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Creating A Culture Of Safety

Overview of Advocate Culture of Safety initiative Everyone must understand Physicians, as leaders, are key to adoption Caring for others is our responsibility Safety is here to stay

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Advocate Case

20 y/o – anticoagulated after kidney transplant and Pulmonary Embolus

Has cervical LEEP procedure Discharged home Returns with vaginal bleeding Admitted – transfused 6 units Physician failed to obtain history or medication history and

failed to do physical exam

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Advocate Event

20 y/o male status post tracheal repair. Chin-Chest flap performed to protect surgical site. Patient combative, intubated, restrained and

sedated. Neurological assessments deferred post-op. 8 days post op patient found to be quadriplegic

due to hyperflexion c-spine injury Example of Fatuous behavior

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Objectives

Share with you what the Safety Initiative is about

Give you an understanding of why humans experience errors

Introduce you to the Behavior-Based Expectations (BBE) and related error prevention tools

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Why Culture is Important

CultureThe shared values and beliefs

of individuals in a group or organization

Culture Shared Values& Beliefs

Shared Values& Beliefs Our Behaviors

Our Behaviors Outcomes

=

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Creating A Culture Of Safety

Very hard to change behavior/culture Need new set of behaviors Do all your behaviors always result in safe,

reliable, productive outcomes We are asking a lot Why did we go into health care?

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Why Error Prevention

44,000 to 98,000 deaths each year

due to medical errors One Boeing 747 fill with passengers

crashing every 3 days At our 600 bed hospitals we have

about 40 preventable deaths/year and at our 300 bed hospitals we have about 15-20 preventable deaths/year.

Advocate employee injury rate 9/100 employees: Heavy Construction 6.8/100: Nuclear Power 0.5/100

“It’s the right thing to do.”But also …

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Six Circles Of Performance Excellence

Quality Satisfaction

TimeCost

Excellence

Safety

Our ChallengeFigure out a way to

achieve excellence in each of the Circles at the same time, all the time.

Safety = No Harm

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Safety Should NOT Be a Priority...

ISMP Medication Safety Alert, September 23, 2004

…but our core value

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Common Causes Of Past Events Within Advocate

Common causes associated with of our past events

- Lack of critical thinking skills

- Non-Compliance with policy, procedure, or

expectations

- Incomplete communication between care providers

- Inadequate Attention to Detail

- Inadequate knowledge & skills

Does anything here surprise you

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Prevention Strategy

1. Establish Expectations

Establish behavior-based expectations consistent with the organization’s mission, goals, and high management standards for event-free performance

2. Educate - Develop Knowledge & Skills

Educate individuals at all levels of the organization on behavior-based expectations and error prevention techniques

3. Manage Accountability for Results

Establish an accountability system to convert behaviors to work habits

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What Is Accountability?

Except in rare cases where people intentionally violate a rule, no one will be punished for

innocent errors.

Something everyone has

Something you want to strive to build and enhance

About being responsible for your actions, conduct, and work

Intrinsic motivation of the individual to meet performance standards

Accountability is…

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Making It Stick

20%

Even

t R

ate

Awareness

Skill Acquisition

Habit Formation

Performance

Time

100%

80% DecreaseIn Event Rate

Over 1-2 Years

2 Years

Our current event rate, set at 100%

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Physician Behaviors Expected

Communicate Clearly

- Insure we give and receive accurate and complete information

- Poor information leads to decision errors, poor choices and poor handoffs

Commit to safety

- Expected of everyone

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Tools To Achieve BBE’s

Phonetic and Numeric Clarification Repeat Backs and Read Backs Clarifying Questions SBAR to communicate problems and improve

handoffs STAR for self checking Peer Checking, Peer Coaching and ARCC Q V&V for critical thinking Red Rules

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Communicate Clearly

Why should we do this? To ensure that we hear things correctly and that we

understand things correctly To prevent avoid wrong assumptions and

misunderstandings that could cause us to make wrong decisions

When you need to communicate about a problem or issue that needs resolution

When should we do this?Whenever we communicate information – either in person or over the phone – that could affect the care and safety of a patient or an employee

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Physician Behaviors

Value: Communicate Clearly

•Use Phonetic/Numeric Clarification•Participate in Readbacks and Repeatbacks•Encourage clarifying questions•Handoff effectively:

•use SBAR •Personally communicate in specific situations

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Communicate Clearly Phonetic/Numeric Clarifications

“D” as in Dog or David or Darth No need to spell out entire word phonetically For sound alike numbers

- “15” that’s one five

- “50” that’s five zero

- “one half” that’s zero point five When to use them

- Difficult or confusing drug or patient name

- Sound alike medications

- Medication doses

- Critical lab values

- Equipment set points

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Communicate Clearly

Read Back Communication Technique

1

2

3

When information is transferred...

