this presentation/publication/ or other product is derived from work supported under a contract with...
TRANSCRIPT
THIS PRESENTATION/PUBLICATION/ OR OTHER PRODUCT IS DERIVED FROM WORK SUPPORTED UNDER A CONTRACT WITH THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ) (Contract No. HHSA290200600022, TASK ORDER # 7). HOWEVER, THIS PRESENTATION/PUBLICATION/OR OTHER PRODUCT HAS NOT BEEN APPROVED BY THE AGENCY.
Your Feedback Is Important!
https://www.surveymonkey.com/s/9YC9D37
4
CUSP ToolsName of CUSP Tool Purpose
Science of Safety Training Attendance Sheet
Verify participation in screenings of the “Understand the Science of Safety” educational video
Staff Safety Assessment
Inventory threats to patient safety that frontline care providers identify
Background Quality Improvement Form (Team List)
Gather names, titles, and contact information for unit safety improvement team
Learning From Defects Set up a process to learn from and respond to defects within the unit
Case Summary Form Analyze a case example of patient harm or a near-miss to identify system factors and opportunities for improvement
Daily Goals Checklist Improve team communication regarding the patient’s plan of care
More CUSP ToolsName of CUSP
ToolPurpose
Morning Briefing Get everyone on the same page at the beginning of a day or shift to set expectations and make the day more predictable
Shadowing Another Professional
Identify and improve communication, collaboration, and teamwork skills among different practice domains
Safety Issues in the Executive Partnership
Identify safety issues and recommendations for improvement identified by frontline staff in conversation with a senior executive.
Status of Safety Issues
Track previously identified safety issues and recommendations for improvement and status of improvement efforts
Culture Debriefing Tool
Provide a structured process to make culture results actionable 5
Learning Objectives
Determine next steps for your team
Review and understand the key steps of the CUSP Toolkit
Review key CUSP tools
Learn how Just Culture principles can augment CUSP
6
CUSP Toolkit Modules
Introduce CUSP
Assemble the Team
Engage the Senior Executive
Understand the Science of Safety
Identify Defects Through Sensemaking
Implement Teamwork and Communication
Apply CUSP
7
Video
(10-minute Conclusion video)
8
Assemble the Team
Understand the importance of your CUSP team
Develop a strategy to build a successful team
Define roles and responsibilities of team members
Identify characteristics of successful teams and barriers to team performance
9
10
Keys to Assembling the Team
Remember that culture is local
Include engaged frontline providers who take ownership of patient safety
Select team members with different levels of experience
Include team members based on clinical intervention
Hold regular meetings (weekly or monthly), set action items, and create meeting agendas
Encourage input from all team members
11
Assemble the Team: What the Team Needs to Do
Recruit a team lead, nurse manager, physician, and executive partner along with any other team members
Meet with hospital departments (risk management, quality improvement, infection prevention) to ensure that CUSP efforts are integrated into overall hospital quality improvement and patient safety efforts.
