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Leonard Plenary ICCH09 PowerPoint


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This plenary took place on Tuesday, October 6, at 8:30 am at the International Conference on Communication in Healthcare (ICCH), in Miami Beach, Florida, USA.

The Path to Safe and Reliable Healthcare
Michael Leonard, MD

Michael Leonard, MD, is the Physician Leader for Patient Safety at Kaiser Permanente, a Principal at Pascal Metrics, and a Faculty member at the Institute for Healthcare Improvement (IHI). An Honors graduate of the University of Missouri School of Medicine, Michael did his postgraduate
training in Internal Medicine and Anesthesiology at Harvard’s Beth Israel Hospital in Boston, with fellowship training in cardiac anesthesia. Michael was a practicing anaesthesiologist for 14 years
with the Colorado Permanente Medical Group, where he was Chief of Anesthesia, Chief of Surgical Services, and Chairman of the Board of Directors. In 1999, he helped Kaiser forge a collaborative relationship with Dr. Robert Helmreich’s Human Factors Research Project to work on the application
of human factors teamwork and communication training in medicine.

For the past several years, he has taught extensively throughout the Kaiser system and outside organizations in high-risk areas such as surgery, obstetrics, critical care and others to enhance safety. His relationships with outside organizations include Duke, Baylor, Sloan Kettering, ICSI, Minnesota Children’s, Ascension, Adventist, VHA, Greater New York Hospital Association and
others. At the IHI, he has been active in several domains, including the Patient Safety Officer Training Course, Transforming Care at the Bedside, the Superior Performance Initiative in the United Kingdom, and Patient Safety Scotland.

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Leonard Plenary ICCH09 PowerPoint

