Build a Foundation for Quality: Interpreting HSOPSC Results and Action Planning

1. Build a Foundation for Quality: Interpreting HSOPSC Results and Action Planning Katherine Jones, PT, PhD Anne Skinner, RHIA Acknowledge colleaguesAcknowledge colleagues

2. 2 Objectives What you should know (knowledge) What you should do (skills) What you should believe/value (attitudes) Acronyms AHRQ = Agency for Healthcare Research and Quality HRO = High Reliability Organization HSOPSC = Hospital Survey on Patient Safety Culture

3. 3 Skills Objectives (What you do) Use examples of HSOPSC results to Identify safety culture strengths & weaknesses Aggregate across an organization Within work areas Within job titles Identify gaps between beliefs & behaviors within dimensions Describe key practices to address weakness Create an action plan to engineer key practices What does engineer mean? To skillfully plan, construct and manageWhat does engineer mean? To skillfully plan, construct and manage

4. 4 Knowledge Objectives (What you know) Build on previous knowledge Recognize that HSOPSC dimensions measure four components of an informed, safe culture Compare beliefs and behaviors within HSOPSC dimensions Identify relationships between HSOPSC dimensions Recognize that culture varies within an organization Define active learning & transformative learning List four stages of active learning Describe three attitudes toward transformative learning Describe key organizational practices that support four components of an informed, safe culture

5. 5 Attitudes Objectives (What you think is important) Believe that active learning in teams leads to transformative learning in organizations Value the cumulative effect of the interaction of key practices that support organizational learning

6. 6 Active and Transformative Learning Active Learning �An approach to working with and developing people which uses work on a real project or problem as the way to learn.� Transformative Learning The use of critical reflection to transform taken-for-granted frames of reference (assumptions); reframe the problem

7. 7 Characteristics of Transformative Learners Seek more accurate and complete information Free from coercion Open to alternative points of view Objectively consider evidence Critically reflect on own assumptions Have an opportunity to participate in discussion and problem solving Willing to accept a new frame of reference that is validated through evidence and discussion

8. 8 Frame of Reference? Think � Pair � Share 1 = not at all 2 = to some extent 3 = a great deal There is an organization wide sense of susceptibility to the unexpected. Everyone feels accountable for reliability. Leaders pay as much attention to managing unexpected events as they do to achieving formal organization goals. We spend time identifying how our activities could potentially harm patients, employees, the organization. We pay attention to when and why our patients and our employees might feel frustrated or disenfranchised. There is widespread agreement about how things could go wrong. Does your organization have the infrastructure to be mindful? >12 infrastructure is excellent 8 � 12 on your way < 8 consider how to improve your mindfulnessDoes your organization have the infrastructure to be mindful? >12 infrastructure is excellent 8 � 12 on your way < 8 consider how to improve your mindfulness

9. 9 What is your frame of reference? Employees should be more careful and professional. My organization could better support employees with the infrastructure they need to be a high reliability organization.

10. 10 Stages of Active Learning Expand an existing frame of reference Communication could be improved; let�s try SBAR Learn a new frame of reference Human beings easily misunderstand each other so communication should be structured; let�s use SBAR Transform your point of view Hospitals should embrace concepts of high reliability because human error is inevitable; HROs use structured communication; let�s use SBAR Transform your habits of mind Because human beings are imperfect, I can use structured communication in my professional and personal communication to decrease likelihood of misunderstandings

11. 11 Attitudes toward Transformative Learning Embrace and absorb Skeptical then connect Resistant and defensive

12. 12 Solution

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14. 14 I want to make it very clear that the AHRQ survey is a diagnostic tool. As a physical therapist, I use diagnostic tools to assess whether a patient�s balance is impaired. Based on the impairments I find, I teach the patient specific, targeted exercises to address each impairment. Similarly, based on the impairments in organizational learning identified by the survey, senior leaders need to implement specific practices or behaviors to support the four components of a safe, informed culture. Another similarity between maintaining balance as an individual and safety culture in organizations, is that reporting is the foundation of both. We can not maintain balance without sensory information from our joints, eyes, and inner ears. We can�t maintain and improve our organizations without information about the success and failures of our processes XXXXX Sensory information reported from the periphery Sensory information integrated in the brain (just culture framework) Coordinated, flexible motor output Falls lead to learning from mistakes Practice leads to improvement I want to make it very clear that the AHRQ survey is a diagnostic tool. As a physical therapist, I use diagnostic tools to assess whether a patient�s balance is impaired. Based on the impairments I find, I teach the patient specific, targeted exercises to address each impairment. Similarly, based on the impairments in organizational learning identified by the survey, senior leaders need to implement specific practices or behaviors to support the four components of a safe, informed culture. Another similarity between maintaining balance as an individual and safety culture in organizations, is that reporting is the foundation of both. We can not maintain balance without sensory information from our joints, eyes, and inner ears. We can�t maintain and improve our organizations without information about the success and failures of our processes XXXXX Sensory information reported from the periphery Sensory information integrated in the brain (just culture framework) Coordinated, flexible motor output Falls lead to learning from mistakes Practice leads to improvement

