Transcript Document

Creating A Culture Of Safety
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Overview of Advocate Culture of Safety initiative
Everyone must understand
Physicians, as leaders, are key to adoption
Caring for others is our responsibility
Safety is here to stay
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Advocate Case
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20 y/o – anticoagulated after kidney transplant and
Pulmonary Embolus
Has cervical LEEP procedure
Discharged home
Returns with vaginal bleeding
Admitted – transfused 6 units
Physician failed to obtain history or medication history and
failed to do physical exam
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Advocate Event
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20 y/o male status post tracheal repair.
Chin-Chest flap performed to protect surgical site.
Patient combative, intubated, restrained and
sedated.
Neurological assessments deferred post-op.
8 days post op patient found to be quadriplegic
due to hyperflexion c-spine injury
Example of Fatuous behavior
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Objectives
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Share with you what the Safety Initiative is about
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Give you an understanding of why humans
experience errors
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Introduce you to the Behavior-Based Expectations
(BBE) and related error prevention tools
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Why Culture is Important
Culture
The shared values and beliefs
of individuals
in a group or organization
Culture
=
Shared Values
& Beliefs
Shared Values
& Beliefs
Our Behaviors
Our Behaviors
Outcomes
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Creating A Culture Of Safety
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Very hard to change behavior/culture
Need new set of behaviors
Do all your behaviors always result in safe,
reliable, productive outcomes
We are asking a lot
Why did we go into health care?
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Why Error Prevention
“It’s the right thing to do.”
But also …
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44,000 to 98,000 deaths each year
due to medical errors
One Boeing 747 fill with passengers
crashing every 3 days
At our 600 bed hospitals we have
about 40 preventable deaths/year and
at our 300 bed hospitals we have
about 15-20 preventable deaths/year.
Advocate employee injury rate 9/100
employees: Heavy Construction
6.8/100: Nuclear Power 0.5/100
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Six Circles Of Performance Excellence
Safety = No Harm
Quality
Satisfaction
Safety
Time
Cost
Our Challenge
Excellence
Figure out a way to
achieve excellence in
each of the Circles at the
same time, all the time.
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Safety Should NOT Be a Priority...
ISMP Medication Safety Alert, September 23, 2004
…but our core value
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Common Causes Of Past Events Within Advocate
Common causes associated with of our past events
- Lack of critical thinking skills
- Non-Compliance with policy, procedure, or
expectations
- Incomplete communication between care providers
- Inadequate Attention to Detail
- Inadequate knowledge & skills
 Does anything here surprise you
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Prevention Strategy
1. Establish Expectations
Establish behavior-based expectations consistent with the
organization’s mission, goals, and high management
standards for event-free performance
2. Educate - Develop Knowledge & Skills
Educate individuals at all levels of the organization on
behavior-based expectations and error prevention
techniques
3. Manage Accountability for Results
Establish an accountability system to convert behaviors to
work habits
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What Is Accountability?
Accountability is…
 Something everyone has
 Something you want to strive to build and enhance
 About being responsible for your actions, conduct, and
work
 Intrinsic motivation of the individual to meet performance
standards
Except in rare cases where people intentionally
violate a rule, no one will be punished for
innocent errors.
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Making It Stick
Our current event rate, set at 100%
100%
Awareness
Event Rate
Skill Acquisition
80% Decrease
In Event Rate
Over 1-2 Years
Habit Formation
20%
Performance
2 Years
Time
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Physician Behaviors Expected
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Communicate Clearly
- Insure we give and receive accurate and
complete information
- Poor information leads to decision errors, poor
choices and poor handoffs
Commit to safety
- Expected of everyone
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Tools To Achieve BBE’s
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Phonetic and Numeric Clarification
Repeat Backs and Read Backs
Clarifying Questions
SBAR to communicate problems and improve
handoffs
STAR for self checking
Peer Checking, Peer Coaching and ARCC
Q V&V for critical thinking
Red Rules
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Communicate Clearly
Why should we do this?
 To ensure that we hear things correctly and that we
understand things correctly
 To prevent avoid wrong assumptions and
misunderstandings that could cause us to make wrong
decisions
 When you need to communicate about a problem or issue
that needs resolution
When should we do this?
Whenever we communicate information – either in person or
over the phone – that could affect the care and safety of a
patient or an employee
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Physician Behaviors
Value: Communicate Clearly
•Use Phonetic/Numeric Clarification
•Participate in Readbacks and Repeatbacks
•Encourage clarifying questions
•Handoff effectively:
•use SBAR
•Personally communicate in specific
situations
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Communicate Clearly Phonetic/Numeric Clarifications
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“D” as in Dog or David or Darth
No need to spell out entire word phonetically
For sound alike numbers
- “15” that’s one five
- “50” that’s five zero
- “one half” that’s zero point five
When to use them
- Difficult or confusing drug or patient name
- Sound alike medications
- Medication doses
- Critical lab values
- Equipment set points
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Communicate Clearly
Read Back Communication Technique
When information is transferred...
