The Path to Safe & Reliable Healthcare Michael Leonard, MD

Profile of Market Leaders Superior safety / quality and operational efficiency is their non-negotiable core value Transparency of clinical data and process Leadership engagement and accountability - senior and clinical, just culture Learning organization - systematic flow of information and intervention Culture / risk maps, direct observation Cultural work - teamwork & communication, environment of respect Reliable /resilient processes - robust process improvement Measurement and feedback - put it on the wall

Superior safety / quality and operational efficiency is their non-negotiable core value

Transparency of clinical data and process

Leadership engagement and accountability - senior and clinical, just culture

Learning organization - systematic flow of information and intervention

Culture / risk maps, direct observation

Cultural work - teamwork & communication, environment of respect

Reliable /resilient processes - robust process improvement

Measurement and feedback - put it on the wall

Team Practice Key Components © 2008 Pascal Metrics LEADERS Leader Attributes Respect is expected Non-negotiable & mutual Psychological safety is assured Everyone is fallible All concerns are important Excellence is expected Determination to fulfill goals Choose team members Knowledge Clinical Improvement Skills Attitudes Behaviors TEAMS Team-member Behaviors The game plan is always known Brief and re-brief Communication is clear Closed loop SBAR — structured communication Learning is continuous Debriefings UNITS Improvement (Improving Improving) Testing is continuous Rapid cycle improvement Lean Six sigma Reliable design Unit structure and resources support performance improvement Conflicts are resolved Critical Language Crucial Conversation Situational awareness is maintained

Respect is expected

Non-negotiable & mutual

Psychological safety is assured

Everyone is fallible

All concerns are important

Excellence is expected

Determination to fulfill goals

Choose team members

Knowledge

Clinical

Improvement

Skills

Attitudes

Behaviors

The game plan is always known

Brief and re-brief

Communication is clear

Closed loop

SBAR — structured communication

Learning is continuous

Debriefings

Testing is continuous

Rapid cycle improvement

Lean

Six sigma

Reliable design

Unit structure and resources support performance improvement

Conflicts are resolved

Critical Language

Crucial Conversation

Situational awareness is maintained

Leading With Safety - Thomas Krause Why do some organizations do well with safety initiatives while others do poorly or fail? The most important factor in predicting success was the quality of leadership and the organizational culture Organizations highly successful in safety were also generally successful in operational performance © 2008 Pascal Metrics

Why do some organizations do well with safety initiatives while others do poorly or fail?

The most important factor in predicting success was the quality of leadership and the organizational culture

Organizations highly successful in safety were also generally successful in operational performance

Attributes of the Right Stuff Behaviors – particularly leadership Engagement at all levels of the organization Understand crucial aspects of human performance To continuously improve performance and achieve superior results the organizational culture must change – meaning behavioral change They address and align the behaviors of everyone © 2008 Pascal Metrics Krause – Leading with Safety 2005

Behaviors – particularly leadership

Engagement at all levels of the organization

Understand crucial aspects of human performance

To continuously improve performance and achieve superior results the organizational culture must change – meaning behavioral change

They address and align the behaviors of everyone

Safety Attitudes Questionnaire: Items Are Grouped Into Six Factors © 2008 Pascal Metrics Factor: Definition Example Items Job Satisfaction: Positivity about the work experience I like my job This hospital is a good place to work Teamwork Climate: Perceived quality of collaboration between personnel Disagreements in this clinical area are appropriately resolved (i.e., what is best for the patient) Our doctors and nurses work together as a well coordinated team Safety Climate: Perceptions of a strong and proactive organizational commitment to safety I would feel safe being treated in this clinical area Medical errors are handled appropriately in this clinical area Perceptions of Management: Approval of managerial action Hospital management supports my daily efforts in this clinical area Hospital management does not knowingly compromise the safety of patients Stress Recognition: Acknowledgement of how performance is influenced by stressors I am less effective at work when fatigued When my workload becomes excessive, my performance is impaired Working Conditions: Perceived quality of the work environment and logistical support (staffing, training, etc.) Trainees in my discipline are adequately supervised This hospital deals constructively with problem personnel

% of respondents reporting above adequate teamwork Teamwork in the eye of the beholder: ICU RNs and ICU MDs rate each other 62 Michigan ICUs 2004 Only ICUs with 5 or more physicians reported here (all had 5 or more RNs)

Teamwork Climate Across Michigan ICUs © 2008 Pascal Metrics The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care No BSI = 5 months or more w/ zero

Teamwork Climate Across Occupations © 2008 Pascal Metrics

“ The physicians and nurses here work together as a well-coordinated team.” © 2008 Pascal Metrics

“ In this clinical area, it is difficult to speak up if I perceive a problem with patient care.” © 2008 Pascal Metrics

“ Disagreements in this clinical area are resolved appropriately (i.e. Not who is right, but what is best for the patient).” © 2008 Pascal Metrics

