Transcript CUSP Communication & Teamwork Tools

Welcome to CUSP Communication & Teamwork Tools
Coaching Call 1
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 1: Getting Started
Learning from Another Defect,
Assessing Current Rounding Practices, and
Exploring Structured Huddles
June 21, 2011
Pat Posa RN, BSN, MSA
System Performance Improvement Leader
St. Joseph Mercy Health System
Ann Arbor, MI
[email protected]
Kimberly O’Brien, MHA
Project Manager
Missouri Center for Patient Safety
Jefferson City, MO
[email protected]
Participating Hospitals
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
3
Barnes-Jewish St. Peters Hospital, St. Peters
Capital Region Medical Center, Jefferson City
Community Hospital – Fairfax, Fairfax
Fitzgibbon Hospital, Marshall
Jefferson Regional Medical Center, Festus
Missouri Southern Healthcare, Dexter
Ozarks Medical Center, West Plains
Saint Louis University Hospital, St. Louis
St. Luke’s Hospital, Kansas City
St. John’s Mercy Hospital, Washington
St. Luke’s Rehabilitation Hospital, Chesterfield
St. Mary’s Health Center, Jefferson City
Texas County Memorial Hospital, Houston
Documents 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.
8.
9.
10.
11.
4
This PowerPoint presentation
Monthly Team Leader Checklist
Sample Agenda for June/July CUSP Team Meeting
MDR and Improving Teamwork Article
MDR and ICU Mortality Article
Lakeland Hospital Experience – daily rounds/goals
SJMHS Interdisciplinary Rounds Checklist
Henry Ford Health System Daily Goals Checklist
Improving Communication Using Daily Goals Article
Effective Communication Daily Goals Article
An audio file recording of this session will be emailed to
you shortly after the call today
Agenda
• Describe the project organization and goals of CUSP
Communications & Teamwork Tools
• Brief overview of CUSP
• Review Learn from a Defect
• Overview of Multidisciplinary Rounds with Daily
Goals
• Overview of Structured Huddles
• Identify next steps
• Answer questions
5
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
6
CUSP Communication & Teamwork Tools
Prerequisites & Goals
• Prerequisites
– The Basics of CUSP
– Functioning CUSP team in place
– Executive and physician support
• Goals
– To implement multidisciplinary rounds (with daily goals) in
each participating unit
– To implement structured huddles in each participating unit
– To solve one defect, using the “Learning from a Defect”
methodology (introduced during The Basics of CUSP)
7
Unit-Based Patient Safety Culture
• Patient safety and quality happens at the local
level
• Build capacity at unit level to tackle multiple
problems
• Build capacity at the leadership level to
support unit-based safety culture
• Raise the quality and safety bar on the units
• Surviving the tsunami!
8
Components of CUSP
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
9
How is CUSP different?
• CUSP identifies problem areas –
– what staff think are impeding patient care vs. what
managers/directors think are priority areas
• CUSP improvement tools are designed for bedside
caregivers – easy for busy staff to use
– unit drives its own quality
• Lean/Six Sigma/CQI – focus more on streamlining the
process than identifying the problem areas
• CUSP can complement other quality improvement
methods – must use multiple tools!
10
Learn from a Defect
• Designed to rigorously analyze the various
components and conditions that contributed to an
adverse event and is likely to be successful in the
elimination of future occurrences.
• Tool can serve to organize factors that may have
contributed to the defect and provides a logical
approach to breaking down faulty system issues
11
Learn from a Defect
• Select a specific defect
– What happened?
– Why did it happen (system lenses) ?
– What could you do to reduce risk ?
– How do you know risk was reduced ?
12
Learn from a Defect Tool
Divided into three sections:
• Section 1 asks the users to identify what happened or the
defect they want to investigate
• Section 2 is a framework provided for the investigators to
identify any contributing factors. These factors include:
patient, task, caregiver, and team related, training and
education, local environment, information technology and
institutional environment.
• Section 3 asks participants to develop an action plan with
assigned responsibility for task completion and follow up
dates for each item.
13
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
14
Learning from Defects Tool
15
CUSP Communication & Teamwork Tools
Interventions
Multidisciplinary Rounds with Daily Goals
Structured Huddles
16
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
17
Evidence For Impact Of MDR Rounds
• Research studies on the effect of structured interdisciplinary rounds show:
– Earlier identification of clinical issues
– More timely referrals
– Improved ratings by nurses and physicians on teamwork, communication and
collaboration.
• Research also indicates variable effects on LOS and cost, with some studies
showing improvement and others having no impact.
Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching
unit.
O'Leary KJ, et. al, Journal Of General Internal Medicine [J Gen Intern Med], ISSN: 1525-1497,
2010 Aug; Vol. 25 (8), pp. 826-32; PMID: 20386996
(Document 4 of your materials for this coaching call)
18
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)
•
•
•
•
19
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
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
–
–
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
–
–
Low intensity
High intensity
Model 3: interaction between intensivist physician staffing
and multidisciplinary care teams
–
–
–
20
Low intensity+ no multidisciplinary team
Low intensity + multidisciplinary team
High intensity + multidisciplinary care
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
21
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
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
22
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.
23
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”
24
Current State Assessment
Results of this assessment should be entered into Survey Monkey by July 8th using this URL:
http://www.surveymonkey.com/s/Z3KVYSQ
What is the state of rounds on your unit?
1. Describe the structure of the participating unit(s). For example, the type of unit
(i.e. ICU, Med Surg, Ancillary), whether the unit is open or closed, whether or not
the unit has intensivists or hospitalists, how many beds the unit has, etc.
2. Are rounds currently held on the participating unit(s)?
3. How often are rounds held?
4. Who usually attends rounds?
5. What are the roles of each member?
6. Where do rounds usually take place?
7. Is there a defined structure/process for rounds? If so what is it? Or does it depend
on who is running them?
8. Are daily goals part of the rounding structure/process?
9. How have rounds made a difference during the past year in improving the
performance on your unit?
10. What is the major barrier for multidisciplinary round implementation on your unit?
25
Patient Daily Goals Form
(Document 6 of Coaching Call Materials)
26
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
27
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
28
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 materials – SJMHS Interdisciplinary Rounds Checklist)
VAP
Delirium
Sepsis
29
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
30
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
31
SICU Huddle Board
32
CUSP Communication & Teamwork Tools
Next Steps
• Multidisciplinary Rounds
– Complete Current State Assessment (See Slide 25)
– Submit answers through Survey Monkey: http://www.surveymonkey.com/s/Z3KVYSQ
– Due by Friday, July 8th
• Learning from a Defect
– Identify next defect to solve
– Make any additions/deletions to team membership
• Structured Huddles
– Review the concept with unit leadership and CUSP team, gather questions
– Questions will be answered/discussed during Coaching Call 2 on July 19th
• CUSP Team Agenda (see Document 3 of Coaching Call Materials)
– Choose next defect to take through the Learning from a Defect Tool
– Review multidisicipnary rounds slides; complete current state assessment
– Review structured huddle slides; get feedback/questions from CUSP team and unit
leadership for next Coaching Call
– Ensure that concepts of Multidisciplinary Rounds and Structured Huddles are vetted by
executive sponsor for unit and VPMA/CMO
33
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.
34
Questions?
35