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Sender initiates communication using
Receivers Name. Sender provides an order,
request, or information to Receiver in a clear
& concise format.
Receiver acknowledges receipt by a readback of the order, request, or information after
writing it down
Sender acknowledges the accuracy of the
repeat-back – “That’s Correct”. If not correct,
repeats the communication.
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Read Back/Repeat Back
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Read Back
- Required for orders and critical values reporting
Repeat Back
- OK in emergency situation
Physician Responsibility – listen and use
indicated response
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Communicate Clearly
Clarifying Questions
Ask 1 to 2 clarifying questions
When in high risk situations
When information is incomplete
When information is ambiguous
WHY: To reduce the probability of making a
wrong assumption. Asking clarifying
questions reduces the risk by 2 1/2 times!!
HOW: Phrase your clarifying questions in a positive way and in a
manner that will get an answer that improves your
understanding of the information
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SBAR for Effective Handoffs
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Daily interaction between many different Advocate staff –
physicians, nurses, therapists, non-clinical personnel
Expectation – we will all work together cooperatively
Requires personal commitment
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Advocate Case
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17 y/o with sore throat
Phone order for mono test – MD leaves for weekend –
evaluation not offered
Family call Friday PM for report – denied
Patient goes to weekend sleepover
Punched in stomach
Presents to Peds Mon AM with ruptured spleen in shock
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Advocate Case
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79 y/o in ED with c/o chest pain for 4 days
Chest X-Ray done in ED not read because it was MD shift
change time
Physician left without telling next MD of pending X-Ray
Patient transferred to ICU
X-Ray not read for 48 hours – recquisition lost in radiology
Patient died due to missed pneumothorax
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Care Coordination For Consultation Requests
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Expectation: For all consultations physicians will
request the consultation directly from another
physician – a goal
Hospital will facilitate physician to physician
communication – a goal
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Care Coordination Using Personal Communication
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Physician to care provider
Physician to family
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Care Coordination Using Handoffs
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What is a handoff?
- Transfer of immediate responsibility for a
patient or project which includes but limited to:
* Physician to physician
* Physician to other caregiver
* Caregiver to transportation
* Transportation to technician
* Transportation to caregiver
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Effective Handoffs
Habits For Effective Handoffs
#1
You own it until you hand it off to an
appropriate person
If you accept a handoff for someone else,
#2
you own it until you hand it off to that
someone else
#3
Use 5P approach when a formal (process)
turnover is not provided
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Communicate Clearly
SBAR Briefing Format
When you need to communicate about a problem or
issue that needs resolution…for handoffs
Situation
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Who you’re calling about, the immediate problem, current vital signs,
your concerns
Background
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Review of pertinent information: procedures, mental status, skin
condition, oxygenation
Assessment
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Your view of the situation: “I think the problem is…” or “I’m not sure what
the problem is”
Urgency of action: “the patient is deteriorating rapidly - we need to do
something”
Recommendation
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Your suggestion to or request of the physician
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Communication Review
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S – Situation - Dr Johnson – I appreciate your covering for
me while I am out of town. Let me give you a quick handoff
on Jim Gerkley
B – Background – He is recovering from knee surgery and
is on PCA for pain
A – Assessment – I am concerned he is getting addicted to
his pain medicine. His right ankle is swollen and he will not
put weight on it
R – Recommendation – I want to get him weaned off
Dilaudid and increase his exercise. I have been watching
him for potential atelactasis
Physicians may hear another technique called 5P which is
explained on the following 30
slide but not on the CD
Communicate Clearly
5P’s for an Effective Handoff
Ensure that complete & accurate information is communicated when
responsibility transfers from one person to another
Patient or Project: What is to be handed off
Plan: What is to happen next - the main effort
Purpose of the plan: The desired end state
Problems: What is known to be different, unusual, or
complicating about this patient or project
Precautions: What could be expected to be different,
unusual, or complicating about this patient or project
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Communication Summary
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Situation – Good evening Dr Stevenson. We need your
assistance with Lois Parker who complains of wakefulness
in spite of sleep medications
Background – She is 76 y/o recovering from knee surgery.
She is on sleep medications – 15 mgm of Temazepam.
Vital signs are stable.
