TeamSTEPPS Team Strategies & Tools to Enhance Performance & Patient Safety - PowerPoint Presentation

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TeamSTEPPSTeam Strategies & Tools to Enhance Performance & Patient SafetySlide2

“TieredSTEPPS”: A Commitment to Address Behaviors that Undermine a Culture of Safety

Gerald B. Hickson, MD

Assistant Vice Chancellor for Health Affairs

Associate Dean for Faculty Affairs

Joseph C. Ross Chair in Medical Education & Administration

Chair, Board of Governors, National Patient Safety Foundation

Center for Patient & Professional Advocacy,

Vanderbilt University School of MedicineSlide3

Pursuit of ReliabilitySafety Culture

Willingness to report or act…Psychological safetyTrust“Behaviors that undermine a culture of safety” threaten trust, therefore must be addressed fairly, quickly, and in a measured way

Hickson

, Moore, Pichert, Benegas Jr. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Jt Comm Resources;2012:1-36.Slide4

Case: “Looks a Little Red”56 yo homeless man with frostbite to feetInitial care in burn unit...to Psych unit. Nurse and Psych Resident (Dr. PR) concerned... redness, mild fever, tachycardia?

Burn Unit resident, Dr. SurgRes, examines... "on right abx...wounds OK, vitals stable...see 1st thing in A.M. ...call with any concern.”Slide5

Case: “Looks a Little Red”2nd call to Dr. SR, 2 hours later…Psych Chief Resident to Dr. SR: "please have the Burn Fellow come now and examine this patient."Shortly thereafter the phone rings in the Psych unit…“Let me speak with Dr. PR”Slide6

Case: “Looks a Little Red”Dr. BurnFellow: "is this Dr. PR or whoever the #%&! is questioning my #%&! resident’s judgment...”

Dr. BF continues, “You guys in psych get so worked up....I bet you consult critical care every time a patient sneezes..."Dr. BF then hangs up...Slide7

Consider the microsystem where you work…

What % of the time would the professionals report Dr. BF’s conduct to either a supervisor or through an

event reporting system?

0 – 20%

20 – 40 %

40 – 60%

60 – 80%

80 – 100

%

Countdown

10Slide8

If reported, what % of the time would a medical leader have a conversation with Dr. BF?

0%-20%20%-40%40%-60%

60%-80%

80%-100%

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A Few QuestionsFrom Reason’s “Unsafe Acts” algorithm (1997):Is the team member intending to cause harm?

Is the team member impaired?Is the team member knowingly and unreasonably increasing risk?Is another team member in the same situation likely to act in a similar manner?Reason J.T.: Managing the Risks of Organizational Accidents.

Aldershot

, UK:

Ashgate

Publishing, 1997.Slide10

Definition of Behaviors That Undermine A Culture of Safety

Include but are not limited to, words or actions that:Prevent or interfere w/an individual’s or group’s work, academic performance, or ability to achieve intended outcomes (e.g. intentionally ignoring questions or not returning phone calls or pages related to matters involving patient care, or publicly criticizing other members of the team or the institution);

Create, or have the potential to create, an intimidating, hostile, offensive, or potentially unsafe work or academic environment (e.g. verbal abuse, sexual or other harassment, threatening or intimidating words, or words reasonably interpreted as threatening or intimidating);

Threaten personal or group safety, aggressive or violent physical actions; Violate VUMC policies, including conflicts of interest and compliance.

It’s About Safety

Vanderbilt University and Medical Center Policy #HR-027, 2010 Slide11

The Balance Beam

Do nothing

Do something

Staff satisfaction and retention

Reputation

Patient safety, clinical outcomes

Liability, risk mgmt costs

Fear of antagonizing

Leaders “blink”

Not sure how lack tools, training

Competing priorities

“Can’t change…”

June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Center for Patient and Professional Advocacy; Hickson GB, Pichert JW.  Disclosure and Apology. National Patient Safety Foundation Stand Up for Patient Safety Resource Guide, 2008; Pichert JW, Hickson GB, Vincent C: “Communicating About Unexpected Outcomes and Errors.” In Carayon P (Ed.).  Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety, 2007Slide12

Professionalism and Self-Regulation

Professionals commit to:

Technical and cognitive competence

Professionals also commit to:

Clear and effective communication

Modeling respect

Being available

“Self awareness”

Professionalism promotes teamwork

Professionalism demands self and group regulation

You have a critical

role

Hickson GB, Moore IN, Pichert JW, Benegas

Jr

M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed.

From Front Office to Front Line.

2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.Slide13

Infrastructure for Promoting Reliability & Professional Accountability (PA)

Leadership commitment (will not blink)Goals, a credo, and supportive policies

Surveillance tools to capture observations/ data

Process to guide graduated interventions

Processes for reviewing observations/data

Multi-level professional/leader training

Resources to address unnecessary variation

Resources to help affected staff and patients

Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring and addressing unprofessional behaviors. Academic Medicine. 2007;

Hickson GB, Moore IN, Pichert JW, Benegas

Jr

M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed.

