Transcript Communication

Moving From a Team
of Presentation
Experts to title
an
Expert Team
Highly Reliable Surgical Teams (HRST)
Critical Events Team Training (CETT)
The Challenges of Teamwork:
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Critical Events Team Training:
Rehearsing Emergencies with Simulation
These sessions will be
designed to:
• help staff prepare to deal
with unanticipated
medical events
• develop teamwork and
communication skills
• increase confidence and
improve performance
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Background:
The Patient Safety Movement
IOM Report
( IOM,2000,Thomas and IOM,2000;Center for Disease Control & Prevention,National Center for Health
Statistics)
Errors are a leading cause of death
 44,000-98,000 die each year
Other leading causes of death
 MVA
 Breast CA
 AIDS
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43,458
42,297
15,516
High Reliability Organization
(HRO)
HRO recognize that human beings
performing complex tasks, errors will
occur
Important Question is
 “How will the inevitable errors be detected and
mitigated before they cause harm”
 How are they managed?
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The Reality of Errors
95% of errors are made by capable,
conscientious individuals
70- 80% of medical errors are system and
human factors derived
 Williamson, JA Resuscitation
1994(28):221-225
Bad things can happen to good people!
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Medical Errors: The Human Condition and
Modern Medicine
Human Factors:
 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
Clinical medicine is an extremely complex environment with:
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Surprises & uncertainty
Incomplete information
Interruptions and multitasking
Very sick patients
Rapidly changing technology
What Will Work if it’s not “Trying Harder”?
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Why Is This So Hard ?
The Fallacies We Hold on To
Strong history and culture: we are trained to be perfect
 Being good at what you do is enough to prevent error
 Error=negligence in most people’s minds
Safety is often assumed at the level of expert individuals, not
assured through effective teamwork and communication
Lack of role models that reinforce the truth about human
limitations
Error can be eliminated
 Trying harder will eliminate errors
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Key Principles of Human Factors
Recognizes that a “team of experts” is not the
same as an “expert team”
 Erases the fallacy that being good at what you do
will prevent error
 Performance and outcome is dependent on how the
team functions
 Communication and coordination of teams is the
key feature
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Teamwork
“A group with complementary skills who are
committed to a common purpose and
performance goals, for which they hold
themselves mutually accountable ”
Requires clear exchange of information that results in appropriate
action.
Benefits from well-defined roles and responsibilities.
Doesn’t require that we like each other, does require mutual respect.
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Recipe for Successful High Performing Teams
All members of the team can:
Identify the team leader
Describe both their own and teammates roles
Describe the team’s norms and what is not tolerated
Use communication skills to share, facilitate, voice concern, and create
action
All members of the team feel:
Respected
Supported (have the resources to “get the job done”)
Accountable
Safe in speaking up (i.e., psychological safety)
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Teamwork in Action
High performing teams  Train together
 Provide and welcome feedback
 Measure their performance and strive to improve
 Encourage the continual sharpening of each
individual team member’s skills
 Communicate, Communicate, Communicate
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Psychological Safety
It is critically important that people feel safe
speaking up. Psychological safety has a
profound impact on team performance.
 Does it feel safe to speak up ?
 Will I be treated with respect?
 Will they help fix my problem?
If you don’t get the right answers, then it gets risky.
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Leadership
Effective Leaders:
 Set the stage actively and positively.
 Support an environment of psychological safety.
 Use peoples names.
 Flatten the hierarchy.
 Share the plan.
 Continuously invite the other team members to offer
input and voice concerns.
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“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.”
--Vascular surgeon doing new, complicated procedure
-- endovascular aortic stent – in CV lab
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Common Mental Models
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Situational Awareness & Red Flags
Definitions
 Situational Awareness: A shared understanding of
“what’s going on” and “what is likely to happen
next”
 Red Flag: An indicator of loss / potential loss of
situational awareness. May indicate something is
wrong.
 Potential Solutions:
 Call outs
 Cross checking
 Critical language to “Stop the Line”
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Red Flags
Ambiguity
Fatigue
This isn’t right
Task Saturation
Task Fixation
Poor communications
Trying something new
Handoffs
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Communication
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Communication
Breakdowns in communication may be the single most
important factor to preventing patient injury.
Virtually all instances of unexpected adverse events
involve communication failures.
JCAHO Sentinel Event data - > 2400 severe cases – 75%
mortality – in their analysis communication failures
were the primary root cause in over 70%.
When everyone shares the same mental model, the
chance of unpleasant surprises decreases
dramatically.
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Communication skills that can avoid or
minimize error
Briefing: A conversation and dialogue (two-way) of concise and
relevant information
SBAR: A structured method to communicate important information in
a succinct manner for the purpose of getting action
Assertion: To have individuals speak up, and state their information
with appropriate persistence until there is a clear resolution.
Readbacks: To ensure that verbal instructions between healthcare
professionals were heard and understood correctly
Callouts: The active sharing of information that is known by one
team member for the benefit of other team members
Debriefing: Team-based discussion & review of a shared experience
to learn from
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Briefings
Step Back. Be sure everyone’s “on the same page”.
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What is a Briefing?
Definition

