Valley Care The Impact of Medical Errors

Valley. Care ™ The Impact of Medical Errors Mod 1 06. 2 Page 1 Mod 1 05. 2 Page 1 TEAMSTEPPS 05. 2 1

Valley. Care ™ Diane Brack Two Boeing 747 s, operated by KLM and Pan Am, collide due to breakdowns in communication and safety checks. Number of people killed: 583 Mod 1 06. 2 Page 2 Mod 1 05. 2 Page 2 TEAMSTEPPS 05. 2 2

Valley. Care ™ This plane flew in a holding pattern for 77 minutes while awaiting landing clearance at JFK and crashed due to a failure to communicate the urgency of fuel situation. Number of people killed: 73 Mod 1 06. 2 Page 3 Mod 1 05. 2 Page 3 TEAMSTEPPS 05. 2 3

Valley. Care ™ As many as 98, 000 deaths occur as a result of medical errors each year Mod 1 06. 2 Page 4 Mod 1 05. 2 Page 4 TEAMSTEPPS 05. 2 4

Valley. Care ™ Mod 1 06. 2 Page 5 Mod 1 05. 2 Page 5 That’s the same as a 747 jet falling out of the sky EVERYDAY for a YEAR!!! TEAMSTEPPS 05. 2 5

Valley. Care ™ More Americans die from medical errors than from breast cancer, AIDS, or car accidents combined Mod 1 06. 2 Page 6 Mod 1 05. 2 Page 6 TEAMSTEPPS 05. 2 6

Valley. Care ™ 22, 980 Obstetrical adverse events every year are caused by medical error Mod 1 06. 2 Page 7 Mod 1 05. 2 Page 7 TEAMSTEPPS 05. 2 7

Valley. Care ™ Cost associated with medical errors is $8– 29 billion annually Mod 1 06. 2 Page 8 Mod 1 05. 2 Page 8 TEAMSTEPPS 05. 2 8

Valley. Care ™ Failures in Communication are the leading contributor to sentinel events. ~The Joint Commision Mod 1 06. 2 Page 9 Mod 1 05. 2 Page 9 TEAMSTEPPS 05. 2 9

Valley. Care ™ Communication Failures contribute to 72% of Root Cause Analysis of sentinel events in perinatal units Mod 1 06. 2 Page 10 Mod 1 05. 2 Page 10 TEAMSTEPPS 05. 2 10

Valley. Care ™ The solution? Mod 1 06. 2 Page 11 Mod 1 05. 2 Page 11 TEAMSTEPPS 05. 2 11

Valley. Care ™ ™ Strategies and Tools to Enhance Performance and Patient Safety Mod 1 06. 2 Page 12 Mod 1 05. 2 Page 12 TEAMSTEPPS 05. 2 12

Valley. Care ™ CHAIN EXERCISE Mod 1 06. 2 Page 13 Mod 1 05. 2 Page 13 TEAMSTEPPS 05. 2 13

Valley. Care ™ Using the materials in front of you, create a paper chain with the most links. You may only use your non-dominant hand. You have 2 minutes to create this chain. Mod 1 06. 2 Page 14 Mod 1 05. 2 Page 14 TEAMSTEPPS 05. 2 14

Valley. Care ™ Objectives n Road To Team. STEPPS n Team. STEPPS Concepts and Tools n Impact on Culture of Safety n The Journey Continues… Mod 1 06. 2 Page 15 Mod 1 05. 2 Page 15 TEAMSTEPPS 05. 2 15

Valley. Care ™ The Road to Team. STEPPS… Mod 1 06. 2 Page 16 Mod 1 05. 2 Page 16 TEAMSTEPPS 05. 2 16

Valley. Care ™ The Components of a Patient Safety Program Mod 1 06. 2 Page 17 Mod 1 05. 2 Page 17 TEAMSTEPPS 05. 2 17

Valley. Care ™ Introduction Evolution of Team. STEPPS Curriculum Contributors • Department of Defense • Agency for Healthcare Research and Quality • Research Organizations • Healthcare Foundations • Private Companies • Universities • Medical and Business Schools Mod 1 06. 2 Page 18 Mod 1 05. 2 Page 18 • Hospitals—Military and Civilian, Teaching and Community-Based TEAMSTEPPS 05. 2 • Subject Matter Experts in Teamwork, Human Factors, and Crew Resource Management (CRM) 18

