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IHI Expedition Engaging Frontline Teams to Create a Culture of Safety
March 14th, 2013
These presenters have
nothing to disclose
Annette Bartley, RN, MS, MPH Tracy Jacobs, BSN, RN
Today’s Host
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Lizzie Grimm, Project Assistant, Institute for
Healthcare Improvement
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Expedition Director
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Tracy Jacobs, BSN, RN, Director, Institute for Healthcare Improvement (IHI), currently directs IHI's work with Improving Patient Care, a wide-reaching improvement program within the Indian Health System, and the ongoing “Achieving Excellence in Primary Care” call series. She has worked on several large IHI collaborative improvement projects, including the Transforming Care at the Bedside inpatient-focused initiative and a ten-year collaborative initiative with the Health Resources and Services Administration's Federally Qualified Health Centers focused on improving chronic disease and preventive care services for the nation's underserved populations. Ms. Jacobs has 12 years of experience in health care quality improvement.
Today’s Agenda
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Introductions
Content: Essentials of Teamwork
Homework for next session
Our Intent – Overall Program Aim
Understand the discipline of patient safety and its role in
minimizing the incidence and impact of adverse events,
and maximizing recovery from them
Create a culture of safety amongst frontline healthcare
teams that protects all
Active participants/homework assignments
Applying the theory in practice
Sharing the learning
Expedition Objectives
At the end of the Expedition each participant will be able to:
Describe background and context of patient safety
Identify tools which will help to improve communication and teamwork, essential to building culture
Apply a range of simple tools and improvement methods for engaging staff in improving patient safety and measuring improvement
Identify strategies for managing conflict management, including: appropriate assertion and critical language
Describe strategies for involving patients and family members in preventing harm
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Schedule of Calls
Session 2 – Essentials of Teamwork
Date: Thursday, March 14, 1:00 PM – 2:00 PM ET
Session 3 – Effective Communication
Date: Thursday, March 28, 1:00 PM – 2:00 PM ET
Session 4 – Measurement of Adverse Events
Date: Thursday, April 11, 1:00 PM – 2:00 PM ET
Session 5 – Tools and Techniques for the Frontline Staff
Date: Thursday, April 25, 1:00 PM – 2:00 PM ET
Session 6 – Engaging Patients and Families in Preventing Harm
Date: Thursday, May 9, 1:00 PM – 2:00 PM ET
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Faculty
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Annette J. Bartley RGN, BA (Hon) MSc, MPH, Programme Director, The Health Foundation's Safer Patient Network, UK, is a registered nurse with over 30 years of health care experience. In 2006 she was awarded a one-year Health Foundation Quality Improvement Fellowship at the Institute for Healthcare Improvement, during which time she also completed an MPH at Harvard University. Ms. Bartley was faculty lead for the Welsh pilot of Transforming Care at the Bedside (TCAB) and now advises the Welsh Assembly Government as TCAB spreads across Wales. She is a founding member of the Welsh Faculty for Healthcare Improvement and serves as faculty for the IHI TCAB Collaborative, the Wales 1,000 Lives plus Transforming Care programme, the South West Quality and Patient Safety Improvement programme, the National Tissue Viability pressure ulcer prevention pilot programme for Quality Improvement Scotland, and the Kings Fund hospital pathways programme.
Work from Action Period
Meet with your team and consider the following:
─ Who makes up your team?
─ Do actually you function as a team?
─ What is your collective purpose?
─ How do you prioritise patient safety issues?
Independently ask 5 different members of your team what is their biggest safety concern
Collectively agree on one specific safety aim/project for improving patient safety your unit
Try testing “Safety Briefings” (see materials)
If you already use them, share your learning
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Feedback from our volunteers
Mary
Martha
Nisha
**Lizzie and Kayla: Please add last
names and the organization they
represent – thanks!!
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Essentials of Teamwork
Session Objectives
By the end of this session participants will be able to:
Describe 5 essentials factors in effective teamwork
Appreciate the value of effective teamwork and
communication in providing safe patient centered care
Identify tools to help individuals speak up reliably
when they perceive risk to a patient
Describe some simple steps/tools that might help to
enhance staff satisfaction and teamwork
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Why is teamwork so important in
healthcare?
“A healthcare system that supports effective teamwork can improve the quality of patient care, enhance patient safety and reduce workload issues that cause burnout among healthcare professionals.”
• Teamwork in Healthcare: Promoting effective teamwork in healthcare in Canada
• Ivy Oandasan, G.Ross Baker, et al. 01/06/2006
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With teamwork we can build towards excellence".
Stew Leonard.
What does teamwork mean to you? Please use ‘chat facility to share your thoughts
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Executive Perceptions vs.
Frontline Perceptions:
Executives overestimate:
Teamwork Climate 4X
Safety Climate 2.5X
Executive Confidence vs.
