Transcript La Comunicación y Cómo Trabajar en Equipo

Teamwork and Communication
La Comunicación y Cómo Trabajar en Equipo
James M. Pappas, MD, MBA
Vice President for Quality and Patient Safety
Vice Presidente para Calidad y Seguridad del Paciente
Elderly Male, A Victim of Assault
Sept 23rd
2011 0805 0945
Arrived
LLUMC
25th
1115
Patient Stable,
amb w/ assist
NS
0.5 L
WBC
7.7
1145
1350
NS
0.5 L
NS IV
75/h
Difficulty
breathing
1536
Transfer!
2108
26th
0700
IV
ABX
WBC
15.6
0910
1000
CT
head
NS 1
Liter
Patient not
transferred
REHAB
1015
FM
consult
(done
1125)
RT, nursing, and MD voice
concern…
1007
A complete lack
of team SA
Patient deteriorates
1830
Level 1
Perception
Level 2
Comprehension
Level 3
Projection
27th
1055
29th
Patient
codes
Patient
dies
Teamwork and Communication
La Comunicación y Cómo Trabajar en Equipo
» About 5 years worth of
investigations into adverse
patient outcomes
~ About 80% of adverse
outcomes/near misses
associated with issues of T
and C
~ Many/most of our most
serious outcomes
associated with poor or
nonexistent team situational
awareness (Team SA)
» Aproximadamente 5 años de
investigaciones sobre los
resultados adversos a los
pacientes
~ Aproximadamente el 80%
de resultados adversos
están asociados con
problemas de Comunicación
y Trabajar en Equipo
~ Muchos/la mayoría de
nuestros resultados más
graves asociados con la
concientización situacional
pobre o no existente del
equipo (CS del Equipo)
Agenda
• Introduction
• Background
• The Science of Patient
Harm
• Teamwork and
Communication
– TeamSTEPPS Methodology
– LLUMC examples
• Conclusion
• Introducción
• Trasfondo
• La ciencia de daños al paciente
• La comunicación y cómo trabajar
en equipo
– Metodología del equipo
STEPPS
– Ejemplos del Centro Médico
de la Universidad Loma Linda
• Conclusión
The Seminal Report
El informe Influyente
» Institute of Medicine (IOM) 1999:
~ To Err is Human: Building a
Safer Health System
“Healthcare in the United
States is not as safe as it
should be - or can be. At least
44,000 and perhaps as many as
98,000 people die in hospitals
each year as a result of
medical errors that could have
been prevented…”
» Instituto de Medicina (IOM) 1999:
~ El Errar es Humano: Cómo
Construir un Sistema del
Cuidado de la Salud, más
Seguro
“El cuidado de la salud en los
EEUU no es tan seguro como
debería ser – ni como podría
serlo. Por lo menos 44.000 y
posiblemente hasta 98.000
personas mueren en los
hospitales cada año como
resultado de errores médicos
que podrían haberse
prevenido …”
The Situation: How can this happen?
La Situacón: ¿Cómo puede suceder esto?
Complexity
“American innovation
out-innovated our
underlying
infrastructure.”
Complejidad
“La inovación
norteamericana le ganó a
la infraestructura
subyacente.”
Atul Gawande – The Checklist Manifesto—How to Get Things Right
El Manifiesto de la Lista de Verificación—Cómo Hacer las Cosas Bien
“Medicine has become the art of
managing extreme complexity and a test of whether such
complexity can, in fact, be
humanly mastered.”
“La Medicina es el arte de
administrar suma complejidad –
y una prueba para determinar si
dicha complejidad puede
dominarse humanamente”.
Atul Gawande – The Checklist Manifesto—How to Get Things Right
El Manifiesto de la Lista de Rutina —Cómo Hacer las Cosas Bien



9th edition WHO classification
of diseases lists 13,000
diseases, syndromes and types
of injury
 Science gives us tools to
help on nearly all
 But for each, the steps are
different and not easy
Clinicians have around 6000
drugs and 4000 medical and
surgical procedures
 Each with its own
requirements and risks
It is a lot to get right!!