Valley. Care ™ Institute of Medicine Report “To Err is Human” (1999) Impact of Error: n 44, 000– 98, 000 annual deaths occur as a result of errors n Medical errors are the leading cause, followed by surgical mistakes and complications n More Americans die from medical errors than from breast cancer, AIDS, or car accidents n 7% of hospital patients experience a serious medication error Cost associated with medical errors is $8– 29 billion annually. Mod 1 06. 2 Page 19 Mod 1 05. 2 Page 19 TEAMSTEPPS 05. 2 19

Valley. Care ™ JCAHO Sentinel Events Mod 1 06. 2 Page 20 Mod 1 05. 2 Page 20 TEAMSTEPPS 05. 2 20

Valley. Care ™ (Pronovost, 2003) Johns Hopkins Journal of Critical Care Medicine (Sexton, 2006) Johns Hopkins (Mann, 2006) Beth Israel Deaconess Medical Center Contemporary OB/GYN Mod 1 06. 2 Page 21 Mod 1 05. 2 Page 21 TEAMSTEPPS 05. 2 21

Valley. Care ™ Team. STEPPS Key Principles n Team Structure n Leadership n Situation Monitoring n Mutual Support n Communication Mod 1 06. 2 Page 22 Mod 1 05. 2 Page 22 TEAMSTEPPS 05. 2 22

Valley. Care ™ Paradigm Shift to Team System Approach Single focus (clinical skills) Individual performance Team performance Under-informed decision-making Informed decision-making Loose concept of teamwork Clear understanding of teamwork Unbalanced workload Managed workload Having information Sharing information Self-advocacy Mutual support Self-improvement Team improvement Individual efficiency Mod 1 06. 2 Page 23 Mod 1 05. 2 Page 23 Dual focus (clinical and team skills) Team efficiency TEAMSTEPPS 05. 2 23

Valley. Care ™ High-Performing Teams that perform well: n Hold shared mental models n Have clear, valued, and shared vision n Have strong team leadership n Engage in a regular discipline of feedback n Develop a strong sense of collective trust and confidence n Optimize resources n Have clear roles and responsibilities n Create mechanisms to cooperate and coordinate n Manage and optimize performance outcomes (Salas et al. 2004) Mod 1 06. 2 Page 24 Mod 1 05. 2 Page 24 TEAMSTEPPS 05. 2 24

Valley. Care ™ Why Teamwork? “High-performance teams create a safety net for your healthcare organization as you promote a culture of safety. " Mod 1 06. 2 Page 25 Mod 1 05. 2 Page 25 TEAMSTEPPS 05. 2 25

Valley. Care ™ Effective Team Leaders n Organize the team n Articulate clear goals n Make decisions through collective input of members n Empower members to speak up and challenge, when appropriate n Actively promote and facilitate good teamwork n Skillful at conflict resolution Mod 1 06. 2 Page 26 Mod 1 05. 2 Page 26 TEAMSTEPPS 05. 2 26

Valley. Care ™ A Continuous Process Situation Monitoring (Individual Skill) Situation Awareness (Individual Outcome) Shared Mental Model (Team Outcome) Mod 1 06. 2 Page 27 Mod 1 05. 2 Page 27 TEAMSTEPPS 05. 2 27

Valley. Care ™ Cross Monitoring Mod 1 06. 2 Page 28 Mod 1 05. 2 Page 28 TEAMSTEPPS 05. 2 28

Valley. Care ™ Shared Mental Model? Mod 1 06. 2 Page 29 Mod 1 05. 2 Page 29 TEAMSTEPPS 05. 2 29

Valley. Care ™ What Do You See? Mod 1 06. 2 Page 30 Mod 1 05. 2 Page 30 TEAMSTEPPS 05. 2 30

Valley. Care ™ Task Assistance Team members foster a climate in which it is expected that assistance will be actively sought and offered as a method for reducing the occurrence of error. “In support of patient safety, it’s expected!” Mod 1 06. 2 Page 31 Mod 1 05. 2 Page 31 TEAMSTEPPS 05. 2 31

Valley. Care ™ Characteristics of Effective Feedback Good Feedback is— n TIMELY n RESPECTFUL n SPECIFIC n DIRECTED toward improvement n Helps prevent the same problem from occurring in the future n CONSIDERATE n FIRST HAND encouraged “Feedback is where the learning occurs. ” Mod 1 06. 2 Page 32 Mod 1 05. 2 Page 32 TEAMSTEPPS 05. 2 32

