Crew Resource Management Slides - including Handoffs - from 2008 National Patient Safety Foundation Meeting - With Dr. Edward Dunn
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Presentation on Crew Resource Management and Team Training in the Department of Veterans Affairs. Dr. Dunn did most of the presentation, and I covered the handoffs portion. (Afterward someone from NPSF told me that this was the highest-rated breakout session at the conference.) One related video is on Youtube at: https://www.youtube.com/watch?v=aYZx1l8rkXA . A story on the software tool we developed for handoffs is at this website, see pages 12-13. http://www.va.gov/opa/publications/vanguard/09janfebVG.pdf An article on the tool in the Joint Commission Journal is on-line at: http://www.ingentaconnect.com/content/jcaho/jcjqs/2010/00000036/00000002/art00003 Sorry it's not a full-text freebie. If you would like a pdf copy of it you can email me at neldridge202@yahoo.com.
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Crew Resource Management Slides - including Handoffs - from 2008 National Patient Safety Foundation Meeting - With Dr. Edward Dunn
- 1. Applying Crew Resource Management to Safe Transitions in Patient Care 2008 NPSF Annual Patient Safety Congress Nashville, TN May 16, 2008 Edward J. Dunn, MD, MPH Noel Eldridge, MS VA National Center for Patient Safety 1
- 2. The Josie King Story 2
- 4. Teamwork 4
- 5. What are the characteristics of a TEAM? 5
- 7. If information flow is the currency of medical practice, why is so little attention paid to communication effectiveness in medical training and education? 7
- 8. Communication Skills In medical school and nursing school, the focus is on successful communication with the patient. 8
- 9. Communication failure is a leading source of adverse events in healthcare. Evidence from Surgery, Medicine, Emergency Medicine • Gawande – 43% of adverse events are due to communication failures between two or more clinicians – Complications (2002) – Better (2007) • Risser* – 54 tort claims from ED due to “teamwork failure” – Med Teams Research Consortium • Sutcliffe – interviewed 26 med residents…communication failure cited in 70 adverse events 9
- 10. 10
- 11. Root Cause Analyses (RCA) Database* • ~70% to 80% of RCAs cited COMMUNICATION FAILURE as, at least one of the root causes/contributing factors for an adverse event or close call report. *VA NCPS Database, January 18, 2008 Total Individual + Aggregate RCAs (1999-2008) = 13,774 11
- 12. Collaboration & Teamwork in ICU = Lower Morbidity & Mortality + Increased RN Retention Evidence from ICUs • Knaus – 5030 ICU pts in 13 hospitals – M&M risk improved with collaboration • Baggs – 286 consecutive Med ICU pts transferred – M&M risk decreased from 16% to 5% • Shortell – 17440 pts from 42 ICU – Teamwork across disciplines improved outcomes & RN retention • Pronovost – Daily briefings in ICU with RNs and Residents – Improved quality of care 12
- 13. Institute of Medicine* (2000): “…establish team training programs for personnel in critical care areas using proven methods such as the crew resource management training techniques employed in aviation.” Corrigan J, Kohn LT, Donaldson MS. To Err Is Human. Washington, DC: National Academy Press; 1999. 13
- 14. Communication Definition: The exchange of thoughts, messages, or information.* A dynamic process between people: • Sender (talks/writes/signals) & Receiver (listens/reads/signals) • Roles alternate back & forth •Verbal vs. non-verbal Feedback: • Sending a message is not sufficient • Was it received…understood? * The American Heritage Dictionary, 4th edition, Houghton Mifflin Company (2001): 179. 14
- 17. Successful Communication • Many communication improvements focus on improving accuracy and availability of content, e.g. CPOE, CPRS, “Hand-Off” templates • Poor communication results from context. Context is vulnerable to culture, gender, education, experience, time pressure, stress, mood, etc. 17
- 18. Communication Context • • • • • • • • • Culture Gender Language barriers Differing mental models Professions and disciplines Power gradient (hierarchy) Differing information needs Temperament and personality Outside interference and distractions 18
- 19. Assertive Statements Direct and clearly communicated statements that facilitate patient advocacy in decision-making. • Not a license to be rude • Use “I” statements, rather than “You” statements • “I” statements describe your experience rather than another’s shortcomings • Give people options 19
- 20. Words to Avoid • “You” - blame/shame, elicits defenses • “Should” – judgmental, value statement • Hyperbole – “never,” “always,” “nothing,” “everything” – Not fact – Not credible – Inflates correctable problem into impossible challenge 20
- 21. Words to Use • “The” statements (policy) – stick to the facts – Avoiding conflating person with behavior – Attack the problem, not the person • “We” statements – shared responsibility and shared interests – Invoke common principle, accepted standard 21
- 23. Call Out • Communicate to all what you see and know • If you “feel the pinch” that trouble is brewing, communicate that to everyone • If you keep it to yourself, the patient may suffer Examples from COPD film? Code Scenario film? 23
