Transcript 1 Coaching Call 2 P.. - Center for Patient Safety

Welcome to CUSP Communication & Teamwork Tools
Coaching Call 2
The session will begin shortly.
To access the audio for the session,
Dial: 800-977-8002, Participant code 083842#.
The materials for this coaching call can be downloaded from the CUSP
Communication & Teamwork Tools password-protected web page. Directions
for how to access this web page can be found on each of the coaching call
meeting notices (appointments) sent to you.
The phone lines will be open during the presentation. Please keep your phone
on mute unless you are asking a question. If you do not have a mute function
on your phone, you can press *6 to mute your phone (and *6 again to unmute
if you want to ask a question). PLEASE DO NOT PUT YOUR PHONE ON HOLD!!!
If you experience any problems, please call Marilyn Nichols at the MOCPS office
at 573-636-1014, ext 221 or [email protected].
Document 1
CUSP Communication &
Teamwork Tools
Coaching Call 2:
Hardwiring Multidisciplinary Rounds with Daily Goals;
Sample Huddles
July 19, 2011
Pat Posa RN, BSN, MSA
System Performance Improvement Leader
St. Joseph Mercy Health System
Ann Arbor, MI
[email protected]
2
Kimberly O’Brien, MHA
Project Manager
Missouri Center for Patient Safety
Jefferson City, MO
[email protected]
Documents/Resources for this Session
(All can downloaded from the CUSP Communication & Teamwork Tools password-protected
web site. Detailed instructions are located on each of the coaching call meeting
notices/appointments emailed to you by Kimberly O’Brien)
1.
2.
3.
4.
5.
6.
7.
3
This PowerPoint presentation
Monthly Team Leader Checklist
Sample Agenda for July CUSP Team Meeting
SJMHS Huddle Process
Learning from a Defect Tool
Video Samples of MDR and Huddles
An audio file recording of this session will be posted
on the password-protected web page following the
call
CUSP Communication & Teamwork Tools
Project Organization
• Monthly coaching calls will be held every third Tuesday
of the month, from 12-1pm (beginning on 6/21/2011)
• Six coaching calls
• Coaching calls will be recorded
• Facilitated by Pat Posa, RN, BSN, MSA
• Team leaders will be provided agendas and materials
for monthly unit team meetings (can be modified)
• Project deliverables: At end of 6 months, each unit will
have implemented multidisciplinary rounds and/or
huddles, and solved at least one defect
– Submit Case Summary from Learning from a Defect Tool to
MOCPS by November 30, 2011
4
Agenda
• Implementing Multidisciplinary Rounds with Daily
Goals
• Structured Huddles: questions and view samples
• Learn from a defect—status of identifying defect
• Identify next steps
• Answer questions
5
CUSP Communication & Teamwork Tools
Interventions
Multidisciplinary Rounds with Daily Goals
Structured Huddles
6
Multidisciplinary Rounds with Daily Goals –
What is it?
• A strategy to assemble the patient care team members to
review important patient care and safety issues and improve
collaboration on the overall plan of care for the patient
• 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, quality measure compliance, LOS
7
Multidisciplinary 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
• 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 checklist or nursing objective card
8
Spectrum of MDR
• Community hospital with all private practice physicians or
hospitalists
– ICU
– Non-ICU
• University affiliated teaching hospital—ICUs with dedicated
intensivists
Remember purpose of MDR:
A strategy to assemble the patient care team members to review important
patient care and safety issues and improve collaboration on the overall plan
of care for the patient
Improve communication among care team and family members regarding
the patient’s plan of care
9
Multidisciplinary Rounds with Daily Goals
Steps to Implementation
1. Commitment by all that MDR with daily goals is a strategy
that will be implemented to improve communication and
patient outcomes
2. CUSP team takes on initiative—identify if there are any
additional team members needed
3. Evaluate current rounding process
These steps you should have completed !!
4. Identify gaps between current process and what you want it
to look like
5. Define the standard work of rounds, roles and
responsibilities of each member and develop checklist and
goal process
6. Define metrics to evaluate MDR
10
Current State Assessment
What is the state of rounds on your unit? (summarize
the survey results)
– Describe unit structure (i.e. ICU, non-ICU, open unit, closed unit,
