aileen r. killen head of casualty risk consulting ... · pdf file20.12.2012 ·...

Talk to Me Teamwork and Communication as Best Practices for

Patient Safety

September 29, 2015

Aileen R. Killen

Head of Casualty Risk Consulting

Healthcare

+1 646 857 0261

[email protected]

International Forum on Quality and Safety in Healthcare

Freedom from accidental injury (IOM)

Discipline in health care sector that applies safety science methods

toward the goal of achieving a trustworthy system of health care

delivery…an attribute of health care systems; it minimizes the

incidence and impact of, and maximizes recovery from, adverse

events (AHRQ).

The avoidance, prevention, and amelioration of adverse outcomes or

injuries stemming from the processes of health care. These events

include “errors”, “deviations”, and “accidents”. Safety emerges from

the interaction of components of the system; it does not reside in a

person, device or department (NPSF)

The absence of preventable harm to a patient during the process of

health care (WHO)

2

What is patient safety? Key definitions

Two or more individuals

Meaningful task interdependence

Have a leader

Have specialized member roles

and responsibilities

Intensive communication

3

Characteristics of all teams

What makes a team?

Posses specialized and

complimentary knowledge and

skills

Know their role and roles of

others on the team

Make decisions

Often function under high-

workload conditions

Act as a collective unit as a

result of interdisciplinary tasks

performed by team members

4

Characteristics

What is a health care team?

World Health Organization (2012)

Core teams

– Direct care providers

Coordinating teams

– Provide operational management and resource management for core

teams

Contingency teams

– Formed for emergent or specific events

Ancillary services

– Provide services that facilitate patient care

Support services and administration

– Leadership

5

Types of teams found in healthcare World Health Organization


Team leadership

– Task Coordination and Planning

– Development and Motivation of team

Mutual performance monitoring

– Understand environment to identify lapses in task assignment or task overload

– Situational Awareness

Backup behavior

– Understand tasks of other team members to in order to redistribute work or support others

Adaptability

– Respond to changes in the environment

Team orientation

– Take others ideas into account

– Team goals more important than individual goals

6

Key dimensions of effective teams

Salas, E., Simms, D.E., & Burke, C.S. (2005).

Respect and trust in order to debrief and give feedback

Good communication skills to accurately convey information

Shared mental model (Situational awareness)

– Be on same page

– Be in same movie

Is your team

– Team of experts ?

or

– An expert team ?

7

Requirements for effective teams

What teamwork is

– Set of interrelated behaviors, cognitions and attitudes

– Distinct from task work

– Members anticipate each others needs

– Collective set of efficacy and “teamness”

– Provide back-up behaviors

What teamwork is NOT

– Not automatic response to putting people together

– You do not need to like all members of your team

– No need to work with team members on a permanent basis

8

Teamwork and patient safety

Salas (2008)

9

What’s different?

Action teams

– Conditions change frequently

– May be assembled ad hoc

– Have a dynamically changing

team membership

– May work together for short

periods of time

– Consist of specialists

– Have to integrate different

professional cultures

Teamwork in healthcare

Manser, T. (2009)

Transfer of information, idea, feelings

Functions of communication in a healthcare system

– Provides knowledge

– Establishes relationships

– Supports leaderships and team co-ordination

Model of communication

– Sender convert an idea into a message

– using medium (written, verbal) to transmit message to one or more

receivers

– who then translate the message back to the original idea

10

What is communication? World Health Organization (WHO)


Transmission failures

– Information not transmitted – message is unclear

Ambiguity of message

Problem with medium

Reception failures

– Information not received

– Information with sent but misrepresented, ignored, etc.

11

What is communication? How can it fail?

Knowing the game plan

Getting in the huddle

Giving signals

Listening to the coach

Revising the game plan

Sitting on the bench

12

Team huddle

Effective communication

What we know about teamwork and communication

13

And the literature says….

