Creating A Culture Of Safety

1. Creating A Culture Of Safety • Overview of Advocate Culture of Safety initiative • Everyone must understand • Physicians, as leaders, are key to adoption • Caring for others is our responsibility • Safety is here to stay

2. Advocate Case • 20 y/o – anticoagulated after kidney transplant and Pulmonary Embolus • Has cervical LEEP procedure • Discharged home • Returns with vaginal bleeding • Admitted – transfused 6 units • Physician failed to obtain history or medication history and failed to do physical exam

3. Advocate Event • 20 y/o male status post tracheal repair. • Chin-Chest flap performed to protect surgical site. • Patient combative, intubated, restrained and sedated. • Neurological assessments deferred post-op. • 8 days post op patient found to be quadriplegic due to hyperflexion c-spine injury • Example of Fatuous behavior

4. Objectives • Share with you what the Safety Initiative is about • Give you an understanding of why humans experience errors • Introduce you to the Behavior-Based Expectations (BBE) and related error prevention tools

5. Shared Values & Beliefs Culture = Shared Values & Beliefs Our Behaviors Outcomes Our Behaviors Why Culture is Important Culture The shared values and beliefs of individuals in a group or organization

6. Creating A Culture Of Safety • Very hard to change behavior/culture • Need new set of behaviors • Do all your behaviors always result in safe, reliable, productive outcomes • We are asking a lot • Why did we go into health care?

7. Why Error Prevention “It’s the right thing to do.” But also … • 44,000 to 98,000 deaths each year due to medical errors • One Boeing 747 fill with passengers crashing every 3 days • At our 600 bed hospitals we have about 40 preventable deaths/year and at our 300 bed hospitals we have about 15-20 preventable deaths/year. • Advocate employee injury rate 9/100 employees: Heavy Construction 6.8/100: Nuclear Power 0.5/100

8. Satisfaction Quality Safety Time Cost Excellence Six Circles Of Performance Excellence Safety = No Harm Our Challenge Figure out a way to achieve excellence in each of the Circles at the same time, all the time.

9. ISMP Medication Safety Alert, September 23, 2004 Safety Should NOT Be a Priority... …but our core value

10. Common Causes Of Past Events Within Advocate Common causes associated with of our past events - Lack of critical thinking skills - Non-Compliance with policy, procedure, or expectations - Incomplete communication between care providers - Inadequate Attention to Detail - Inadequate knowledge & skills • Does anything here surprise you

11. Prevention Strategy 1. Establish Expectations Establish behavior-based expectations consistent with the organization’s mission, goals, and high management standards for event-free performance 2. Educate - Develop Knowledge & Skills Educate individuals at all levels of the organization on behavior-based expectations and error prevention techniques 3. Manage Accountability for Results Establish an accountability system to convert behaviors to work habits

12. What Is Accountability? Accountability is… Except in rare cases where people intentionally violate a rule, no one will be punished for innocent errors. • Something everyone has • Something you want to strive to build and enhance • About being responsible for your actions, conduct, and work • Intrinsic motivation of the individual to meet performance standards

13. Our current event rate, set at 100% 100% Awareness Skill Acquisition 80% Decrease In Event Rate Over 1-2 Years Habit Formation Event Rate 20% Performance 2 Years Time Making It Stick

14. Physician Behaviors Expected • Communicate Clearly - Insure we give and receive accurate and complete information - Poor information leads to decision errors, poor choices and poor handoffs • Commit to safety - Expected of everyone

15. Tools To Achieve BBE’s • Phonetic and Numeric Clarification • Repeat Backs and Read Backs • Clarifying Questions • SBAR to communicate problems and improve handoffs • STAR for self checking • Peer Checking, Peer Coaching and ARCC • Q V&V for critical thinking • Red Rules

16. Communicate Clearly Why should we do this? • To ensure that we hear things correctly and that we understandthings correctly • To prevent avoid wrong assumptions and misunderstandings that could cause us to make wrong decisions • When you need to communicate about a problem or issue that needs resolution When should we do this? Whenever we communicate information – either in person or over the phone – that could affect the care and safety of a patient or an employee

17. Physician Behaviors Value: Communicate Clearly • Use Phonetic/Numeric Clarification • Participate in Readbacks and Repeatbacks • Encourage clarifying questions • Handoff effectively: • use SBAR • Personally communicate in specific situations

18. Communicate Clearly Phonetic/Numeric Clarifications • “D” as in Dog or David or Darth • No need to spell out entire word phonetically • For sound alike numbers - “15” that’s one five - “50” that’s five zero - “one half” that’s zero point five • When to use them - Difficult or confusing drug or patient name - Sound alike medications - Medication doses - Critical lab values - Equipment set points