List team member names and contact information on the Background Quality Improvement Form and post the form in a central location
Leverage the 4Es to ensure team engagement:
1. Engage them in the process
2. Educate them about their roles
3. Execute the processes
4. Evaluate what you did
12
Engage the Senior Executive
Identify the main characteristics and responsibilities of the Senior Executive
Understand the role of the Senior Executive in addressing technical and adaptive work
Learn how to engage and hold your Senior Executive accountable
Apply tactics used by leaders to engage the Senior Executive
13
Keys to Engaging the Senior Executive
Show how CUSP supports and leverages other improvement projects
Illustrate how CUSP will increase the senior executive’s visibility
Ensure that a senior executive is assigned to and meets regularly with the CUSP team
Identify safety issues in the Safety Issues Worksheet for Senior Executive Partnership or a tracking log
14
Engage the Senior Executive: What the Team Needs to Do
The CUSP team leader or members of the safety team should meet with the senior executive before the executive holds safety rounds to share unit-specific information• In preparation, gather relevant information about the unit for the
senior executive
During executive safety rounds, the patient safety team, senior executive, and unit providers should review any safety issues identified, particularly those related to CAUTI, and list them on a tracking log• In preparation for executive safety rounds, the unit champion
should: Brief providers on the purpose of partnering with a senior
executive Ask them to be prepared to discuss their own safety concerns and
suggestions for resolution during rounds
15
Understand the Science of Safety
Recognize the historical and contemporary context of the science of safety
System design affects system results
List the principles of safe design
Safe design principles apply to technical and team work
Teams make wise decisions when there is diverse and independent input
16
Keys to Understanding the Science of Safety
Develop a plan to have all staff on your unit view the Understand the Science of Safety video
Make watching the video mandatory for all unit staff
Create a list of who has watched the video
Describe the three principles of safe design:
1. Standardize
2. Create independent checks
3. Learn from defects
Identify Defects Through Sensemaking
Introduce tools that will help teams identify defects
Introduce Sensemaking: • A process of assigning meaning to ambiguous
events or data
Show teams how to identify defects
Show how Sensemaking relates to Learning from Defects
Answer each of the four questions from the Learning from Defects Tool
17
18
Keys to Identifying Defects Through Sensemaking
A defect is anything that you do not want to happen again
The team should use the Learning from Defects Tool, which asks teams to answer these four questions:
1. What happened?
2. Why did it happen?
3. What will you do to reduce the risk of recurrence?
4. How do you know it worked?
The team should:• Share summaries of defects within your organization • Engage staff in conversations to enhance Learning from Defects
19
Identify Defects Through Sensemaking: What the Team Needs to Do
The CUSP team leader, or another designee, should distribute the Staff Safety Assessment to all clinical and non-clinical providers on the unit.
Safety assessments should be:
Grouped by common types of defects
Prioritized based on the following criteria: • Likelihood of harming the patient• Severity of harm• Commonality• Likelihood that it can be defended against in daily work
Shared with the senior executive
Implement Teamwork and Communication
Recognize the importance of effective communication
Notice the barriers to communication
Discover any connections between communication and medical error
Identify and apply effective communication strategies from CUSP and TeamSTEPPS
20
The Keys to Effective Communication
21
22
Implement Teamwork and Communication:
What the Team Needs to Do
Identify opportunities to improve teamwork and communication by reviewing barriers the team identified while learning from a safety defect
Discuss with frontline providers how and where they want to improve communication
Select a tool that best addresses providers’ concerns
Use teamwork and communication tools and incorporate them into team meetings and other relevant project processes
23
CUSP and TeamSTEPPS Communication Strategies
Daily Goals Checklist
Briefing and Debriefing
Shadowing another professional
Handoff
I PASS the BATON
Check-back
Call out
Completing the Staff Safety Assessment
Step 1. Identify clinical or operational problems that threaten patient safetyStep 1. Identify clinical or operational problems that threaten patient safety
Step 2. Identify ways in which patients on the unit might be harmedStep 2. Identify ways in which patients on the unit might be harmed