Valley. Care ™ CHAIN EXERCISE Mod 1 06. 2 Page 33 Mod 1 05. 2 Page 33 TEAMSTEPPS 05. 2 33

Valley. Care ™ Using the materials in front of you, create a paper chain with the most links. You may only use your non-dominant hand AND you cannot speak. You have 2 minutes to create this chain. Mod 1 06. 2 Page 34 Mod 1 05. 2 Page 34 TEAMSTEPPS 05. 2 34

™ Strategies and Tools to Enhance Performance and Patient Safety TOOLS

Valley. Care ™ Leadership Tools ™ Mod 1 06. 2 Page 36 Mod 1 05. 2 Page 36 TEAMSTEPPS 05. 2 36

Valley. Care ™ Briefing Checklist TOPIC Who is on core team? All members understand agree upon goals? Roles and responsibilities understood? Plan of care? Staff availability? Workload? Available resources? Mod 1 06. 2 Page 37 Mod 1 05. 2 Page 37 TEAMSTEPPS 05. 2 37

Valley. Care ™ Debrief Checklist TOPIC Communication clear? Roles and responsibilities understood? Situation awareness maintained? Workload distribution? Did we ask for or offer assistance? Were errors made or avoided? What went well, what should change, what can improve? Mod 1 06. 2 Page 38 Mod 1 05. 2 Page 38 TEAMSTEPPS 05. 2 38

MUTUAL SUPPORT Conflict Resolution Tools ™

Valley. Care ™ Two-Challenge Rule Invoked when an initial assertion is ignored… n It is your responsibility to assertively voice your concern at least two times to ensure that it has been heard n “Empower any member of the team to “stop the line” if he or she senses or discovers an essential safety breach. ” n If the outcome is still not acceptable: n n Mod 1 06. 2 Page 40 Mod 1 05. 2 Page 40 Take a stronger course of action Use supervisor or chain of command TEAMSTEPPS 05. 2 40

Valley. Care ™ Please Use CUS Words but only when appropriate! Mod 1 06. 2 Page 41 Mod 1 05. 2 Page 41 TEAMSTEPPS 05. 2 41

Communication Tools Assumptions Fatigue Distractions HIPAA ™

Valley. Care ™ R-SBAR n “I am concerned about………” n “I need you to come in now because…. ” n Situation―What is going on with the patient? n Background―What is the clinical background or context? n Assessment―What do I think the problem is? n Recommendation―What would I recommend? Remember to introduce yourself… Mod 1 06. 2 Page 43 Mod 1 05. 2 Page 43 TEAMSTEPPS 05. 2 43

Valley. Care ™ Check-Back is… Mod 1 06. 2 Page 44 Mod 1 05. 2 Page 44 TEAMSTEPPS 05. 2 44

Valley. Care ™ Team Effectiveness BARRIERS n Inconsistency in Team n n n n Membership Lack of Time Lack of Information Sharing Hierarchy Defensiveness Conventional Thinking Complacency Varying Communication Styles Conflict Lack of Coordination and Follow-Up with Co-Workers Distractions Fatigue Workload Misinterpretation of Cues Lack of Role Clarity Mod 1 06. 2 Page 45 Mod 1 05. 2 Page 45 TOOLS and STRATEGIES Brief Huddle Debrief STEP Cross Monitoring Feedback Advocacy and Assertion Two-Challenge Rule CUS Collaboration SBAR Call-Out Check-Back Handoff TEAMSTEPPS 05. 2 OUTCOMES v Shared Mental Model v Adaptability v Team Orientation v Mutual Trust v Team Performance v Patient Safety!! 45

Valley. Care ™ Perinatal Safety Program ■ Mandatory Team STEPPS Training ■ Mandatory Simulation Training ■ Implementation of Laborist Program ■ Leadership Rounds ■ Quality Initiatives ● Intradepartmental Performance Improvement ● Peer Review ● Case Conferences ■ Mandatory Debriefing Mod 1 06. 2 Page 46 Mod 1 05. 2 Page 46 TEAMSTEPPS 05. 2 46