Assessment – She is not sleeping
Recommendation – Would you consider increasing
Temazepam to 30 mgm Qhs
Readback occurs
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Communication Summary
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4 Communication techniques reviewed
Phonetic and Numeric clarification
 Read backs and repeat backs
 Clarifying Questions
 SBAR for effective communication of problems and handoffs
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Commit To Safety
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Second Behavioral Expectation
Our patient expect it
Our co-workers expect it
You expect it
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Advocate Case
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Elderly patient with Diabetes and Peripheral Vascular
Disease
Scheduled for toe amputation
Surgical holding – toe bandaged and could not check site
marking
OR finds site not marked
Nurse asked Surgeon to mark site – refused
Nurse asked a second time – refused
Incorrect toe amputated
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Advocate Case
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80 y/o to ED with elevated blood sugar
MD writes order for 7 u insulin
Nurse reads order as 70 units insulin
Pharmacist does not question order – rule to clarify orders
with prohibited abbreviations had been rescinded
Patient given 70 units insulin
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Advocate Case
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34 y/o scheduled for lap/choly
Anesthesiologist failed to check syringe he used to inject a
sedative
Syringe contained neuromuscular blocker – administered
by error
Patient suffers respiratory arrest
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Tools That Demonstrate Our Commitment To Safety
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STAR – a tool for self checking
Peer Checking, Peer Coaching and ARCC
Critical Thinking using Q V&V
Red Rules
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STOP… In The Name Of Safety!!
An airline pilot once told a hospital administrator…
“In healthcare, you rush in all the wrong places.”
Benefits of a 2 second STOP
Gives your brain a chance to catch up with what your
hands are ready to do
Increases the chance that you’ll recognize a high-risk
situation and prevent yourself from practicing a highrisk behavior
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What situations in your job create time pressure that
lead you to RUSH when you really should STOP??
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Self Checking Using STAR
Stop:
Pause for 1 to 2 seconds to focus on
what you’re about to do
Think:
Think about what you’re about to do –
is it the right thing?
Act:
Concentrate and perform the task
Review:
Check to see if the task was done right
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Peer Checking & Peer Coaching
Peer Checking
 Take advantage of working together
 Check others when working together
 Point out problems in a constructive manner
Peer Coaching
 Encourage (or positively reinforce) safe and productive behaviors
 Discourage (or negatively reinforce) unsafe and unproductive behaviors.
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Responding To ARCC
Allows another care provider to express a concern that will
result in review of the situation
Ask a question
Make a Request
Voice a Concern
Safe Word
If not, then use...
Chain of Command
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(Inquire)
(Advocate)
(Assert)
ARCC Example
 RN “excuse me doctor, we are about to start our time out, can
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you join us?” MD “go ahead with the Time Out, I will be there
shortly
RN – Doctor, everyone needs to participate. I need to request
your presence and attention for the time out. It’s a patient safety
requirement and we can’t get started on time until we do it”
MD “OK I’m ready – Gloves and Gown Please
RN “Doctor, I have a concern. We have not done the required
time out and Advocate policies do not allow us to proceed
without a time out. I am afraid I would have to involve my
management to do otherwise
MD “Gotcha, Gotcha thanks, I appreciate your keeping me on
track. I’m getting ahead of myself. Let’s do the time out
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Questioning Attitude
QV&V Technique
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A 3-step method for processing raw information
into FACT
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A method for processing confusing or conflicting
rules into rules you can use with CONFIDENCE
Qualify Validate Verify -
the source – is source reliable
Does it make sense to me?
Check it with a second source
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Intelligent Compliance With Expectations
Red Rules
1. Know, comply, and use policies, procedures, and job aids.
2. Know and comply with Red Rules.
3. STOP when unsure and check with
expert source
Do not proceed in the face of uncertainty...
 if there is a question
 if the situation doesn’t match your experience,
training, or expectations
 if the activity can’t be performed as specified
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What Is A Red Rule?
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“Red Rules” indicate the highest priority for exact
compliance with rules - compliance must come before any
other consideration, including revenue and personal desire
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Highest degree of risk to patient safety
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A clear, discrete, decision-based act
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Few in number
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Self-evident
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Important Points About Red Rules
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Purpose is NOT discipline
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Red Rules focus our attention on acts most
critical to patient and employee safety
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Red Rules align our values and beliefs around
these acts and motivate us to make Red Rule
behaviors our consistent work habits
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Advocate Hospital Red Rule
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Perform a Time Out/Patient Safety Check
before operative and other invasive patient
procedures
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Commitment to Safety – Summary
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We expect everyone to Commit to Safety
Tools for Commit to Safety
STAR
 Peer Checking
 Peer Coaching
 Q V&V
 Red Rules
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Advocate Culture Of Safety
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Importance of Culture of Safety within Advocate
Presented 2 Behavior Based Expectations
- We expect everyone to communicate clearly
- We expect everyone to commit to safety
- Presented 8 tools to accomplish these BBE’s
Use of these tools has been proven to save lives
We expect of you as physician leaders
- To learn and use these tools and demonstrate
commitment to these behaviors
- To support and encourage use of these error reduction
tools
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