Transcript JAX-Oct5-2009-ARS

Myths, Dilemmas,
and Perceptions of
Patient Safety
What Does the AUDIENCE Have
to Say About THAT?
Jacksonville, FL
October 5, 2009
John S. Webster, MD, MBA
Let’s Talk Demographics: I am…
1.
2.
3.
4.
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6.
7.
8.
Nurse
Physician
Other Provider
Technician
Administrator
Senior Leader
Patient
Other
23%
20%
13%
10%
10%
10%
7%
1
2
7%
3
4
5
6
7
8
Key Premise: Four Qualities
• Diversity
• Decentralized
• Needs a way to
summarize
opinions
• People need to be
independent
Evidence-Based Benefits
25 Years Behavioral Research
•
•
•
•
•
•
Reduce clinical errors
Improve patient outcomes
Improve process outcomes
Increase patient satisfaction
Increase staff satisfaction
Reduce malpractice claims
…Ultimately change the
culture
Advancing care and
safety through teamwork
What is the REAL REASON We Resist Moving
Forward (Even) With an Excellent Program ?
What is the REAL REASON We Resist Moving
Forward (Even) With an Excellent Program ?
11% 1.
11% 2.
11% 3.
11% 4.
11% 5.
11% 6.
11% 7.
11% 8.
11% 9.
We are waiting for senior leader commitment
Change is very hard despite best intentions
Physicians remain unconvinced of the merits
Not invented HERE
It is too confusing; not sure what to do
Competing initiatives…can’t do it all
We don’t have TIME
I have NO idea….
OTHER
Here’s What I Observed…..
• Bypass surgery
• Superlative record
• Great outcome
• But nobody
said a word
Introduction
WHO Surgical Checklist
• N= 3733 Pre; 3955 Post
• RESULTS
– Death Rate PRE=
– Death Rate POST=
P=0.003
• RESULTS:
– Complications PRE=
1.5%
0.8%
11%
– Complications POST= 7.0%
P<0.001
JAN 29, 2009 360:491-9
The Main Reason Some People in
Healthcare are SO RESISTENT is…
The Main Reason Some People in
Healthcare are SO RESISTENT is…
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Change is very difficult (personal or professional)
Arrogance / Ego
Lack of specific training and experience
Nobody sets expectations
Lack of a sufficient business case
Lack of accountability
Lack of caring
Lack of TIME
Other
Important Question:
Do we know what we don’t know?
• Human factors
• Medical error
• Structured
communication
• Clinical leadership
• Behavioral literature
• Quality and Safety
• Handoffs***
• Doctor-Patient
Communication
Information I
Don’t Know…
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 CoWorkers
• Distractions
• Fatigue
• Workload
• Misinterpretation of Cues
• Lack of Role Clarity
TOOLS and
STRATEGIES
Brief
Huddle
Debrief
STEP
Cross Monitoring
Feedback
Advocacy and Assertion
Two-Challenge Rule
CUS
DESC Script
Collaboration
SBAR
Call-Out
Check-Back
Handoff
Communication
OUTCOMES
• Shared Mental
Model
• Adaptability
• Team Orientation
• Mutual Trust
• Team
Performance
• Patient Safety!!
Team Success Video
Peri-Operative
E.D.
Peri-Natal
How Would YOU Grade This TEAM?
How Would YOU Grade This TEAM?
20%
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Poor
So-So
Average
Good
Excellent
Consider:
Communication, Working Together,
Leadership, Knowing What’s Going On
Myth #2: We need outside experts to
observe our teams….