Retrospective analysis of incident and adverse events found

communication and teamwork issues to be among the most frequent

contributing factors

Observational studies and retrospective analysis show that many

factors that contribute to incidents or adverse events come from

inadequate teamwork and NOT lack of clinical skills

Healthcare providers place a great deal of importance on aspects of

teamwork such as communication and collaboration

Studies identified differences in perceived quality of teamwork

between professional groups

Studies indicate staff perceptions of teamwork are related to quality

and safety of patient care

14

Key concepts about teamwork and safety From review of the literature (1998-2007)

Manser, T. (2009)

Patient safety; Hospital risk

WHO HOW MANY WHEN HOW

Hospital C-Suite

Executives and

Risk Managers

from hospitals

representative of

the US landscape

N=250 Hospital C-Suite

Executives

N=100 Risk Managers

46% CNO

40% COO

Remainder CEO, CMO

and CFO

Data collection

occurred

November 13 –

December 20, 2012

Computer-Assisted

Telephone

Interviews

Perspectives of hospital C-Suite and Risk Managers

AIG (2013)

Four core themes emerged…

1 Patient safety and financial sustainability challenge hospital C-Suite and

Risk Managers for their time and attention

2 Who is “responsible for” patient safety and who “owns” patient safety do

not fall within the same role at the hospital.

3 “Lack of teamwork, negative culture and poor communication” is

the number one barrier to ensuring a safe environment for patients.

4 Perceived “enhancements” to patient safety—such as technology, regulation

and metrics —can have the opposite effect.

AIG (2013)

17 17

Lack of teamwork, negative culture and communication are

seen as the top barrier to patient safety.

B5. In your own words, what do you feel are the barriers to improving patient safety in your hospital? (split sample;

n=125 C-Suite, n=96 Risk Managers)

*Statistically significant difference between C-Suite and Risk Managers

The culture between the nurses

and the physicians. The lack of

autonomy the nurses have. The

amount of control medical staff

have.

– C-Suite

“ “ The barriers are the

communication with the

healthcare team. The handoff from

one unit to another and from one

physician to another physician or

nurse is a hard transition for the

patient.

– Risk Manager

“ “ Barriers to Improving Patient Safety

42%

22%

18%

10%

8%

7%

13%

4%

3%

55%

10%

4%

3%

9%

14%

15%

10%

28%*

Lack of team work /

negative culture and

Lack of staff

Financial issues

Tim e

Resources/equipm ent

Training/education

O ther

Nothing

DK/Refused

C-suite

Risk M anagers

communication

18 18

Teamwork and communication problems are at the core of

patient safety risk.

B4. Which of the following contribute to patient safety risk? (n=250 C-Suite, n=100 risk managers)

*Statistically significant difference between C-Suite and Risk Managers

Prospective intervention study in Oxford, UK

Using models from Formula 1 and aviation to improve handovers from

surgery to ICU

Results

– Mean decrease in technical errors during handovers from 5.42 to 3.15

– Mean decrease in omissions 2.09 to 1.07

– Duration of handover reduced 10.8 to 9.4 minutes

39% of patients pre-intervention had more than one error in handover;

11.5 % of patients with new protocol

19

Effective communication Patient handover

Catchpole, KR, De Leval, MR, McEwan, A, Pigott, et al (2007)

Survey of 60 hospitals

Use of Safety Attitudes

Questionnaire

Response rate 77.1 %

(2,135 / 2,769)

20

In the eye of the beholder

Operating Room teamwork

Makary, MA, Sexton, JB, Freischlag, JA, Holzmulueller, et al (2006)

Differing perceptions

From members of the healthcare team

Anesth

.

Nurse

Surgeon

CRNA


From the view of the surgeon


Anesth

84%

Nurse

88%

Surgeon

85%

CRNA

87%


From view of anesthesiologist

Anesth

96%

Nurse

89%

Surgeon

70%

CRNA

92 %



From the view of the CRNA


Anesth

75%

Nurse

76%

Surgeon

58%

CRNA

93%


From the view of the OR nurse

Anesth

63%

Nurse

81%

Surgeon

48%

CRNA

68%



Do not delay operating room start times ( Ali,et al , 2011) – 5-10 minute safety briefing between surgeons, anesthesia staff and

nursing staff to discuss operating list

– Great Western Hospital, UK

Reduce nonroutine events ( Einav, et al 2010)

– Reduction (25%) in number of nonroutine events with briefing;

– increase in number of surgeries with no nonroutine events ( Einav, et al 2010)

– Haifa Israel

Do not take a long time (Berenholtz,et al 2009) – 2.9 minutes for briefing

– 2.5 minutes for debriefing

– Baltimore, MD , USA

Improve compliance with antibiotic and DVT prophylaxis ( Lingard, et al (2011; (Paull, et al 2010) – Ontario, Canada

– USA

26

Briefings as a communication tool Preoperative briefings and huddles

Strategies from around the globe

27

International Experiences

Program developed to respond to areas identified as needing improvement in

culture surveys over several year

– Teamwork across hospital units

– Handover

Based on “ideal” communication and teamwork of Formula 1 car racing pit

crew

– Mind your Ps - 4 “P’s”

Presider : leadership

Player: role of each member

Process: vital steps

Purpose: common goal

28

An effective approach to patient safety National University Hospital Singapore

Mujumdar,S. & Santos, D (2014)

Need effective communication of the 4 Ps to execute the patient safety task at

hand

What else gets in the way?