  1. 1. The Path to Safe & Reliable Healthcare Michael Leonard, MD
  2. 2. Profile of Market Leaders <ul><li>Superior safety / quality and operational efficiency is their non-negotiable core value </li></ul><ul><li>Transparency of clinical data and process </li></ul><ul><li>Leadership engagement and accountability - senior and clinical, just culture </li></ul><ul><li>Learning organization - systematic flow of information and intervention </li></ul><ul><li>Culture / risk maps, direct observation </li></ul><ul><li>Cultural work - teamwork & communication, environment of respect </li></ul><ul><li>Reliable /resilient processes - robust process improvement </li></ul><ul><li>Measurement and feedback - put it on the wall </li></ul>
  3. 3. Team Practice Key Components © 2008 Pascal Metrics LEADERS Leader Attributes <ul><li>Respect is expected </li></ul><ul><ul><li>Non-negotiable & mutual </li></ul></ul><ul><li>Psychological safety is assured </li></ul><ul><ul><li>Everyone is fallible </li></ul></ul><ul><ul><li>All concerns are important </li></ul></ul><ul><li>Excellence is expected </li></ul><ul><ul><li>Determination to fulfill goals </li></ul></ul><ul><li>Choose team members </li></ul><ul><ul><li>Knowledge </li></ul></ul><ul><ul><ul><li>Clinical </li></ul></ul></ul><ul><ul><ul><li>Improvement </li></ul></ul></ul><ul><ul><li>Skills </li></ul></ul><ul><ul><li>Attitudes </li></ul></ul><ul><ul><li>Behaviors </li></ul></ul>TEAMS Team-member Behaviors <ul><li>The game plan is always known </li></ul><ul><ul><li>Brief and re-brief </li></ul></ul><ul><li>Communication is clear </li></ul><ul><ul><li>Closed loop </li></ul></ul><ul><ul><li>SBAR — structured communication </li></ul></ul><ul><li>Learning is continuous </li></ul><ul><ul><li>Debriefings </li></ul></ul>UNITS Improvement (Improving Improving) <ul><li>Testing is continuous </li></ul><ul><ul><li>Rapid cycle improvement </li></ul></ul><ul><ul><li>Lean </li></ul></ul><ul><ul><li>Six sigma </li></ul></ul><ul><ul><li>Reliable design </li></ul></ul><ul><li>Unit structure and resources support performance improvement </li></ul><ul><li>Conflicts are resolved </li></ul><ul><ul><li>Critical Language </li></ul></ul><ul><ul><li>Crucial Conversation </li></ul></ul><ul><li>Situational awareness is maintained </li></ul>
  4. 4. Leading With Safety - Thomas Krause <ul><li>Why do some organizations do well with safety initiatives while others do poorly or fail? </li></ul><ul><li>The most important factor in predicting success was the quality of leadership and the organizational culture </li></ul><ul><li>Organizations highly successful in safety were also generally successful in operational performance </li></ul>© 2008 Pascal Metrics
  5. 5. Attributes of the Right Stuff <ul><li>Behaviors – particularly leadership </li></ul><ul><li>Engagement at all levels of the organization </li></ul><ul><li>Understand crucial aspects of human performance </li></ul><ul><li>To continuously improve performance and achieve superior results the organizational culture must change – meaning behavioral change </li></ul><ul><li>They address and align the behaviors of everyone </li></ul>© 2008 Pascal Metrics Krause – Leading with Safety 2005
  6. 6. 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
  7. 7.   % 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)
  8. 8. 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
  9. 9. Teamwork Climate Across Occupations © 2008 Pascal Metrics
  10. 10. “ The physicians and nurses here work together as a well-coordinated team.” © 2008 Pascal Metrics
  11. 11. “ In this clinical area, it is difficult to speak up if I perceive a problem with patient care.” © 2008 Pascal Metrics
  12. 12. “ Disagreements in this clinical area are resolved appropriately (i.e. Not who is right, but what is best for the patient).” © 2008 Pascal Metrics
  13. 13. “ Nurse input is well received in this clinical area.” © 2008 Pascal Metrics
  14. 14. 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
  15. 15. Within Hosp #22, which units are the most/least culturally positive?
  16. 16. Radar Diagram
  17. 17. HUMAN FACTORS: Performance in a Complex Environment
  18. 18. Inherent Human Limitations <ul><li>Limited memory capacity – 5-7 pieces of information in short term memory </li></ul><ul><li>Negative effects of stress – error rates </li></ul><ul><ul><li>Tunnel vision </li></ul></ul><ul><li>Negative influence of fatigue and other physiological factors </li></ul><ul><li>Limited ability to multitask – cell phones and driving </li></ul>
  19. 19. © 2008 Pascal Metrics
  20. 20. Structuring the Nursing Work <ul><li>Big picture or task performance? </li></ul><ul><li>Tucker & Spear: med-surg observation, at least 100 discrete tasks per 8 hour shift: </li></ul><ul><li>Average 3 minutes / task </li></ul><ul><li>No ability to sequence – juggling, prioritizing tasks </li></ul><ul><li>Formally interrupted at least once / hour </li></ul>Tucker AL, Spear SJ, HSR, June 2006
  21. 21. Human Factors: The Foundation of Reliability <ul><li>Effective team performance </li></ul><ul><li>Structured communication </li></ul><ul><li>Reliable processes </li></ul><ul><li>Continuous learning and improvement </li></ul>© 2008 Pascal Metrics
