Quality and Safety: Are you creating an environment for safe, high quality care?

Carolyn O’Brien, MSN, RN

Mayo Clinic

• International reputation for excellent patient care

• Long tradition of focus on quality care, putting the patient first

• Primary Value:• “The needs of the patient come first”

Mission and Vision

• To inspire hope and contribute to health and well-being by providing the best care to every patient through integrated clinical practice, education and research

• Mayo will provide an unparalleled experience as the most trusted partner for healthcare

• In order to be trusted, we must be safe

How does Mayo define Quality?

• Service

• Outcomes

• Safety

Service

• Patient Satisfaction

• Awarded #1 hospital in patient satisfaction in 2010 and 2011 by Professional Research Consultants, Inc. (PRC) –patient satisfaction vendor

• Strong organizational focus and leadership involvement

Outcomes

• Quality Improvement (QI)• Strongly woven into the fabric of our

organization• Improve outcomes by improving systems

and processes

• Positive, healthy culture is determining factor in success or failure of performance improvement interventions

Safety

• Foundation of Quality Care

• Mayo’s Commitment to Safety• Healthy culture, where staff speak up about

safety concerns and work in an environment where we learn from and respond fairly to errors

• Safe behaviors• Safe systems and processes

Culture and Patient Safety

• Required elements for a healthy culture• Psychological safety• Organizational fairness• Transparency

Psychological Safety

• Definition: “people’s perception of the consequences associated with taking personal risks.” (TEM Field Manual, 2012)

• Present when people feel free to speak up and questions are welcomed

• Mutual respect is key• Professional tone of communication• Flattened hierarchy between disciplines• Management of disruptive behavior

How do we know if we have psychological safety?

• Staff are not hesitant to speak about patient safety concerns

• Staff are treated with respect when concerns are expressed

• Concerns are acted on

How do we promote psychological safety?

• Unit and organizational leaders encourage staff to raise concerns and welcome it

• Encourage feedback and act on it

• Celebrate and praise new ideas

Organizational Fairness

• Historically- healthcare has been a culture of blame and punishment, a punitive culture

• A punitive culture discourages staff from speaking up

• Safety depends on people speaking up• Reporting errors• Reporting and identifying “near misses”

Just Culture

• “Leaders, managers and staff all value safety and create an environment where mistakes can be shared and learning occurs through identification of faulty processes and at-risk behaviors (J of Nurs Qual Vol 22, No.3 pp 210-212)

• Encourages staff to use their unique position on the “frontline” to identify safety issues and speak up

Fair and Just Culture

• Moving from culture of blame, to “fair and just”

• Responding to errors in a fair and consistent manner

• System of accountability

• Systems and behaviors are examined

• Not individuals and outcomes(Mayo Clinic and Pascal Metrics, Inc. 2012)

Individual Behavioral Choice

• Human error• Inadvertent action • Lapse, slip, mistake• Often involve underlying system issues• Increases with complexity of task

Individual Behavioral Choice

• Risky (Drift)• Behavioral Choice that increases risk where

risk is unrecognized or mistakenly believed to be justified

• Drift- “individual drifts away from what has been taught through the human desire to accomplish more or through a fading perception of risk as the individual becomes increasingly comfortable or competent in their work”

(Outcomes Engineering, LLC, 2007)

Individual Behavioral Choices

• Reckless• Behavioral choice to consciously disregard a

substantial and unjustifiable risk• Putting self-interest above that of the patient

or organization

Management Response

• Thoughtful deliberation related to staff choices

• Human error• Console and Learn

• Risky • Coach/Learn

• Reckless• Corrective Action

Transparency

• Leaders conduct rounds to seek out and discuss current processes and opportunities for improvement

• Outcomes, adverse event, near misses are openly discussed on regular basis and data is shared with all caregivers

• Learning is visible - Boards on units that show active work on process improvement

This is Mayo Clinic’s Commitment to Safety

System Competency

Behavioral Competency

Clearly Defined Behaviors

• Pay attention to detail

• Communicate clearly• Have a questioning

and receptive attitude

• Hand-off effectively• Support each other

Accountability for Behavior

Preventable Harm

Commitment to Safety in a fair & just culture

Standardization & Diffusion of Best Practices

Safe Care & Value

• Handoffs and transitions

• Medication errors• Rapid response team

and deteriorating patient

Approved by BOG/Management Team 1/24/2011

Pay Attention to Detail

• Intentional focus on specific task to avoid errors

• Mindful of task and ramifications

• Eliminate distractions-noise, interruptions, other thoughts

(Mayo Clinic and Pascal Metrics, Inc.)

