Armstrong Institute for Patient Safety and Quality1

On Boarding Call Schedule –Tuesdays 8/21–9/25 @ 2:00

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Learning Objectives

• To understand the basics of communication

• To understand the importance of having daily goals

• To learn how to implement daily goals in your ICU

• To understand that daily goals is a tool to improve teamwork and communication AND supports interventions to reduce VAP

Implementing Daily Goals

Nishi Rawat , M.D.Johns Hopkins Community PhysiciansArmstrong Institute for Patient Safety and Quality

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CUSP & VAP Interventions

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Basic Components and Process of Communication

Elizabeth Dayton, Joint Commission Journal, Jan. 2007

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Six Factors of Communication Risk

Woods. Pt Saf Qual Healthcare May/June 2006

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Communication and Health Care

Lawton et al. BMJ Qual Saf 2012;21:369-80

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Communication and Health Care

• 65% of all sentinel events occur due to breakdowns in communication (JCAHO 2005)

• Nurses: communication with physicians is a leading contributing factor for medical errors (NCSBN)

• 7% of respondents involved in medication error in past year in which intimidation played a role (ISMP 2003)

• High performing ICUs: team-oriented, shared beliefs, education, collegiality, informal but direct communication, collaborative problem-solving (Zimmerman et al. 2003)

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ICU Physicians and ICU RN Collaboration

Huang, DT et al. Crit Care Med 2007 jan 35(1): 165-76 S Data

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ICU Physician Rounds

• Should include a multidisciplinary group of professionals as applicable:– Physicians, nurses, pharmacists, respiratory

therapists• Should be conducted at bedside if at all

possible– Allows patient and/or family involvement

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Crew Resource Management (CRM)

• Safety training program focused on effective team management to improve performance

• Targets cognitive and interpersonal skills• Goal: improve situational and self-awareness,

communication, flexibility, assertiveness, adaptability

• Create a culture where there is freedom to question authority

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Communication and Aviation Accidents

Aviation Safety Network

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Conventional rounds

• Communication defects are common

• Rounds are generally provider rather than patient centered

• Discussion on rounds is more divergent (brainstorming) rather than convergent (explicit plan)

• Prevents effective real-time or future feedback regarding plan of care

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Rounds with Daily Goals

• Creates explicit goals and enables feedback toward goals to achieve more for the patient

• Standardizes communication to reduce encoding and decoding errors, and creates independent checks

• Adds convergent thinking to often divergent rounds

• Helps ensure diverse input

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Structure of Daily Goals Tool

• Items organized by organ system• Medication review section• To Do, Disposition, Family meeting and Code

status sections• What can we eliminate? Lines, labs, abx…• Safety item• Include VAP process measures• Check boxes vs open-ended vs combination• One column vs second column for night goals

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How to Use Goals?

• Be explicit

• Important questions– What needs to be done for discharge?– What will we do today?– What is the patient’s greatest safety risk?

• Completed on rounds and nurse reads back

• Stays with bedside nurse

• Modify to fit your hospital

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Percent Understanding Patient Care Goals

Pronovost J Crit Care 2003;18(2):71-5.

Implemented patient goals sheet

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Impact on ICU Length of Stay

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Recent Data in Support of Daily Goals

• Narasimhan et al. 2006: MICU– Provider understanding of goals improved– Improvement in communication scores– LOS decreased from 6.4 to 4.3 days

• Agarwal et al. 2008: PICU– Provider understanding of goals improved– Trend toward decrease in LOS, not significant

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Comprehensive Unit-based Safety Program (CUSP)

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Action Plan

• Present the idea to your ICU team• Draft a daily goals form• Obtain support from one or more ICU

physicians• Pilot test on a couple of patients on rounds• Get feedback from nurses and physicians• Revise and expand• Monitor physician paging, track LOS….• Share your tool with the other teams

Armstrong Institute for Patient Safety and Quality

Questions

– Karol G. Wicker, MHSSenior Director, Quality Policy & AdvocacyMaryland Hospital Associationkwicker@mhaonline.org

– Mary Catanzaro RN BSMT CIC Project Manager HAIs Hospital and Healthsystem Association of Pennsylvaniamcatanzaro@haponline.org

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What Should you do NOW?

CUSP Preparation: 1) Assemble team2) Schedule meetings

CUSP Implementation:1) Science of Safety Training for all staff2) Identify Defects: How will the next patient be harmed?3) Use elements of Toolkit, including Daily Goals

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References - 1

Slide 5Dayton E, Henriksen K. Jt Comm J Qual Saf. 2007 Jan;33(1);34-47.

Slide 6Woods MS. How Communication Complicates the Patient Safety Movement. 2006 May/June. http://www.psqh.com/mayjun06/dun.html.

Slide 7Lawton R, McEachan RR, Giles SJ, Sirriyeh R, Watt IS, Wright J. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ Qual Saf. 2012 May;21(5):369-80. Epub 2012 Mar 15.

Slide 9Huang DT, Clermont G, Sexton JB, Karlo CA, Miller RG, Weissfeld LA, Rowan KM, Angus DC. Perceptions of safety culture vary across the intensive care units of a single institution. Crit Care Med. 2007 Jan;35(1):165-76.

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References - 2

Slide 12 Aviation Safety Network

Slide 17 and 18Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communications in the ICU using daily goals. J Crit Care. 2003 Jun;18(2):71-5.

Slide 19Narasimhan M, Eisen LA, Mahoney CD, Acerra FL, Rosen MJ. Improving nurse-physician communication and satisfaction in the intensive care unit with a daily goals worksheet. Am J Crit Care. 2006 Mar;15(2):217-22.Agarwal S, Frankel L, Tourner S, McMillan A, Sharek PJ. Improving communication in a pediatric intensive care unit using daily patient goal sheets. J Crit Care. 2008 Jun;23(2):227-35.