- 24. Step Back • “Pause in the Action” – can be dramatic • Reassess a situation that doesn’t appear to be working • Challenge all previous assumptions • Protects against fixation on prior assumptions that are not supported by accruing evidence “Fixation Error:” Persisting in a planned action despite incoming data that contradicts previous assumptions. Wakefield continuing to attempt intubation when the patient might do well with mask ventilation. 24
- 25. Clear Communication • Read Back – Write down what you heard – Read back what you wrote – Confirm with the sender • Repeat Back – Reflect back what you hear – Confirm with sender 25
- 26. Dynamic Skepticism • Attitude of constantly questioning and evaluating the patient care environment – Avoid trusting what appears to be obvious – Do not assume! – Seek facts – Verification is NOT a mistrust of others – Questioning and verifying is safe practice 26
- 27. Assume Nothing! Communicate what you see and know! 27
- 28. Safe Transitions in Patient Care Responsibility 28
- 29. Some Conspicuous Types of Handoffs (formality • Shift Changes and temporality varies widely) – Physicians – Nurses • Intrafacility (within facilities) – ICU to Med/Surg and vice versa, etc. • Interfacility (between facilities) • Short-term – Med/Surg to radiology, etc. – Lunch or bathroom break (for caregiver) 29
- 30. Why are Goodor unknown clinical information Handoffs Important? • Provide access to new • Increase efficiency/flow – Prevent pointless re-tests – Decrease length of stay • Key issue for across all levels of healthcare – Nursing shortage; therefore, temporary staff – Resident 80-hour workweek means more handoffs – Various medical specialties have their own issues • ICU, Surgeons, et al. • Reduce likelihood of adverse events… – or substandard care based on misinformation or lack of information 30
- 31. What Should be in a Good Handoff? • • • • • • • • • • • • Team Identifiers - Staff names, phone numbers, covering staff contact info, distinctive team name/color Appropriate patient identifier - 2 forms of identification 1-2 sentence of patient presentation Active problem list - pertinent past medical history Medications – all active listed Allergies Access - Venous / Arterial Access and what to do if changes Code status Pertinent labs Concerns over next 18-24 hours and what to do in those situations (problem vs. system based) Long term plans / family questions that could arise if indicated Psychological concerns Ref: Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs, Academic Medicine, Dec 2005 31
- 32. 2007 (and 2008) Joint Commission National Patient Safety Goal • (2) Improve the effectiveness of communication among caregivers – Requirement 2e– implement a standardized approach to “hand-off” communications, including an opportunity to ask and respond to questions – Rationale – the primary objective of a “hand-off” is to provide accurate information about a patient’s care, treatment and services, current condition and any recent or anticipated changes. The information communicated during a hand off must be accurate in order to meet patient safety goals 32
- 33. RCAs and Handoffs • Most RCAs cite communications as a contributing factor • Handoffs are situations where communications lapses can be especially hazardous • Full disclosure: we haven’t specifically searched for handoffs cited as the cause of specific adverse events – Speculation: more likely to be seen as a “contributing factor” than a stand-alone “cause” 33
- 34. Top 10 Topics of VA RCAs Delay in Treatment/Diagnosis/Surgery 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) Falls (close to 50% of VA reports, but only ~12% of VA RCAs) Delay in Treatment/ Diagnosis/ Surgery High Alert Adverse Drug Events Death Other Than Suicide Misidentification Missing Patient Outpatient Suicide Hospital Acquired Infection Communication about Abnormal Result Medical Device Incorrect Surgery 34
- 35. Developing a Standardized Approach to Hand-off Communications • A standardized approach should identify :– The “hand-off” situations that it applies to – Who is, or should be, involved in the communication – What information should be communicated • Diagnoses and current condition of the patient • Recent changes in condition or treatment • Anticipated changes in condition or treatment • What to watch for in the next interval of care – Opportunities to ask and respond to questions – When to use certain techniques (repeat-back; SBAR) – What print or electronic information should be available 35
- 36. Examples • Flowcharts for two standardized kinds of shift-change handoffs for nurses – Had more pre-existing standardization • Shift Handoff Tool software developed for physicians – Had less pre-existing standardization 36
