HANYS Teamwork Technique: Achieving Critical Care Excellence

1. HANYSTeamwork � Technique: Achieving Critical Care Excellence A presentation by Capt. Stephen Harden

2. Agenda Quick review of CRM and its two key components The five step formula for changing culture Key components of the methodology to permanently improve teamwork and system processes Identify the leaders in your organization who are critical to the success of your improvement project The formula to recruit and win the support of project champions How to explain the impact of your project to gain credibility and support

3. �Our Systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time. We, as leaders, have a responsibility to put into place systems to support safe practice.�

4. CRM is� Crew Any team� cockpit, maintenance, ATC, etc... ICU staff, ICU physicians, ECMO team Resource Other team members, equipment, procedures, systems Management Specific behavioral skills to lead, communicate, decide and catch errors before they become serious /fatal (Example: Pilots working with ATC, conducting a �readback� of a new altitude clearance� or ICU team transferring pt. to Step Down unit and conducting a �readback� of critical information) Self-explanatory.Self-explanatory.

5. CRM Teamwork Training + Systems Approach Error is inevitable because of human limitations The key to safety is managing error �Stop being surprised by it, and be prepared for it� Aviation (and some hospitals) manages error by training specific team & communication behaviors & implementing systems that require those behaviors The behaviors and the systems supporting the behaviors is CRM Inevitable�we know more (have more knowledge), technology is better, etc., but the human brain which processes the knowledge and uses the technology is unchanged. Just because of the way we are �wired�, we have limitations and are prone to certain kinds of errors. The key to better safety is managing the inevitable error. We manage the error by training the team to use specific behaviors and implementing systems that require the use of those behaviors to detect and trap error before they become fatal mistakes. Error is inevitable. An effective, proven way to manage error is through training specific team behaviors. In aviation, the behaviors (software) and the systems (hardware, e.g. processes, procedures, checklists, guidelines, etc.) is what we call CRM.Inevitable�we know more (have more knowledge), technology is better, etc., but the human brain which processes the knowledge and uses the technology is unchanged. Just because of the way we are �wired�, we have limitations and are prone to certain kinds of errors. The key to better safety is managing the inevitable error. We manage the error by training the team to use specific behaviors and implementing systems that require the use of those behaviors to detect and trap error before they become fatal mistakes. Error is inevitable. An effective, proven way to manage error is through training specific team behaviors. In aviation, the behaviors (software) and the systems (hardware, e.g. processes, procedures, checklists, guidelines, etc.) is what we call CRM.

6. Aviation�s Solution Technology Aviation�s solution to its accident rate contained three main components. Technology� is important, but not the complete answer. TCAS Terminal Collision Avoidance Systems Black boxes in the airplanes talk to each other and generate guidance to the pilot on what to do to avoid a collision EGPWS A black box that uses an internal GPS system to tell the airplane where it is in relation to all terrain and obstacles around the world and warns when it is too close. GPS Global Position system for precise navigation AFS Automatic Flight Systems�.computers that control flight path of the airplane Teamwork Skills Team training�training to reduce errors generated by small group dynamics (how do the humans interface with one another?) Systems Checklists, guidelines, processes, procedures (healthcare calls these protocols) to minimize over reliance on memory and create system that requires the use of effective team skills. Software = Behaviors/Skills Hardware = processes, systems, procedures, guidelines, etc� You must have both to be successful. Aviation�s solution to its accident rate contained three main components. Technology� is important, but not the complete answer. TCAS Terminal Collision Avoidance Systems Black boxes in the airplanes talk to each other and generate guidance to the pilot on what to do to avoid a collision EGPWS A black box that uses an internal GPS system to tell the airplane where it is in relation to all terrain and obstacles around the world and warns when it is too close. GPS Global Position system for precise navigation AFS Automatic Flight Systems�.computers that control flight path of the airplane Teamwork Skills Team training�training to reduce errors generated by small group dynamics (how do the humans interface with one another?) Systems Checklists, guidelines, processes, procedures (healthcare calls these protocols) to minimize over reliance on memory and create system that requires the use of effective team skills. Software = Behaviors/Skills Hardware = processes, systems, procedures, guidelines, etc� You must have both to be successful.

