Welcome!

1. Welcome! Improving Teamwork & Communication in Surgery November 15, 2012

2. Agenda • Table Discussion • Storyboards • World Café • Patient Perspective • Team Planning Time • Learning Systems • Future Directions

3. Table Discussions • “Fresh eyes” from everyone at your table • Some questions to get us started…

4. Was there a moment when you said to yourself, “This is why culture is important”? • I feel like I’m banging my head against the wall when ____. • I laughed when ____ happened. • If I could go back in time and do one thing differently, it would be _____. • Is there someone in your unit who really understands the purpose of culture improvement? Tell us about this person and what it’s like to work with them.

5. Theory Burst: A Shared Mental Model is… The perception of, understanding of, or knowledge about a situation or process that is shared among team members through communication. “Teams that perform well hold shared mental models.” (Rouse, Cannon-Bowers, and Salas 1992)

6. Shared Mental Model? Credit: TeamSTEPPS

7. Storyboard review • Identify two topics to discuss during the World Café • Worksheet in folder

8. Theory Burst Please Use CUS Wordsbut only when appropriate! Credit: TeamSTEPPS

9. World Café • Topic 1 • Topic 2 • Topic 3 • Topic 4 • Topic 5 7 minutes per topic

10. Patient Perspective

11. Team Planning • Plan the next steps for when you return to your unit • Worksheets in the folder • For those without SAQ data, the project overview is provided for discussion

12. The Components of Learning and Improvement • 1. Aims • 2. Mapping Strategy and Tactics • 3. Small Tests of Change (aka PDSA cycles) • Let us look at each of these in detail and apply them to your work:

13. How The 3 Relate To Each Other:Aim Strategy Mapping PDSA’s Outcome Major Influences Action 1 1 2 Aim 3 1 2 2 Let’s Explain Each Of These:

14. Let’s use David to explain these relationshps: • David comes to America, eats an American diet, now has a bit of a problem. • He wants to get fit again. • What should he do?

15. New David Outcome Major Influences Diet Aim: A new David! Exercise

16. New David Outcome • Aim: David weighs 180 lbs in 18 months. • Examples of Healthcare Aims: • Decrease Surgical Site Infection by 25% in one year. • In this unit, 75% of those surveyed will agree or strongly agree with the statement “It is easy for personnel here to ask questions when there is something that they do not understand” in 5 months. Aim: A new David!

17. Produce Aim Statement(s) • Aim Statement: • What by When • Stretch goal • Unambiguous • Numeric • Measurable (Use measures to help clarify Aims) • Think about relative (better) versus absolute goals

18. Getting from Influences to Interventions Outcome Major Influences Action Limit daily intake Diet Substitute low calorie foods Aim: A new David! Avoid alcohol Bike to work Exercise Hacky Sack in office

19. Adding In Measurement Outcome Major Influences Action Limit daily intake • Avg. calorie daily • Weight • BMI • Body Fat • Waist Size Diet • Meals off- plan/week Substitute low calorie foods • Daily calorie count • Sodas/week Aim: A new David! Avoid alcohol • Avg. drinks per week Bike to work • Percent of days on bike Exercise Hacky Sack in office • Repetitions/Day • Total Exercise calorie count

20. What This Looks Like On A Worksheet Low Calorie Food Smaller Portion Size Avoid Alcohol Diet David180 lbswithin 1 year Bike to Work Hacky Sack SittingExercise Exercise Weight Waist Size See inWorksheet

21. Model for Improvement:Plan Do Study Act (PDSA) • What are we trying to accomplish? • How will we know that a change is an improvement? • What changes can we make that will result in an improvement? Make a Prediction PLAN ACT DO STUDY

22. Making a Prediction • What is your hypothesis? • What do you think will happen? • No result is a failure as long as learning occurs • Think ahead to future tests and how they might be shaped by the current small test.

23. Guidance for Testing a Change Concept • A test of change should answer a specific question! • A test of change requires a theoryand a prediction! • Test on a small scale and collect data over time • Build knowledge sequentiallywith multiple PDSA cycles for each change idea • Include a wide range of conditions in the sequence of tests • Don’t confuse a task with a test!

24. PDSA Testing: Questions and Components See inWorksheet

25. PDSA Testing: Applied to David riding a bike David agrees to ride a bike to work. Design the first and second tests that will get David riding his bike to work. Think – SMALL tests of change In putting together each test, answer every question to the right.

26. PDSA Testing: Questions and Components

27. Incremental Changes in PDSA Outcome Major Influences Action Limit daily intake Diet • Weight • BMI • Body Fat • Waist Size Substitute low calorie foods • Daily calorie count Aim: A new David! Avoid alcohol Bike to work Exercise Hacky Sack in office • Total Exercise calorie count Can David ride a borrowed bike? 1 Can David ride to and from work in one day? 3 Can David ride safely at night in the dark? 4 Can David ride to work one morning? 2

28. Action Planning Worksheet: Linking Aim Statement, Influences, and Interventions

29. Do: Carry out the change or test and collect data Study: Analyze data and compare with your predictions; provide a summary Act: Are we ready to make a change? Plan for the next cycle

30. PDSA cycles over time

31. Learning Systems • Describe the concept • Expand on Allan Frankel’s presentation in June • Connection between learning systems and culture improvement • Learning processes can support our culture improvement work • We can direct our culture improvement efforts toward creating a learning culture

32. Definition • A learning system is constantly learning about itself and using that information to move toward its goals. • Some learning systems are learning organizations.

33. Organizational Layers Culture Organizational Structure Processes Tasks

34. Learning System • Systems Thinking • Vision • Information Infrastructure • Team Approach • Personal Mastery

35. Systems Thinking

36. Systems Thinking • How is catheter insertion in the OR affecting UTIs in the wards? • How are changes in sterile processing affecting the operating room? • How discharge might affect readmission

37. Organizational Layers Culture Organizational Structure Processes Tasks

38. VISION

39. Vision • It is easy to ask a question if there is something I don’t understand. • It’s like being a part of a big family. • Catheters will be removed within 48 hours of insertion 90% of the time.

40. Organizational Layers Culture Organizational Structure Processes Tasks

41. Information Infrastructure

42. Transparency Accountability

43. People are the basic unit TEAM APPROACH PERSONAL MASTERY

44. Organizational Layers Culture Organizational Structure Processes Tasks

45. Learning Organization Culture Systems Thinking Vision Information Infrastructure Team Approach Personal Mastery Organizational Structure Processes Tasks

46. Culture 2 Organizational Structure Processes 1 Tasks

47. We can’t make a learning system without a culture shift Because we are changing culture, we have the option to make a learning culture

48. Discussion • What would tasks and processes that support learning look like in surgery areas? • What do you think about working toward a culture of learning?

49. Future Directions Embed teamwork behaviour Improve a clinical outcome (Connect with NSQIP) Improve on a specific culture metric Build a learning culture & learning system

50. Timeline November December January February March April • Can we aim to present our experience in March? • Do we want to repeat the survey? Spring or Fall? Re-survey? Or Fall 2013? Continue Improvement Quality Forum