15. 15 A Reporting culture is engineered by implementing practices . . . �Any safety information system depends crucially on the willing participation of the workforce, the people in direct contact with the hazards. To achieve this, it is necessary to engineer a reporting culture�an organization in which people are prepared to report their errors and near-misses.� (Reason, p. 195) Reporting, obtaining information about the processes and outcomes of care, is the foundation of a safe, informed culture. Psychologist James Reason states, �Any safety information system depends crucially on the willing participation of the workforce, the people in direct contact with the hazards. To achieve this, it is necessary to engineer a reporting culture�an organization in which people are prepared to report their errors and near-misses.� The practices that support a reporting culture include formal reporting systems that are Nonpunitive Confidential Independent Expert analysis Timely Systems-oriented Responsive Other forms of reporting are Chart Audit, Secret Shopper, Safety Briefings, Leadership WalkRounds Reporting, obtaining information about the processes and outcomes of care, is the foundation of a safe, informed culture. Psychologist James Reason states, �Any safety information system depends crucially on the willing participation of the workforce, the people in direct contact with the hazards. To achieve this, it is necessary to engineer a reporting culture�an organization in which people are prepared to report their errors and near-misses.� The practices that support a reporting culture include formal reporting systems that are Nonpunitive Confidential Independent Expert analysis Timely Systems-oriented Responsive Other forms of reporting are Chart Audit, Secret Shopper, Safety Briefings, Leadership WalkRounds

16. 16 A Reporting culture is engineered by implementing practices . . . Practices/Tools Reporting Form Near miss log Chart audit Secret Shopper Safety Briefings Leadership WalkRoundsTM Bulletin board/ suggestion box/telephone hotline Successful reporting systems (Leape, 2002) Nonpunitive Confidential Independent Expert analysis Timely Systems-oriented Responsive Reporting, obtaining information about the processes and outcomes of care, is the foundation of a safe, informed culture. Psychologist James Reason states, �Any safety information system depends crucially on the willing participation of the workforce, the people in direct contact with the hazards. To achieve this, it is necessary to engineer a reporting culture�an organization in which people are prepared to report their errors and near-misses.� The practices that support a reporting culture include formal reporting systems that are Nonpunitive Confidential Independent Expert analysis Timely Systems-oriented Responsive Other forms of reporting are Chart Audit, Secret Shopper, Safety Briefings, Leadership WalkRounds Reporting, obtaining information about the processes and outcomes of care, is the foundation of a safe, informed culture. Psychologist James Reason states, �Any safety information system depends crucially on the willing participation of the workforce, the people in direct contact with the hazards. To achieve this, it is necessary to engineer a reporting culture�an organization in which people are prepared to report their errors and near-misses.� The practices that support a reporting culture include formal reporting systems that are Nonpunitive Confidential Independent Expert analysis Timely Systems-oriented Responsive Other forms of reporting are Chart Audit, Secret Shopper, Safety Briefings, Leadership WalkRounds

17. 17 Characteristics of Successful Reporting Systems Nonpunitive: reporters do not fear punishment Confidential: reporter not revealed to those who discipline Independent: reporting system independent of discipline Expert analysis: reports analyzed by those with systems knowledge Timely: reports are analyzed promptly; recommendations disseminated rapidly Systems-oriented: recommendations focus on systems Responsive: those receiving reports are capable of disseminating/implementing recommendations

18. 18 84144772 MEDMARX is an anonymous medication error reporting program that subscribing hospitals and health systems participate in as part of their ongoing quality improvement initiatives. Nationally, data from MEDMARX contributes to knowledge about the causes and prevention of medication errors. Over 870 hospitals and health systems have submitted more than 1.3 million medication error records to MEDMARX. Analyses of voluntary medication error reports from large patient safety databases, such as MEDMARX, can identify system sources of error and lead to the establishment of safe medication practices. 84144772 MEDMARX is an anonymous medication error reporting program that subscribing hospitals and health systems participate in as part of their ongoing quality improvement initiatives. Nationally, data from MEDMARX contributes to knowledge about the causes and prevention of medication errors. Over 870 hospitals and health systems have submitted more than 1.3 million medication error records to MEDMARX. Analyses of voluntary medication error reports from large patient safety databases, such as MEDMARX, can identify system sources of error and lead to the establishment of safe medication practices.

19. 19 Systematic Data Collection in Medication Error Reporting Description of the error Error severity based on the outcome to patient Phase of the medication use process in which the error originates Type of the error Cause of the error Contributing factors to the error Information about the drug(s) involved

20. 20 NCC MERP Taxonomy of Error Severity A: capacity to cause error B: error occurred, did not reach patient C: error reached patient, no harm D: error reached patient, monitoring and intervention required E: temporary harm requiring intervention F: temporary harm requiring initial or prolonged hospitalization G: permanent harm H: intervention required to sustain life I: error contributed to or resulted in death

