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 5 Teamwork and Communication Tools 6/27/2012

2. Learning Objectives • Discuss Teamwork and Communication Tools to improve safety culture • Discuss “how to” implement Multidisciplinary Rounds with daily goals 2

3. Coaching Call 5 Documents • This PowerPoint presentation • Monthly Team Leader Checklist • Sample Agenda for May/June CUSP Team Meeting • MDR and Improving Teamwork Article • MDR and ICU Mortality Article • Lakeland Hospital Experience – daily rounds/goals • SJMHS Interdisciplinary Rounds Checklist • Henry Ford Health System Daily Goals Checklist • Improving Communication Using Daily Goals Article • Effective Communication Daily Goals Article • Mercy-Des Moines Interdisciplinary Care Plan and Daily Goals 3

4. CUSP & CLABSI Interventions Educate on the Science of Safety Identify Defects (Staff Safety Assessment) Senior Executive Partnership Learn from Defects Implement Teamwork & Communication Tools Insertion Maintenance Assessment & Site Care Tubing, Injection Ports, Catheter Entry Technical CABSI/ NICU Adaptive/ Cultural CUSP 4

5. Why Mistakes Happen Process Factors People Factors Fatigue Inattention/distraction Unfamiliar situations/new problem Using past solutions Equipment design flaws Communications errors Mislabeling/inadequate instructions • Variable input (diff pts) • Inconsistency/variation • Complexity • Too many/complicated steps • Human intervention • Tight time constraints • Hierarchical culture 5

6. Tools and strategies to improve safety and teamwork • Pre-procedure briefing • Morning briefing • Shadowing • Daily rounds/goals • Huddles • Learn from a defect 6

7. “How To” for Multidisciplinary Rounds with Daily Goals WHY this intervention? • Impacts large amount of the unit staff • Rapidly assists to improve communication and teamwork • Builds capacity at unit level for problem solving and owning safety and quality 7

8. Multidisciplinary Rounds with Daily Goals – What is it? • A strategy to assemble the patient care team members to review important patient care and safety issues and improve collaboration on the overall plan of care for the patient • 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 8

9. Multidisciplinary Rounds with Daily Goals – What is it? • 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, quality measure compliance, LOS 9

10. Evidence For Impact Of MDR Rounds • Research studies on the effect of structured interdisciplinary rounds show: • Earlier identification of clinical issues • More timely referrals • Improved ratings by nurses and physicians on teamwork, communication and collaboration. • Research also indicates variable effects on LOS and cost, with some studies showing improvement and others having no impact. Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. O'Leary KJ, et. al, Journal Of General Internal Medicine [J Gen Intern Med], ISSN: 1525-1497, 2010 Aug; Vol. 25 (8), pp. 826-32; PMID: 20386996 10

11. 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 11

12. The Effect of Multidisciplinary Care Teams on Intensive Care Unit MortalityArch Intern Med Feb 22, 2010 12

13. Multidisciplinary Rounds with Daily GoalsChallenges 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 13

14. Multidisciplinary Rounds with Daily GoalsChallenges and Opportunities • 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 checklist or nursing objective card 14

15. Multidisciplinary Rounds with Daily GoalsSteps to Implementation • Commitment by all that MDR with daily goals is a strategy that will be implemented to improve communication and patient outcomes • CUSP team takes on initiative—identify if there are any additional team members needed • Evaluate current rounding process • Identify gaps between current process and what you want it to look like • Define the standard work of rounds, roles and responsibilities of each member and develop checklist and goal process • Define metrics to evaluate MDR 15

16. Standardized Work Paradigm Old Paradigm - I know you’ll be able to figure it out. Just get it done the best way you can. New Paradigm - In order to have consistent results we must do things the same way every time. 16

17. Standard Work System • Standardized Work is a system for achieving a stable baseline for a process in order to systematically improve it. • Standardized Work Systems are the basis for Continuous Improvement. “What you permit, you promote” “We deserve what we tolerate” 17

18. MDR with DG Action Plan 18

19. Current State Assessment What is the state of rounds on your unit? • Describe the structure of the participating unit(s). For example, the type of unit (i.e. ICU, Med Surg, Ancillary), whether the unit is open or closed, whether or not the unit has intensivists or hospitalists, how many beds the unit has, etc. • Are rounds currently held on the participating unit(s)? • How often are rounds held? • Who usually attends rounds? 19

20. Current State Assessment What is the state of rounds on your unit? • What are the roles of each member? • Where do rounds usually take place? • Is there a defined structure/process for rounds? If so what is it? Or does it depend on who is running them? • Are daily goals part of the rounding structure/process? • How have rounds made a difference during the past year in improving the performance on your unit? • What is the major barrier for multidisciplinary round implementation on your unit? 20

21. MDR with DG Action Plan 21

22. Who? • Physician • Team leader: guide rounds, ensure follow defined process, elicit input from all members, summarizes define daily goal • Resident: • Present patient in system format • Place orders in computer during rounds • Document note in chart • Bedside nurse • Provide clinical information, current patient status, changes over previous 24hrs, patient or family concerns/issues (if not present on rounds) 22

23. Who? • Case manager/social work • Could function as leader if physician not present • Oversee discussion of discharge planning • Define patient/family concerns/issues • Charge nurse/CNS/CNL • Function in leader role if designated and physician not present • Family member-parents • Others • Pharmacist, respiratory therapy, PT/OT, pastoral care, palliative care 23

24. Structure of MDR • Time of day • Frequency • Process for each patient • Checklist • Documenting • Which pieces of rounds? • Daily goal • Define daily goal follow up process 24

25. Multi-Disciplinary RoundsCommunication Tool Overall Plan of Care • Diagnosis? • Patient’s Chief Concern? • What does patient need to accomplish to be discharged? • Tests today? • Procedures today? • Medication changes today? • Medication issues? • Consulting services? • Expected discharge date? Discharge Plans • Placement? • Home health needs? • Transportation? • Equipment? Patient safety • On VTE prophylaxis? • Can any lines or tubes be removed? • Can we reduce fall risk? • Can we reduce skin injury risk? GOAL FOR THE DAY 25

26. Patient Daily Goals Form

27. Daily Goal Sheet

28. Daily Goal Sheet (continued)

29. Nursing Card 29

30. MDR with DG Action Plan

31. Test of Change • One nurse, one physician, one day, one patient • Test the roles and process(checklist) • Get feedback • Observe rounds • Survey participants • Make revisions 31

32. Evaluate 32

33. Evaluate 33

34. Evaluate • Survey participants: (5 point scale) • Was your voice/opinions heard and valued? • Did you have a understanding of what the goals and plan for the patient was for the day? • Did the leader facilitate the rounds to ensure efficiency and open communication? • Did MDR with DG improve how you cared for your patient? • What worked? • What could be improved? 34

35. 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 35

36. CUSP & CLABSI Interventions Educate on the Science of Safety Identify Defects (Staff Safety Assessment) Senior Executive Partnership Learn from Defects Implement Teamwork & Communication Tools Insertion Maintenance Assessment & Site Care Tubing, Injection Ports, Catheter Entry Technical CABSI/ NICU Adaptive/ Cultural CUSP 36

37. Where are you Struggling? • Getting your CUSP team to meet? • Physician buy-in and support? • Executive buy-in and support? • Time to educate staff on Science of Safety? • Working through the LFD tool? 37

38. 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

39. Questions? 39