A briefing is a dialogue between two or
more people using concise and relevant
information.
Briefings help us to:

Facilitate clear, effective communication.
 Foster an environment where team
members can and do speak up if they see a
problem.
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Briefings - When to Brief
Start of Shift
Prior to Procedures
On the spot - As need
arises
Handoffs
• Breaks
• Shift Changes
• Across continuum
When new staff arrive to
help
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Briefings – How To Checklist
Get the team’s attention, set a positive tone, introduce
yourself and use people’s names.
Describe the plan, including relevant background
information…and contingencies.
Explicitly ask for input – have a 2-way conversation –
effective leaders continuously invite the other team
members into the conversation.
Encourage ongoing monitoring and cross-checking.
Specifically ask team members to speak up if they have a
question or concern.
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Poor Communication
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SBAR
SBAR provides structure to the communication of
critical information to help ensure it is:
 Action-oriented
 Concise
 Complete
Instances when it might be appropriate to use:
 Conversations with a physician, either in person or over
the phone
 Conversations with peers - Change of shift report
 Escalating a concern
 Discussions with ancillary departments (lab,
pharmacy…
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Situational Brief
S-B-A-R:
Situation (the problem, what is going on)
Background ( pertinent, brief, related to the point)
Assessment (what you found/think is going on)
Recommendation (what you want, request/recommend)
Followed by respectful response, discussion and plan
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Assertion - What is it?
“Individuals speak up, and state
their information with appropriate
persistence until there is a clear
resolution.”
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Assertion - What it’s not
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Why is Assertion So Hard ?
Hierarchy and power distances are inherent in
medicine.
Lack of common mental model – if you don’t
know what the plan, it’s hard to speak up.
No one wants want to look dumb or to announce
they don’t know what’s going on.
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Helpful Hints for the Difficult Conversation
Focus on the common goal: quality care, the welfare of
the patient, safety – it’s hard to disagree with safe, high
quality care
Avoid who’s right / who’s wrong
De-personalize the conversation
Actively avoid being perceived as judgmental
Use SBAR to help effectively communicate the concerns
Be hard on the problem, not the people
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Assertion
Model to guide and
improve assertion in
the interest of
patient safety
ESCALATE (if necessary)
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GET PERSON’S
ATTENTION
REACH
DECISION
2 Challenge
Rule
EXPRESS
PROPOSE
ACTION
CONCERN
STATE
PROBLEM
Readbacks
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Readbacks
• Readbacks are used routinely in other high-reliability
industries.
• Readbacks provide assurance to both the sender and
the receiver of verbal communication that we’ve got
it right.
• Like all redundancies, they should be used
selectively, but rigorously.
• Should be “Write down – Readbacks” unless not
feasible.
• Use key words or phrases such as:
 "Please give me a readback on that", or
 "Can I have a readback“
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Call-Outs
 The active sharing of information that is known by
one team member, for the benefit of other team
members.
 Used routinely in other high-reliability industries,
and less routinely in ours.
 Helps keep team on the same page.
 May be used for information only, soliciting input,
or creating action.
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Call-Outs
May be used:
 To announce key milestones (e.g. “1 mg of Epi is
in”)
 To note an unexpected complication (e.g. “the O2
sat is dropping”)
 To update the team when there is a change in
plans (e.g. “please call the ICU as it looks like we
may need to bring this patient there”)
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Debriefing
An opportunity for individual, team,
and organizational learning
The more specific, the better
The basic questions:
 What did we do well?
 What didn’t work as well?
 What systems problems did we find?
 What teamwork glitches did we find?
 What will we do differently next time ?
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Effective Debriefing
• Do it when the experience is fresh.
• Everyone gets a chance to speak.
• Start with the junior folks – otherwise they can be
overshadowed by the veterans.
• Be crisp and to the point.
• Avoid judgment – this has to be a positive learning
experience.
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Successful teams:
 Have clear roles, goals and objectives
 Communicate well and often
 Respect and listen to each other
 Realize that patients and members are an essential part
of the team and to engage them
 Practice together
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Critical Event Drills
• Drills offer a “safe” learning environment
• Drills safely reveal positive and negative
communication patterns/teamwork
• Drills safely reveal system strength and
weaknesses
• Lifelike in real time
• Normal noise -- confusion -- resources
• Situation must be managed by team exactly as in
real life
• You will be doing your usual job at all times
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What might you see?
Errors and excellence in management
System weaknesses
Good and bad communication
Good and bad teamwork
A free and open learning discussion
No patient at risk
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How To Look Great (and rescue your patients)
Optimum location, people and equipment
Brief the Team
Know the environment, clearly delegate
tasks
Clear Leader- (This may change!)
Regain Situational Awareness
 Chaos is Never OK
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“The Take Home Messages”
•
•
•
•
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You are already a great team
If you practice, you will get better
Debrief your real cases!
Have fun!