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Confidential & Proprietary
A Systematic Framework for Safe & Reliable Surgical Care Allan Frankel, MDMichael Leonard, MDMichael Woods, MD
Confidential & Proprietary
Systematic Framework for Safe & Reliable Care
It’s all about the patient
Leadership
Organizational Fairness
Safety Culture
Effective Teamwork & Communication
Building and Sustaining a Learning System
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3*Adapted from Safeskies 2001, “Aviation Safety Culture,” Patrick Hudson, Centre for Safety Science, Leiden University
PATHOLOGICALWho cares as long as we’re not caught Chronically Complacent
REACTIVESafety is important. We do a lot every time we have an accident
CALCULATIVEWe have systems in place to manage
all hazards
PROACTIVEAnticipating and preventing problems before
they occur
GENERATIVESafety is how we do business
around hereConstantly Vigilant
Incr
easing A
wareness
& Tr
ust
Evolution of A Culture of Safety and Reliability
Where are you?
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Psychological Safety
Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes.
A shared sense of psychological safety is a critical input to an effective learning system
Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, Vol. 44, No. 2 (Jun., 1999), pp. 350-383 Amy Edmondson
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Psychological Safety Is Local
© 2012 Pascal Metrics
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Culture of Safety
No one is ever hesitant to voice a concern about a patient
Caregivers - capable, conscientious and playing by the rules – feel comfortable to speak up regarding errors, near misses and adverse events
When people do speak up, they have a high degree of confidence that the organization will act on their concerns and demonstrate such.
There is a cyclic flow of information that leads to analysis, action and feedback - a learning organization – to reinforce well defined behaviors and values
Confidential & Proprietary© 2011 Pascal Metrics Inc.
Benchmarking clinical units
Perceptions of Senior Management
Confidential © 2012 Pascal Metrics, Source: Pascal HealthBench™
Confidential & Proprietary
Confidential & Proprietary© 2011 Pascal Metrics Inc.
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10
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RN rates Physician Physician rates RN
% o
f res
pond
ents
repo
rtin
g ab
ove
adeq
uate
team
wor
k Teamwork in the eye of the beholder: ICU RNs and ICU MDs rate
each other
62 Michigan ICUs 2004Only ICUs with 5 or more physicians reported here (all had 5 or more RNs)
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Teamwork Climate Across Michigan ICUs
No BSI 21%
No BSI = 5 months or more w/ zero
The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient
care
No BSI 31% No BSI 44%
Attribution: J. Bryan Sexton
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OR
Nu
rse
Su
rgeo
n
Su
pp
ort
Sta
ff
Su
rg T
ech
An
esth
MD
An
esth
Tec
h
< 5
Res
po
nd
Confidential & Proprietary
OR
Nu
rse
Su
rgeo
n
Su
pp
ort
Sta
ff
Su
rg T
ech
An
esth
MD
An
esth
Tec
h
< 5
Res
po
nd
Confidential & Proprietary
OR
Nu
rse
Su
rgeo
n
Su
pp
ort
Sta
ff
Su
rg T
ech
An
esth
MD
An
esth
Tec
h
< 5
Res
po
nd
Confidential & Proprietary
OR
Nu
rse
Su
rgeo
n
Su
pp
ort
Sta
ff
Su
rg T
ech
An
esth
MD
An
esth
Tec
h
< 5
Res
po
nd
Confidential & Proprietary© 2011 Pascal Metrics Inc.
Teamwork Climate within OR B
Confidential © 2012 Pascal Metrics, Source: Pascal HealthBench™
Confidential & Proprietary© 2011 Pascal Metrics Inc.
Teamwork Climate item within OR B
Confidential © 2012 Pascal Metrics, Source: Pascal HealthBench™
Nurse input is well received in this work setting.
Confidential & Proprietary© 2011 Pascal Metrics Inc.
Teamwork Climate item within OR B
Confidential © 2012 Pascal Metrics, Source: Pascal HealthBench™
I have the support I need from others in this work setting to care for patients.
Confidential & Proprietary© 2011 Pascal Metrics Inc.
Safety Climate within OR B
Confidential © 2012 Pascal Metrics, Source: Pascal HealthBench™
Confidential & Proprietary© 2011 Pascal Metrics Inc.
Safety Climate item
Confidential © 2012 Pascal Metrics, Source: Pascal HealthBench™
I would feel safe being treated here as a patient.
Confidential & Proprietary© 2011 Pascal Metrics Inc.
Safety Climate item within OR B
Confidential © 2012 Pascal Metrics, Source: Pascal HealthBench™
I am encouraged by others in this work setting to report any patient safety concerns I may have.