Communicate Clearly

• Accurate exchange of information that ensures comprehension

• Communication is intentional, respectful

• Be aware of body language and tone

• Verify accuracy and understanding

(Mayo Clinic and Pascal Metrics, Inc.)

Have a Questioning and Receptive Attitude

• Empowerment to speak up without fear in order to prevent harm

• Open and respectful to those asking questions

• Responsive and appreciative for concerns raised

• Mutual respect

(Mayo Clinic and Pascal Metrics, Inc.)

Hand off Effectively

• Interactive process of passing on specific information from one person to another, transferring responsibility

• Watch body language, tone, respectful, non-intimidating

(Mayo Clinic and Pascal Metrics, Inc.)

Support Each Other

• A spirit of teamwork, collaboration and cooperation across professions and at all staff levels

• Mutually supportive and respectful behavior- keeping a common goal first- the patient

(Mayo Clinic and Pascal Metrics, Inc.)

Safe Behaviors = How we communicate

• Effective communication is integral part of a healthy, safe culture• Communicate clearly- “speak up”• Handoff effectively• Questioning and receptive attitude• Support each other

How do nurse leaders at every level contribute to safe, high quality care?

• Create environment and culture where staff feel empowered to:• Speak up• Question the way we do things• Support one another• Are accountable for choices/actions• Learn from errors, don’t blame others

Leadership

• Unit and organizational culture is shaped by leaders attitudes and behaviors

• Effective leaders • Set a positive tone on unit• Share the plan, think out loud and elicit staff

input related to their expertise, ideas and concerns

• Are approachable, encourage open communication

Teamwork and Communication

• The next steps in keeping our patients safe and preventing harm focuses on teamwork

• High performing, effective teams have• Team Behaviors

• Structured communication• “Hard-wire” performance improvement

into everyday work• Team Attitudes

• Ensure psychological safety• Set expectation of excellence

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A Team is a Group with:

• Common goals and a game plan• Agreed upon behaviors• Agreed upon attitudes

MAYO’S 5 SAFE BEHAVIORS ARE NORMS

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A Team:

Plans Forward

Reflects Back

Briefings (huddle, pause, timeout, check-in)

Debriefings

Communicates Clearly Using Structured Critical Language

The associated behaviors:

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Briefings

•Also known as:•Huddle•Pause•Timeout•Check-in

COMPONENTS

• Everyone knows the game plan

• Psychological Safety is ensured

• Expectation of excellence is set

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Debriefings

•Debriefings can be the best tool for learning

•Three Questions

• What did we do well?

• What could we do better?

• What do we want to dodifferently tomorrow ornext time?

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Critical Language:

•Positive Assertion•A PHRASE THAT STOPS THE WORK•“I just need a little clarity.”•“I am concerned, unclear, this is unsafe.”

•SBAR•Situation, Background, Assessment, Recommendation•Structured, predictable method of communication

•Repeat Back•Critical labs, medication dosages

“Mayo’s Model of Teamwork”Team Training

• ID unit, collect data, share results, team training

• Ensure psychological safety

• Embed team behaviors• Briefings, debriefings, critical language

• Improve processes

• Make work visible- transparent• Learning boards• Set goals• PDSA• Display knowledge gained

• Sustainable process to effect needed improvement

Team-Based Engagement

Collect Data

TeamTraining

Identify Unit

Implement Team

Behaviors 1

Improve Systems (based on

debriefings)2

Display the Data (learning

boards)

3

Eliminate

Preventable

Harm

Culture & Teamwork

Systems

©2011 MFMER | slide-38

Learning Board3 North

Ongoing Work: Further shifting our culture

• Model of teamwork

• How we….• do our work• communicate • identify safety concerns• improve safety• improve outcomes• improve quality

• It is a journey……

Questions?

References• Mayo Clinic and Pascal Metrics, “Commitment to Safety Team-based Engagement Model

(TEM)” PowerPoint, July 31, 2012.

• Mayo Clinic. (2012). Mayo Clinic Commitment to Safety. Retrieved July 28, 2012 from Mayo Clinic Web site: http://intranet.mayo.edu/charlie/commitment-to-safety/

• Mayo Clinic and Pascal Metrics, Inc., Team-based Engagement Model (TEM) Field Manual, 2012.

• Outcomes Engineering, LLC. (2007). Just Culture Training for Healthcare Managers. Plano, TX: Outcome Engineering, LLC.

• Volgesmeier, A., Scott-Cawiezell, J. (2007). A Just Culture The Role of Nursing Leadership. Journal of Nursing Quality, Vol 22, No.3 pp 210-212.