Pat Posa RN, BSN, MSA Kimberly O’Brien, MHA System Performance Improvement Leader Director, Program Development

1. Document 1 THEBASICS OF CUSP Coaching Call 6: An Introduction to Teamwork & Communication Tools June 19, 2012 Pat Posa RN, BSN, MSA Kimberly O’Brien, MHA System Performance Improvement Leader Director, Program Development St. Joseph Mercy Health System Missouri Center for Patient Safety Ann Arbor, MI Jefferson City, MO patposa@comcast.netkobrien@mocps.org

2. Documents for Coaching Call 6 • Coaching Call 6 Presentation (this document) • Coaching Call 6 Team Leader Monthly Checklist • Sample Agenda for Team meeting 5 or 6 • Article: Impact of a Statewide Intensive Care Unit Quality Improvement Initiative on Hospital Mortality and Length of Stay • Article: The Effect of Multidisciplinary Care Teams on Intensive Care Unit Mortality

3. Before We Get Started . . . A Brief Recap of Coaching Call 5 (5/15/2012) • Step 2 of CUSP: Measure Unit Culture – HSOPS Results • Step 5 of CUSP: Learn from one Defect per Quarter – Learning from a Defect Tool & Case Summary Form • Coaching Call 5 Team Leader Checklist • Complete action items from Coaching Call 4 • Facilitate team meeting 4 or 5 • Work through the Learning from a Defect Tool • Begin action planning with HSOPS or other patient safety survey results

4. The “Secret Ingredient”Comprehensive Unit-Based Patient Safety Program Form a unit CUSP team with executive sponsorship Measure unit culture Educate staff on Science of Safety Identify defects using the Staff Safety Assessment; prioritize defects Learn from one defect per quarter Implement team/communication tools

5. Step 6: Implement Team/communication tools

6. Communication is Key Reader, CCM 2009 Vol 37 No 5; Donchin CCM 1995 Vol 23 • Effective communication amongst caregivers is essential for a functioning team • The Joint Commission reports that ineffective communication is the most commonly cited cause for a sentinel event • Observations of ICU teams have shown errors in the ICU to be concentrated after communication events (shift change, handoffs, ect) • 30% of errors are associated with communication between nurses and physicians

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 Daily rounds/goals Huddles Handoff standardization Pre-procedure briefing Morning briefing Executive Safety Rounds/Partnership Learn from a defect

9. The Effect of Multidisciplinary Care Teams on Intensive Care Unit MortalityArch Intern Med Feb 22, 2010 • Retrospective cohort study (using state discharge data from Pennsylvania Health Care Cost Containment Council) • 112 hospitals • Non-cardiac, non-surgical ICUs • 30 day mortality • Looked at 3 types of multidisciplinary care models • multidisciplinary care staffing alone • intensivist physician staffing alone • interaction between intensivist physician staffing • and multidisciplinary care teams

10. The Effect of Multidisciplinary Care Teams on Intensive Care Unit MortalityArch Intern Med Feb 22, 2010 Association Between Intensivist Physician Staffing and 30-Day Mortality for All Patients Variable OR (95% CI) P Value Model 1: multidisciplinary care staffing alone • No multidisciplinary care 1 [Reference] • Multidisciplinary care 0.84 (0.76-0.93) .001 Model 2: intensivist physician staffing alone • Low intensity 1 [Reference] • High intensity 0.84 (0.75-0.94) .002 Model 3: interaction between intensivist physician staffing and multidisciplinary care teams • Low intensity+ no multidisciplinary team 1 [Reference] • Low intensity + multidisciplinary team 0.88 (0.79-0.97) .01 • High intensity + multidisciplinary care 0.78 (0.68-0.89) .001

11. Interdisciplinary rounds with daily goals Purpose: Improve communication among care team and family members regarding the patient’s plan of care Goals should be specific and measurable Documented where all care team members have access Checklist used during rounds prompts caregivers to focus on what needs to be accomplished that day to safely move the patient closer to transfer out of the ICU or discharge home Measure effectiveness of rounds—team dynamics, communication

12. Interdisciplinary rounds with daily goals---Challenges and Opportunities • Should be done in ICUs and all units in hospital • Hard initiative to implement, especially if you have an open unit and/or no intensivists or in non-ICU area • Standardize the structure and process for all units • Benefits seen even if physician can not attend consistently or at all • Second rounds should be done in afternoon—include at least physician and bedside nurse • Evaluate if goals for day have been met; readjust if necessary • Identify if patient can be discharged (or transferred ) the next day and if so, what needs to be accomplished • Focused first on defining daily goals and recording those either on the white board in the room or on a sheet of paper • Then standardize rounds—who should attend and what is discussed • Implemented nursing objective card—to clearly define role of nurse in interdisciplinary rounds

13. Nursing Card VAP Delirium Sepsis

14. Huddles Use this strategy to begin to recovery immediately from defects---IE: falls, sepsis and daily to focus on unit outcomes 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.

