Sara Atwell, BSN, MHAChief Quality and Patient Safety Officer

Oakwood Healthcare SystemyCNO Symposium

April 26 & 27, 2012

“Our Systems are too complex “Our Systems are too complex to expect merely to expect merely to expect merely to expect merely

extraordinary people to extraordinary people to perform perfectly 100% of perform perfectly 100% of perform perfectly 100% of perform perfectly 100% of the time. We, as leaders, the time. We, as leaders,

have a responsibility to put have a responsibility to put have a responsibility to put have a responsibility to put into place systems to into place systems to

support safe practice ”support safe practice ”support safe practice.support safe practice.

James Conway, IHI Senior Fellow

44,000 to 98,000 deaths annually in the USfrom medical errors (IOM 1999)

Equivalent to 2 – 747’s crashing every weekEquivalent to 2 747 s crashing every week

CDC estimates that hospital-acquired infections alone kill 99 000 people each yearalone kill 99,000 people each year

More people die each year in the US as a result of medical errors than from AIDS and breast cancer combined.errors than from AIDS and breast cancer combined.

This terrible outcome is the equivalent number of lives that would be lost if a Boeing 767 full of passengers g p gcrashed every day of the year.

The IOM report is serious business and providers p pare responding.Every unnecessary death in your healthcare

t i t bl Y t h d th system is unacceptable. Yet many such deaths occurThe problem is urgent ; we cannot turn a blind eye to it while conducting business as usualgLeadership is needed to change culture behaviors, and processes that allow medical errors to happen.Caregivers must be given the tools to identify impending events and be empowered to STOP them from occurring. f g

From the Eyes and Ears of the From the Eyes and Ears of the Nurses:

Time Pressures - high census, high acuity more patients than they can adequately manage. Team work is poor - morale low , burn out highIncrease in administrative tasks take nurses away from the bedside.

C fFrom the Eyes and Ears of the Nurses:Mounting Confusion

Look alike sound alike Medications , similar packagingpackagingDifferent equipment same usePhysician preference - Individual vs . system y p yprocesses

Behaviors inconsistent with safe cultureAdministrator complacencyArrogant and disruptive behaviorg p

“Our Systems are too complex “Our Systems are too complex to expect merely to expect merely to expect merely to expect merely

extraordinary people to extraordinary people to perform perfectly 100% of perform perfectly 100% of perform perfectly 100% of perform perfectly 100% of the time. We, as leaders, the time. We, as leaders,

have a responsibility to put have a responsibility to put have a responsibility to put have a responsibility to put into place systems to into place systems to

support safe practice.”support safe practice.”support safe practice.support safe practice.

James Conway, IHI Senior Fellow

Make D i iMake D i i

CommunicateCommunicate

DecisionsDecisions

RecognizeRecognize

CommunicateCommunicate

RecognizeAdverse situationsRecognizeAdverse situations

Create a TeamCreate a Team

Manage FatigueManage Fatigue

Wh t i “Ad Sit ti “ What is an “Adverse Situation “

A situation where events areleading to an undesirable outcomeg

These situations are normally indicted by Warning Signs

No IV - central line pulledNo IV central line pulledEyes rolling back15% weight loss15% weight lossNot listening to family’s concernUnusual pt behaviorUnusual pt behaviorNurse appeared hurried, nervous, “odd”Methadone administered after “No narcotics” verbal order

• 7 errors per neonatal arterial switcharterial switch operations (de Levalet al 00)

• 8.8 team errors per ED malpractice case (Riser et al 99)( )

• 4 errors precede/coincide with every medical accident (Reason)97)

“ among all types of medical errors, cases in which the wrong patient undergoes an invasive

d ffi i tl di t i t procedure are sufficiently distressing to warrant special attention. After examining the case of a patient who was mistakenly taken for case of a patient who was mistakenly taken for another patient’s invasive electrophysiology procedure and the results of the institution’s proot cause analysis the team members discovered at least 17 distinct errors, no single

f hi h ld h d hi d one of which could have caused this adverse event by itself.