21. 21 Near-miss Log Sheet

22. 22 Reporting Error Severity

23. 23 Reporting Where Errors Originate

24. 24 Reporting Types of Errors

25. 25 Reporting Causes

26. 26 Reporting Contributing Factors

27. 27 What we heard about using MEDMARX as the foundation for reporting in Critical Access Hospitals: �Before the project, we just counted errors. We never went past the type of error.� �Without the language of errors associated with MEDMARX, all we could talk about was who did it and not what happened and why. MEDMARX created a standardized process that allowed us to collect more information. The use of MEDMARX and its graphs and charts contributes to the perception of errors as having a system source.�

28. 28 Safety Briefings Background Based on briefings developed in aviation to overcome barriers to communication� All staff are equal when voicing safety concerns Safety is discussed routinely, 24/7, in the context of daily work

29. 29 Ground Rules for Briefings All gather in a designated area Be brief�5 minutes and stick to it! Remember the purpose: increase awareness of safety issues Remember non-punitive: information for patient care only�never used in performance appraisal All opinions have equal value Ask open-ended questions

30. 30 Start of Shift Briefing What safety issues should staff be aware of today? Are there patients with similar names ? Non-formulary drugs ordered? Elderly patients at risk for falls? New equipment? Changes in the work environment? Changes in work flow? Any staff assigned work that is not routine? Any staff doing work usually performed by others? Any staff working unusual shifts?

31. 31 End of Shift Debriefing Who encountered a safety issue related to medications? Who had a �near miss� with a medication today? How many staff had patients who asked questions or made comments about medications today? How many were near misses that a patient�s comment prevented? Are there safety issues (staff or patient) that should prompt action? Are there process changes that should be made?

32. Improvements in nurse perceptions of reporting culture 2005 vs. 2007 as a result of systematic reporting of medication errors using MEDMARX

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34. 34 A Just culture is engineered by implementing practices . . . The willingness of workers to report depends on their belief that management will support and reward reporting and that discipline occurs based on risk-taking�there is a clear line between acceptable and unacceptable behavior �organizational practices support a just culture. The willingness of workers to report depends on their belief that management will support and reward reporting and that discipline occurs based on risk-taking�there is a clear line between acceptable and unacceptable behavior �organizational practices support a just culture. Discipline does not take place in response to human error but in response to knowingly increasing the risk to patients or peers. These practices include�.The willingness of workers to report depends on their belief that management will support and reward reporting and that discipline occurs based on risk-taking�there is a clear line between acceptable and unacceptable behavior �organizational practices support a just culture. Discipline does not take place in response to human error but in response to knowingly increasing the risk to patients or peers. These practices include�.

35. 35 A Just culture is engineered by implementing practices . . . Practices/Tools Understanding human error (Reason 2003, 2006) Active errors (sharp end) Latent errors Just Culture and behavior (Marx, 2001) Conduct: human error, negligence, reckless, intentional rule violation Disciplinary decision-making: outcome-based, rule-based, risk-based Unsafe Acts Algorithm Disruptive Behavior Policy/Standards The willingness of workers to report depends on their belief that management will support and reward reporting and that discipline occurs based on risk-taking�there is a clear line between acceptable and unacceptable behavior �organizational practices support a just culture. Discipline does not take place in response to human error but in response to knowingly increasing the risk to patients or peers. These practices include�.The willingness of workers to report depends on their belief that management will support and reward reporting and that discipline occurs based on risk-taking�there is a clear line between acceptable and unacceptable behavior �organizational practices support a just culture. Discipline does not take place in response to human error but in response to knowingly increasing the risk to patients or peers. These practices include�.

36. 36 A �just culture� requires an understanding of the nature of human error. In complex systems, errors are intercepted when defenses and barriers are intact. Errors occur when these defenses are breached. We are aware of hazards due to reporting and feedback. Policy/procedure to guide behavior Automated warnings and alerts Environmental barriersIn complex systems, errors are intercepted when defenses and barriers are intact. Errors occur when these defenses are breached. We are aware of hazards due to reporting and feedback. Policy/procedure to guide behavior Automated warnings and alerts Environmental barriers

38. 38 The single greatest impediment to error prevention in the medical industry is �that we punish people for making mistakes.� Dr. Lucian Leape Professor, Harvard School of Public Health Testimony before Congress on Health Care Quality Improvement Importance of Just Culture A single case of a reporter being disciplined can shut off the supply of information Mindset of expecting perfection (zero errors) leads us to count events instead of looking for hints at how things can go wrong, learning from them ( being resilient)A single case of a reporter being disciplined can shut off the supply of information Mindset of expecting perfection (zero errors) leads us to count events instead of looking for hints at how things can go wrong, learning from them ( being resilient)

39. Improvements in nurse perceptions of just culture 2005 vs. 2007 as a result of systematic reporting of medication errors using MEDMARX and education about human error

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41. 41 A Flexible culture is engineered by implementing practices . . . The willingness of workers to report depends on their belief that authority patterns relax when safety information is exchanged because managers respect the knowledge of front-line workers�organizational practices support a flexible culture, which adapts to changing demands. The willingness of workers to report depends on their belief that authority patterns relax when safety information is exchanged because managers respect the knowledge of front-line workers�organizational practices support a flexible culture. Relaxing authority patterns to ensure effective communication is included in team skillsThe willingness of workers to report depends on their belief that authority patterns relax when safety information is exchanged because managers respect the knowledge of front-line workers�organizational practices support a flexible culture. Relaxing authority patterns to ensure effective communication is included in team skills