Sender initiates communication using Receivers Name. Sender provides an order, request, or information to Receiver in a clear & concise format.

Receiver acknowledges receipt by a read-back of the order, request, or information after writing it down

Sender acknowledges the accuracy of the repeat-back – “That’s Correct”. If not correct, repeats the communication.

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Read Back/Repeat Back

Read Back

- Required for orders and critical values reporting Repeat Back

- OK in emergency situation

- Physician Responsibility – listen and use indicated response

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Communicate Clearly

Clarifying Questions

Ask 1 to 2 clarifying questionsWhen in high risk situations

When information is incomplete

When information is ambiguous

WHY: To reduce the probability of making a wrong assumption. Asking clarifying questions reduces the risk by 2 1/2 times!!

HOW: Phrase your clarifying questions in a positive way and in a manner that will get an answer that improves your understanding of the information

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SBAR for Effective Handoffs

Daily interaction between many different Advocate staff – physicians, nurses, therapists, non-clinical personnel

Expectation – we will all work together cooperatively Requires personal commitment

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Advocate Case

17 y/o with sore throat Phone order for mono test – MD leaves for weekend –

evaluation not offered Family call Friday PM for report – denied Patient goes to weekend sleepover Punched in stomach Presents to Peds Mon AM with ruptured spleen in shock

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Advocate Case

79 y/o in ED with c/o chest pain for 4 days Chest X-Ray done in ED not read because it was MD shift

change time Physician left without telling next MD of pending X-Ray Patient transferred to ICU X-Ray not read for 48 hours – recquisition lost in radiology Patient died due to missed pneumothorax

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Care Coordination For Consultation Requests

Expectation: For all consultations physicians will request the consultation directly from another physician – a goal

Hospital will facilitate physician to physician communication – a goal

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Care Coordination Using Personal Communication

Physician to care provider Physician to family

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Care Coordination Using Handoffs

What is a handoff?

- Transfer of immediate responsibility for a patient or project which includes but limited to:

* Physician to physician

* Physician to other caregiver

* Caregiver to transportation

* Transportation to technician

* Transportation to caregiver

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Effective Handoffs

Habits For Effective Handoffs

You own it until you hand it off to an

appropriate person

If you accept a handoff for someone else,

you own it until you hand it off to that

someone else

Use 5P approach when a formal (process)

turnover is not provided

#1

#2

#3

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Communicate Clearly

SBAR Briefing FormatWhen you need to communicate about a problem or issue that needs resolution…for handoffs

Situation Who you’re calling about, the immediate problem, current vital signs, your

concerns

Background Review of pertinent information: procedures, mental status, skin

condition, oxygenation

Assessment Your view of the situation: “I think the problem is…” or “I’m not sure what

the problem is” Urgency of action: “the patient is deteriorating rapidly - we need to do

something”

Recommendation Your suggestion to or request of the physician

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Communication Review

S – Situation - Dr Johnson – I appreciate your covering for me while I am out of town. Let me give you a quick handoff on Jim Gerkley

B – Background – He is recovering from knee surgery and is on PCA for pain

A – Assessment – I am concerned he is getting addicted to his pain medicine. His right ankle is swollen and he will not put weight on it

R – Recommendation – I want to get him weaned off Dilaudid and increase his exercise. I have been watching him for potential atelactasis

Physicians may hear another technique called 5P which is explained on the following slide but not on the CD

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Communicate Clearly

5P’s for an Effective Handoff

Ensure that complete & accurate information is communicated when

responsibility transfers from one person to another

PPatient or Project: What is to be handed off

Plan: What is to happen next - the main effort

Purpose of the plan: The desired end state

Problems: What is known to be different, unusual, or

complicating about this patient or project

Precautions: What could be expected to be different,

unusual, or complicating about this patient or project

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Communication Summary

Situation – Good evening Dr Stevenson. We need your assistance with Lois Parker who complains of wakefulness in spite of sleep medications

Background – She is 76 y/o recovering from knee surgery. She is on sleep medications – 15 mgm of Temazepam. Vital signs are stable.

