On the CUSP: Stop BSI NICU Project

1. On the CUSP: Stop BSI NICU Project Pat Posa RN, BSN, MSA System Performance Improvement Leader St. Joseph Mercy Health System Ann Arbor, MI patposa@gmail.com Kimberly O’Brien, MHA Director, Program Development Missouri Center for Patient Safety Jefferson City, MO kobrien@mocps.org Coaching Call 4 Teamwork and Communication Tools 5/23/2012

2. Learning Objectives • Discuss Teamwork and Communication Tools to improve safety culture • Discuss “how to” implement Structured Huddles • Team sharing 2

3. CUSP & CLABSI Interventions Adaptive/ Cultural CUSP Educate on the Science of Safety Identify Defects (Staff Safety Assessment) Senior Executive Partnership Learn from Defects Implement Teamwork & Communication Tools Technical CABSI/ NICU Insertion Maintenance • Assessment & Site Care • Tubing, Injection Ports, Catheter Entry 3

4. Process Factors People Factors Why Mistakes Happen Variable input (diff pts) Inconsistency/variation Complexity Too many/complicated steps Human intervention Tight time constraints Hierarchical culture Fatigue Inattention/distraction Unfamiliar situations/new problem Using past solutions Equipment design flaws Communications errors Mislabeling/inadequate instructions

5. 2005 study by AACN and Vital Smarts: Silence Kills • 1,700 nurses, physicians, clinical care staff and administrators • More than 50% witnessed their co-workers breaking rules, making mistakes, failing to support others, demonstrating incompetence, showing poor teamwork, acting disrespectfully and micromanaging • Despite the risk to patients, less than 10% of physicians, nurses, and other clinical staff directly confronted their colleagues about their concerns 195,000 deaths per year in US hospitals because of medical mistakes

6. 2010 Silent Treatment Study—AACN, AORN and Vital Smarts • Healthcare has made great strides over past 5 years to improve systems to prevent errors • Safety tools are an essential part of the formula for solving avoidable medical errors caused by poor communication. • Silent Treatment study of 6,500 nurses and nurse managers reveals that safety tools fail to address a second category of communication breakdowns---undiscussables. • Tools don’t create safety—people do • In study—85% of respondents had been in a situation where a safety tool warned them of a problem----BUT 58% had also been in situations where they felt unsafe to speak up about the problems or were not able to get others to listen • Staff need the tools to know how to effectively speak up!

7. Effective Communication and Teamwork Requires: Structured Communication Assertion/Critical Language Psychological Safety Effective Leadership SBAR, structured handoffs Key words, the ability to speak up and stop the show An environment of respect 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

8. Tools and Strategies to Improve Safety and Teamwork Pre-procedure briefing Morning briefing Shadowing Daily rounds/goals Huddles Learn from a defect

9. Discuss “How To” for Huddles and MDR with Daily Goals WHY these two interventions? • Both strategies impact large amount of the unit staff • Rapidly assist to improve communication and teamwork • Build capacity at unit level for problem solving and owning safety and quality

10. 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 recovery immediately from defects—ie: falls, sepsis and daily to focus on unit outcomes

11. Metrics Don’t Change Until You Have Been Successful

13. Huddle Board 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 13

14. SICU Huddle Board

15. NICU Huddle Board

16. Structured Huddles Action Plan

17. Selecting Metrics • Should reflect improvement opportunities that have been identified by unit, aligned with unit and hospital goals and objectives • Must be specific and measureable – and feasible to monitor frequently • Identify who will be collecting data and updating board • Define goal for metric – this will help you decide how long to keep metric going

18. Selecting Metrics - Examples Quality: core measures, hand hygiene, falls, delirium, skin integrity, etc. Patient Satisfaction: use results from hospital’s patient satisfaction survey – pain is controlled, noise at night, etc. Operations:unit functioning, efficiencies – % of patients discharged by 11am, time from transfer or discharge order until patient is moved 18

