Transcript 1-The-Basics-of-CUSP.. - Center for Patient Safety

Document 1
THEBASICS
OF CUSP
Coaching Call 6:
An Introduction to Teamwork & Communication Tools
June 19, 2012
Pat Posa RN, BSN, MSA
System Performance Improvement Leader
St. Joseph Mercy Health System
Ann Arbor, MI
[email protected]
Kimberly O’Brien, MHA
Director, Program Development
Missouri Center for Patient Safety
Jefferson City, MO
[email protected]
Documents for Coaching Call 6
1.
2.
3.
4.
Coaching Call 6 Presentation (this document)
Coaching Call 6 Team Leader Monthly Checklist
Sample Agenda for Team meeting 5 or 6
Article: Impact of a Statewide Intensive Care Unit
Quality Improvement Initiative on Hospital
Mortality and Length of Stay
5. Article: The Effect of Multidisciplinary Care Teams
on Intensive Care Unit Mortality
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Before We Get Started . . . A Brief
Recap of Coaching Call 5 (5/15/2012)
• Step 2 of CUSP: Measure Unit Culture – HSOPS Results
• Step 5 of CUSP: Learn from one Defect per Quarter – Learning
from a Defect Tool & Case Summary Form
• Coaching Call 5 Team Leader Checklist
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Complete action items from Coaching Call 4
Facilitate team meeting 4 or 5
Work through the Learning from a Defect Tool
Begin action planning with HSOPS or other patient safety survey
results
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The “Secret Ingredient”
Comprehensive Unit-Based Patient
Safety Program
1. Form a unit CUSP team with executive
sponsorship
2. Measure unit culture
3. Educate staff on Science of Safety
4. Identify defects using the Staff Safety
Assessment; prioritize defects
5. Learn from one defect per quarter
6. Implement team/communication tools
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Step 6:
Implement
Team/communication tools
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• 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
• 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
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• Structured Communication
• SBAR, structured handoffs
• Assertion/Critical Language
• Key words, the ability to speak
up and stop the show
• Psychological Safety
• 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
• Effective Leadership
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• Daily rounds/goals
• Huddles
• Handoff standardization
• Pre-procedure briefing
• Morning briefing
• Executive Safety Rounds/Partnership
• Learn from a defect
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The Effect of Multidisciplinary Care Teams on
Intensive Care Unit Mortality
Arch Intern Med Feb 22, 2010
• Retrospective cohort study (using state discharge data from
Pennsylvania Health Care Cost Containment Council)
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112 hospitals
Non-cardiac, non-surgical ICUs
30 day mortality
Looked at 3 types of multidisciplinary care models
•multidisciplinary care staffing alone
•intensivist physician staffing alone
•interaction between intensivist physician staffing
and multidisciplinary care teams
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The Effect of Multidisciplinary Care Teams on Intensive Care Unit
Mortality
Arch Intern Med Feb 22, 2010
Association Between Intensivist Physician Staffing and 30-Day Mortality for All Patients
Variable
Model 1: multidisciplinary care staffing alone
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No multidisciplinary care
Multidisciplinary care
OR (95% CI)
P Value
1 [Reference]
0.84 (0.76-0.93)
.001
1 [Reference]
0.84 (0.75-0.94)
.002
1 [Reference]
0.88 (0.79-0.97)
0.78 (0.68-0.89)
.01
.001
Model 2: intensivist physician staffing alone
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Low intensity
High intensity
Model 3: interaction between intensivist physician staffing
and multidisciplinary care teams
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Low intensity+ no multidisciplinary team
Low intensity + multidisciplinary team
High intensity + multidisciplinary care
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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 or discharge
home
• Measure effectiveness of rounds—team dynamics,
communication
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Interdisciplinary rounds with daily goals--Challenges and Opportunities
• Should be done in ICUs and all units in hospital
• Hard initiative to implement, especially if you have an open unit
and/or no intensivists or in non-ICU area
– Standardize the structure and process for all units
– Benefits seen even if physician can not attend consistently or at all
– Second rounds should be done in afternoon—include at least physician and
bedside nurse
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Evaluate if goals for day have been met; readjust if necessary
Identify if patient can be discharged (or transferred ) the next day and if so, what needs to be
accomplished
• Focused first on defining daily goals and recording those either on the
white board in the room or on a sheet of paper
• Then standardize rounds—who should attend and what is discussed
• Implemented nursing objective card—to clearly define role of nurse in
interdisciplinary rounds
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Nursing Card
VAP
Delirium
Sepsis
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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.