Assessment – She is not sleeping Recommendation – Would you consider increasing

Temazepam to 30 mgm Qhs Readback occurs

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Communication Summary

4 Communication techniques reviewed Phonetic and Numeric clarification Read backs and repeat backs Clarifying Questions SBAR for effective communication of problems and handoffs

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Commit To Safety

Second Behavioral Expectation Our patient expect it Our co-workers expect it You expect it

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Advocate Case

Elderly patient with Diabetes and Peripheral Vascular Disease

Scheduled for toe amputation Surgical holding – toe bandaged and could not check site

marking OR finds site not marked Nurse asked Surgeon to mark site – refused Nurse asked a second time – refused Incorrect toe amputated

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Advocate Case

80 y/o to ED with elevated blood sugar MD writes order for 7 u insulin Nurse reads order as 70 units insulin Pharmacist does not question order – rule to clarify orders

with prohibited abbreviations had been rescinded Patient given 70 units insulin

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Advocate Case

34 y/o scheduled for lap/choly Anesthesiologist failed to check syringe he used to inject a

sedative Syringe contained neuromuscular blocker – administered

by error Patient suffers respiratory arrest

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Tools That Demonstrate Our Commitment To Safety

STAR – a tool for self checking Peer Checking, Peer Coaching and ARCC Critical Thinking using Q V&V Red Rules

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An airline pilot once told a hospital administrator…

“In healthcare, you rush in all the wrong places.”

STOP… In The Name Of Safety!!

Benefits of a 2 second STOP

Gives your brain a chance to catch up with what your hands are ready to do

Increases the chance that you’ll recognize a high-risk situation and prevent yourself from practicing a high-risk behavior

What situations in your job create time pressure that lead you to RUSH when you really should STOP??

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Stop:

Think:

Act:

Review:

Pause for 1 to 2 seconds to focus on what you’re about to do

Think about what you’re about to do – is it the right thing?

Concentrate and perform the task

Check to see if the task was done right

Self Checking Using STAR

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Peer Checking & Peer Coaching

Take advantage of working together

Check others when working together

Point out problems in a constructive manner

Peer Checking

Encourage (or positively reinforce) safe and productive behaviors

Discourage (or negatively reinforce) unsafe and unproductive behaviors.

Peer Coaching

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Responding To ARCC

Ask a question

Make a Request

Voice a Concern

Allows another care provider to express a concern that will result in review of the situation

If not, then use...

(Inquire)

(Advocate)

(Assert)

Safe WordChain of Command

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ARCC Example

RN “excuse me doctor, we are about to start our time out, can you join us?” MD “go ahead with the Time Out, I will be there shortly

RN – Doctor, everyone needs to participate. I need to request your presence and attention for the time out. It’s a patient safety requirement and we can’t get started on time until we do it”

MD “OK I’m ready – Gloves and Gown Please RN “Doctor, I have a concern. We have not done the required

time out and Advocate policies do not allow us to proceed without a time out. I am afraid I would have to involve my management to do otherwise

MD “Gotcha, Gotcha thanks, I appreciate your keeping me on track. I’m getting ahead of myself. Let’s do the time out

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Questioning Attitude

QV&V Technique

Qualify - the source – is source reliableValidate - Does it make sense to me?Verify - Check it with a second source

A 3-step method for processing raw information into FACT

A method for processing confusing or conflicting rules into rules you can use with CONFIDENCE

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Intelligent Compliance With Expectations Red Rules

1. Know, comply, and use policies, procedures, and job aids.

2. Know and comply with Red Rules.

3. STOP when unsure and check with expert source

Do not proceed in the face of uncertainty...

if there is a question

if the situation doesn’t match your experience, training, or expectations

if the activity can’t be performed as specified

STOP

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What Is A Red Rule? “Red Rules” indicate the highest priority for exact compliance with rules - compliance

must come before any other consideration, including revenue and personal desire

Few in number

Highest degree of risk to patient safety

A clear, discrete, decision-based act

Self-evident

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Important Points About Red Rules

Purpose is NOT discipline

Red Rules focus our attention on acts most critical to patient and employee safety

Red Rules align our values and beliefs around these acts and motivate us to make Red Rule behaviors our consistent work habits

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Advocate Hospital Red Rule

Perform a Time Out/Patient Safety Check before operative and other invasive patient procedures

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Commitment to Safety – Summary

We expect everyone to Commit to Safety Tools for Commit to Safety

STAR Peer Checking Peer Coaching Q V&V Red Rules

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Advocate Culture Of Safety

Importance of Culture of Safety within Advocate Presented 2 Behavior Based Expectations

- We expect everyone to communicate clearly

- We expect everyone to commit to safety

- Presented 8 tools to accomplish these BBE’s Use of these tools has been proven to save lives We expect of you as physician leaders

- To learn and use these tools and demonstrate commitment to these behaviors

- To support and encourage use of these error reduction tools