42. 42 A Flexible culture is engineered by implementing practices . . . TeamSTEPPS stands for Team Strategies and Tools to Enhance Performance and Patient Safety. TeamSTEPPS is an evidence-based framework developed by the Department of Defense and the Agency for Healthcare Research and Quality. It builds on 25 years of research on teams and team performance in high-risk areas such as aviation, the military, nuclear power, and healthcare in which poor performance may lead to serious consequences or death. TeamSTEPPS is designed to optimize team performance across the healthcare delivery system by focusing on specific skills supporting team performance principles. TeamSTEPPS stands for Team Strategies and Tools to Enhance Performance and Patient Safety. TeamSTEPPS is an evidence-based framework developed by the Department of Defense and the Agency for Healthcare Research and Quality. It builds on 25 years of research on teams and team performance in high-risk areas such as aviation, the military, nuclear power, and healthcare in which poor performance may lead to serious consequences or death. TeamSTEPPS is designed to optimize team performance across the healthcare delivery system by focusing on specific skills supporting team performance principles.

43. 43 Outcomes of Team Competencies TeamSTEPPS is composed of four teachable-learnable skills: leadership, situation monitoring, mutual support, and communication; which form the core of the TeamSTEPPS framework. Encircling the four skills is the patient care team which not only represents the patient and direct caregivers, but those who play a supportive role within the healthcare delivery system�administrative assistants, housekeepers, maintenance, supply managers. The red arrows depict the interaction between the four skills and team-related outcomes. Team competencies required for a high-performing team, can be grouped into the categories of Knowledge, Skills, and Attitudes (KSAs). Team-related knowledge results in a shared mental model; attitudes result in mutual trust and team orientation. Adaptability, accuracy, productivity, efficiency and safety are the outcomes of a high-performing team. TeamSTEPPS is composed of four teachable-learnable skills: leadership, situation monitoring, mutual support, and communication; which form the core of the TeamSTEPPS framework. Encircling the four skills is the patient care team which not only represents the patient and direct caregivers, but those who play a supportive role within the healthcare delivery system�administrative assistants, housekeepers, maintenance, supply managers. The red arrows depict the interaction between the four skills and team-related outcomes. Team competencies required for a high-performing team, can be grouped into the categories of Knowledge, Skills, and Attitudes (KSAs). Team-related knowledge results in a shared mental model; attitudes result in mutual trust and team orientation. Adaptability, accuracy, productivity, efficiency and safety are the outcomes of a high-performing team.

44. 44 Importance of Team Structure I want to re-emphasize that it is the presence of a team structure that ensures that team skills result in the desired outcomes of team knowledge, attitudes of trust and team orientation, and our desired performance outcomes of safe, evidence-based, patient-centered care. The TeamSTEPPS curriculum is available in three formats: A 2 and � day �Train the Trainer� course conducted by a Master Trainer, a 4 � 6 hour Fundamentals course that provides training in the four skills, and a 1 hour Essentials course that provides an overview of all of the skills. Due to our time constraints today, I�m going to give you an overview of the four skills. I�ll provide more detail about the leadership and communication skills fundamental to ensuring that we keep our patients safe by effectively communicating. I want to re-emphasize that it is the presence of a team structure that ensures that team skills result in the desired outcomes of team knowledge, attitudes of trust and team orientation, and our desired performance outcomes of safe, evidence-based, patient-centered care. The TeamSTEPPS curriculum is available in three formats: A 2 and � day �Train the Trainer� course conducted by a Master Trainer, a 4 � 6 hour Fundamentals course that provides training in the four skills, and a 1 hour Essentials course that provides an overview of all of the skills. Due to our time constraints today, I�m going to give you an overview of the four skills. I�ll provide more detail about the leadership and communication skills fundamental to ensuring that we keep our patients safe by effectively communicating.

45. 45 Skill Overview: Leadership Organize the team set clear goals & delegate tasks manage resources Ensure team members share information Formal team meetings & informal exchange sessions Make decisions through collective input Empower team members to speak up Resolve conflict Actively model and facilitate good teamwork May be designated or situational Leadership is the ability to coordinate the activities of team members by organizing the team and ensuring team members share information. Organizing the team includes setting clear goals, delegating tasks, and managing resources. Effective team leaders don�t hand down solutions, they facilitate team problem solving by sharing information. Team leaders� Use formal team meetings & informal exchange sessions Make decisions through collective input Empower team members to speak up Actively model and facilitate good teamwork May be designated or situational Team leaders can be formal and designated or situational. A situational leader emerges at designated times, such as shift change, and at spontaneous times, for instance, the first responder to a code or the first one to notice a work overload. In an effective team, any member with the skills to best manage the situation can assume the role of situational leader. Once the situation has been resolved or the designated leader is ready to assume control, the situational leader again assumes the role of team member. Leadership is the ability to coordinate the activities of team members by organizing the team and ensuring team members share information. Organizing the team includes setting clear goals, delegating tasks, and managing resources. Effective team leaders don�t hand down solutions, they facilitate team problem solving by sharing information. Team leaders� Use formal team meetings & informal exchange sessions Make decisions through collective input Empower team members to speak up Actively model and facilitate good teamwork May be designated or situational Team leaders can be formal and designated or situational. A situational leader emerges at designated times, such as shift change, and at spontaneous times, for instance, the first responder to a code or the first one to notice a work overload. In an effective team, any member with the skills to best manage the situation can assume the role of situational leader. Once the situation has been resolved or the designated leader is ready to assume control, the situational leader again assumes the role of team member.

