Quality Conversations for Staff and Families

1. Quality Conversations for Staff and Families Quality Week at WIH October 23, 2013 Marcia W. VanVleet, MD, MPH

2. or perhaps… Silence Kills

3. Disclosure • I have no financial interest in the material presented. • I am no way an expert when it comes to conversations, but I am open to feedback and commit that I will keep trying. http://www.clipartheaven.com/show/clipart/business_&_office/cartoons_(a_-_c)/crossroads-gif.html

5. Objectives By the end of this presentation the participant will be able to: • Identify examples of conversations that are crucial for patient safety • Explain how medical literacy can effect the quality of our conversations

6. So What Do We See Now? Harm Nationwide…. • 1/20 are given the wrong med • 3.5 million infections from someone who didn’t wash their hands • 195,000 will die from a mistake in a hospital

7. Crossing the Quality Chasm: A New Health System for the 21st Century IOM Report (2001) U.S. health care system does not provide CONSISTENT, high-quality medical care to all people.

8. Communication Model for use with EVERY PERSON, EVERY TIME “AIDET” AAcknowledge everyone in the room I Introduce yourself, your role D Duration – tell how long it will take E Explain the purpose of your visit T Teach back & Thank them for their time

9. What is Quality? IOM’s Definition of Quality “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” http://www.iom.edu/Global/News%20Announcements/Crossing-the-Quality-Chasm-The-IOM-Health-Care-Quality-Initiative.aspx

10. IOM’s 6 Aims…Apply to Conversations As explained by Dr. Donald Berwick … • Safe:be as safe for patients in health care facilities as in their homes; • Effective:science and evidence behind health care should be applied and serve as the standard in the delivery of care; • Efficient:should be cost effective, and waste should be removed from the system; • Timely:no waits or delays in receiving care and service; • Patient centered:revolve around the patient, respect patient preferences, and put the patient in control; • Equitable:Unequal treatment should be a fact of the past; disparities in care should be eradicated. Http://healthmatters4.blogspot.com/2011/06/iom-six-aims-of-quality-health-care.html

11. Joint Commission’s Report(2005) • Pursue Patient Safety Initiatives that Prevent Medical Injury • Promote Open Communication Between Patients and Practitioners • Create an Injury Compensation System that it Patient-Centered and Serves the Common Good http://www.jointcommission.org/assets/1/18/Medical_Liability.pdf

12. “Wall of Silence” “In addition to the fear of litigation, the wall of silence is amplified by the fears of physicians and health care organizations about the loss of reputation, accreditation or licensure, and income. The wall of silence severely undermines efforts to create a culture of safety within health care organizations and across the health care system. Indeed, patients will not be safe until caregivers feel safe to talk about and act on medical error.” http://www.jointcommission.org/assets/1/18/Medical_Liability.pdf

13. “A mistake does not mean a bad practitioner…not correcting a mistake does.”

14. The Silent Treatment study • 6,500 nurses and nurse managers • United States during 2010 • All research participants were • American Association of Critical-Care Nurses (AACN) • Association of periOperative Registered Nurses (AORN) • Two research instruments: • a Story Collector • Traditional Survey by David Maxfield, Joseph Grenny, Ramón Lavandero, and Linda Groah

15. Snap Shot of Study Results

16. The Silent Treatment Results: Examples of Conversations that Are Crucial • Dangerous shortcuts: • Common: • 84 % work with people who take shortcuts • Dangerous: • 26% say these shortcuts have actually harmed patients • Un-discussed: • 31 % have shared with the colleague http://www.silenttreatmentstudy.com/media/

17. The Silent Treatment Results: Examples of Conversations that Are Crucial • Incompetence: • Common: • 82% say colleague is missing basic skills • Dangerous: • 19% say has harmed patients • Un-discussed: • 21% have spoken to the colleague http://www.silenttreatmentstudy.com/media/

18. The Silent Treatment Results: Examples of Conversations that Are Crucial • Disrespect: • Common: • 85% say they work with disrespectful people • Causes Problems: • 46% undercuts respect for professional opinion • 19% makes them unable to get others to listen • 20% considering leaving their job/profession • Un-discussed: • 24% have confronted the colleague http://www.silenttreatmentstudy.com/media/

19. 2 Types of Communication Breakdowns (Chris Argyris) Honest Mistakes • Poor handwriting • Accents • Competing tasks • “Human equivalent of gravity” James Reason Solution: “Undiscussables” • “Knows” strongly or suspects • Calculated decision not to speak up • Undermine the safety tools Solution: • CPOE, • Checklists, • SBAR Hand off protocols CULTURE CHANGE

20. “Knowing is not enough; we must apply. Willing is not enough; we must do.” Johann Wolfgang von Goethe (1749-1832)

21. Crucial Conversations • Definition: • Dialogue: the free flow of meaning between two or more people. • “Pool of shared meaning” Crucial Conversations, 2012.