Step 3. Determine what can be done to minimize harm or prevent safety hazardsStep 3. Determine what can be done to minimize harm or prevent safety hazards
24
25
Using the Safety Issues Worksheet for Senior Executive Partnership
1. Engage the senior executive to address safety issues identified in the form
2. Use the worksheet during safety rounds to identify safety issues, potential solutions, and available resources
3. Keep the project leader apprised of the information on the worksheet
26
Learning from Defects
27
Using Daily Goals
During morning and evening rounds, the care team should use the checklist to review the goals for the patient
Once a checklist is completed, the attending signs it and gives it to the patient’s nurse to keep it at the bedside, and the team moves on to the next patient
The Daily Goals Checklist should be tailored to fit your environment
Applying Just Culture Principles
28
Video
29
Just Culture
A system that –o Holds itself accountableo Hold staff members accountableo Has staff members that hold
themselves accountable
30
31
Understanding Risk andHuman Behavior
Human ErrorHuman Error: : Inadvertently doing Inadvertently doing
other than what other than what should have been should have been done; slip, lapse, done; slip, lapse,
mistakemistake
Human ErrorHuman Error: : Inadvertently doing Inadvertently doing
other than what other than what should have been should have been done; slip, lapse, done; slip, lapse,
mistakemistake
At-Risk BehaviorAt-Risk Behavior: : Choosing to behave Choosing to behave
in a way that in a way that increases risk where increases risk where
risk is not risk is not recognized or is recognized or is
mistakenly believed mistakenly believed to be justifiedto be justified
At-Risk BehaviorAt-Risk Behavior: : Choosing to behave Choosing to behave
in a way that in a way that increases risk where increases risk where
risk is not risk is not recognized or is recognized or is
mistakenly believed mistakenly believed to be justifiedto be justified
Reckless BehaviorReckless Behavior: : Choosing to Choosing to consciously consciously disregard a disregard a
substantial and substantial and unjustifiable riskunjustifiable risk
Reckless BehaviorReckless Behavior: : Choosing to Choosing to consciously consciously disregard a disregard a
substantial and substantial and unjustifiable riskunjustifiable risk
Managing Error and Risk
32
Human Error
Product of Our Current System
Design and Behavioral Choices
Manage through changes in:•Choices•Processes•Procedures•Training•Design•Environment
Console
At-Risk Behavior
A Choice: Risk Believed Insignificant
or Justified
Manage through:•Removal of incentives for at-risk behaviors•Creation of incentives for healthy behaviors•Situational awareness
Coach
Reckless Behavior
Conscious Disregard of Substantial and Unjustifiable Risk
Manage through:•Remedial action•Punitive action
Punish
Systems and BehaviorsWork Together to
Improve Outcomes
33
Mission, Values Mission, Values and Expectationsand Expectations
SystemSystemDesignDesign
BehavioralBehavioralChoicesChoices
Improved Improved OutcomesOutcomes
LearningLearningSystemsSystemsLearningLearningSystemsSystems
AccountabilityAccountabilityand Justiceand Justice
AccountabilityAccountabilityand Justiceand Justice
34
Engineering System Design to Support Behavior Choices
Punitive Culture: Transparency is impossible
Blame-Free Culture: No accountability
Just Culture: Optimally supports a system of safety
35
Leadership Team’s Role inApplying Just Culture Principles
Have a procedure in place for employees to follow
Ensure employees are properly trained
Offer positive reinforcement at the monthly Learning from Defects meeting
Video
36
Video
37
38
Team Members’ Role inApplying Just Culture Principles
Lisa noticed that several of her patients had catheters left in place that, per the protocol, should have been removed during the prior shift
Lisa used Just Culture principles to review the situation
Summary
The seven CUSP Toolkit modules:o Introduce CUSPo Assemble the Teamo Engage the Senior Executiveo Understand the Science of Safetyo Identify Defects through Sensemakingo Implement Teamwork and Communicationo Apply CUSPWhen implementing CUSP for the first time, it is recommended to use the modules in this order.
o For subsequent implementations, use the modules based on the unit’s needsUse the Just Culture principles in tandem with the CUSP principles
39
Your Feedback Is Important!
https://www.surveymonkey.com/s/9YC9D37
References
Agency for Healthcare Research and Quality. TeamSTEPPS Fundamentals Course: Module 6 Communication. Available at: http://teamstepps.ahrq.gov/abouttoolsmaterials.htm Accessed August 18, 2011.
Agency for Healthcare Research and Quality. Sensemaking. Available online at: http://dkv.columbia.edu/demo/medical_errors_reporting/site/module3/0100-module-outline.html. Accessed August 18, 2011.
Dayton E, Henricksen K. Communication failure: basic components, contributing factors and the call for structure. Joint Commission Journal. 2007;33(1):36.