• Consistent
observations by
thousands
• Can apply to our
own work areas
• Measurable
• Pertinent
• Motivating
Perceptions: I am “Data-Driven”
(and would not change behavior
without sufficient, quality DATA)
OR Teamwork Climate and Postoperative Sepsis Rates
(per 1000 discharges)
18
16
14
12
Group Mean
AHRQ National Average
10
8
6
Low Teamwork
Climate
Mid Teamwork
Climate
4
High Teamwork
Climate
2
0
Teamwork Climate Based on Safety Attitudes Questionnaire
Low

High
(Sexton, 2006)
Johns Hopkins
Perceptions: I am “Data-Driven”
(and would not change behavior
without sufficient, quality DATA)
Adverse Outcomes
Indemnity Experience
Pre-Teamwork Training
Post-Teamwork Training
25
20
50%
Reduction
20
50%
Reduction
15
11
10
5
0
Malpractice Claims, Suits, and Observations
(Mann, 2006)
Beth Israel Deaconess Medical Center
Contemporary OB/GYN
Data? ……..What About STORIES?
• 18 mo old
• Burns from hot bath
• Good recovery in
hospital
• Near discharge
• Cardiac arrest and
death
– Dehydration (15% bw)
– Methadone
• Failed handoff
http://www.josieking.org/
What MOST Motivates ME to Change is
What MOST Motivates ME to Change is
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Meaningful stories
Directive from senior leaders
My data
Others’ data
Regulators
Payers
Respected colleagues
Nothing (won’t change)
Doing the RIGHT Thing
Other
Key Players and Partnerships
• Executive Sponsor (s)
• Leadership Team
(Guiding Coalition)
• Change Team (unit level)
• Consultant
• Front line providers
– Nurses
-- Physicians
• Physician champion (s)
4/2/2016
Engaging Physicians in
Quality and Safety
Initiatives
Lessons from Implementation and Sustainment of…..
and from the Literature about
Engagement and Resistance
John S. Webster, MD, MBA
Physician Champion
• Clinically respected
• Already exhibits the teamwork
and communication behaviors
(role model)
• Leadership abilities (influence)
• Early adopter
• Willing to devote (some) time
for something they believe in
(passion for patient outcome)
– Doing the “right thing”
• Can create/explain the vision
• Respectful cross-disciplinary
communication
Do We NEED Physician Champions?
Do We NEED Physician Champions?
50%
50%
1. YES
2. NO
Early Postcard Circa 1900
How Should We Create Physician
Champions?
How Should We Create Physician
Champions?
1. Leaders should select
them
2. Nurses should ask,
invite them
3. They should volunteer
4. Peers should identify
them
5. Professional
development path
6. Not sure
7. Some other way….
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Bridging the Gap….
Creating Alignment for Physicians
• Saving time….efficiency
• Appealing to
competitiveness
• Improving patient
outcome
• Personal accountability
• Reliable data (generate
light not heat)
• Appealing to natural
desire to be clinical team
leaders
• Understanding impact on
financial issues
Which NEW SKILLS do we NEED Now
in Healthcare?
Which NEW SKILLS do we NEED Now
in Healthcare?
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Teamwork
Communication
Change management
Clinical leadership
Continuous improvement
Best practices
Coaching
Data and evidence
Engaging patients
All of these?
Transforming Culture with
TeamSTEPPS™
Pre-training
2-3 months later
training sessions
Ongoing coaching, monitor,
reassess, spreads
9-12 months post
38
The Dilemma about Time Line….
• Complexity
• Culture
• Multi-layered
LEADERSHIP
• Sense of Urgency
(Kotter)
• Autonomy
• Hierarchy / Power
How Long Will it Take to IMPLEMENT
Quality & Safety Initiatives, Such As…..
•
•
•
•
TeamSTEPPS
Just Culture
Safety Culture
Stop Disruptive
Behaviors
• True Clinical
Leadership
• Patient Centric Care
How Long Will it Take to IMPLEMENT
Quality & Safety Initiatives, Such As…..