22. How Do We Know it’s a Crucial Conversation? • Our Physical response • Fright or flight, dry eyes, tight stomach • Our Emotional response • Fear, scared, hurt, angry • Our Behavioral response • “Out of body experience”

24. Outcomes of Crucial Conversations • Good outcomes • Bad outcomes • Silence • Violence

25. “Understand this, my dear brothers and sisters: You must all be quick to listen, slow to speak, and slow to get angry.” ~ James 1:19, NLT

26. Difficult Dialogue

28. How do We Create a Safe Culture? Mutual Purpose Do others believe I care about their goals? Do they trust my motives? Mutual Respect Do others believe I respect them? If safety is lost… Apologize Contrast Create a mutual purpose Crucial Conversations, 2012.

29. A+ Service Recovery… (AcAp)2 or VAFT Acknowledge: Validate after they vent, then summarize (you teach back to them) Apologize…without the but Act: Fix it Appreciate: Thank you

30. Medical/Health Literacy What if we Don’t Speak the Same Language?

31. Issues that Effect Communication • Language • Hearing • Vision • Education • Fear/Anxiety

32. Perspective/Past Experiences

33. Health Literacy • Defined by IOM as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.“ • “Health literacy is not simply the ability to read. It requires a complex group of reading, listening, analytical, and decision-making skills, and the ability to apply these skills to health situations.” http://nnlm.gov/outreach/consumer/hlthlit.html#A1

34. Required Skills (AKA Literacy) • Visually literate (understand graphs or other visual information) • Computer literate (operate a computer) • Information literate (obtain and apply relevant information) • Numerically or computationally literate (calculate or reason numerically) http://nnlm.gov/outreach/consumer/hlthlit.html#A1

35. National Assessment of Adult Literacy (NAAL 2003) • Proficient 12% • Intermediate 52% • Basic 22% • Below Basic 14% • 5% are not literate in English 80 Million Adults http://nnml.gov/outreach/consumer/hlthlit.html

36. Medical Literacy Outcomes • Lower Rates of: • Utilization of preventative care: • flu shots, mammograms • Higher rates of: • Mortality for seniors* • Med errors (take, interpret labels/messages) • Self ratings of “Poor Health” • ER visits and hospitalizations AHRQ Pub No. 11-E006-1, March 2011

37. IOM’s 10 Attributes http://iom.edu/~/media/Files/Perspectives-Files/2012/Discussion-Papers/BPH_Ten_HLit_Attributes.pdf

38. Checklist for Improving the Usability of Health Information • Identify the intended users • Use pre- and post-tests • Limit the number of messages • Use plain language • Practice respect • Focus on behavior • Check for understanding • Supplement with pictures • Use a medically trained interpreter or translator http://www.health.gov/communication/literacy/quickguide/healthinfo.htm

39. An Example from WIH • Series of 3 Patients in a week seen at the WIH Follow-up Clinic • Each with issues related to feeding and the mixing of formula • Started asking patients what they were doing…

40. OLD NEW Directions for Mixing Formula http://www.who.int/foodsafety/publications/micro/pif2007/en/

41. What helped the “Exceptional Conversationalists”? • When issue not urgent, collect the facts/test • Assumed the best, and spoke up • Explained their positive intent, to help caregiver and patient • Took special effort to make it safe for the caregiver (avoid creating defensiveness) • Used facts and data, actual situation • Avoided negative stories or accusations • Diffused or deflected the anger or emotions (keep in check) Crucial Conversations, 2012.

42. Speak UP! Hold Accountable and… Ask for Help. Vital Smarts Webinar, The 4 Culture Viruses in Healthcare, April 24 2013.

43. “Some people make cutting remarks, but the words of the wise bring healing.” ~ Proverbs 12:18, NLT

44. Comments, Suggestions, Questions? mvanvleet@wihri.org Phone: 274-1122 x 47470 Pager: 452-0091