La 9na edición de la lista WHO para
la clasificación de enfermedades
anota13,000 enfermedades,
síndromes y tipos de lesiones
 La ciencia nos da herramientas
para ayudarnos casi en todas
 Pero para cada, los pasos son
diferentes y no son fáciles
Los clínicos tienen
aproximadamente 6000 drogas y
4000 procedimientos médicos y
quirúrgicos
 Cada uno tiene sus propios
requisitos y riesgos
¡ Es mucho para hacer bien!!
Agenda
• Introduction
• Background
• The Science of Patient
Harm
• Teamwork and
Communication
– TeamSTEPPS Methodology
– LLUMC examples
• Conclusion
• Introducción
• Trasfondo
• La ciencia de daños al
paciente
• La comunicación y cómo
trabajar en equipo
– Metodología del equipo
STEPPS
– Ejemplos del Centro Médico
de la Universidad Loma Linda
• Conclusión
Hazards, Defenses, and Harm
Defense
DANGER
Hazards
Patient
Harm
• Error  Harm
• Harm involves breaching of the barriers and safeguards
Defense in depth
• Error causes harm by putting holes in defense
Defense in Depth…and
Swiss Cheese
HAZARDS
The
ideal
Defense
in depth
The
reality
Potential harm
to patients
• Ideal world: intact defenses
• Real world: weaknesses and gaps
Summary
Defenses
Patient
injury
DANGER
Hazards
Latent
condition
pathway

Unsafe acts
Local workplace factors
Organizational factors
Our biggest ‘hole’ is a latent (blunt end)
defect—teamwork and communication.
“Sharp’ end — active
failures
 Immediate, direct
 At point of care
• ‘Blunt’ end — latent
failures
– Delayed, indirect
– ‘Behind the scenes’
Agenda
• Introduction
• Background
• The Science of Patient
Harm
• Teamwork and
Communication
– TeamSTEPPS
Methodology
– LLUMC examples
• Conclusion
• Introducción
• Trasfondo
• La ciencia de daños al
paciente
• La comunicación y cómo
trabajar en equipo
– Metodología del equipo
STEPPS
– Ejemplos del Centro Médico
de la Universidad Loma
Linda
• Conclusión
TeamSTEPPS
EquipoSTEPPS
»Program developed
by DOD and AHRQ
Designed for hospitals to
address teamwork and
communication

Train the trainer
programs
»Programa desarrollado
por el departamento de
defensa y AHRQ
Diseñado para hospitales para
resolver los problemas de
comunicación y el trabajar en
equipo
Programas
para capacitar a
los capacitadores




First, a team…
Four teachable/
learnable skills
Primero, un
equipo…
Cuatro habilidades
que se pueden
enseñar y aprender
Team Effectiveness
BARRIERS
Inconsistency in Team
Membership
Lack of Time
Lack of Information Sharing
Hierarchy
Defensiveness
Conventional Thinking
Complacency
Varying Communication
Styles
Conflict
Lack of Coordination and
Follow-Up with Co-Workers
Distractions
Fatigue
Workload
Misinterpretation of Cues
Lack of Role Clarity
TOOLS &
STRATEGIES
Brief
Huddle
Debrief
STEP
Cross Monitoring
Feedback
Advocacy and Assertion
Two-Challenge Rule
CUS
DESC Script
Collaboration
SBAR
Call-Out
Read-Back
Handoff
OUTCOMES
Shared Mental Model
Adaptability
Team Orientation
Mutual Trust
Team Performance
Patient Safety!!
TeamSTEPPS
Group
Brief
Short meeting prior to start: essential roles, expectations, anticipate
outcomes and contingencies.
Huddle
Ad hoc planning to reestablish situation awareness; reinforce existing
plans
Debrief
After action review designed to improve team performance.
Person-to-Person
SBAR
Technique for communication of critical information:
Situation Background Assessment and Recommendation
Handoff
The transfer of information (along with authority and responsibility)
during transitions in care.