- 37. HANDOFF PROCESS WITH IN-PERSON TRANSFER OF PATIENT INFORMATION Midnight (AM) to Morning (AM) Shift Change (7:30 – 8:00 am) Night Staff Nurse prepares tape recorded report for late AM Staff Nurse Night Staff Nurse briefs AM Charge Nurse on critical / urgent patient care issues. YES Is AM Staff Nurse LATE or ABSENT? NO AM Staff Nurse goes to report room AM Staff Nurse review patient assignment list. AM Charge Nurse addresses urgent patient care issues identified by Night Staff Nurse. AM Staff Nurse locates respective Night Staff Nurse (s) to get verbal report on prospective patients on his / her assignment listing. AM Charge Nurse gives AM Staff Nurse verbal report of patient care topics. Night Staff Nurse and AM Staff Nurses conducts walking (bedside) rounds for all patients assigned to the respective AM Staff Nurse and provides summary information on patient status and needs schedules. AM Staff Nurse listens to tape recorded reports. AM Charge Nurse clarifies /answers all questions from AM Staff Nurse regarding patient care topics. AM Staff Nurse review end of shift report list of all active patients on the ward. HandOff complete for All Active Patients Night Staff Nurse clarifies / answer all questions from AM Staff Nurse regarding patient care topics. Note: Morning and Evening Shift Change is the same as above
- 38. HANDOFF PROCESS WITH TAPE RECORDED PATIENT INFORMATION Midnight (AM) to Morning (AM) Shift Change (7:30 – 8:00 am) Night Staff Nurses prepares tape recorded reports for AM Staff Is AM Staff Nurse LATE or ABSENT? AM Staff Nurses goes to report room NO YES Review end of shift report. AM Staff review patient assignment list. Review patient assignment list. AM Staff Nurse listens to tape recorded reports. AM Staff Review end of shift report list of all active patients on the ward. AM Charge Nurse and Staff Nurses listen to tape recorded reports. AM Charge Nurse clarifies /answers all questions from AM Staff Nurse regarding patient care topics. AM Charge Nurse conduct walking (bedside) rounds with Night Charge Nurse to discuss patient care topics before he/she leaves. HandOff complete for All Active Patients Note: Morning and Evening Shift Change is the same as above AM Staff Nurse may leave room to discuss patient care topics with Night Staff nurses before he /she leaves. 38
- 39. Options for nurses: In the event that a question remains or occurs after getting a shift report by tape, face-to-face, or in a text (paper or electronic) version, the following options may be available: 1) Ask face-to-face to the nurse from previous shift if he or she hasn’t left yet and is still present in the unit. 2) Ask a nurse whose schedule is crossing the shift change (e.g., on a 12 hour shift, staggered overlapping shift, or doing overtime into the new shift). 3) Ask the charge nurse that received a separate report from the previous shift’s charge nurse. 4) Ask another member of the staff if the question is within their areas of expertise to answer, for example: – Ask the resident or attending physician that is responsible for the patient, either in-person or by pager/mobile phone. – Ask ancillary staff on duty, for example, a respiratory therapist or phlebotomist, if the question is within their scope of knowledge. 5) Read the recent progress notes, nursing notes, or other information in the patient’s medical record. 6) Telephone the nurse from the previous shift, calling their home or mobile phone number. (A list of all the mobile and home phone numbers for all the nurses on the unit would have to be readily available when needed for official use if this method is recommended by the organization.) 7) Some questions may be appropriate to ask the patient, depending on the nurse’s assessment of the patient’s ability to answer accurately, e.g., questions about what the patient ate, if the patient was visited by a specialist that had been scheduled, etc. 39
- 40. Shift Handoff Tool (Short) History Created by Indianapolis (Roudebush) VAMC with inputs from pilot testers at the following VAMCs: Washington, DC; Iowa City; Des Moines; Ann Arbor; Loma Linda; Dallas; White River Junction December 2005: • Paper published in Academic Medicine by Indianapolis VAMC: Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs, Academic Medicine, Dec 2005 January 2006: • New JCAHO Patient Safety Goal to standardize Handoffs goes into effect, software from Indianapolis reviewed… September 2006: • Meeting in Washington, DC to establish consensus requirements July 2007: • Tool installed & being tested and/or used at 12 facilities. • Selected for upgrade to “Class 1” software – Helpdesk support, etc. April/May 2008 (planned): • Made available to VA System (150+) hospitals 40
- 41. Create Link To HANDOFF TOOL in CPRS Tool Bar 41
- 42. 42
- 43. These fields can be specified by site/department – i.e. HPI Time limits to ensure fields are updated 43
- 44. HPI Covering Physician Problem List To Do List Pending Workup 44
- 45. Patient and Team Identifiers from CPRS which can be site specified. i.e.) Full SSN vs. last four / DOB / Sex / Age i.e.) Date of admission / Length of stay / Admitting diagnosis i.e.) Room location / Assigned team, attending, outpatient provider 45
- 46. CODE status from CPRS Allergies from CPRS Active medications from CPRS 46
- 47. Typically 3-5 patients per printed page -depends mostly on meds 47
- 48. Team list name/ Sign-out provider info Entire Team name / titles / contact numbers Identifiers / CPRS retrieved fields Modifiable fields 48