intensivist, hospitalist)
– How often are rounds held?
– Who usually attends rounds?
– What are the roles of each member?
– Where do rounds usually take place?
– Is their a defined structure/process for rounds? If so what is it? Or
does it depend on who is running them?
– How have rounds made a difference during the past year in
improving the performance on your unit?
– What is the major barrier for multidisciplinary round
implementation on your unit?
11
Multidisciplinary Rounds with Daily Goals
Steps to Implementation
4. Identify gaps between current process and what you want it
to look like
5. Define the standard work of rounds, roles and
responsibilities of each member and develop checklist and
goal process
6. Define metrics to evaluate MDR
12
Future State
What Multidisciplinary Rounds should
look like?
• Video samples
• Defined and agreed upon purpose and goals
for MDR with Daily Goals
• Consistent time, members, member roles and
structure to rounds
• Defined checklist and daily goal
documentation
13
Standardized Work Paradigm
Old Paradigm - I know you’ll be able to figure it out.
Just get it done the best way you can.
New Paradigm - In order to have consistent results
we must do things the same way every time.
14
Standard Work System
• Standardized Work is a system for achieving a stable
baseline for a process in order to systematically
improve it.
• Standardized Work Systems are the basis for
Continuous Improvement.
“What you permit, you promote”
“We deserve what we tolerate”
15
MDR with DG Action Plan
Task
Obtain executive buy-in
Define members of rounds and their
roles
Define time of day and frequency
Structure of rounds:
•Review of systems (or major issues)
•Define components of checklist
•Time for each patient
Documentation:
•What is documented in medical record
• daily goal—where is it documented?
Define metrics and evaluation process
16
Responsibility
Due Date
Who?
•
•
•
•
•
•
17
Physician
– Team leader: guide rounds, ensure follow defined process, elicit input from all
members, summarizes define daily goal
Resident:
– Present patient in system format
– Place orders in computer during rounds
– Document note in chart
Bedside nurse
– Provide clinical information, current patient status, changes over previous
24hrs, patient or family concerns/issues (if not present on rounds)
Case manager/social work
– Could function as leader if physician not present
– Oversee discussion of discharge planning
– Define patient/family concerns/issues
Charge nurse/CNS/CNL
– Function in leader role if designated and physician not present
Others
– Pharmacist, respiratory therapy, PT/OT, pastoral care, palliative care
Structure of MDR
• Time of day
• Frequency
• Process for each patient
– Checklist
• Documenting
– Which pieces of rounds?
– Daily goal
• Define daily goal follow up process
18
Patient Daily Goals Form
(Document 6 of Coaching Call 1 Materials)
19
Daily Goal Sheet
6492-016-W-2s-3 (Rev. 02-07-05
Interdisciplinary Critical Care Plan and Daily Goals – CCU
Relevant System / Discipline
Key: “Yes” = issues identified needing to be addressed (list issues)
(Information in parentheses is the standard patient goal –
check in daily column whether specific need identified)
Date:
Time:
Initials:
Date:
Time:
Initials:
Date:
Time:
“No” = no issues identified
Initials:
Date:
Time:
Initials:
Goal(s)
Patient greatest safety issue
Lab work / tests
Tests / Procedures for today
Admit
Hgb
K+
CPK
Neurologic (alert / oriented w/o
deficit)
 Yes
 No
Cardiovascular
 Yes Rhythm
 No Vasopressors
Antiarrythmic
 Need for anticoagulation
 Yes Rhythm
 No Vasopressors
Antiarrythmic
 Need for anticoagulation
 Yes Rhythm
 No Vasopressors
Antiarrythmic
 Need for anticoagulation
 Yes Rhythm
 No Vasopressors
Antiarrythmic
 Need for anticoagulation
 Yes O2
SpO2
 No  HOB  30O
 Smoking cessation
Vent  Yes  No RSBI
 Daily weaning trial completed
 Sedation vacation MAS score
 Oral care every 2 hours
 Yes O2
SpO2
 No  HOB  30O
 Smoking cessation
Vent  Yes  No RSBI
 Daily weaning trial completed
 Sedation vacation MAS score
 Oral care every 2 hours
 Yes O2
SpO2
 No  HOB  30O
 Smoking cessation
Vent  Yes  No RSBI
 Daily weaning trial completed
 Sedation vacation MAS score
 Oral care every 2 hours
 Yes O2
SpO2
 No  HOB  30O
 Smoking cessation
Vent  Yes  No RSBI
 Daily weaning trial completed
 Sedation vacation MAS score
 Oral care every 2 hours
 Yes Dialysis  Yes  No
 No
Ready to DC urinary catheter
 Yes  No
 Yes  Stress bleeding prophylaxis
 No  Tolerating present nutrition
 Diet
 Tolerating TF
 Goal Rate
 Last BM