– Number of lines of communication in complex patient care scenarios

– Mode of communication – oral, written, electronic

– Cultural factors

Nurses are narrative and descriptive

Physicians prefer brevity

Strategies

– Practice, Practice, Practice

Assertion

Empathy

SBAR

TeamSTEPPS®

29

An effective approach to patient safety National University Hospital Singapore

“Between the Flags” program in NSW Public Hospitals (2010)

– Over 200 facilities

Role of High reliability teams in responding to clinical deterioration

Based on work in 1980’s in UK to identify patients who were

deteriorating

– Vital signs thresholds

– Criteria for escalation

Evaluation under way

– Also role of culture on implementation

of program (with University of NSW)

30

Keeping patients safe New South Wales, Australia

www.cec.health.nsw.gov.au/programs/between-the-flags

http://www.cec.health.nsw.gov.au/programs/between-the-flags





Doing what we already know how to do

Create conditions that prompt, reward and facilitate appropriate

behaviors

7 step plan Overcoming educational barriers

1. Teach effective communication strategies e.g. SBAR

2. Train teams together

3. Train teams using simulation

– Overcoming psychological barriers

4. Define inclusive teams

5. Create democratic teams

– Overcoming organizational barriers

6. Support teamwork with protocols and procedures

7. Develop an organizational culture supporting healthcare teams

31

Overcoming barriers to effective communication University of Auckland, New Zealand

Weller, J., Boyd, M., & Cumin, D. (2014)

Means to reduce the authority gradient

– Among different professional groups

– Among senior and junior staff in the same professional groups

– Reluctance to speak up often related to previous rudeness or intimidation

Overcome ineffective communication due to differences in communication styles

Strategies

– Team Briefings and debriefings

You cant debrief it you did not brief (ark)

Huddles

– Structured Communication Tools

SBAR

CUS

Memory Joggers (checklists)

32

Strategies to improve communication University of Mandurah, Western Australia

Gluyas (2015)

A different methodology to study handoffs

Use of philosophy and methodology of Appreciative Inquiry (AI)

– Change management technique that looks at what works well

– Positive cousin of root cause analysis

Because most handoffs go well

– Structured interviews with 29 nurses, 5 ward clerks, 2 home health

coordinators, 9 allied health clinicians, 2 patients, 1 family member

– Key Themes

Identified situational variables necessary for perfect transfer

Mode and transfer –related communication

Important factors with patient and family

33

Building teamwork and trust University of Manitoba, Canada

Clarke, D., Werestiuk, K., Schoffner, A., Gerard, J., et al (2012)

What do “we” all need to do?

34

So what does it all mean?

Know thy self

– What kind of clinician am I?

Do I take shortcuts

– Be mindful

Do I have it right?

What is the worst it could

be?

– Develop Internal Alarms

Know when you are drifting

– What is drift?

Gradually downgrade the

significance of risk until it is

accepted as normal part of

work

35

How to be safe

Picture here

Patient Safety

Know thy Colleagues

– Teamwork

Who is on your team?

Do your know their names?

– Formal leaders

Board

C-suite

– Informal leaders

– Patients

36

How to be safe

Patient Safety

TeamSTEPPS®

– Developed by Agency for Healthcare Research and Quality

– Incorporated by WHO in Patient Safety Curriculum

– Strategies & Tools to Enhance Performance and Patient Safety

Key Principles

– Team Structure

– Leadership

– Situation Monitoring

– Mutual Support

– Communication

37

Team Training It takes practice, practice, practice

www.ahrq.gov/health-care-information/topics/topic-teamstepps

http://www.ahrq.gov/health-care-information/topics/topic-teamstepps







Organize and lead team events

– Brief

– Huddle

– Debrief

Effective Leadership

– Flat hierarchy

– Share the plan

– Invite others into the conversation

– Explicitly ask people to share questions and concerns

38

TeamSTEPPS® Leadership









Continually scanning and assessing the environment to maintain

situational awareness

Ensure all team members are “on the same page” and “have each

others back”