46. 46 Skill Overview: Situation Monitoring Situation monitoring is the process of actively scanning the environment to obtain an accurate understanding of the situation. Situation monitoring is an individual skill, which implies that it can be trained and developed. Situation awareness is the result of situation monitoring. It is the state of knowing the conditions that affect one�s work. Shared mental models are the result of each team member maintaining his or her situation awareness and sharing relevant facts with the entire team. Everyone on the team is �on the same page.� The continuum that leads to the team outcome of a shared mental model begins with the individual skill of situation monitoring. Processing of monitored information results in the individual outcome of situation awareness. And sharing your situation awareness with fellow team members results in the team outcome of a shared mental model. STEP is a tool to monitor situations in healthcare delivery. STEP is an acronym that stands for Status of the patient � hx, VS, physical exam, meds, plan of care, cognitive and functional impairments, psychosocial & support system Team Members � Current performance, Fatigue, workload, skill level required, stress level Environment � facility, equipment, human resources including administrative support, acuity level Progress toward Goal � Know the goal, know the tasks to achieve the goal, consider whether the plan to achieve the goal is still appropriate Situation monitoring is the process of actively scanning the environment to obtain an accurate understanding of the situation. Situation monitoring is an individual skill, which implies that it can be trained and developed. Situation awareness is the result of situation monitoring. It is the state of knowing the conditions that affect one�s work. Shared mental models are the result of each team member maintaining his or her situation awareness and sharing relevant facts with the entire team. Everyone on the team is �on the same page.� The continuum that leads to the team outcome of a shared mental model begins with the individual skill of situation monitoring. Processing of monitored information results in the individual outcome of situation awareness. And sharing your situation awareness with fellow team members results in the team outcome of a shared mental model. STEP is a tool to monitor situations in healthcare delivery. STEP is an acronym that stands for Status of the patient � hx, VS, physical exam, meds, plan of care, cognitive and functional impairments, psychosocial & support system Team Members � Current performance, Fatigue, workload, skill level required, stress level Environment � facility, equipment, human resources including administrative support, acuity level Progress toward Goal � Know the goal, know the tasks to achieve the goal, consider whether the plan to achieve the goal is still appropriate

47. 47 Skill Overview: Mutual Support �Back up behavior� to prevent work overload Task assistance is sought and offered Provide effective feedback: Timely, Respectful, Specific, Directed towards improvement, Considerate Advocate for the patient through conflict resolution �CUS� to solve information conflicts I�m concerned ( I need clarity) I�m uncomfortable Consequences in terms of patient safety DESC Script to solve personal conflicts Describe the behavior Express how the situation makes you feel Suggest alternatives Consequences stated in terms of patient safety

48. 48 TeamSTEPPS Mutual SupportTwo-Challenges Rule

49. 49 Skill Overview: Communication Exchange of information between a sender and a receiver Effective communication Brief Clear Timely Complete: Know the plan, share the plan, review risk JCAHO National Patient Safety Goals require improvement in communication The greatest problem in communication is the illusion that it has been accomplished. --George Bernard Shaw Recall that, ineffective communication was identified as the root cause for 66 percent of reported errors in the Sentinel Event data compiled by the Joint Commission between 1995 and 2005. Communication is defined as The exchange of information between a sender and a receiver. Effective communication is Complete, Clear, Brief, and Timely. JCAHO National Patient Safety Goals require improvement in communication and include Improve the effectiveness of communication among caregivers Read-Back Handoff Accurately and completely reconcile medications and other treatments across the continuum of care, specifically during handoffs Encourage the active involvement of patients and their families in the patient�s care, as a patient safety strategy The greatest problem in communication is the illusion that it has been accomplished. --George Bernard Shaw Recall that, ineffective communication was identified as the root cause for 66 percent of reported errors in the Sentinel Event data compiled by the Joint Commission between 1995 and 2005. Communication is defined as The exchange of information between a sender and a receiver. Effective communication is Complete, Clear, Brief, and Timely. JCAHO National Patient Safety Goals require improvement in communication and include Improve the effectiveness of communication among caregivers Read-Back Handoff Accurately and completely reconcile medications and other treatments across the continuum of care, specifically during handoffs Encourage the active involvement of patients and their families in the patient�s care, as a patient safety strategy