Read back
Process of employing closed-loop communication to ensure info
conveyed by sender is understood by the receiver;.
Individual
Call out
Strategy used to communicate important information simultaneously
to all team members; helps anticipation.
CUS
I am Concerned; I am Uncomfortable; This is a Safety issue.
Agenda
• Introduction
• Background
• The Science of Patient
Harm
• Teamwork and
Communication
– TeamSTEPPS Methodology
– LLUMC examples
• Conclusion
• Introducción
• Trasfondo
• La ciencia de daños al
paciente
• La comunicación y
cómo trabajar en equipo
– Metodología del equipo
STEPPS
– Ejemplos del Centro Médico
de la Universidad Loma
Linda
• Conclusión
Elderly Male, A Victim of Assault
Sept 23rd
2011 0805 0945
Arrived
LLUMC
25th
1115
Patient Stable,
amb w/ assist
NS
0.5 L
WBC
7.7
1145
1350
NS
0.5 L
NS IV
75/h
Difficulty
breathing
1536
Transfer!
2108
26th
0700
IV
ABX
WBC
15.6
0910
1000
CT
head
NS 1
Liter
Patient not
transferred
REHAB
1015
FM
consult
(done
1125)
RT, nursing, and MD voice
concern…
1007
A complete lack
of team SA
Patient deteriorates
1830
Level 1
Perception
Level 2
Comprehension
Level 3
Projection
27th
1055
29th
Patient
codes
Patient
dies
A Young Man with Trauma
SBAR
Situation
I am calling about Mr. Smith. I am worried about his vital signs.
Background
He was admitted two days ago with chest and abdominal trauma.
Assessment
He is hypotensive and tachycardic. I think he is going into shock.
Recommendation
I need you to come see him NOW. Are you available?
TeamSTEPPS
Group
Brief
Short meeting prior to start: essential roles, expectations, anticipate
outcomes and contingencies.
Huddle
Ad hoc planning to reestablish situation awareness; reinforce existing
plans
Debrief
After action review designed to improve team performance.
Person-to-Person
SBAR
Technique for communication of critical information:
Situation Background Assessment and Recommendation
Handoff
The transfer of information (along with authority and responsibility)
during transitions in care.
Read back
Process of employing closed-loop communication to ensure info
conveyed by sender is understood by the receiver;.
Individual
Call out
Strategy used to communicate important information simultaneously
to all team members; helps anticipation.
CUS
I am Concerned; I am Uncomfortable; This is a Safety issue.
An Elderly Rehab Patient
Day 1
Day 2
2300
0130
Patient stable
(took Tylenol for
pain)
0230
Awake, restless,
diaphoretic, cool
to touch
Asleep, no obvious
problems
0500
0330
0515
Pt transfer to ICU
without orders.
Dr. A1 leaves
0340
Slurred speech,
diaphoretic, unable
to get BP, O2 sat is
86%, RRT called
0515 to 0700
0700
Pt. hypotensive, tachypneic
0400
0430
R1 talks with A1, calls
R2 to take pt.
'Unattached' so needs
call A2. A2 accepts, no
further word
Dr. R1 (primary
service) in. BP
100/55; patient
confused
Presumptive dx of
med oversedation
O2 at 6L/min
RRT arrives
ICU without orders, pages
Dr. A2 x 3, no answer.
Dr. R1 (primary
service) leaves
0355
Dr. A1 finds no BP,
HR 95, pulse
palpable. NS
bolus, EKG & labs
0730
Dr. A2 discuses
with Dr. R3, who
accepts patient
Dr. A3 (rehab)
discusses care of
his pt. with R3
0730
0845
Patient
condition
deteriorates
Patient
pronounced
dead, aspiration
pneumonia
TeamSTEPPS
Group
Brief
Short meeting prior to start: essential roles, expectations, anticipate
outcomes and contingencies.
Huddle
Ad hoc planning to reestablish situation awareness; reinforce existing
plans
Debrief
After action review designed to improve team performance.