19. Communicate Clearly Read Back Communication Technique When information is transferred... Sender initiates communication using Receivers Name. Sender provides an order, request, or information to Receiver in a clear & concise format. Receiver acknowledges receipt by a read-back of the order, request, or information after writing it down Sender acknowledges the accuracy of the repeat-back – “That’s Correct”. If not correct, repeats the communication. 1 2 3

20. Read Back/Repeat Back • Read Back - Required for orders and critical values reporting • Repeat Back • OK in emergency situation • Physician Responsibility – listen and use indicated response

21. Communicate Clearly Clarifying Questions Ask 1 to 2 clarifying questions When in high risk situations When information is incomplete When information is ambiguous WHY: To reduce the probability of making a wrong assumption. Asking clarifying questions reduces the risk by 2 1/2 times!! HOW: Phrase your clarifying questions in a positive way and in a manner that will get an answer that improves your understanding of the information

22. SBAR for Effective Handoffs • Daily interaction between many different Advocate staff – physicians, nurses, therapists, non-clinical personnel • Expectation – we will all work together cooperatively • Requires personal commitment

23. Advocate Case • 17 y/o with sore throat • Phone order for mono test – MD leaves for weekend – evaluation not offered • Family call Friday PM for report – denied • Patient goes to weekend sleepover • Punched in stomach • Presents to Peds Mon AM with ruptured spleen in shock

24. Advocate Case • 79 y/o in ED with c/o chest pain for 4 days • Chest X-Ray done in ED not read because it was MD shift change time • Physician left without telling next MD of pending X-Ray • Patient transferred to ICU • X-Ray not read for 48 hours – recquisition lost in radiology • Patient died due to missed pneumothorax

25. Care Coordination For Consultation Requests • Expectation: For all consultations physicians will request the consultation directly from another physician – a goal • Hospital will facilitate physician to physician communication – a goal

26. Care Coordination Using Personal Communication • Physician to care provider • Physician to family

27. Care Coordination Using Handoffs • What is a handoff? - Transfer of immediate responsibility for a patient or project which includes but limited to: * Physician to physician * Physician to other caregiver * Caregiver to transportation * Transportation to technician * Transportation to caregiver

28. Effective HandoffsHabits For Effective Handoffs You own it until you hand it off to an appropriate person If you accept a handoff for someone else, you own it until you hand it off to that someone else Use 5P approach when a formal (process) turnover is not provided #1 #2 #3

29. When you need to communicate about a problem or issue that needs resolution…for handoffs Situation Who you’re calling about, the immediate problem, current vital signs, your concerns Background Review of pertinent information: procedures, mental status, skin condition, oxygenation Assessment Your view of the situation: “I think the problem is…” or “I’m not sure what the problem is” Urgency of action: “the patient is deteriorating rapidly - we need to do something” Recommendation Your suggestion to or request of the physician Communicate Clearly SBAR Briefing Format

30. Communication Review • S – Situation - Dr Johnson – I appreciate your covering for me while I am out of town. Let me give you a quick handoff on Jim Gerkley • B – Background – He is recovering from knee surgery and is on PCA for pain • A – Assessment – I am concerned he is getting addicted to his pain medicine. His right ankle is swollen and he will not put weight on it • R – Recommendation – I want to get him weaned off Dilaudid and increase his exercise. I have been watching him for potential atelactasis • Physicians may hear another technique called 5P which is explained on the following slide but not on the CD

31. Communicate Clearly 5P’s for an Effective Handoff Ensure that complete & accurate information is communicated when responsibility transfers from one person to another Patient or Project: What is to be handed off Plan: What is to happen next - the main effort Purpose of the plan: The desired end state Problems: What is knownto be different, unusual, or complicating about this patient or project Precautions: What could be expected to be different, unusual, or complicating about this patient or project

32. Communication Summary • Situation – Good evening Dr Stevenson. We need your assistance with Lois Parker who complains of wakefulness in spite of sleep medications • Background – She is 76 y/o recovering from knee surgery. She is on sleep medications – 15 mgm of Temazepam. Vital signs are stable. • Assessment – She is not sleeping • Recommendation – Would you consider increasing Temazepam to 30 mgm Qhs • Readback occurs

33. Communication Summary • 4 Communication techniques reviewed • Phonetic and Numeric clarification • Read backs and repeat backs • Clarifying Questions • SBAR for effective communication of problems and handoffs