Mark Chassin MD, MPP, MPH and Elise c. Becher MD, MA , , ,

Case Study

A warning sign to tell you that an adverse situation may be developingsituation may be developingPrepares Team members to take action to prevent an unwanted outcomep

C fli ti F il t t Conflicting inputs

Failure to meet targets

Preoccupation

Not Not addressing discrepanciesNot

communicating

C f iFatigue

Confusion

Violating policy Stress

Violating policy or procedures

“Red Flags”“H d ”

Red Flags“Heads‐up”

“Probable adverse situation”“Probable adverse situation”

See ItSee It

Be able to recognize Red FlagsIf l k f hIf you see one – look for others

Say ItSay It

Fi ItFi ItCommunicate what you see

Say ItSay It

Fix ItFix ItTake action or “Huddle” as appropriateTake action or “Huddle” as appropriate

See it Say itSay it Fix itFix it

CommunicationCommunicationCommunication

Communication

The greatest problem in communication Is the illusion that it has been

accomplished.

It is the critical factor in delivering good healthcare

A factor inA factor in…•80% of adverse events/close-calls

(VA N ti l C t f P ti t S f t E ti S 2007)

•66% of sentinel events

50% f OR (Joint Commission Sentinel Event Alert - Issue 12)

(VA National Center for Patient Safety Executive Summary, 2007)

•50% of OR errors (Gawande et al, 2003)

•30% of OB/GYN adverse events (White et al, 2005)

Assertive

Aggressive

Passive or Passive AggressivePassive or Passive Aggressive

The goal is to dominate and win

“This is what I think, what you think does not tt if d”matter‐you are uniformed”

Often expression of feelings, thoughts in a way that is not wholly truthful

Usually done in an inappropriate and unprofessional manner

Body language‐clenched fists, crossed arms, y g g , ,glaring eyes, intrusive on personal space

How does an aggressiveHow does an aggressive Communication style impact patient safety?

The goal is to appease and avoid conflict at allThe goal is to appease and avoid conflict at all costs

Fail to express your thoughts/opinions

Sarcastic

Give in with resentment

Remain silent

Body language – “The Victim Stance”Body language  The Victim Stance

How does a passive communication style impactcommunication style impact patient safety?

Assertiveness is an attitude and a way of positively relating to those around you;positively relating to those around you; skill set for effective communication includes:includes: 

See yourself as having “worth”See yourself as having  worthYou value others equally, respecting their right to an opinion.to an opinion.Engage in communication respectfully, while also respecting your own opinions.p g y p

Being appropriately assertive means:

Organized in thought and communication

Speak clearly, and audibly

Owned by the entire team (not just a “subordinate” skill‐set, and it must be valued by the receiver to work)the receiver to work)

Seeking clarification/common understandingSeeking clarification/common understanding

Saying “yes” when indicated, but “no” when you mean “no”mean “no”

U i “I” h t ki f th tUsing “I” when not speaking for the team.

R i l d f di i i ifRespectively defending your position, even if it provokes conflict.

Body language – Secure upright position in a relaxed manner making eye contact standingrelaxed manner, making eye contact, standing with open hands.

A iAggressive HostileConfrontationalAmbiguousDemeaningCondescendingCondescendingSelfish

Focus on the common goal:  Patient safety, quality of care – who can disagree with this?

Avoid the issue of who’s right and who’s wrong (check your ego at the door – it is not about you it(check your ego at the door  it is not about you, it is about the patient).

l hDe‐personalize the conversation.

Actively avoid being perceived as judgmental.y g p j g

Be hard on the problem, not the people.