19. Selecting Metrics Quality:(core measures, hand hygiene, falls, etc.) Med-Surg: pneumonia core measure—your unit is falling short in one area—vaccination. Metric: # of patients who received the vaccine(PNE) # of patients who qualified for it ICU: ventilator associated pneumonia prevention-your unit is not consistently performing the spontaneous awakening trial (SAT) Metric: # of patient who received a SAT # of patients who qualified for SAT LAB: turnaround time for stat lab—CBC Metric: # of CBC resulted within 30 minutes # of CBC in previous 24 hrs 19

20. Selecting Metrics Patient Satisfaction: (results from hospital’s patient satisfaction survey) Med-surg: call lights being answered within 5 minutes Metric: # of call lights anwered withing 5 minutes # of call lights in 24 hrs ICU: pain reassessment in 1 hour Metric: # of patient who’s pain was reassessed in 1 hour # of patient episodes audited Radiology: patient waiting Metric: # of in-patients that waiting in the hallway 5min # of inpatients brought to department for testing in 24 hrs 20

21. Selecting Metrics Operations: (unit functioning, efficiencies, etc.) Med-surg: percent of patients discharged by 11am Metric: # patients discharged by 11am # of patients with discharge orders in place before 11am ICU: delirium assessment Metric: # of patient with 2 documented CAM-ICU in last 24 hours # of patient in ICU Radiology: no show rate Metric: # of out patients that miss schedule appointment # of outpatients scheduled for testing in 24 hrs 21

22. Define Process • Define time of day and frequency • Who will lead huddle • Expectations of staff—who will attend • Create agenda (in first huddles include overview of purpose of huddles and huddle process)

23. Structured Huddles Action Plan

24. Huddle Evaluation:Outcome/Process Metrics • Improvement in metrics on huddle board • AHRQ results: • “Our procedures and systems are good at preventing errors from happening” • “We are actively doing things to improve patient safety” • “After we make changes to improve patient safety, we evaluate their effectiveness” • “In this unit, we discuss ways to prevent errors from happening again”

25. Structured Huddles Evaluation:Survey the Staff • Select which department you work for: • I have attended a daily huddle - Once - 2-5 times - 5-10 times - 10-20 times - 20 or more times - I have not attended a huddle • I understand the purpose of the daily huddles - Strongly agree - Agree - N/A • Disagree • Strongly Disagree 4. I feel comfortable asking questions and expressing ideas during the huddles • Strongly Agree • Agree • N/A • Disagree • Strongly Disagree

26. Structured Huddles Evaluation:Survey the Staff 5. I feel that the daily huddle provides me with information to be able to provide safe, effective and efficient care to my patients • Strongly Agree • Agree • N/A • Disagree • Strongly Disagree 6. The huddle board has provided me the opportunity to see how my practice impacts patient outcomes • Strongly Agree • Agree • Disagree • Strongly Disagree 7. The huddle board and daily huddles empowers me to improve my own practice • Strongly Agree • Agree • Disagree • Strongly Disagree 8. Please provide any suggestions to improve both the huddle board and the huddle process

27. Evidence Based local solutions:Safety “If-Then” • If staff lack consensus about quality and safety issues? • ThenSafety as a System Training (free 27 Minute online course) www.dukepatientsafetycenter.com • If staff feel unengaged in safety and quality? • Then build grassroots with Learning from Defects • If staff feel unengaged, unsafe, & unresourced for quality? • Then build infrastructure & capacity with Structured Huddles and Executive Partnerships

28. Evidence based local solutions: Teamwork “If-Then” • If staffing levels inadequate/info lost at shift change: • ThenMorning/Shift Briefings/Huddles • If interdisciplinary patient management issues: • ThenDaily Goals • If conflicts unresolved/role clarity lacking: • ThenShadowing Exercise • If difficulty speaking up: • Then standardizing with SBAR,Critical Language, Crucial Conversations or TeamSTEPPS training

29. A Healthcare Imperative “In medicine, as in any profession, we must grapple with systems, resources, circumstances, people-and our own shortcomings, as well. We face obstacles of seemingly endless variety. Yet somehow we must advance, we must refine, we must improve.” - Atul Gawande, Better: A Surgeon’s Notes on Performance 38

30. Questions? 39