Loss of Situational Awareness

– Trying to do something new under pressure

– Doesn’t feel right

– Boredom

– Being rushed being behind schedule

39

TeamSTEPPS® Situation Monitoring









Foster climate where it is expected that assistance will be actively

sought and offered

– Go from “I am not sure but this must be right” to “ I will assume this is not

right until I get proof otherwise”

Provide feedback to improve team performance – Timely, respectful, specific, directed towards improvement, considerate

Advocate for the patient when team member viewpoint do not agree

with decision maker

Assert a correction action

– Two- Challenge Rule

– “Stop the line”

– It’s okay to CUS

40

TeamSTEPPS®

Mutual Support









SBAR

– Situation

– Background

– Assessment

– Recommendation

Call Outs for critical information

– Informs all at same time in emergency

– Airway status? Airway clear

Closed- Loop Communication

Critical Language

Handoff

41

TeamSTEPPS® Communication









42

Final Thoughts

Questions, please!

43

Discussion

44

References

AIG (2013). Patient Safety; Hospital Risk – Perspectives of Hospital C-suite

and Risk Managers.

Ali, M., Osborne, A., Bethune, R., & Pullyblank, A. (2011). Preoperative

surgical briefings do not delay operating room start times and are popular with

surgical team members. Journal of Patient Safety, 7 (3): 139-43.

Berenholtz, B.M., Shumacher, K., Hayanga, A.J., Simon, M. Goeschel, C.,

Pronovost, P.J., Shanley, C.J., & Welsh, R.j. (2009). Implementing

standardized operating room briefings and debriefings at a large regional

medical center. Joint Commission Journal of Quality and Patient Safety, 35 (8):

391-7.

Cathchpole, K.R., De Leval, M.R.. McEwan, A., Pigott, N., Elliot, M.J.,

McQuillan, A., MacDonald, C., & Goldman, A.J. (2007). Patient handover from

surgery to intensive care: using Formula 1 pit-stop and aviation models to

improve safety and quality. Pediatric Anesthesia, 17: 470-478.

45

References

Einav, Y. Gopher, D. Kara, I. Ben-Yosef, O. Lawn, M., Laufer, N. Lievergall,

M. Donchin, Y. (2010). Preoperative Briefing in the operating room: shared

cognition, teamwork and patient safety. Chest. 137 (2): 443-9.

Lingard, l., Reghr, G. Cartmill, C. Orser, B. Espin, S., Bohen, J., Reznick, R.

Baker, R. Rotstein, L., & Doran, D. (2011). BMJ Quality and Safety, 20 (6): 475-

82.

Makary, MA, Sexton, JB, Freischlag, JA, Holzmulueller, et al (2006).

Operating Room Teamwork among Physicians and Nurses: Teamwork is in the

Eye of the Beholder. Journal of the American of Surgeons, 202 (5), 746-752.

Manser, T. (2009) Teamwork and patient safety in dynamic domains of

healthcare: a review of the literature. Acta Anaesthesiologica Scandinavica, 53,

143-151.

46

References

Mujumdar, S. & Santos, D. (2014). Teamwork and communication: An

effective approach to patient safety. World Hospitals and Health Services, 50

(1), 19-22.

Salas, E., Sims, D, Klein, C. & Burke, C.S. (2003). Can Teamwork enhance

safety?. Risk Management Foundation Forum, 5-9.

Salas, E., Simms, D.E., & Burke, C.S. (2005). Is there a “Big Five” in

teamwork? Small Group Research, 36, 555-99.

Weller, J., Boyd, M., & Cumin, D. (2014) Teams, tribes and patient safety:

overcoming barriers to effective teamwork in healthcare. Postgraduate

Medicine Journal,90,149-154

47

References – Websites


www.cec.health.nsw.gov.au/programs/between-the-flags

World Health Organization (2009). Human Factors in patient safety: review of

topic and tools. Report for methods and measures working group of WHO

patient safety. Retrieved from

www.who.int/patientsafety/research/methods_measures/human_factors/hum

an_factors_review.pdf

World Health Organization (2012). Being a team player. To Err is Human

Course, 1-5. Retrieved from

www.who.int/patientsafety/education/curriculum/course4_handout.pdf













http://www.who.int/patientsafety/education/curriculum/course4_handout.pdf

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aileen r. killen head of casualty risk consulting ... · pdf file20.12.2012 ·...

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