“ Nurse input is well received in this clinical area.” © 2008 Pascal Metrics

Labor and Delivery Collaboration Map ⓒ 2008 Lotus Forum Inc. ⓒ 2008 Lotus Forum Inc. Table 1: Labor and Delivery Respondent Demographics a LVN/OB is licensed vocational nurse/obstetrical technician Job Position Response Rate (Returned/Admin) Age Mean Years (± SD) Obstetrician 67% (494/739) 45 (9.91) Anesthesiologist 54% (213/401) 44 (7.83) Registered Nurse 77% (1877/2442) 42 (10.71) LVN/OB a 81% (227/280) 42 (10.95) Nurse Manager & Charge Nurse 79% (136/172) 46 (7.56) OBSTETRICIANS ANESTHESIOLOGISTS NURSE MANAGERS/ CHARGE NURSES REGISTERED NURSES LVN/OB TECHNICIANS

Within Hosp #22, which units are the most/least culturally positive?

Radar Diagram

HUMAN FACTORS: Performance in a Complex Environment

Inherent Human Limitations Limited memory capacity – 5-7 pieces of information in short term memory Negative effects of stress – error rates Tunnel vision Negative influence of fatigue and other physiological factors Limited ability to multitask – cell phones and driving

Limited memory capacity – 5-7 pieces of information in short term memory

Negative effects of stress – error rates

Tunnel vision

Negative influence of fatigue and other physiological factors

Limited ability to multitask – cell phones and driving

© 2008 Pascal Metrics

Structuring the Nursing Work Big picture or task performance? Tucker & Spear: med-surg observation, at least 100 discrete tasks per 8 hour shift: Average 3 minutes / task No ability to sequence – juggling, prioritizing tasks Formally interrupted at least once / hour Tucker AL, Spear SJ, HSR, June 2006

Big picture or task performance?

Tucker & Spear: med-surg observation, at least 100 discrete tasks per 8 hour shift:

Average 3 minutes / task

No ability to sequence – juggling, prioritizing tasks

Formally interrupted at least once / hour

Human Factors: The Foundation of Reliability Effective team performance Structured communication Reliable processes Continuous learning and improvement © 2008 Pascal Metrics

Effective team performance

Structured communication

Reliable processes

Continuous learning and improvement

Why Communication? Why Teamwork? The overwhelming majority of untoward events involve communication failure Wrong site surgery — somebody knows there’s a problem but can’t get everyone in the same movie The clinical environment has evolved beyond the limitations of individual human performance © 2008 Pascal Metrics

The overwhelming majority of untoward events involve communication failure

Wrong site surgery — somebody knows there’s a problem but can’t get everyone in the same movie

The clinical environment has evolved beyond the limitations of individual human performance

© 2008 Pascal Metrics ngerman

Christian et al – Patient Safety in the OR “ Problems in communication and information flow, and workload and competing tasks were found to have measurable impact on team performance and patient safety in all 10 cases” Information loss – 19 delays, 30 instances of uncertainty among other providers Circ RN leaves room for something 33 times / case, average of once every 8 minutes Counts – while closing, 14 % of their time counting Surgery 2006, 139: 159-173

“ Problems in communication and information flow, and workload and competing tasks were found to have measurable impact on team performance and patient safety in all 10 cases”

Information loss – 19 delays, 30 instances of uncertainty among other providers

Circ RN leaves room for something 33 times / case, average of once every 8 minutes

Counts – while closing, 14 % of their time counting

Effective Communication and Teamwork Requires: © 2008 Pascal Metrics Structured Communication SBAR Assertion/Critical Language Key words, the ability to speak up and stop the show Psychological Safety An environment of respect Effective Leadership 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 Communication Have a plan The value of a structured process Hand-offs are dangerous Structured language/clarity Who owns the patient? What are the parameters for increasing the intensity of care? © 2008 Pascal Metrics

Have a plan

The value of a structured process

Hand-offs are dangerous

Structured language/clarity

Who owns the patient?

What are the parameters for increasing the intensity of care?

© 2008 Pascal Metrics ob money

Setting the Stage Vascular surgeon doing new, complicated procedure – endovascular aortic stent — in CV lab: “ I don’t have any pride invested here. I just want to get this right, so if you think of anything helpful or see me doing anything wrong, please let me know.” © 2008 Pascal Metrics

Vascular surgeon doing new, complicated procedure – endovascular aortic stent — in CV lab:

“ I don’t have any pride invested here. I just want to get this right, so if you think of anything helpful or see me doing anything wrong, please let me know.”