34. Commit To Safety • Second Behavioral Expectation • Our patient expect it • Our co-workers expect it • You expect it

35. Advocate Case • Elderly patient with Diabetes and Peripheral Vascular Disease • Scheduled for toe amputation • Surgical holding – toe bandaged and could not check site marking • OR finds site not marked • Nurse asked Surgeon to mark site – refused • Nurse asked a second time – refused • Incorrect toe amputated

36. Advocate Case • 80 y/o to ED with elevated blood sugar • MD writes order for 7 u insulin • Nurse reads order as 70 units insulin • Pharmacist does not question order – rule to clarify orders with prohibited abbreviations had been rescinded • Patient given 70 units insulin

37. Advocate Case • 34 y/o scheduled for lap/choly • Anesthesiologist failed to check syringe he used to inject a sedative • Syringe contained neuromuscular blocker – administered by error • Patient suffers respiratory arrest

38. Tools That Demonstrate Our Commitment To Safety • STAR – a tool for self checking • Peer Checking, Peer Coaching and ARCC • Critical Thinking using Q V&V • Red Rules

39. STOP… In The Name Of Safety!! An airline pilot once told a hospital administrator… “In healthcare, you rush in all the wrong places.” Benefits of a 2 second STOP • Gives your brain a chance to catch up with what your hands are ready to do • Increases the chance that you’ll recognize a high-risk situation and prevent yourself from practicing a high-risk behavior What situations in your job create time pressure that lead you to RUSH when you really should STOP??

40. Stop: Think: Act: Review: Pause for 1 to 2 seconds to focus on what you’re about to do Think about what you’re about to do – is it the right thing? Concentrate and perform the task Check to see if the task was done right Self Checking Using STAR

41. Peer Checking & Peer Coaching Peer Checking • Take advantage of working together • Check others when working together • Point out problems in a constructive manner Peer Coaching • Encourage (or positively reinforce) safe and productive behaviors • Discourage (or negatively reinforce) unsafe and unproductive behaviors.

42. Ask a question Make a Request Voice a Concern Responding To ARCC Allows another care provider to express a concern that will result in review of the situation (Inquire) (Advocate) (Assert) If not, then use... Safe Word Chain of Command

43. ARCC Example • RN “excuse me doctor, we are about to start our time out, can you join us?” MD “go ahead with the Time Out, I will be there shortly • RN – Doctor, everyone needs to participate. I need to request your presence and attention for the time out. It’s a patient safety requirement and we can’t get started on time until we do it” • MD “OK I’m ready – Gloves and Gown Please • RN “Doctor, I have a concern. We have not done the required time out and Advocate policies do not allow us to proceed without a time out. I am afraid I would have to involve my management to do otherwise • MD “Gotcha, Gotcha thanks, I appreciate your keeping me on track. I’m getting ahead of myself. Let’s do the time out

44. Questioning Attitude QV&V Technique • A 3-step method for processing raw information into FACT Qualify - the source – is source reliable Validate - Does it make sense to me? Verify - Check it with a second source • A method for processing confusing or conflicting rules into rules you can use with CONFIDENCE

45. STOP Intelligent Compliance With Expectations Red Rules • Know, comply, and use policies, procedures, and job aids. • Know and comply with Red Rules. 3. STOP when unsure and check with expert source Do not proceed in the face of uncertainty... • if there is a question • if the situation doesn’t match your experience, training, or expectations • if the activity can’t be performed as specified

46. What Is A Red Rule? • “Red Rules” indicate the highest priority for exact compliance with rules - compliance must come before any other consideration, including revenue and personal desire • Highest degree of risk to patient safety • A clear, discrete, decision-based act • Few in number • Self-evident

47. Important Points About Red Rules • Purpose is NOT discipline • Red Rules focus our attention on acts most critical to patient and employee safety • Red Rules align our values and beliefs around these acts and motivate us to make Red Rule behaviors our consistent work habits

48. Advocate Hospital Red Rule • Perform a Time Out/Patient Safety Check before operative and other invasive patient procedures

49. Commitment to Safety – Summary • We expect everyone to Commit to Safety • Tools for Commit to Safety • STAR • Peer Checking • Peer Coaching • Q V&V • Red Rules

50. Advocate Culture Of Safety • Importance of Culture of Safety within Advocate • Presented 2 Behavior Based Expectations - We expect everyone to communicate clearly - We expect everyone to commit to safety - Presented 8 tools to accomplish these BBE’s • Use of these tools has been proven to save lives • We expect of you as physician leaders - To learn and use these tools and demonstrate commitment to these behaviors - To support and encourage use of these error reduction tools