3.Disagree
 4.Strongly disagree
Assess Culture of Safety and Teamwork

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

1.   Strongly agree
2.   Agree
3.   Disagree
4.   Strongly disagree
Can we change practice through
Can we change practice through
 process improvement alone?
  process improvement alone?


              or

 Will successful change require
 Will successful change require
an altering of the value structure
an altering of the value structure
          within the unit?
          within the unit?
Medical errors most often
result from a complex
interplay of multiple factors.
Only rarely are they due to
the carelessness or
misconduct of single
individuals.


                     Lucien L. Leape, MD
           Harvard School of Public Health
         Why Mistakes Happen?

Process Factors             People Factors
Variable input (diff pts)   Fatigue
Inconsistency/variation     Inattention/distraction
Complexity                  Unfamiliar situations/new
Too many/complicated        problem
steps                       Using past solutions
Human intervention          Equipment design flaws
Tight time constraints      Communications errors
Hierarchical culture        Mislabeling/inadequate
                            instructions
         The “Secret Recipe”
 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
           The Science of Safety
• Understand that safety is the property of a system
   – Efforts to improve patient safety should focus on
      improving systems rather than blaming caregivers
   – End the culture of blame
• Use strategies to improve system performance
              “They are a good nurse,
              doctor, pharmacist…but”
   – Standardize
   – Create independent checks (Checklist) for key
      process
   – Learn from mistakes
• Recognize that teams make wise decisions when there
  is diverse and independent input
• Apply strategies to both technical work and team work.
                     Pronovost, PJ et al. Clin Chest Med, 2009;30:169-179
  Use “Engaging” Improvement
           Methods

• Standardize what is standardizable, no more
• Generate light, not heat, with data (use data
  sensibly)
• Simulation team training
• Make the right thing easy to try
• Make the right thing easy to do
• Use a focused model…PDCA & rapid cycle
  measurements
         The “Secret Recipe”
 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
Identify Defects
 •   Staff feedback
 •   Event reporting
 •   Quality and safety measures
 •   Gaps in application of the evidence
 •   Staff 3 question survey
     – Tell us about the last patient who would have been
       harmed without your intervention.
     – How will the next patient be harmed?
     – What steps can you do to prevent this harm?
      • By either preventing the mistake, making the mistake
         visible or mitigating the harm
          Learn from one defect per quarter
Executive to Adopt the Unit
• Senior executive at the hospital
• Open lines of communication between
  frontline staff and executive (visible)
• Educate leaders about clinical issues & safety
  hazards (shadowing a provider)
• Provide staff resources to mitigate hazards
• Hold staff accountable for reducing patient risk
       Communication is Key

Effective communication amongst caregivers is
essential for a functioning team
The Joint Commission reports that ineffective
communication is the most commonly cited cause
for a sentinel event (70%)
Observations of ICU teams have shown errors in
the ICU to be concentrated after communication
events (shift change, handoffs, ect)
30% of errors are associated with communication
between nurses and physicians


                      Reader, CCM 2009 Vol 37 No 5;
                      Donchin CCM 1995 Vol 23
“   Our lives begin to end the
     day we become silent
    about things that matter”



                       Martin Luther King Jr.
Silence Kills
 • 84% of physicians and 62% of nurses and other
   clinical-care providers have seen coworkers taking
   shortcuts that could be dangerous to patients.
 • 88% of physicians and 48% of nurses and other
   providers work with people who show poor clinical
    Confidence in the ability to speak
   judgment.
 • Fewer than 10% of physicians, nurses and other
                  breaks the their colleagues about
             up directly confrontchain!!
   clinical staff
   their concerns, and one in five physicians said they
   have seen harm come to patients as a result.
 • 10% of healthcare workers who raise these crucial
   concerns observe better patient outcomes, work
   harder, are more satisfied and are more committed
   to staying in their jobs.
                        www.aacn.org/WD/Practice/Docs/PublicPolicy/SilenceKills.pdf
 That is just
how we do it                         I am concerned,
   here!                             but if I say
                                     something I get
                                     yelled at.