50. 50 Communication Skills SBAR Situation � what is going on with the pt. Background � clinical background Assessment � what do I think is the problem Recommendation � how can we correct it Call-out Inform all team members simultaneously Check-back Close the loop as receiver accepts a message, sender double-checks to ensure message was received There are four strategies to designed to reduce errors associated with miscommunication or lack of information. These four strategies are simple to integrate into daily practice and have been shown to improve team performance. SBAR (Situation� Background� Assessment� Recommendation) is an easy-to-remember, concrete mechanism that is useful for framing any conversation, especially a critical one requiring a clinician's immediate attention and action. SBAR originated in the U.S. Navy submarine community to quickly provide critical information to the captain. Standards of communication are essential for developing teamwork and fostering a culture of patient safety. Situation � what is going on with the pt. (Pt arrived for appointment on wrong day) Background � clinical background (Pt arrive today at 11 AM, appt is for tomorrow, pt lives 40 miles away and needed a family member to drive them, the one appt slot you keep open for emergencies is available) Assessment � what do I think is the problem/your position (we should see the pt today) Recommendation � how can we correct it (use the emergency slot) A call-out is a tactic used to communicate critical information during an emergent event. Critical information called out in these situations helps the team anticipate and prepare for vital next steps in patient care. It also benefits a recorder when present during a code or emergent event. One important aspect of a call-out is directing the information to a specific individual. A check-back is a closed-loop communication strategy used to verify and validate information exchanged. The strategy involves the sender initiating a message, the receiver accepting the message and confirming what was communicated, and the sender verifying that the message was received. There are four strategies to designed to reduce errors associated with miscommunication or lack of information. These four strategies are simple to integrate into daily practice and have been shown to improve team performance. SBAR (Situation� Background� Assessment� Recommendation) is an easy-to-remember, concrete mechanism that is useful for framing any conversation, especially a critical one requiring a clinician's immediate attention and action. SBAR originated in the U.S. Navy submarine community to quickly provide critical information to the captain. Standards of communication are essential for developing teamwork and fostering a culture of patient safety. Situation � what is going on with the pt. (Pt arrived for appointment on wrong day) Background � clinical background (Pt arrive today at 11 AM, appt is for tomorrow, pt lives 40 miles away and needed a family member to drive them, the one appt slot you keep open for emergencies is available) Assessment � what do I think is the problem/your position (we should see the pt today) Recommendation � how can we correct it (use the emergency slot) A call-out is a tactic used to communicate critical information during an emergent event. Critical information called out in these situations helps the team anticipate and prepare for vital next steps in patient care. It also benefits a recorder when present during a code or emergent event. One important aspect of a call-out is directing the information to a specific individual. A check-back is a closed-loop communication strategy used to verify and validate information exchanged. The strategy involves the sender initiating a message, the receiver accepting the message and confirming what was communicated, and the sender verifying that the message was received.

51. 51 Communication Skills Introduction Patient Assessment Situation Safety Concerns Background Actions Timing Ownership Next Handoffs include the transfer of knowledge and information about the degree of uncertainty (or certainty) about diagnoses, response to treatment, recent changes in condition and circumstances, and the plan of care (including contingencies). In addition, both authority and responsibility are transferred. Lack of clarity about who is responsible for care and for decision-making has often been a major contributor to medical error (as identified in root cause analyses of sentinel events and poor outcomes). JCAHO NPSG 2E requires facilities to implement a standardized approach to handoff communications, including an opportunity to ask and respond to questions. The rationale is stated by the Joint Commission: �The primary objective of a handoff is to provide accurate information about a patient's/client's/resident's care, treatment and services, current condition, and any recent or anticipated changes. The information communicated during a handoff must be accurate to meet patient safety goals.� �I Pass the Baton" is an option for structured handoffs. I Introduction�Introduce yourself and your role/job (include patient) P Patient�Name, identifiers, age, sex, location A Assessment�Presenting chief complaint, vital signs, symptoms, and diagnosis S Situation�Current status/circumstances, including code status, level of uncertainty, recent changes, response to treatment S Safety Concerns�Critical lab values/reports, socio-economic factors, allergies, alerts (falls, isolation, etc.) THE B Background�Co-morbidities, previous episodes, current medications, family history A Actions�What actions were taken or are required? Provide brief rationale T Timing�Level of urgency and explicit timing and prioritization of actions O Ownership�Who is responsible (nurse/doctor/team)? Include patient/family responsibilities N Next�What will happen next? Anticipated changes? What is the plan? Are there contingency plans? Handoffs include the transfer of knowledge and information about the degree of uncertainty (or certainty) about diagnoses, response to treatment, recent changes in condition and circumstances, and the plan of care (including contingencies). In addition, both authority and responsibility are transferred. Lack of clarity about who is responsible for care and for decision-making has often been a major contributor to medical error (as identified in root cause analyses of sentinel events and poor outcomes). JCAHO NPSG 2E requires facilities to implement a standardized approach to handoff communications, including an opportunity to ask and respond to questions. The rationale is stated by the Joint Commission: �The primary objective of a handoff is to provide accurate information about a patient's/client's/resident's care, treatment and services, current condition, and any recent or anticipated changes. The information communicated during a handoff must be accurate to meet patient safety goals.� �I Pass the Baton" is an option for structured handoffs. I Introduction�Introduce yourself and your role/job (include patient) P Patient�Name, identifiers, age, sex, location A Assessment�Presenting chief complaint, vital signs, symptoms, and diagnosis S Situation�Current status/circumstances, including code status, level of uncertainty, recent changes, response to treatment S Safety Concerns�Critical lab values/reports, socio-economic factors, allergies, alerts (falls, isolation, etc.) THE B Background�Co-morbidities, previous episodes, current medications, family history A Actions�What actions were taken or are required? Provide brief rationale T Timing�Level of urgency and explicit timing and prioritization of actions O Ownership�Who is responsible (nurse/doctor/team)? Include patient/family responsibilities N Next�What will happen next? Anticipated changes? What is the plan? Are there contingency plans?