From Front Office to Front Line.

2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.Slide14

“So, is this TeamSTEPPS stuff required?”

What about:Hand hygiene

Handoffs/documentation

Time outs

Arriving on time

Answering pages

Refraining from jousting

Practicing EBMSlide15

Our organization has Leadership Commitment to address behaviors that undermine TeamSTEPPS…

Strongly agreeAgree

Uncertain

Disagree

Strongly disagree

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I am committed (act, report) to address behaviors that undermine safety…

Strongly agreeAgreeUncertain

Disagree

Strongly disagree

10Slide17

Policies and programs will not work if behaviors that undermine a culture

of safety go unobserved, unreported and unaddressedSlide18

What Are “Surveillance Tools”?Risk Event Reporting System

“Dr. __ entered the room without foaming in… proceeded to touch area with purulent drainage…I offered gloves…took and dropped them into trash.”Patient Relations Department Record pt/family concerns: Father: “Son had surgery so I asked Dr. XX to explain plan. Dr. XX said, ‘I drew a picture. If you don't get it, you just don't get it.’“Compliance hotline; Equal Opportunity, Affirmative Action, and Disability Services (EAD)

Hickson GB, Moore IN, Pichert JW, Benegas

Jr

M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed.

From Front Office to Front Line.

2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.Slide19

Promoting Professionalism Pyramid

Adapted from Hickson GB, Pichert JW, Webb LE, Gabbe SG. Acad Med

.

Nov 2007. © 2011 Vanderbilt University

Apparent pattern

Single

“unprofessional"

incidents (merit?)

"Informal" Cup of Coffee Intervention

Level 1 "Awareness" Intervention

Level 2 “Guided" Intervention by Authority

Level 3 "Disciplinary" Intervention

Pattern persists

No

∆

Vast majority of professionals - no issues - provide feedback on progress

Mandated Reviews

Egregious

MandatedSlide20

3 Conversations for Professionals and Leadership

to address unnecessary variation

Authority: EDICTS Conversation

Awareness: An Awareness Intervention

Informal: Cup of Coffee Conversation and Espresso ConversationSlide21

But are “awareness” interventions effective?Slide22

Patient Advocacy Reporting System® (PARS®)

The CPPA Tool:

Analyzes existing

pt

complaint data to identify unnecessary variation/outlier performance (Risk

):

Evidence-based PARS Risk Score

Local and/or national comparisons

a

. Reliably coded*

b.

Data aggregated & analyzed**

c.

PARS Risk Score***

d.

Local &

nat’l

comparisons****

* Hickson et al, 2002;

** Hickson et al, 2002; 2006;

***Mukherjee et al, 2010;

****Stimson et al, 2010

a

. Promote complaint collection and

Service Recovery

best practices*

b.

Unsolicited

pt

/family complaints collected/recorded by

Pt

Relations

c.

Transmitted to CPPA

*

Hayden et al, 2010; Moore et al, 2006; Pichert et al, 2004

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Does it work? PARS®

Progress Report

Total # high complaint physicians

810

Departed after initial intervention

59

First follow-up in

2012 - 2013

149

Total

with follow-up results

602

Results

for those with follow-up data:

Good

–

Intervention

Visits suspended

302

(50%)

Good

– Anticipate

suspension

in

20

12 - 2013

93

(16%)

Some

Improvement—still needs tracking

43

(7%)

Subtotal

438

(73%)

Unimproved/worse

127

(21%)

Departed

Unimproved

37

(6%)

Total with follow-up

results

602

Pichert JW, Moore IN, Hickson GB. Professionals promoting professionalism.

Jt Comm J

Qual

Patient Safe.

2011; 37(10):446.

This document is confidential and privileged pursuant to the provisions of State StatutesSlide24

Malpractice Claims (per 100 MDs) FY1992 –

2011*

*

Data

used with permission, State Volunteer Mutual Insurance Company, a mutual insurer of 10,500 TN non-VUMC physicians of all specialties, 29% to 33% who practiced in Middle TN during the target date.

**TN Certificate of Merit

*

*

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Infrastructure for Promoting Reliability & Professional Accountability (PA)

Leadership commitmentGoals, a credo, and supportive policies

Surveillance tools to capture observations/data

Processes for reviewing

observations/data

Model to guide graduated interventions

Multi-level professional/leader training

Resources to help address unnecessary variation

Resources to help those affected

Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring and addressing unprofessional behaviors. Academic Medicine. 2007. Hickson GB, Moore IN, Pichert JW, Benegas

Jr

M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed.

From Front Office to Front Line.

2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.Slide26

CPPA ConferencesPromoting Professional Accountability: Addressing Behaviors That Undermine A Culture of Safety

The How and When of Communicating Adverse Outcomes and Errors

For details, please visit our website:

http://www.mc.vanderbilt.edu/centers/cppa/courses.htm

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Let Us Hear Your Comments, Questions

Now or Later

www.mc.vanderbilt.edu/cppa