  22. 22. Why Communication? Why Teamwork? <ul><li>The overwhelming majority of untoward events involve communication failure </li></ul><ul><li>Wrong site surgery — somebody knows there’s a problem but can’t get everyone in the same movie </li></ul><ul><li>The clinical environment has evolved beyond the limitations of individual human performance </li></ul>© 2008 Pascal Metrics
  23. 23. © 2008 Pascal Metrics ngerman
  24. 24. Christian et al – Patient Safety in the OR <ul><li>“ 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” </li></ul><ul><li>Information loss – 19 delays, 30 instances of uncertainty among other providers </li></ul><ul><li>Circ RN leaves room for something 33 times / case, average of once every 8 minutes </li></ul><ul><li>Counts – while closing, 14 % of their time counting </li></ul>Surgery 2006, 139: 159-173
  25. 25. 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
  26. 26. Effective Communication <ul><li>Have a plan </li></ul><ul><li>The value of a structured process </li></ul><ul><li>Hand-offs are dangerous </li></ul><ul><li>Structured language/clarity </li></ul><ul><li>Who owns the patient? </li></ul><ul><li>What are the parameters for increasing the intensity of care? </li></ul>© 2008 Pascal Metrics
  27. 27. © 2008 Pascal Metrics ob money
  28. 28. Setting the Stage <ul><li>Vascular surgeon doing new, complicated procedure – endovascular aortic stent — in CV lab: </li></ul><ul><li>“ 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.” </li></ul>© 2008 Pascal Metrics
  29. 29. © 2008 Pascal Metrics
  30. 30. “ I know the names of all the personnel that I worked with during my last shift”   © 2008 Pascal Metrics
  31. 31. Briefings <ul><li>Share the game plan </li></ul><ul><li>Set the stage — psychological safety </li></ul><ul><li>Norms of conduct </li></ul><ul><li>Disavow perfection – a little humility goes a long way </li></ul><ul><li>Engage every participant using eye contact and people’s names </li></ul><ul><li>Explicitly ask for input about concerns or issues </li></ul><ul><li>Provide information and talk about next steps </li></ul><ul><li>Seek useful information </li></ul><ul><li>Update as needed — build into procedure </li></ul>© 2008 Pascal Metrics
  32. 33. © 2008 Pascal Metrics
  33. 34. SBAR <ul><li>Enhances predictability — how we are going to talk with each other </li></ul><ul><li>Crisp — to the point </li></ul><ul><li>Promotes critical thinking </li></ul><ul><li>Similar in structure to the SOAP model (subjective/objective/ assessment/plan) that is taught in nursing and medical schools </li></ul>© 2008 Pascal Metrics
  34. 35. Courtesy Dr. David Morehead
  35. 36. Why is Assertion/Critical Language Important? <ul><li>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 </li></ul><ul><li>Often people do not speak up or do so quite indirectly </li></ul><ul><li>Knowing the plan — using SBAR — makes it much easier to speak up </li></ul>© 2008 Pascal Metrics
  36. 37. Assertion <ul><li>Model to guide and improve assertion in the interest of patient safety </li></ul>© 2008 Pascal Metrics GET PERSON’S ATTENTION EXPRESS CONCERN STATE PROBLEM PROPOSE ACTION REACH DECISION
  37. 41. Red Flags: Loss of Situational Awareness <ul><li>Ambiguity </li></ul><ul><li>Reduced/poor communication </li></ul><ul><li>Confusion </li></ul><ul><li>Trying something new under pressure </li></ul><ul><li>Deviating from established norms </li></ul><ul><li>Verbal violence </li></ul><ul><li>Doesn’t feel right </li></ul><ul><li>Fixation/boredom/task saturation </li></ul><ul><li>Being rushed/behind schedule </li></ul>© 2008 Pascal Metrics
  38. 42. How do experts and novices make decisions? <ul><li>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. </li></ul><ul><li>Novices cannot do this; their library is empty; they have not seen it before. They use a slow, error-prone process. </li></ul><ul><li>Experts need to teach the patterns to novices, even if the answers appear overly obvious — that’s how we help them become expert. </li></ul>© 2008 Pascal Metrics
  39. 43. Glitch Book <ul><li>A physical book that is used to document and help track the solution with: </li></ul><ul><ul><li>Equipment that needs to be fixed or replaced </li></ul></ul><ul><ul><li>Information that got lost </li></ul></ul><ul><ul><li>Something that was supposed to happen for the patient and did not </li></ul></ul>© 2008 Pascal Metrics
  40. 44. Debriefing <ul><li>An opportunity for individual, team and organizational learning </li></ul><ul><li>The more specific, the better </li></ul><ul><li>What did we do well? What did we learn? What would we do differently next time? </li></ul><ul><li>Take a minute or two to learn while it is fresh in everyone’s head </li></ul>© 2008 Pascal Metrics
  41. 45. Effective Debriefing <ul><li>Be crisp and to the point </li></ul><ul><li>Do it while the experience is fresh </li></ul><ul><li>Everyone gets a chance to speak </li></ul><ul><li>Start with the junior folks — otherwise they can be overshadowed by the veterans </li></ul><ul><li>Avoid judgment and criticism — this has to be a positive learning experience </li></ul>© 2008 Pascal Metrics
  42. 46. 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