 Yes Dialysis  Yes  No
 No
Ready to DC urinary catheter
 Yes  No
 Yes  Stress bleeding prophylaxis
 No  Tolerating present nutrition
 Diet
 Tolerating TF
 Goal Rate
 Last BM

 Yes Dialysis  Yes  No
 No
Ready to DC urinary catheter
 Yes  No
 Yes  Stress bleeding prophylaxis
 No  Tolerating present nutrition
 Diet
 Tolerating TF
 Goal Rate
 Last BM

 Yes Dialysis  Yes  No
 No
Ready to DC urinary catheter
 Yes  No
 Yes  Stress bleeding prophylaxis
 No  Tolerating present nutrition
 Diet
 Tolerating TF
 Goal Rate
 Last BM

 Yes  Insulin gtt
 No  SSI
 Glucose 80 – 110 mg/dL
 Steroids
 
 Yes  Insulin gtt
 No  SSI
 Glucose 80 – 110 mg/dL
 Steroids
 
 Yes  Insulin gtt
 No  SSI
 Glucose 80 – 110 mg/dL
 Steroids
 
 Yes  Insulin gtt
 No  SSI
 Glucose 80 – 110 mg/dL
 Steroids
 
 Yes  Sedation protocol utilized
 No  Treatment
 Yes  Sedation protocol utilized
 No  Treatment
 Yes  Sedation protocol utilized
 No  Treatment
 Yes  Sedation protocol utilized
 No  Treatment
LVEF Measurement:ECHO____________
Coronary Cath ____________
ICD / PPM
Respiratory / vent management
Date Intubated
Date Extubated
Reintubation required
Combivent / Nebs
ARDS: Low TV management
Renal / Fluid Status
Baseline Cr
Output goals
Recognize Daily weight gain / loss
GI / Nutrition
Baseline Prealbumin
Enteral tube feeding protocol
Supplements/speech evaluation
Document malnutrition
Bowel management
Endocrine
Glucose control: Goal 80 – 120, if intubated,
blood sugar every 6 hours. If blood sugar
121 – 149, initiate diabetic management orders.
Hypoglycemia protocol utilized
Pain / Sedation medications
20
Goal to remain calm and pain managed at
acceptable level
Culture
Hct
Cr+
Troponin
 LOC
 Seizure Precautions
HgA1C
Hgb
K+
CPK
 Yes
 No
Culture
Hct
Cr+
Troponin
 LOC
 Seizure Precautions
HgA1C
Hgb
K+
CPK
 Yes
 No
Culture
Hct
Cr+
Troponin
 LOC
 Seizure Precautions
HgA1C
Hgb
K+
CPK
 Yes
 No
Culture
Hct
Cr+
Troponin
 LOC
 Seizure Precautions
Daily Goal Sheet (continued)
(Information in parentheses is the standard patient goal –
check in daily column whether specific need identified)
Date:
Activity – Skin – Mobility
 Yes  No  PT consult  ROM
 DVT prophylaxis
 Consult ET RN
 Dressing, wound, incision
 Pressure ulcer prevention standard
 Impaired skin management standard
 Yes Temp
 No  Readiness to DC
Arterial Line Day #
ER/Elective