                PATIENT SAFETY ISSUE


                Why should I
                bother, they don’t
                listen to me!
              Conflicts in the ICU
Methodology
  One day cross-sectional survey
  7498 ICU staff members
  323 ICUs in 24 countries
Results
  71.6%: perceived conflicts
  32.6%: nurse-physician
  27.3%: nurse-nurse
  26.6%: staff-relative
  53.0%: severe conflicts
  Conflict causing behaviors: personal animosity, mistrust
  and communication gaps
  Key factors associated with conflict: inadequate
  communication, workload, end-of-life care
                           Azoulay E, et al. Am J of Respir Crit Care Med, 2009;July 30th
            Effective Communication and
                Teamwork Requires:
 • Structured Communication               • SBAR (Situation-Behavior-
                                            Assessment-Recommendation),
                                            structured handoffs,

 • Assertion/Critical Language            • Key words, the ability to speak up
                                            and stop the show, STAR (stop,
                                            think, act & review)
 • 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
Manser T. Acta Anaesthesiol Scand, 2009;53:143-151
                Unit Culture Assessment
                                                                      t?
                                                             i ng i
                                                 te   in fix
                                      arti c i pa
                              o   p
                    go i ng t                                              Ha
         e   yo u                          Tweeners                          ve
H   ow ar                                                                         yo
                                                                                    u
                                                                                        ta
                                                                                           lk   ed
                                                                                                     to
                                                                                                       …
                                                                                                           …

               Negatoids                                                   Positrons


                          If you Permit it you Promote it
    Tools and Strategies to Improve
    Communication and Teamwork

•   Daily rounds/goals
•   Morning briefing
•   Huddles
•   Learn from a defect
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.
                                       Halm MA. AJCC, 2008;17:577-580
Daily Goal Sheet
• A daily goals worksheet must be individualized to your
  particular ICU and the specific needs and traditions of your
  hospital. Below are some considerations for daily goals
  worksheets:
   – What work needs to happen for the patient to leave the ICU?
   – What is the patient's greatest safety risk?
   – What will we do for each organ system or patient problem we
     identify?
   – Key processes for ventilator patients — have they been done?
   – Scheduled labs — have they been obtained/ordered?
   – Catheter — site care, inspection, consideration for removal?
   – Communication/family issues — have we talked to the family
     today?


 http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/IndividualChanges/CreateaDailyGoalsWorksheet.htm
                Morning Briefing
• Purpose: Increase communication between physicians
  and nursing staff while efficiently prioritizing patient care
  delivery and ICU admissions and discharges
• What is it & what is included?
   – A morning briefing is a dialogue between 2 or more
     persons using concise and relevant information to
     promote effective communication prior to rounds
   – What happened overnight that I need to know about?
   – Where should I begin rounds? (patient that requires
     immediate attention based on acuity)
   – Which patients do you believe will be transferring out of
     the unit today?
   – Who has discharge orders written?
                         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.
    Tools and Strategies to Improve
         Safety and Teamwork

•   Daily rounds/goals
•   Pre-procedure briefing
•   Morning briefing
•   Huddles
•   Learn from a defect
        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.
   – Section 1 asks the users to identify what happened
     or the defect they want to investigate
   – Section 2 is a framework provided for the
     investigators to identify any contributing factors.
     These factors include: patient, task, caregiver, and
     team related, training and education, local
     environment, information technology and institutional
     environment.
   – Section 3 asks participants to develop an action
     plan with assigned responsibility for task completion
     and follow up dates for each item.
     Quality is never an accident. It
represents the wise choice of many
      “                alternatives.”