Use this strategy to begin to recovery
immediately from defects---IE: falls, sepsis
and daily to focus on unit outcomes
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Components
Metric 1: Quality/Safety
Metric 2: Patient Satisfaction
Metric 3: Operations
Daily Critical Communications
Information
Ideas in Motion
How to do it?
•Beginning or mid shift
•5 minutes
•Lead by member of unit
leadership team
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RN-RN Shift Handoff Checklist
S (Situation)
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Reason for admission
Contact Information
Allergies
Current attending/resident
B (Background)
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Status of advanced directives/ code status
Pertinent medical history
Brief overview of hospital/ICU course
Labs: abnormals this shift and pending or to do next shift
Tests/procedures: current shift and anticipated for next shift
Current Problems: medical and nursing
A (Assessment)
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VS/pain past 24hours/shift
Neuro
CV
Respiratory
GI/GU (include I and O)
Skin
Mobility
Patient safety issues-current and anticipated
Medication concerns and updates
R (Recommendation)
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Pending/anticipated tests and procedures
Other concerns
Current and anticipated family issues
Pending patient/family education needs
Status of current shift goals/problems
Anticipated Goals/problems for next shift
Other TO DOs/ Do you have any questions?
Patient/Nurse introduction
Joint review of lines/drips, neuro check etc.
Pre-procedure briefing
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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
Used this when rolled out CLABSI bundle to non-ICU
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Morning Briefing
• Purpose: Increase communication between physicians and
nursing staff while efficiently prioritizing patient care delivery
and ICU admissions and discharges
• What is it?
– A morning briefing is a dialogue between 2 or more
persons using concise and relevant information to promote
effective communication prior to rounds
Have used this for a long time between charge nurses from shift to shift.
Since we have closed the units, now this also occurs with charge nurse
and intensivist.
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Morning Briefing
• Tool: answer following questions
– 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?
– How many admissions are planned today?
– What time is the first admission?
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Evidence: Over time results indicate
that…
• Safety climate improves overall
• Perceptions of management improve overall
• Magic number for exposure of staff ≥ 60%
having participated in at least one per year
• Nurse managers and charge nurses become
more realistic (their safety climate scores
actually decrease), while physicians, nurses,
RTs, nurses aides, etc, improve.
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90
RNs improve over time, while Nurse Managers/Charge Nurses
recalibrate
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30
20
10
0
Baseline
Post
Respiratory Therapist
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Staff Physician
50
Nrs Mgr/Chrg Nurse
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Adapted from:
Frankel et al. HSR (2008)
PCA/Hosp Aid/Care Partner
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RN
% Reporting Positive Safety Climate
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Safety Climate Scores across
Caregiver Roles Pre-Post EWR
Impact of a statewide intensive care unit quality
improvement initiative on hospital mortality and
length of stay
BMJ, February 2011
Method
• Retrospective comparative analysis
• Study period: October 2001 to December 2006
• Study sample: all hospital admissions with an ICU stay for
adults age 65 or older at hospitals with 50 or more acute care
beds and 200 or more admissions to the ICU during that time
period
• 95 study hospitals in Michigan compared with 364 hospitals in
surrounding Midwest region
• Look at hospital mortality and length of hospital stay
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Impact of a statewide intensive care unit quality
improvement initiative on hospital mortality and
length of stay
BMJ, February 2011
Results: Odds ratio for mortality in Michigan
and comparison hospitals
Study group
Comparison
group
P value
PreImplementation
0.98(0.94 to 1.01)
0.96 (0.95 to 0.98)
0.373
PostImplementation
1-12 months
0.83 (0.79 to 0.87)
0.88 (0.85 to 0.90)
0.041
PostImplementation
13-22 months
0.76 (0.72 to 0.81)
0.84 (0.81 to 0.86)
0.007
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What are your next steps?
Finish Learn from a Defect summary
Create action plan for HSOPS
Chose one teamwork or
communication tool to implement
over next 3 months
Celebrate your successes!!!
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Module 1: The Basics of CUSP
• Session 1:
• Session 2:
• Session 3:
• Session 4:
• Session 5:
• Session 6:
Forming a CUSP team and
Science of Safety Education
Staff Safety Assessment and
Measuring Culture
Learning from a Defect-part 1
Learning from a Defect-part 2
Safety Culture Results and
Action Planning
Teamwork & Communication
Tools
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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 us, then who??”
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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
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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 in his book, Better: A Surgeon’s Notes on Performance
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Questions?
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