© 2008 Pascal Metrics

“ I know the names of all the personnel that I worked with during my last shift” © 2008 Pascal Metrics

Briefings Share the game plan Set the stage — psychological safety Norms of conduct Disavow perfection – a little humility goes a long way Engage every participant using eye contact and people’s names Explicitly ask for input about concerns or issues Provide information and talk about next steps Seek useful information Update as needed — build into procedure © 2008 Pascal Metrics

Share the game plan

Set the stage — psychological safety

Norms of conduct

Disavow perfection – a little humility goes a long way

Engage every participant using eye contact and people’s names

Explicitly ask for input about concerns or issues

Provide information and talk about next steps

Seek useful information

Update as needed — build into procedure

© 2008 Pascal Metrics

SBAR Enhances predictability — how we are going to talk with each other Crisp — to the point Promotes critical thinking Similar in structure to the SOAP model (subjective/objective/ assessment/plan) that is taught in nursing and medical schools © 2008 Pascal Metrics

Enhances predictability — how we are going to talk with each other

Crisp — to the point

Promotes critical thinking

Similar in structure to the SOAP model (subjective/objective/ assessment/plan) that is taught in nursing and medical schools

Courtesy Dr. David Morehead

Why is Assertion/Critical Language Important? Because we know 25-40% of nurses tell us on the Safety Attitude Questionnaire they would be hesitant to speak up if they saw an MD making a mistake Often people do not speak up or do so quite indirectly Knowing the plan — using SBAR — makes it much easier to speak up © 2008 Pascal Metrics

Because we know 25-40% of nurses tell us on the Safety Attitude Questionnaire they would be hesitant to speak up if they saw an MD making a mistake

Often people do not speak up or do so quite indirectly

Knowing the plan — using SBAR — makes it much easier to speak up

Assertion Model to guide and improve assertion in the interest of patient safety © 2008 Pascal Metrics GET PERSON’S ATTENTION EXPRESS CONCERN STATE PROBLEM PROPOSE ACTION REACH DECISION

Model to guide and improve assertion in the interest of patient safety

Red Flags: Loss of Situational Awareness Ambiguity Reduced/poor communication Confusion Trying something new under pressure Deviating from established norms Verbal violence Doesn’t feel right Fixation/boredom/task saturation Being rushed/behind schedule © 2008 Pascal Metrics

Ambiguity

Reduced/poor communication

Confusion

Trying something new under pressure

Deviating from established norms

Verbal violence

Doesn’t feel right

Fixation/boredom/task saturation

Being rushed/behind schedule

How do experts and novices make decisions? Experts pattern match against a large mental library of past experience. It is very quick and quite accurate if they continue to seek confirming evidence. Novices cannot do this; their library is empty; they have not seen it before. They use a slow, error-prone process. Experts need to teach the patterns to novices, even if the answers appear overly obvious — that’s how we help them become expert. © 2008 Pascal Metrics

Experts pattern match against a large mental library of past experience. It is very quick and quite accurate if they continue to seek confirming evidence.

Novices cannot do this; their library is empty; they have not seen it before. They use a slow, error-prone process.

Experts need to teach the patterns to novices, even if the answers appear overly obvious — that’s how we help them become expert.

Glitch Book A physical book that is used to document and help track the solution with: Equipment that needs to be fixed or replaced Information that got lost Something that was supposed to happen for the patient and did not © 2008 Pascal Metrics

A physical book that is used to document and help track the solution with:

Equipment that needs to be fixed or replaced

Information that got lost

Something that was supposed to happen for the patient and did not

Debriefing An opportunity for individual, team and organizational learning The more specific, the better What did we do well? What did we learn? What would we do differently next time? Take a minute or two to learn while it is fresh in everyone’s head © 2008 Pascal Metrics

An opportunity for individual, team and organizational learning

The more specific, the better

What did we do well? What did we learn? What would we do differently next time?

Take a minute or two to learn while it is fresh in everyone’s head

Effective Debriefing Be crisp and to the point Do it while the experience is fresh Everyone gets a chance to speak Start with the junior folks — otherwise they can be overshadowed by the veterans Avoid judgment and criticism — this has to be a positive learning experience © 2008 Pascal Metrics

Be crisp and to the point

Do it while the experience is fresh

Everyone gets a chance to speak

Start with the junior folks — otherwise they can be overshadowed by the veterans

Avoid judgment and criticism — this has to be a positive learning experience

ICU Percent of Patients Receiving all Four Aspects Of Ventilator Bundle © 2008 Pascal Metrics Inc. Annotations 1: Marked beds at 30 degree angle 2: Fact Sheet for staff education 3: Poster with weekly data feedback 4: Vent bundle posted in all vent patient rooms 5: Began initial trials of Daily goal sheet and pre-extubation sheet 6: Initiated Powerpoint education for RT/RN 7: Initiated Clinical Pharm rounds 8: 1st test of multidisciplinary rounds 9: Expanded use of Pre-extubation sheet 10: Staff education on Goal sheet; mini inservices on unit on SBT and Pre-extubation sheet 11: Incorporated Goal Sheet into Multidisciplinary Rounds 12: Impact Extravaganza (staff/MD education) 13: Expanded multidisciplinary rounds to include additional disciplines 14: Check compliance on night shift past 2 weeks 15: New sign at HOB, 16: One on one follow up by Nursing & RT managers on collaboratiion in weaning process