NAMES FIRST – Get their attention

Make EYE ContactMake EYE Contact

Express your concern 

St t th i ( l i )State the issue (clean, concise)

Propose action(s)

Re‐assert as necessary

Agree on a course of actionAgree on a course of action

Escalate up the chain of command if no resolution – remember it is about theresolution – remember, it is about the patient

Assertive StatementAssertive Statement

E

→ Call them by nameGet attention

State the problem

→“I am concerned”Express concern

→ Brief objective & clear

Propose a solution →“We” or “Let’s”

State the problem → Brief, objective & clear

AssertiveAssertiveStatementStatementNo response?No response?

Add “Check”Add “Check”No response?No response?

Relay InfoRelay Info

Nurse Danner: “Doctor, we don’t

Nurse Danner: “Doctor Smith, I’m concerned we h h i Doctor, we don t

have a patient named Morris on

have the wrong patient. We don’t have a patient named Morris on the

h d l b d h the schedule. I’m concerned there

i ht b i ”

schedule but we do have a Morrison. Let’s check her chart and call the fl f hmight be a mix-up.”

Doctor: “This is our patient ”

floor to see if we have the right patient before we proceed.”patient. p

Get A Get A DecisionDecisionDecisionDecision

AssertiveAssertiveStatementStatementN ?N ?

Add “Ch k”Add “Ch k”

StatementStatementNo response?No response?

Start at any Blockb d iti lit

Add “Check”Add “Check”No response?No response?

based on criticalityof situation

Relay InfoRelay Info

AssertiveAssertiveStatementStatementStatementStatement

E

→ Call them by nameGet attention

State the problem

→“I am concerned”Express concern

→ Brief objective & clear

Propose a solution →“We” or “Let’s”

State the problem → Brief, objective & clear

Front Line EXAMPLESEXAMPLES

A ti t i i l l t dA patient is crying, clearly upset and uncomfortable.  The patient’s caregiver, S i t lki d l hi th hSue, is talking and laughing on the phone, clearly on a personal call, and you believe h i i i th ti tshe is ignoring the patient.

What would an assertive statement sound like?

Sue, I am concerned.  Your patient is upset and needs some attentionupset and needs some attention.  Let’s see what we can do for her.

An interventional room is undergoing construction, so the physician decides toconstruction, so the physician decides to perform a case in the OR, despite having been asked not to by the Charge RN, duebeen asked not to by the Charge RN, due to staffing/equipment availability.  The doctor tells the RN to take the patient todoctor tells the RN to take the patient to the OR and the rest of the team can “catch up”.catch up .

Dr., I am concerned that we will not have the things we need to safelyhave the things we need to safely care for the patient.  Let’s discuss this further and get everything into placefurther and get everything into place.

Th k h d l h j bThe new work schedule has just been posted.  Your co‐worker, Nancy,  is unhappy with her assignments and proceeds to disparage the manager p p g gand the schedule in front of patients and familiesand families.

Nancy, I am concerned that your comments may send the wrongcomments may send the wrong message to our patients and families.  Let’s take this discussion to a privateLet s take this discussion to a private area.

You are relieving another RN AnitaYou are relieving another RN, Anita, for lunch in the middle of a 

d Th iprocedure.  There are specimens on the field that have not yet been identified or labeled.  Anita gives report, states she is “very hungry” p , y g yand that you should be able to handle the specimenshandle the specimens.

Anita, I am concerned that th ’ bi t ti l fthere’s a big potential for error here.  Let’s label and verify the yspecimens together before you gogo.

The PACU RN notes a developing hematoma after a carotid procedure, and informs the physician.  The physician states “why are you calling me?  The nurses at the other hospitals never call me for this.  I am not coming there now.”

What would you say in response?What would you say in response?

Dr., I am concerned that this h t ihematoma may compromise your patient’s airway.  Let’s y p ydiscuss our plan of action.

Each and everyone of us are responsible for our individual pcontributions to the team.

And our teams will only be asAnd our teams will only be as successful as our individual contributions to the team allow.

Wh t i lWhat is your personal commitment?commitment?

Recognition and thank you to LifeWings Partners LLC