7. The Formula for Changing Culture Thoughts (training) Actions (system tools) Habits (leadership actions + proof it works) Character Culture

9. How do you change the culture and go from �Me� to �We?�

10. How do you change the culture and go from �Me� to �We?�

11. How do you change the culture and go from �Me� to �We?�

12. How do you change the culture and go from �Me� to �We?�

13. How do you change the culture and go from �Me� to �We?�

14. Aviation�s Solution Technology Aviation�s solution to its accident rate contained three main components. Technology� is important, but not the complete answer. TCAS Terminal Collision Avoidance Systems Black boxes in the airplanes talk to each other and generate guidance to the pilot on what to do to avoid a collision EGPWS A black box that uses an internal GPS system to tell the airplane where it is in relation to all terrain and obstacles around the world and warns when it is too close. GPS Global Position system for precise navigation AFS Automatic Flight Systems�.computers that control flight path of the airplane Teamwork Skills Team training�training to reduce errors generated by small group dynamics (how do the humans interface with one another?) Systems Checklists, guidelines, processes, procedures (healthcare calls these protocols) to minimize over reliance on memory and create system that requires the use of effective team skills. Software = Behaviors/Skills Hardware = processes, systems, procedures, guidelines, etc� You must have both to be successful. Aviation�s solution to its accident rate contained three main components. Technology� is important, but not the complete answer. TCAS Terminal Collision Avoidance Systems Black boxes in the airplanes talk to each other and generate guidance to the pilot on what to do to avoid a collision EGPWS A black box that uses an internal GPS system to tell the airplane where it is in relation to all terrain and obstacles around the world and warns when it is too close. GPS Global Position system for precise navigation AFS Automatic Flight Systems�.computers that control flight path of the airplane Teamwork Skills Team training�training to reduce errors generated by small group dynamics (how do the humans interface with one another?) Systems Checklists, guidelines, processes, procedures (healthcare calls these protocols) to minimize over reliance on memory and create system that requires the use of effective team skills. Software = Behaviors/Skills Hardware = processes, systems, procedures, guidelines, etc� You must have both to be successful.

15. Tools in the �Safety Toolkit� Pre �briefs � pre-op time outs, morning huddles Checklists � room set-up, holding room exit, line insertion protocol, pregnant trauma treatment flow, Hand-offs Debriefings � post-procedure, conflict mediation, teaching moments Standardized communication formats

16. A standardized format for hand-off communication Addresses a JCAHO Safety Goal for 2006 Used by RN�s, Attendings, and Housestaff

19. Trauma Protocol Standardized, common approach to OB patients with severe trauma. Jointly developed by OB and Trauma Services Covers care in ER, L&D and Trauma Units Trauma Protocol This protocol was developed for the effective handoff of a trauma patient with an unborn fetus The protocol was initiated following a root cause analysis involving miscommunication between two health care teams � OB & Trauma Note that this protocol includes a collaborative decision point Trauma Protocol This protocol was developed for the effective handoff of a trauma patient with an unborn fetus The protocol was initiated following a root cause analysis involving miscommunication between two health care teams � OB & Trauma Note that this protocol includes a collaborative decision point

20. L & D SnapShot Briefing Conducted each morning and soon, each evening Attendees include: OB Attendings & residents OB Anesthesiology attendings & residents Charge RN from a) L&D and b) Floor Nurse midwivery service (representative) Others as needed Briefing initiated by 3rd year OB resident Typically takes 5 minutes Required cultural change from standard patient-by-patient sign offL & D SnapShot Briefing Conducted each morning and soon, each evening Attendees include: OB Attendings & residents OB Anesthesiology attendings & residents Charge RN from a) L&D and b) Floor Nurse midwivery service (representative) Others as needed Briefing initiated by 3rd year OB resident Typically takes 5 minutes Required cultural change from standard patient-by-patient sign off

21. Take Advantage of History Guerilla Campaign Secure Base of Operations Support of Strong Government Support of 15% of population Cultural Change Campaign Secure Base: No end runs allowed, willing to impose consequences for non-compliance, leadership mandate Government Support: Board support, Executive support, funding, Med Exec, Joint Commission, CMS Support of 15%: Champions

22. The Key Members of the 15%... CEO or COO or President (funding) CMO or VPMA (Med Exec � MD partnership) Chief of Service or Department Chair (Support of Tools) Director of Department (Daily reinforcement) Key departmental managers (Daily reinforcement) At least two physician champions (MD partners) Leaders from Quality/Safety/Risk Management (Measurement and feedback)

23. Recruiting Champions Pages 1-12 and 1-13

24. The Briefing Protocol Page 3 - 1

25. Page 3 - 3 Briefing the Implementation Process

26. Objectives The five step formula for changing culture Key components of the methodology to permanently improve teamwork and system processes Identify the leaders in your organization who are critical to the success of your improvement project The formula to recruit and win the support of project champions How to explain the impact of your project to gain credibility and support

27. FocusSimplicityFollow-upDiscipline

28. Thank Youwww.SaferPatients.com