52. 52 Multiple barriers can prevent us from achieving our goal of providing evidence-based, patient-centered, safe care. Clinical and technical competency are not enough. We must learn the specific teamwork and communication tools and strategies that overcome barriers inherent in healthcare in general. In addition, there are specific barriers inherent in the care of older adults that require teamwork and communication skills. These �geriatric-specific� barriers are that patients have complex medical, cognitive, and functional deficits; they often lack robust social support systems, and care tends to be fragmented by multiple specialized providers practice in different settings. Keeping the Complex Community Dwelling Older Adult in his or her own home requires clinical and as teamwork and communication skills. The outcomes of care we are striving for include: Evidence-based Shared Mental Model Adaptability Team Orientation Mutual Trust Team Performance Patient Centered Patient Safety!!Multiple barriers can prevent us from achieving our goal of providing evidence-based, patient-centered, safe care. Clinical and technical competency are not enough. We must learn the specific teamwork and communication tools and strategies that overcome barriers inherent in healthcare in general. In addition, there are specific barriers inherent in the care of older adults that require teamwork and communication skills. These �geriatric-specific� barriers are that patients have complex medical, cognitive, and functional deficits; they often lack robust social support systems, and care tends to be fragmented by multiple specialized providers practice in different settings. Keeping the Complex Community Dwelling Older Adult in his or her own home requires clinical and as teamwork and communication skills. The outcomes of care we are striving for include: Evidence-based Shared Mental Model Adaptability Team Orientation Mutual Trust Team Performance Patient Centered Patient Safety!!

53. 53 Disruptive Behavior Old frame of reference Tolerate the behavior as a way of doing business Shrug off the problem; minor occurrence with no ill effects to patients or staff New frame of reference Disruptive behaviors have profound effect on patient safety and quality of care Not unique to physicians or healthcare Consequences permeate the organization Affect staff morale, patient and family Community perceptions and hospital reputation. Hospitals can no longer take a passive approach to disruptive behaviors

54. 54 Disruptive Behavior Calls for Leadership Joint Commission Standard LD.03.01.01 (1/09) Leaders create and maintain a culture of safety and quality throughout the organization. Elements of Performance for LD.03.01.01 Leaders regularly evaluate the culture of safety and quality using valid and reliable tools. Leaders prioritize and implement changes identified by the evaluation. . . .3 - 11

55. Improvements in nurse perceptions of flexible culture 2005 vs. 2007 as a result of systematic reporting of medication errors using MEDMARX, education about human error, introduction of SBAR

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59. 59 The Problem� Absence of team-related skills such as leadership, structured communication, adaptability to changing workloads, planning, team performance improvement The Solution� �People make fewer errors when they work in teams.� To Err is Human: Building a Safer Health System

60. 60 Current Intervention: TeamSTEPPS Knowledge Shared Mental Model of Team Skills Attitudes Mutual Trust Team Orientation Performance Adaptability Accuracy Productivity Efficiency Safety

61. 61 Reporting, Just, and Flexible practices support organizational Learning Ultimately, the willingness of workers to report depends on their belief that the organization will analyze reported information and then implement appropriate change�organizational practices support a learning culture. Practices/Tools Individual RCA Aggregate RCA FMEA Safety Briefings Leadership WalkRounds Close the loop with reporting A learning culture takes action based on information about its systems. A learning culture is driven to improve through constant feedback about the successes and failures of its processes. The foundation of a learning culture is information systems�reporting. Ultimately, the willingness of workers to report depends on their belief that the organization will analyze reported information and then implement appropriate change�organizational practices support a learning culture. Root cause analysis, individual and aggregate, FMEA, Safety Briefings, and Leadership WalkRounds are the tools that organizations use to learn from their experience. A learning culture takes action based on information about its systems. A learning culture is driven to improve through constant feedback about the successes and failures of its processes. The foundation of a learning culture is information systems�reporting. Ultimately, the willingness of workers to report depends on their belief that the organization will analyze reported information and then implement appropriate change�organizational practices support a learning culture. Root cause analysis, individual and aggregate, FMEA, Safety Briefings, and Leadership WalkRounds are the tools that organizations use to learn from their experience.