15. 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

16. Transitions in care: Handoffs RN-RN Shift Handoff Checklist S (Situation) Reason for admission Contact Information Allergies Current attending/resident B (Background) Status of advanced directives/ code status Pertinent medical history Brief overview of hospital/ICU course Labs: abnormals this shift and pending or to do next shift Tests/procedures: current shift and anticipated for next shift Current Problems: medical and nursing A (Assessment) VS/pain past 24hours/shift Neuro CV Respiratory GI/GU (include I and O) Skin Mobility Patient safety issues-current and anticipated Medication concerns and updates R (Recommendation) Pending/anticipated tests and procedures Other concerns Current and anticipated family issues Pending patient/family education needs Status of current shift goals/problems Anticipated Goals/problems for next shift Other TO DOs/ Do you have any questions? Patient/Nurse introduction Joint review of lines/drips, neuro check etc.

17. Pre-procedure briefing • Make introductions • Discuss patient information and procedure • Agree upon a time for line insertion • Review best practice for line insertion (if necessary) • Nurse defines their role to physician: provide equipment, monitor patient, provide patient comfort, observe for compliance with best practices and STOP procedure if sterile process compromised • Establish communication expectation for sterile procedure breaks • Examples include: your sleeve has touched the IV pole, the guide-wire touched the headboard • Identify any special supply or procedural needs • Discuss any special patient issues (IE: patient confused, patient awake) • Answer any additional questions • TIME OUT: RIGHT PATIENT---RIGHT PROCEDURE Used this when rolled out CLABSI bundle to non-ICU

18. Morning Briefing Have used this for a long time between charge nurses from shift to shift. Since we have closed the units, now this also occurs with charge nurse and intensivist. • Purpose: Increase communication between physicians and nursing staff while efficiently prioritizing patient care delivery and ICU admissions and discharges • What is it? • A morning briefing is a dialogue between 2 or more persons using concise and relevant information to promote effective communication prior to rounds

19. Morning Briefing • Tool: answer following questions • What happened overnight that I need to know about? • Where should I begin rounds? (patient that requires immediate attention based on acuity) • Which patients do you believe will be transferring out of the unit today? • Who has discharge orders written? • How many admissions are planned today? • What time is the first admission?

21. Evidence: Over time results indicate that… • Safety climate improves overall • Perceptions of management improve overall • Magic number for exposure of staff ≥ 60% having participated in at least one per year • Nurse managers and charge nurses become more realistic (their safety climate scores actually decrease), while physicians, nurses, RTs, nurses aides, etc, improve.

22. Safety Climate Scores across Caregiver Roles Pre-Post EWR RNs improve over time, while Nurse Managers/Charge Nurses recalibrate % Reporting Positive Safety Climate Adapted from: Frankel et al. HSR (2008)

23. Impact of a statewide intensive care unit qualityimprovement initiative on hospital mortality and length of stayBMJ, February 2011 Method • Retrospective comparative analysis • Study period: October 2001 to December 2006 • Study sample: all hospital admissions with an ICU stay for adults age 65 or older at hospitals with 50 or more acute care beds and 200 or more admissions to the ICU during that time period • 95 study hospitals in Michigan compared with 364 hospitals in surrounding Midwest region • Look at hospital mortality and length of hospital stay

24. Impact of a statewide intensive care unit qualityimprovement initiative on hospital mortality and length of stayBMJ, February 2011 Results: Odds ratio for mortality in Michigan and comparison hospitals

25. What are your next steps? • Finish Learn from a Defect summary • Create action plan for HSOPS • Chose one teamwork or communication tool to implement over next 3 months • Celebrate your successes!!!

26. Module 1: The Basics of CUSP Session 1: Forming a CUSP team and Science of Safety Education Session 2: Staff Safety Assessment and Measuring Culture Session 3: Learning from a Defect-part 1 Session 4: Learning from a Defect-part 2 Session 5: Safety Culture Results and Action Planning Session 6: Teamwork & Communication Tools

27. Be Courageous We all are responsible for the safety of our patients----Own the issues • “If not this, then what??” • “If not now, then when?” • “If not us, then who??”

28. Notes on Hospitals: 1859 “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.” Florence Nightingale Advocacy = Safety

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 in his book, Better: A Surgeon’s Notes on Performance

30. Questions?