Executive Accuracy:
-Often wrong but rarely in doubt…
-Currently no incoming data-streams
-Halo Effects
-Frontline data fills the gap
The View from the top
Getting to Goal
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Video
New Zealand Ruby Chant
http://www.youtube.com/watch?v=Nrkvpi9IuSk
Insert name of presentation on Master Slide
Five Principles of Teamwork • Edward Davey
http://www.tips4teamwork.com/5-essentials-of-great-teamwork.htm
T.E.A.M. Together Everyone Achieves More
1. Communication
This is the essence of effective Teamwork.
Effective communication provides
understanding, interpretation and action.
Ineffective communication leads to
misunderstanding, misinterpretation, and
either inaction or inappropriate action.
2. Active Listening
There are two responsibilities here: That of
the sender/transmitter and that of the
receiver. The sender must ensure that the
message is clear and understood and the
receiver must ensure that if the message
is not clear that they ask for clarification.
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3. Resolving Conflict
People are different and inevitably clashes
of personality or other conflicts may arise.
The conflict must be resolved and people
should use an effective, consistent
approach to resolve it.
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4. Team Diversity
People come from different backgrounds
and this can present challenges and
opportunities. People have to recognise
and understand their own uniqueness and
that of others and make allowances.
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5. Team Motivation
Motivation inspires commitment,
innovation and teamwork. Team leaders
and members need to be aware of the
factors affecting motivation and techniques
they can use to enhance and maintain
motivation levels.
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Criteria for Effective Teamwork
Visible and transformational leadership
Multiple disciplinary input with active participation of all members - diversity of distinct knowledge and skills needed for patient care
Team members share information & coordinate services
Good communication
Clear purpose (shared vision)
Plan of care reflects an integrated set of goals
Measurement system & supportive processes/protocols
Effective mechanisms to resolve conflict when it arises.
Schmitt, Farrell and Heinemann; 1988 27
Barriers to Teamwork
Failure to appreciate the value of different roles
Power struggles inhibit communication
The ‘attitude virus’!
Frequent staff changes complicate staff learning
Conflict and compromise may be caused by predominance of less experienced workers
Poor communication
Adapted from Opie, 1997 28
Barriers to Safety
Trained to be perfect - knowledge and
competence are equated with the absence of error
Mistakes are seen as episodes of personal failure
Catastrophic events are rare-“It won’t happen to
me”
Assuming safety, not assuring safety
Focus on individuals, not complex systems
Fix the person and the problem goes away
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Psychological Safety…
Recognition that human error is inevitable
• Complex systems • Inherent Human Limitations – stress, limited memory
capacity, fatigue, & multitasking
• Safety is often ASSUMED, not ASSURED
• Familiarity with others is a critical component of effective teamwork:
• 74% of all commercial aviation accidents happen on the first day of a crew flying together
• Familiarity trumps fatigue
• Highlights the importance of predictable patterns of behavior
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Error Is Inevitable Because of Human Limitations
Limited memory capacity – 5-7 pieces of information in short term memory
Negative effects of stress – error rates • Tunnel vision
Negative influence of fatigue and other physiological factors • Cognitive performance after 24 hrs. without sleep
equivalent to blood alcohol of .10 ! Dawson et al, Nature, 1997
Limited ability to multitask – cell phones and driving
Multitasking, Interruptions, Distractions
Humans are poor multi-taskers
– Drivers on mobile phones have 50% more accidents,
25% of traffic accidents are "distracted drivers”
*Interruptions and distractions increase error rates
Humans need very formal cues to get back on task
when interrupted and distracted
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*Anita L Tucker and Steven J Spear Health Serv Res. 2006 June; 41(3 Pt 1): 643–662. Operational Failures and Interruptions in Hospital Nursing
Red Flags – Loss of Situational Awareness
Ambiguity
Reduced/Poor communication
Confusion
Trying something new under
pressure
Deviating from established norms
Verbal violence
Doesn’t feel right
Fixation/Boredom/Task saturation
Being rushed/Behind schedule
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Fatigue
24 hours without sleep is equivalent to a blood alcohol
level of 0.10 – a 30% decrease in cognitive processing
Nurses are 3 times more likely to make mistakes after
12 hours on the job
Junior doctors made 30% more errors in ICU patients
when on traditional 24 hour call schedules
The best countermeasure for fatigue is teamwork –
more people in the same movie
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Psychological Safety…
Do you know all the names of the personnel you work
with?
– Safety Briefings= Level the playing field
– “Hi, I’m ___. I’m sorry I missed your name.”
– “I don’t have any pride invested here. I just
want to get it right, so if you think I am doing
anything wrong, please let me know.”
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Communication Styles
National Culture
Gender
Roles (Physician, Nurse, Manager)
– Nurses: narrative & descriptive
– Physicians: problem solvers “just give
me the facts”
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Effective Communication
Have a plan
Acknowledge that hand-offs are dangerous
Recognize the value of a structured process
Structured language/clarity
Who owns the patient?
Criteria for increasing the intensity of care?
Use structured communication tools
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Speaking Up- Critical Assertion
CUSS to communicate concern
C – “I’m Concerned” or “I need clarity”
U – Uncomfortable
S – Stop the line/procedure
S – Patient Safety is at risk!