Person-to-Person
SBAR
Technique for communication of critical information:
Situation Background Assessment and Recommendation
Handoff
The transfer of information (along with authority and responsibility)
during transitions in care.
Read back
Process of employing closed-loop communication to ensure info
conveyed by sender is understood by the receiver;.
Individual
Call out
Strategy used to communicate important information simultaneously
to all team members; helps anticipation.
CUS
I am Concerned; I am Uncomfortable; This is a Safety issue.
Retained Foreign Object
Objeto Extraño Retenido
»Young female with
parietal-occipital mass
»After difficulty, craniotome
foot plate found broken
»Surgeons thought
instrument handed to
them broken
»Scrub tech did not speak
up
»No mention of incident at
stage four checklist
discussion of case
»Una jovencita con masa
parietal-occipital
»Tras dificultad, se encuentra
un reposapiés craneótomo
quebrado
»Cirujanos piensan que el
instrumento que se les da
está quebrado
»El técnico de quirófano no
dijo nada
»No se mencionó el incidente
en la discusión de la lista
de verificación de la
cuarta etapa sobre el caso
TeamSTEPPS
Group
Brief
Short meeting prior to start: essential roles, expectations, anticipate
outcomes and contingencies.
Huddle
Ad hoc planning to reestablish situation awareness; reinforce existing
plans
Debrief
After action review designed to improve team performance.
Person-to-Person
SBAR
Technique for communication of critical information:
Situation Background Assessment and Recommendation
Handoff
The transfer of information (along with authority and responsibility)
during transitions in care.
Read back
Process of employing closed-loop communication to ensure info
conveyed by sender is understood by the receiver;.
Individual
Call out
Strategy used to communicate important information simultaneously
to all team members; helps anticipation.
CUS
I am Concerned; I am Uncomfortable; This is a Safety issue.
Agenda
• Introduction
• Background
• The Science of Patient
Harm
• Teamwork and
Communication
– TeamSTEPPS Methodology
– LLUMC examples
• Conclusion
• Introducción
• Trasfondo
• La ciencia de daños al
paciente
• La comunicación y cómo
trabajar en equipo
– Metodología del equipo
STEPPS
– Ejemplos del Centro Médico
de la Universidad Loma
Linda
• Conclusión
How do we teach teamwork and
communication?
¿Cómo enseñamos la comunicación y
a trabajar en equipo?
We know what doesn’t work…
Sabemos lo que no funciona …
What works much better…
Lo que funciona mucho mejor . . .
»Expertise is primarily a
function of:
~ relevant practice with
feedback.
»This experience bank can
be built from:
~ Direct experience
~ Vicarious experience (those
described by others)
~ Simulated experience
»La pericia es
principalmente una
función de:
~ Práctica pertinente con
realimentación.
»Este banco de
experiencia se puede
construir de:
~ La experiencia Directa
~ La experiencia Vicaria
(las que describen otros)
~ La experiencia Simulada
Training for Teamwork and Communication
La capacitación para la Comunicación y para Trabajar en Equipo
»Started training T&C about
5 years ago
»Commercial aviation started
30+ years ago…
»It is very difficult to change
personal behavior:
~ Many if not most attendings
won’t know about TS or use it.
~ Some will actually ridicule it.
~ Some will champion it.
»La capacitación de C y T/E
empezó hace como 5 años
»La aviación comercial
empezó hace más de 30
años . . .
»Es muy difícil cambiar la
conducta personal:
~ Muchos, si no la mayoría, de
aquellos que asisten, no
saben de TS o lo usarán.
~ Algunos hasta lo ridiculizarán.
~ Algunos lo fomentarán como
campeones.
Training for Teamwork and Communication
La capacitación para la Comunicación y para Trabajar en Equipo
»Regardless, you need to:
»No importa; ud. necesita :
~ Become aware of the role
of T&C in safe patient care
~ Become a champion for
better communication.
~ Aprender del rol de C & T/E
en cuidado seguro para el
paciente
~ Llegar a ser un campeón
para la mejor
comunicación