                        Willa Foster
So What Happens When We
 Focus on Work Culture &
     Patient Safety?
"Needs Improvement“ Statewide
  Michigan CUSP ICU Results
                                    100

                                    90
 Less than 60% of respondents       80
                                          84%
 reporting good safety or           70
                                                           82%
 teamwork climate =“needs
 improvement”                       60

 Statewide in 2004 84% needed       50

 improvement, in 2006 41%           40                           47%
 Non-teaching and Faith-based       30
                                                  41%
 ICUs improved the most             20
 Safety Climate item that drives
 improvement:                       10

 “I am encouraged by my              0

 colleagues to report any patient         Safety Climate   Teamwork
 safety concerns I may have”                                Climate

                                                 2004            2006
ICU Teamwork Climate 2004-2008
ICU Safety Climate 2004 - 2008
      Time period   Median CLA-BSI Rate

Baseline                    2.7
Intervention                1.6
0-3 months                  0
4-6 months                  0
7-9 months                  0
10-12 months                0
13-15 months                0
16-18 months                0
                                                                 Teamwork Climate Across Michigan ICUs
                                                    100
% of respondents within an ICU reporting good teamwork climate

                                                                 90
                                                                      The strongest predictor of clinical excellence:
                                                                 80   caregivers feel comfortable speaking up if they
                                                                      perceive a problem with patient care
                                                                 70


                                                                 60


                                                                 50


                                                                 40

                                                                 30


                                                                 20            No BSI = 5 months or more w/ zero
                                                                 10
                                                                       No BSI 21%           No BSI 31%           No BSI 44%
                                                                  0
                   Results
Lives Saved – 1,729*

Patient Days Saved – in excess of 127,000*

Dollars Saved – 0ver $246 Million*

Culture of Safety improved 28%

Teamwork improved 15%


             * Based on the Johns Hopkins Opportunity Calculator
Key Lessons from Keystone

  • Structured yet flexible interventions
  • Convert EB guidelines to measures with face
    validity
  • Package interventions
  • Support /Weekly calls
  • Specific interventions for executives
  • Rigorous DATA collection
In God We
   Trust!
The things included in the measurement
becomes relevant, the things omitted are
        out of sight out of mind
                         Peter F. Drucker
Name of Tool                   Recommended for                           Purpose
Learning from Defects          Requirement for all units                 Set up a local process to
                                                                         learn from and respond to
                                                                         defects locally, within the
                                                                         unit
Daily Goals Checklist          Units in which less than 60% agree with   Improve team
                               the item: “The physicians and nurses here communication regarding
                               work together as a well coordid team.”    patient’s plan of care

Morning Briefing               Units in which more than 20% agree with      Get everyone on the same
                               the item: “In this ICU, it is difficult to   page at the beginning of a
                               speak up if I perceive a problem with the    day or shift, so that
                               care of a patient.”                          expectations are set and
                                                                            the day is more predictable
Observing Rounds               Recommended for all units                    Improving teamwork and
                                                                            communication behaviors
                                                                            across and between
                                                                            disciplines
Shadowing Another Profession   Units in which less than 60% agree with      Identify and improve
                               the item: “Disagreements in this ICU are     communication,
                               resolved appropriately, i.e., not who is     collaboration & teamwork
                               right, but what is best for the patient.”    skills between different
                                                                            practice domains
Culture Debriefing Tool        Requirement for all units                    Provide a structured
                                                                            process to make culture
                                                                            results actionable
Physician Call List            Recommended for all units                    Improve the effectiveness
                                                                            of nurse to physician
                                                                            communication when using
                                                                            the paging system
     What are your next steps?
• Take a defect or safety concern that you
  identified this morning and/or go back to your
  unit and look for one—and apply one of the
  tools we talked about today
     Notes on Hospitals: 1859


“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 Nightingale


    Advocacy = Safety
A Healthcare Imperative

 “In medicine, as in any profession,
   we must grapple with systems,
   resources, circumstances, people-
   and our own shortcomings, as well.
   We face obstacles of seemingly
   endless variety. Yet somehow we
   must advance, we must refine, we
   must improve.”




   Atul Gawande, Better: A Surgeon’s Notes on Performance
Looking Through A Different
           Lens
“Your Future Depends on
Many Things, but Mostly
             Yourself.”