62. 62 Five Basic Steps ofRoot Cause Analysis 1. Gather the facts using a timeline 2. Understand what happened 3. Identify root causes using causal statements 4. Determine system improvements to minimize risk of repeating the error 5. Create action plans to implement and monitor effectiveness of changes

63. 63 Aggregate RCA Staff may be more receptive to change Process change based on multiple events Focus on potentially serious events--close calls and errors that reached the patient Staff may be less defensive because focus not on a harmful event...blame less prevalent May be used in any setting Inpatient, outpatient, long term care, acute care, home care Use in all types of reported events Falls, pressure ulcers, employee events, lab

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65. 65 Leadership WalkRoundsTM Senior leaders demonstrate commitment to safety and learn about safety issues by making regular rounds to discuss safety with staff Communication is two-way, leaders and staff talk honestly and listen carefully (reporting) Unannounced or announced but must be regular (weekly) Focus on systems not individuals (just) Close the loop on communication (flexible) use a notebook and database to track reported events and their resolution (learning) Digital camera can capture unsafe equipment/environment Senior leaders wishing to demonstrate their commitment to safety and learn about the safety issues in their own organization can do so by making regular rounds for the sole purpose of discussing safety with the staff. During the WalkRounds�, the communication should go two ways, with both the executives and the staff talking honestly and listening carefully. Many organizations have found Patient Safety Leadership WalkRounds� especially effective in conjunction with Safety Briefings which often provide material for executives to start discussions. Senior leaders wishing to demonstrate their commitment to safety and learn about the safety issues in their own organization can do so by making regular rounds for the sole purpose of discussing safety with the staff. During the WalkRounds�, the communication should go two ways, with both the executives and the staff talking honestly and listening carefully. Many organizations have found Patient Safety Leadership WalkRounds� especially effective in conjunction with Safety Briefings which often provide material for executives to start discussions.

66. 66 �We�re interested in focusing on the system and not individuals� �Can you think of any events in the past day or few days that have resulted in prolonged hospitalization for a patient?� �Have there been any near misses that almost caused patient harm but didn�t?� �Have there been any incidents lately that you can think of where a patient was harmed? �What aspects of the environment are likely to lead to the next patient harm?� �Is there anything we could do to prevent the next adverse event?� �Can you think of a way in which the system or your environment fails you on a consistent basis?� �How are we actively promoting a just culture and a non-punitive, confidential reporting policy?�

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68. Improvements in nurse perceptions of learning culture 2005 vs. 2007 as a result of systematic reporting of medication errors using MEDMARX, education about human error, introduction of SBAR, quarterly aggregate RCAs of falls and nonharmful medication errors, and individual RCA of harmful medication errors

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73. 73 The Importance of Teams in Organizational Learning �Teams are the fundamental learning units in modern organizations. Unless teams can learn, organizations cannot learn.� Peter Senge (1990). The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Doubleday Currency, p. 10.

74. 74 Active Learning Form groups of 5 Review the Benchmark Graph What are the strengths and weaknesses revealed by the aggregate data? What practices are needed to support an informed, safe culture? Do you need additional information? Premier Excel Data Tool What are the top three practices you would recommend?

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76. 76 What is a learning culture? It observes and collects data It reflects and draws correct conclusions from information systems It creates and plans change based on information It has the will to act and implement change �Learning disabilities are tragic in children, but they are fatal in organizations.� -- Peter Senge

77. 77 8 Steps of Change

78. 78 Lessons Learned HSOPSC is a strategic management tool Identifies practices needed to support an informed, safe culture Rural-adapted survey reveals culture variation within small rural hospitals Detects and evaluates change in culture over time Reassessment with HSOPSC reveals How leaders use information If organizations engineered practices to support four components of culture in response to baseline survey Presence/absence of change strategy Driver of culture: how we collect, analyze, disseminate, use information, which is dependent upon leadership style and professional training Driver of culture: how we collect, analyze, disseminate, use information, which is dependent upon leadership style and professional training

79. 79 Lessons Learned Behaviors that support an informed safe culture Assess safety culture using effective data collection methods Create an infrastructure that supports systematic error reporting�reporting is the foundation of an informed, safe culture Adhere to principles of just culture Implement team training to support a flexible culture Learn from error in the context of daily work (Safety Briefings and Leadership WalkroundsTM) Systematically learn from events using individual RCA and aggregate RCA to learn from multiple non-harmful errors

80. 80 �Once the AHRQ survey identified areas for improvement, through the grant, we spent the next year working on those areas. The education and training on teamwork, communication, and RCA gave us tools we hadn�t heard of. We have seen our organization change from one that makes the same errors over and over to one that analyzes errors and attempts to learn from them.� (pop. 2,109) James Reason has a quote: Learning disabilities(pop. 2,109) James Reason has a quote: Learning disabilities

81. 81 Contact Information Katherine Jones, PhD, PT kjonesj@unmc.edu Anne Skinner askinner@unmc.edu Web site where tools are posted www.unmc.edu/rural/patient-safety

82. 82 The AHRQ Hospital Survey on Patient Safety Culture A Service Offered by the University of Nebraska Medical Center and the National Rural Health Association For more information, please contact:Anne Skinneraskinner@unmc.edu 402-559-8221