Central Line Day #
ER/Elective
Peripheral IV Day #
ER/Elective
 Yes  No  PT consult  ROM
 DVT prophylaxis
 Consult ET RN
 Dressing, wound, incision
 Pressure ulcer prevention standard
 Impaired skin management standard
 Yes Temp
 No  Readiness to DC
Arterial Line Day #
ER/Elective
Central Line Day #
ER/Elective
Peripheral IV Day #
ER/Elective
 Yes  No  PT consult  ROM
 DVT prophylaxis
 Consult ET RN
 Dressing, wound, incision
 Pressure ulcer prevention standard
 Impaired skin management standard
 Yes Temp
 No  Readiness to DC
Arterial Line Day #
ER/Elective
Central Line Day #
ER/Elective
Peripheral IV Day #
ER/Elective
 Yes  No  PT consult  ROM
 DVT prophylaxis
 Consult ET RN
 Dressing, wound, incision
 Pressure ulcer prevention standard
 Impaired skin management standard
 Yes Temp
 No  Readiness to DC
Arterial Line Day #
ER/Elective
Central Line Day #
ER/Elective
Peripheral IV Day #
ER/Elective
Safety / Restraints
 Yes
 No
 Assess need every 2 hours
 Order obtained
 Yes
 No
 Assess need every 2 hours
 Order obtained
 Yes
 No
 Assess need every 2 hours
 Order obtained
 Yes
 No
 Assess need every 2 hours
 Order obtained
Family – Psychosocial – Spiritual
 Yes Code Status
 No
 Family Conf. (LOS>3 Days)
Plan of care reviewed with pt/family
 Yes  No
 Financial Services Consult
 Social Services Consult
 Yes Code Status
 No
 Family Conf. (LOS>3 Days)
Plan of care reviewed with pt/family
 Yes  No
 Financial Services Consult
 Social Services Consult
 Yes Code Status
 No
 Family Conf. (LOS>3 Days)
Plan of care reviewed with pt/family
 Yes  No
 Financial Services Consult
 Social Services Consult
 Yes Code Status
 No
 Family Conf. (LOS>3 Days)
Plan of care reviewed with pt/family
 Yes  No
 Financial Services Consult
 Social Services Consult
 Yes
 No
Ready to discharge from CCU?
 Yes  No
ECF Planning  Yes  No
 Social Services Consult
 Yes
 No
Ready to discharge from CCU?
 Yes  No
ECF Planning  Yes  No
 Social Services Consult
 Yes
 No
Ready to discharge from CCU?
 Yes  No
ECF Planning  Yes  No
 Social Services Consult
 Yes
 No
Ready to discharge from CCU?
 Yes  No
ECF Planning  Yes  No
 Social Services Consult
 Yes
 No
Can any be discontinued?
IV to PO
 Yes
 No
Can any be discontinued?
IV to PO
 Yes
 No
Can any be discontinued?
IV to PO
 Yes
 No
Can any be discontinued?
IV to PO