                 Frank Tyger
        Be Courageous

We all are responsible for the safety
of our patients……Own the Issues


  •“If not this, then what??”
  •“If not now, then when?”
  •“If not me, then who??”

    Sit it Out or Dance
“If the matter can be settled by observation, make
the observation yourself. Aristotle could have avoided the
mistake of thinking that women had fewer teeth than men
by the simple device of asking Mrs. Aristotle to keep her
mouth open while he counted. He did not do so because
he thought he knew. Thinking that you know when in
fact you don’t is a fatal mistake, to which we are all
prone.”

                                     Bertrand Russell
                                     Unpopular Essays, 1950
Why Checklists?
  “Levels of cognitive function are often compromised with
   increasing levels of stress and fatigue, as is often the norm in
   certain complex, high-intensity fields of work.
   Aviation, aeronautics, and product manufacturing have come
   to rely heavily on checklists to aid in reducing human error.
   The checklist is an important tool in error management
   across all these fields, contributing significantly to reductions
   in the risk of costly mistakes and improving overall
   outcomes.
   Such benefits also translate to improving the delivery of
   patient care. Despite demonstrated benefits of checklists in
   medicine and critical care, the integration of checklists into
   practice has not been as rapid and widespread as with other
   fields.”
                                           J Crit Care 2003;21:233
Assess Culture of Safety and Teamwork

The culture in this clinical area makes it easy to
learn from the errors of others

1.Strongly agree
2.Agree
3.Disagree
4.Strongly disagree
             It is Time to Change!!

• 44,00 to 98,000 preventable death in hospitals
   Highest medical errors annually (IOM report,
  related to Incidence of Safety Indicators:
  1999) to rescue/ 96.2 per 1000 pts, (death among
    Failure
     surgical inpatients with serious treatable
•   92,888 deaths directly attributable to safety
     complications)
      Pressure ulcer/ 32 billion pts
    indicators, $6.9 per 1000of excess cost
    between 2005-2007 (HealthGrades 2009)
      Post-operative respiratory failure/ 17.2 per 1000pts
•   $50 billion in total costs per 1000 pts.
      Post-operative sepsis/ 14.9
• 5th leading cause of death in US-more than
  AIDS, breast cancer, MVAs
  System Factors Impact Safety

                             Institutional
                              Hospital
               Departmental Factors
               Work Environment
                 Team Factors
         Individual Provider
            Task Factors
Patient Characteristics



                                  Adapted from Vincent BMJ
  No Decision has been made
unless carrying it out in specific
 steps has become someone’s
     work assignment and
         responsibility

                 Peter F. Drucker
                 Management Guru
Assess Culture of Safety and Teamwork

Medical errors are handled appropriately in this unit.

1.Strongly agree
2.Agree
3.Disagree
4.Strongly disagree
From the Staff Answers

 • Create your stories…helps people to
   connect/anchor to the values they already
   hold
 • Learn from the defect
 • Identify vital behavior that have the power to
   change behavior
 • Implement/PDCA or rapid cycle
 • Share your results
 Line Insertion Pre-Procedure Briefing
 •   Make introductions
 •   Discuss patient information and procedure
 •   Agree upon a time for line insertion
 •   Review best practice for line insertion (if necessary)
 •   Nurse defines their role to physician: provide equipment,
     monitor patient, provide patient comfort, observe for
     compliance with best practices and STOP procedure if sterile
     process compromised
     • Establish communication expectation for sterile procedure breaks
     • Examples include: your sleeve has touched the IV pole, the
       guide-wire touched the headboard
 • Identify any special supply or procedural needs
 • Discuss any special patient issues (IE: patient confused,
   patient awake)
 • Answer any additional questions
TIME OUT: RIGHT PATIENT---RIGHT PROCEDURE
Observation – Why?

•   People do not always do what they say they do
•   People do not always do what they think they do
•   People do not always do what you think they do
•   People cannot always tell you what they need
•   Things are not always as they seem …




                                    (adapted from IDEO)

								
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