Perinatal Patient Safety

An interdisciplinary approach to improve performance

J. Chris Carey MDDirector, Obstetrics and Gynecology, Denver Health

Professor, Obstetrics and Gynecology

**High reliability organizations are those that operate highly complex and hazardous

technological systems essentially without mistakes over long periods of time.

High reliability patient care units are built on a solid foundation of timely communication and collegial teamwork to maintain patient

safety as a top priority.** “Managing the Unexpected: Assuring High Performance in an Age of Complexity”

K. Sutcliff, MSN, PhDSan Francisco: Jossey-Bass; 2001

In these units…………• Concise, real-time and constant communication is

valued• Teamwork and collegiality characterize the

professional relationships• Hierarchy is minimized• Safety is the hallmark of the organizational culture• Their operations are viewed as potentially

dangerous• Emergencies are rehearsed and the unexpected

practiced

Partnering Relationships Are………………..

• Collaboration and teamwork that is an authentic partnership in which power on both sides is valued

• Each recognizes and accepts spheres of activity and responsibility

• Each mutually safeguards the interests of each other

• Each recognizes a commonality of goals• Based more on respect and contribution than

power and dependency

Partnership is evidenced by ……

• Communicating with patient’s family and healthcare providers regarding patient care and all providers’ role in the provision of that care

• Collaborating in creating a documented plan, focused on outcomes and communication with families and others

• Partners with others to effect change and generate positive outcomes through knowledge of the patient or situation

Strategies to achieve a strong partnership ethic include:

• Thinking expansively

• Being flexible

• Challenging assumptions

• Abandon the comfort zone

• Redefine boundaries

• Realize the vision

Think Expansively, become a “Totalist”

• Always learning and supporting the changes that benefit the patient

• Thinks beyond the confines of own experiences or knowledge

• Sees the whole picture

• Sees how people and processes work together

Be Flexible

• Adapt to change

• When situations are not controllable, your reaction to it is

• Work together to manage the surprises, ambiguity, conflict or disorientation that are part of every change

Challenge Assumptions

• Never blindly trust assumptions• Build on knowledge and understanding• Mistakes, errors, wrong turns and confusion are

often built on assumptions• Knowing your partners is essential• Believing assumptions to be true encourages a

lose-lose situation that fosters resentment, confusion, delays and waste.

• Stop Making Stuff Up – check it out!

Abandon the Niche

• Step outside of your personal comfort zone• Understand your team• Cannot continue to do things in the old way• Be willing to trust others• Be willing to stretch and share our expertise• Be willing to work on projects that involve others

in the organization• Be willing to take risks

Redefine Boundaries

• Let go of traditional roles

• Eliminate “turf protection”

• Remove barriers to cross-functional interactions

• Think big and out of the box

• Focus on patient needs

Key Elements for success

• Partnership• Equity• Outcomes• Benefits• Barriers• Accountability• Ownership

Why Effective Communication and Teamwork ?

• The overwhelming majority of untoward events involve communication failure

• Somebody knows there’s a problem but can’t get everyone in the same movie

• The clinical environment has evolved beyond the limitations of individual human performance

MD –RN: DifferentCommunication Styles

• Nurses are trained to be narrative and descriptive

• Physicians are trained to be problem solvers - “what do you want me to do” – “ just give me the headlines”

• Complicating factors: gender, national culture, the pecking order, prior relationship

• Perceptions of teamwork depend on your point of view

Effective Communication Requires:

* Structured communication – SBAR* Assertion/ Critical Language – key words,

the ability to speak up and stop the show* Psychological safety – an environment of

respect

Situational Briefing Model

S-B-A-R*Situation*Background*Assessment*Recommendation

SBAR in OB

* S – Impending uterine rupture* B – VBAC, dense epidural, persistent

breakthrough pain, complete* A – I’m concerned, something’s

wrong* R – I think she needs a C-S. I need

you now

SBAR

* Situation – the punch line 5-10 seconds* Background – the context, objective

data, how did we get here * Assessment – what is the problem ?* Recommendation – what do we

need to do ?

Assertion

• Model to guide andimprove assertion inthe interest of patient safety

GET PERSON’SATTENTION

EXPRESSCONCERN

REACHDECISION

STATEPROBLEM

PROPOSEACTION

*

The Difficult Conversation

* Focus on the common goal – high quality, safe care

* 3rd person – depersonalize the conversation – it’s not about you and me

* Avoid judgment; who’s right, who’s wrong is a loser

* What needs to happen for us to do the right thing here?

“Difficult Conversations”: Stone, Patton, Heen; Viking (1999)

Sustaining SBAR Use

• “Give it to me in SBAR”

• Use prompts and ticklers– Checklists– Phone labels– Pocket cards

• “Thanks for using SBAR”

• Reward and recognize