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3-6 months
6-24 months
3-5 years
5-10 years
10-15 years
More than that
Other
•
•
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•
TeamSTEPPS
Just Culture
Safety Culture
Stop Disruptive
Behaviors
• True Clinical
Leadership
• Patient Centric Care
High-Performing Teams
Teams that perform well:
– Hold shared mental models
– Have clear roles and responsibilities
– Have clear, valued, and shared vision
– Optimize resources
– Have strong team leadership
– Engage in a regular discipline of feedback
– Develop a strong sense of collective trust and
confidence
– Create mechanisms to cooperate and coordinate
– Manage and optimize performance outcomes
(Salas et al. 2004)
What is the BEST Way to Create
TEAMS that use These Principles?
What is the BEST Way to Create
TEAMS that use These Principles?
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1. Teach them in medical/nursing school
2. Leadership mandates good
communication and teamwork
3. Undergo cross-disciplinary training
4. Patients choose teams that do this…
5. Clinical leaders role model behaviors
6. Incentivize these behaviors: Rewards
7. We wait for it to just happen
8. Other
Team Structure
Teaming UP: Patients Highly Engaged in Their
Own Quality and Safety
• Educate yourself
• Ask questions
• Manage your
medications and
treatment
• Understand changes in
the plan
• Provide your
perspective
• Focus on quality and
safety
dodpatientsafety.usuhs.mil
Would YOU Use this Guide to Better
Help Patients and Families Engage…?
Would YOU Use this Guide to Better
Help Patients and Families Engage…?
25%
1.
25% 2.
25% 3.
25% 4.
Definitely “YES”
Definitely “NO”
Maybe Give It a TRY….
Other
Leadership
™
Effective Team Leaders
• Organize the team
• Articulate clear goals
• Make decisions through collective
input of members
• Empower members to speak up
and challenge, when appropriate
• Actively promote and facilitate
good teamwork
• Skillful at conflict resolution
What Would it TAKE to Have YOU
Personally Use this “Job Description”
What Would it TAKE to Have YOU
Personally Use this “Job Description”
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I already do
Knowing that it works
Practice with Feedback
Use in a medical SIMULATOR
Being asked
Seeing PEERS successfully
using these tools and
strategies
7. Other
Dilemma: Responsibility and
Accountability
“If we do this team
stuff, WHO is
ACCOUNTABLE?”
THE ANSWER:
We are accountable (as
always) to our
professional expertise
& expectations
AND We are accountable to the TEAM.”
Top Drawer Tools & Strategies
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•
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Planning – Problem solving
– Briefs**
– Huddles**
– Debriefs**
– Handoffs**
Structured communication
– SBAR**
Critical language
– Two challenge rule**
– CUS**
Climate, Culture of Safety
– Advocacy & Assertion
– Question-clarify
Workload management
– Delegation
– Task assistance
– Prioritization
•
•
•
•
Error reduction, mitigation
– Situational Awareness
– Shared Mental Model**
Conflict Resolution
– DESC Script**
Closed-loop Communication
– Call Out
– Check Back**
Continuous improvement
– FEEDBACK
– Debriefs
Myths, Dilemmas,
and Perceptions of
Patient Safety
What DID the AUDIENCE Have
to Say About THAT?
Jacksonville, FL
October 5, 2009
John S. Webster, MD, MBA
TeamSTEPPS™ Evaluation Plan
Kirkpatrick’s Model
Level 5 – Return on Investment
Was the training worth the cost?
Level 4 – Results
Did the change in behavior positively affect the
organization?
Level 3 – Behavior / Training Transfer
Did the participants change their behavior on-the-job based on
what they learned?
Level 2 – Learning
What skills, knowledge, or attitudes changed after training? By how
much?
Level 1 – Reaction
Did the participants like the training?
What do they plan to do with what they learned?
Bottom Line
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MUST engage the physicians…..or fail
Match the approach to the phase
Individualize the message, “the urgency”
Make it personal…yet Benefits for the PATIENTS !
Create opportunity to practice the skills (e.g. briefs)
Clarify the alignment with “what’s in it for me”
Use the energy and influence of the nurses, but
we must have physician champions
• Patients and staff benefit
• Long term commitment….but worth the effort
• ASK them….