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Debriefing Culture Data Locally
- CONFIDENTIAL-
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Local debrief sessions target improvement at the clinical area level
Sessions empower caregivers to “own the data”
Use the DEBRIEFer tool
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Workforce Engagement – 7S Surgical Floor
2009 Percent Favorable 2010 Percent Favorable 2010 Hospital Partner
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ICU’s that reflected on their SAQ scores and took action:
• Increased their SAQ scores in 5 of 6 domains
• Achieved a 10.2% decrease in BSI rates
• Achieved a 15.2% decrease in VAP rates
ICU’s that did NOT reflect on their SAQ scores and take action:
• Increased their SAQ scores in 1 of 6 domains
• Achieved a 2.2% decrease in BSI rates
• Achieved a 4.8% increase in VAP rates
Linking Culture and Outcomes:RI ICU Effort to Decrease Infection
Attribution: Margaret Cornell, MS, RN
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Effective Teamwork and Communication in Surgical CarePractical tools and behaviors to enhance teamwork and deliver high quality, safe surgical care.
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Effective Communication and Teamwork Requires:
Structured Communication
Briefing, Checklist, SBAR, Debriefing
Assertion/Critical Language
Key words, the ability to speak up and stop the show
Psychological Safety An environment of respect
Effective Leadership Flat hierarchy, sharing the plan, continuously inviting other team members into the conversation, explicitly asking people to share questions or concerns, using people’s names
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Effective Communication
Have a plan
The value of a structured process
Hand-offs are dangerous
Structured language/clarity
Who owns the patient?
What are the parameters for increasing the intensity of care?
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Briefings
Share the game plan
Set the stage — psychological safety
Norms of conduct
Disavow perfection – a little humility goes a long way
Engage every participant using eye contact and people’s names
Explicitly ask for input about concerns or issues
Provide information and talk about next steps
Seek useful information
Update as needed — build into procedure
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Setting the Stage
Vascular surgeon doing new, complicated procedure – endovascular aortic stent — in CV lab:
“I don’t have any pride invested here. I just want to get this right, so if you think of anything helpful or see me doing anything wrong, please let me know.”
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VA Surgical Teamwork
18% reduction in mortality
Significant improvement in safety culture scores, surgical process measures – DVT, antibiotic administration On time OR starts – went from 38% to 60%
25% reduction nursing turnover
Circulating nurses left the room less
144 serious events prevented, 11 million dollars
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WHO Surgical Checklist
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Debriefing – the link between teamwork and improvement
What went well?
What did we learn?
What do want to differently tomorrow?
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Building a Learning System
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Acute Medicines Unit WorkstreamNinewells Hospital, Dundee, ScotlandArun Chaudhur, Medical Director
O2 PrescribingDVT PrescribingCompliance
SNAP-CAP ABX PrescribingCompliance
Bld CultureContamination
Pressure UlcerPrevention Bundle
Compliance with Med. Reconciliation
Early WarningScores Bundle
Hand Hygiene
?
?
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Arun Chaudhur, Medical Director
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Annotations
1: Marked beds at 30 degree angle2: Fact Sheet for staff education3: Poster with weekly data feedback4: Vent bundle posted in all vent patient rooms5: Began initial trials of Daily goal sheet and pre-extubation sheet6: Initiated Powerpoint education for RT/RN7: Initiated Clinical Pharm rounds8: 1st test of multidisciplinary rounds9: Expanded use of Pre-extubation sheet
ICU Percent of Patients Receiving all Four Aspects Of Ventilator Bundle
10: Staff education on Goal sheet; mini inservices on unit on SBT and Pre-extubation sheet11: Incorporated Goal Sheet into Multidisciplinary Rounds12: Impact Extravaganza (staff/MD education)13: Expanded multidisciplinary rounds to include additional disciplines14: Check compliance on night shift past 2 weeks15: New sign at HOB,16: One on one follow up by Nursing & RT managers on collaboratiion in weaning process
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Mercy Regional Medical Center
© Mercy 2010 ‘Turtle Board’
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The Importance of Reducing Variation and Avoiding Avoidable Harm
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Avoiding Avoidable Harm is Key for Success
Never Events – retained surgical objects, transfusion injury, etc.
Healthcare Associated Infections
The current rate of adverse and avoidable harm is unacceptable
Quality and safety will have progressively more financial impact – more metrics
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No Preventable mortality – HSMR, sepsis, rapid response, etc.
No preventable harm – Triggers, AE – Baylor 30% patients with positive trigger / 6% patients adversely affected or increased LOS
- North Carolina study – 10 hospitals, 25% patients experienced harm – 60% “avoidable”
- Health Affairs – 1/3 patients experienced avoidable harm, 2/3 “avoidable”
No preventable risk
Evolution of Risk Mitigation
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ADE Detection at LDS Hospital
*Total - 731
Computerized Surveillance*
90 (12%)641 (88%)9
Enhanced ReportingAutomated DetectionTraditional
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Confidential & Proprietary© 2008 Pascal Metrics
Confidential & Proprietary