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Safety Briefings/Huddles
Can be done standing up
At shift handover
Used to convey vital safety information
Safety first items on the handover
Highlights key safety issues
Increases awareness
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Debriefing - An Opportunity for Individual,
Team and Organizational Learning
Take a minute or two to learn when it’s
fresh in everyone’s head
The more specific, the better
What did we do well?
What did we learn?
What would we do differently next time?
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Teamwork-Where Do We Begin?
1. Create a sense of urgency
2. Pull together the guiding team
3. Formulate a change vision and strategy
4. Communicate your vision for understanding and
buy-in
5. Set aims & use the Model for Improvement
6. Measurement and feedback loop
7. Test ‘one’ tool on one shift with one team
8. Test and Learn from it/build upon it and refine the
process
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Putting the Pieces Together
Culture – respect/recognition and the tools to
do the job
Leadership, at every level
A safety culture, teamwork, joy
Reliable processes – embed teamwork
practices in these
Cycles of improvement – build a learning
organization with continual improvement
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Keeping an Ear to the Ground
Regularly take the pulse of the team
Staff will leave
Measure sickness, turnover, and vacancy rate
Seek staff opinion
Empower and actively engage them
Groan/Ideas board
Insert name of presentation on Master Slide
Little things mean a lot
Inspire and motivate
Listen & observe
Give recognition
Appreciate everyone
Star of the month
Chocolate/ Pizza parties
Team building events
Make it fun…
3rd March 2011
The Wisdom of Flying Geese
Basic Truth #1- Whenever a goose falls out of formation, it suddenly feels the drag and resistance of trying to go it alone and quickly gets back into formation to take advantage of the lifting power of the bird immediately in front. - People who share a common direction and sense of community can get where they are going quicker and easier because they are travelling on the thrust of one another. Basic Truth #2- When the lead goose gets tired, he rotates back in the wing and another goose flies point. If we have as much sense as a goose, we will stay in formation with those who are heading in the same direction as we are. Basic Truth #3- These geese honk from behind to encourage those up front to keep up their speed. It pays to take turns doing hard jobs, with people or with flying geese. Basic Truth #4- Finally, when a goose gets sick, or is wounded by gunshot, and falls out, two geese fall out of formation and follow him down to help and protect him. They stay with him until he is either able to fly or until he is dead, and then they launch out on their own or with another formation until they catch up with their group. We need to be careful what we say when we honk from behind. Final Truth- If we have the sense of a goose, we will stand by each other, protect one another and sometimes make new friends who seem to be going in our direction.
Hey… what’s a mountain goat doing way up here in a cloud bank?
Questions?
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Key Take Homes Respect the wisdom of the front line workers Culture is related to clinical and operational outcomes Culture is local – work unit culture trumps hospital culture Lots of variability across work units Familiarity improves predictable patterns of behavior (improves performance) Perceptions of teamwork differ by role, whereas perceptions of safety climate are consistent within a work unit Senior leader contact with front-line workers is key to improving perceptions of safety climate Frontline providers have demonstrated a striking ability to improve culture in an relatively short time, when they are leading the effort Answer the question: “Are We Safer than Last Year?”
Repeated Use of the PDSA Cycle
Hunches Theories Ideas
Changes That Result in Improvement
A P
S D
A P
S D
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
Model for Improvement
PDSA Cycle No 1 :
Worksheet for Testing Change
Aim:
(Overall goal you would like to reach) Every goal will require multiple smaller tests of change
Describe your first (or next) test of change
Person
Responsible
When to
be done
Where to
be done
Plan
List the tasks needed to set up this test of change
Person
Responsible
When to
be done
Where to
be done
Predict what will happen when the test is carried out Measures to determine if prediction succeeds
Act: What will you differently as a result of your test?
What will your next test be? When will it be?
Repeat the cycle
Test over a wide variety of conditions, different patients, different staff, days, nights,
secondary care/primary care .
Measure, collect enough data to tell you if your test was a success.
Keep testing until the changes you are making result in improvements.
Do:
Study: What happened?
What did you learn?
What surprised you?
The Improvement Guide, API
Data for Improvement
Using Data to understand progress toward the team’s aim
Using Data to answer the questions posed on in the plan for each PDSA cycle
Questions?
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Raise your hand
Use the Chat
Summary
Content and background to patient safety
Essentials of teamwork
Effective communication
Measurement of adverse events
Tools and techniques for the frontline staff
Engaging patients and families in
preventing harm
Work for Action Period
We would like you to undertake PDSA’s
Consider testing:
Simple ways of acknowledging a job well done
The G’rrrr board
Safety briefings on shift handover
Debriefings post incident/event
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Volunteers?
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Questions?
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Raise your hand
Use the Chat
Expedition Communications
Listserv for session communications:
To add colleagues, email us at
Pose questions, share resources, discuss
barriers or successes
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Next Session
Thursday, March 28, 1:00 PM – 2:00 PM ET
Session 2 – Effective Communication
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