ACE for EF < 40%
 Yes Plavix
 No
Aspirin
Beta Blocker
ACE / ARB
Lipid lower
 Yes ACE
 No ARB
 Yes Plavix
 No
Aspirin
Beta Blocker
ACE / ARB
Lipid lower
 Yes ACE
 No ARB
 Yes Plavix
 No
Aspirin
Beta Blocker
ACE / ARB
Lipid lower
 Yes ACE
 No ARB
 Yes Plavix
 No
Aspirin
Beta Blocker
ACE / ARB
Lipid lower
 Yes ACE
 No ARB
RN Signature
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Intensivist Signature
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
(Adequate activity progression, no skin
breakdown)
“If Braden < 18 at risk for skin breakdown”
VAD
(No ethical concerns, e.g., end of life issues,
financial issues)
Spokesperson
 DPOA
 Living Will
Discharge / Transfer Plans
Long term discharge goal
Medication Review (no concerns re: IV
to PO, home med, renal adjustments, sedation
requirements, new allergies, adverse reaction,
unnecessary medications)
Other patient specific issues /
Other needed consults
AMI / ACS Indicators
Cardiac Cath
ACE for EF < 40%
CHF Indicators
Initials:
 Physician  PCM
 RN
 Pharmacy  RT
 SS
 PT
 Dietary
 Chaplain
 Palliative Care  Other
21
Date:
Initials:
 Physician  PCM
 RN
 Pharmacy  RT
 SS
 PT
 Dietary
 Chaplain
 Palliative Care
 Other
Date:
Initials:
 Physician  PCM
 RN
 Pharmacy  RT
 SS
 PT
 Dietary
 Chaplain
 Palliative Care  Other
Date:
Initials:
 Physician  PCM
 RN
 Pharmacy  RT
 SS
 PT
 Dietary
 Chaplain
 Palliative Care  Other
Nursing Card
(see Document 7 of the Coaching Call 1 materials – SJMHS Interdisciplinary Rounds
Checklist)
VAP
Delirium
Sepsis
22
Video Example:
MDR with Daily Goals at Kaiser Permanente
(on YouTube)
• http://www.youtube.com/watch?v=PKN8a8bL
rSI&feature=email
• Remember . . . This is an example of MDR with
DG with a physician present during rounding.
There are also models of effective rounding
without a physician present, as discussed in
Coaching Call 1
23
Structured 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
24
Huddles
• View sample videos
• What questions do you have?
25
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
26
SICU Huddle Board
27
General Surgery Huddle Board
28
MICU Huddle Board
29
MICU Huddle Board Location
30
Example Videos: Structured Huddles
(all videos are also located on the password-protected web page for this project)
Download Viewing Option
YouTube Viewing Option
(the download/buffering time is lengthy – approx 5-7 minutes)
•
•
•
31
Video Example of Structured Huddles
– Non ICU:
http://www.mocps.org/wpcontent/uploads/2011/07/Huddle%2
0on%208.wmv
Video Example 1 of Structured
Huddles – ICU:
http://www.mocps.org/wpcontent/uploads/2011/07/Huddle%2
0on%20SICU.wmv
Video Example 2 of Structured
Huddles – ICU:
http://www.mocps.org/wpcontent/uploads/2011/07/Huddlevid
eo.mp4
•
Video Example of Structured Huddles
– Non ICU:
http://www.youtube.com/watch?v=6
0Ru5eDWleo
•
Video Example 1 of Structured
Huddles – ICU:
http://www.youtube.com/watch?v=3
lnS5QAAf6M
•
Video Example 2 of Structured
Huddles – ICU:
http://www.youtube.com/watch?v=B
ZE3HI7X_34
Structured Huddles Action Plan
Task
Obtain executive buy-in
Order Huddle board
Select Huddle metrics for first board:
operational, quality/safety and patient
satisfaction
Define huddle process:
•Define time of day and frequency
•Who will lead huddle
•Expectations of staff—who will attend
•Create agenda (in first huddles include
overview of purpose of huddles and huddle
process)
Hang huddle board and fill in metrics
Identify when huddles will begin
Define process for changing huddle metrics
Create evaluation process: how will I know
if huddles are successful?
32
Responsibility
Due Date
Identifying a Defect
 AHRQ HSOPS results
 Staff safety assessment—how will the next patient be
harmed?
 Non-compliance with a core measure
 Event/incident reports
 Issues identified on Executive patient safety rounds
Have you identified a defect? If not, where are you
stuck?
33
33
Learning from Defects Tool
34
CUSP Communication & Teamwork Tools
Next Steps
• Multidisciplinary Rounds
– Ask CUSP team to view sample videos
– Complete action plan (slide 16)
• Learning from a Defect
– Identify next defect to solve (if haven’t done it yet)
– Begin/complete through LFD steps
• Structured Huddles
– Show sample videos to unit leadership and CUSP team, gather questions
– Complete action plan (slide 27)
• CUSP Team Agenda (see Document 3 of Coaching Call Materials)
–
–
–
–
35
Choose next defect to take through the Learning from a Defect Tool or begin LFD process
Show videos of MDR to CUSP team; Complete MDR with DG action plan
Show videos of structured huddles; Complete Structured Huddles action plan
Ensure that concepts of Multidisciplinary Rounds and Structured Huddles are vetted by
executive sponsor for unit and VPMA/CMO
We Are On a Continuous Journey
• We have toolkits, manuals, websites, and monthly calls to
learn from and with each other.
• Your job is to join the calls, share with us your successes
and more importantly the barriers you face.
• Commit to the premise that harm is untenable.
36
Questions?
37