Valley. Care ™ Team STEPPS Team Assessment Questionnaire “The team is a safety net for patients. ” Pre Team STEPPS training Mod 1 06. 2 Page 47 Mod 1 05. 2 Page 47 TEAMSTEPPS 05. 2 Post Team STEPPS training 47

Valley. Care ™ Hospital Survey on Patient Safety Culture 2011 Composite Report - MCH Patient Safety Culture Composites Average % Positive 2009 AHRQ n=196, 462 2011 AHRQ n=472, 397 2009 Valley. Care n=600 2011 Valley. Care n=593 2009 MC n=68 2011 MC N=41 1. Teamwork Within Units 79% 80% 85% 82% 90% 92% 2. Supervisor/Manager Expectations & Actions Promoting Patient Safety 75% 76% 85% 89% 3. Organizational Learning—Continuous Improvement 71% 72% 76% 78% 90% 86% 4. Management Support for Patient Safety 70% 72% 74% 78% 89% 5. Overall Perceptions of Patient Safety 64% 66% 62% 69% 71% 73% 6. Feedback & Communication About Error 63% 64% 62% 67% 72% 76% 7. Communication Openness 62% 59% 62% 66% 8. Frequency of Events Reported 60% 63% 57% 60% 72% 9. Teamwork Across Units 57% 58% 60% 64% 69% 71% 10. Staffing 55% 57% 49% 57% 64% 57% 11. Handoffs & Transitions 44% 45% 42% 45% 54% 56% 12. Nonpunitive Response to Error 44% 35% 39% 41% 50% Mod 1 06. 2 Page 48 Mod 1 05. 2 Page 48 TEAMSTEPPS 05. 2 48

Valley. Care ™ Mod 1 06. 2 Page 49 Mod 1 05. 2 Page 49 TEAMSTEPPS 05. 2 49

Valley. Care ™ Hospital Survey on Patient Safety Culture 2011 Item Level Report - MCH 2009 2011 AHRQ Valley. C MCH Averag are Averag e e Percent Percent Positive (n=196, (n=472, Positive (n=68) (n=41) 462) 397) (n=600) (n=593) 1. People support one another in this unit. (A 1) 85% 86% 93% 89% 97% 100% 2. When a lot of work needs to be done quickly, we work together as a team to get the work done. (A 3) 86% 90% 88% 96% 98% 3. In this unit, people treat each other with respect. (A 4) 78% 86% 81% 93% 90% 4. When one area in this unit gets really busy, others help out. (A 11) 68% 69% 72% 73% 76% 80% TEAMWORK WITHIN UNITS Mod 1 06. 2 Page 50 Mod 1 05. 2 Page 50 TEAMSTEPPS 05. 2 50

Valley. Care ™ COMMUNICATION OPENNESS 1. Staff will freely speak up if they see something that may negatively affect patient care. (C 2) 76% 76% 80% 84% 83% 2. Staff feel free to question the decisions or actions of those with more authority. (C 4) 47% 43% 44% 52% 53% 3. Staff are NOT afraid to ask questions when something does not seem right. (C 6) 63% 59% 61% 62% 61% Mod 1 06. 2 Page 51 Mod 1 05. 2 Page 51 TEAMSTEPPS 05. 2 51

Valley. Care ™ TEAMWORK ACROSS UNITS 1. Hospital units coordinate well with each other. (F 2) 45% 46% 44% 51% 49% 59% 2. There is good cooperation among hospital units that need to work together. (F 4) 58% 59% 63% 67% 78% 71% 3. It is often pleasant to work with staff from other hospital units. (F 6) 58% 59% 63% 62% 69% 76% 4. Hospital units work well together to provide the best care for patients. (F 10) 67% 68% 69% 77% 78% 80% Mod 1 06. 2 Page 52 Mod 1 05. 2 Page 52 TEAMSTEPPS 05. 2 52

Valley. Care ™ Valley. Care’s Key Success Factors n n n n Strong Need for Team Approach Identified Support From Senior Administration Support From Department Leadership Support From Physician Champions Support From Ancillary Department Leadership Support From Staff Buy In Strength in Numbers-Multidisciplinary Core Team Mod 1 06. 2 Page 53 Mod 1 05. 2 Page 53 TEAMSTEPPS 05. 2 53

Valley. Care ™ The Journey Continues… Mod 1 06. 2 Page 54 Mod 1 05. 2 Page 54 TEAMSTEPPS 05. 2 54