- 49. Time and date sign-out created Page numbers i.e.) 2 of 3 49
- 50. Shift Handoff Tool • Uniform and Easy to Learn – Not another software training requirement • Legible, and standardized abbreviations in text pulled from CPRS (VA’s EMR) • Forces updates to predetermined fields – Minimizes obsolete data or information • Site/service customizable (within limits) • Time saving (in preparing report for recipient) 50
- 51. Results from Research Project • Selected findings from surveys and abstracted ad hoc (pre) and software-based (post) tools – – – – Less Time Typing Same Time Talking Perception of improving safety among users Perception of having received more complete information among users – Key information measured as always or almost always present in software-based tool • Medications • Allergy info • Demographics and Room number 51
- 52. Take Home Points • Good information in a Handoff Tool does not replace the medical record/chart • Faster Handoffs (i.e., less time talking face-to-face) is not the goal • Handoffs that foster real communication (text and verbal) is the goal • Need standardization/ consistency/ 52
- 53. Special Thanks to: Richard J. Sowinski, Chief of Application Development, Roudebush VAMC, MSCS, BSEE Charlet Lynn Cottee, Senior Developer, Roudebush VAMC, BSCS Divya Shroff, MD, Associate Chief of Staff – Informatics Washington DC VAMC Jaclyn Anderson, DO, VA Quality Scholar Iowa City VAMC Research Project Mentioned: Abstract at 2008 SGIM Conference THE PHYSICIAN-TO-PHYSICIAN HANDOFF: THE VETERANS AFFAIRS CAIRO PROJECT J.K. Anderson1; D. Shroff2; A. Curtis1; N. Eldridge3; K. Cannon1; R.M. Karnani1; T.E. Abrams1; P. Kaboli1. 1VA Iowa City Health Care System/University of Iowa, Iowa City, IA; 2Washington DC VA Healthcare System, Washington, DC; 3VA Central Office, Washington, DC. (Tracking ID # 190036) 53
- 54. What are the elements of a safe patient hand-off? 54
- 56. SBAR Clearly communicates the critical elements of a case to another clinician: Situation What is the problem? Background Brief background information Assessment What is your assessment of the patient? Recommendations What do you recommend? 56
- 57. SBAR • Melds MD and RN cultures – RN: holistic focus; background important; paints a complete picture of the patient – MD: time urgency; focus on specific problem; data • SBAR is a rule of language for communicating information, such as patient handoffs – RN-to-RN at change of shift/admission/transfer – MD-to-MD on call – RN-to-MD report of change in patient condition 57
- 58. SBAR Film 5: MD-to-MD Hand-Off Hospitalist-to-PCP 58
- 59. Debrief SBAR Film 5 MD-to-MD Hand-Off Hospitalist-to-PCP 59
- 60. NCPS SBAR Hand-Off Guide RN-to-RN or MD-to-MD Patient Transfer S Situation Situation: What is the situation with this patient? Patient Condition? Patient Name: ______________________ SSN: __________ DOB: _________ Admit Date: __________ Clinical Service: _________________ Attending MD: ________________ Resident MD: ________________ Admitting Diagnosis: _____________________ Procedure(s): ______________________________________ Brief Clinical Summary:______________________________________________________________________ ____________________________________________________________ Expected Time of Arrival: ______ B Background Background: What is relevant in this patient’s past medical history? 1. Relevant Past Med/Surg History: ___________________________________________________________ _________________________________________________________________________________________ 2. Medications: _____________________________________ Allergies: ____________________________ 3. Code Status: _____________________ Health Care Proxy: _____________________________________ 4. Family / Social Support: __________________________________________________________________ A Assessment R Recommendation Assessment: What is your assessment of this patient? 1. Nursing Assessment (choose relevant items only) BP ____/_____ HR ______ Resp. Rate _________ Temp _________ SaO2 ___________ Pain (1-10)_______ Cardiac: __________________________________________________________________________________ Respiratory: _______________________________________________________________________________ GI: ____________________________________________________________ Diet: _____________________ GU: ______________________________________________________________________________________ Musculoskeletal: ____________________________________ Fall Precautions: _________________________ Neuro: ____________________________________________________________________________________ Skin: ________________________________ Wound(s):_____________________________________________ Psychosocial: ______________________________________________________________________________ 2. Rx Concerns: ____________________________________________________________________________ 3. Lab / Imaging Data: _____________________________________________________________________ 4. Lines/Fluids:___________________________________ Tubes/Drains: ____________________________ Recommendations: What is the recommended plan of care? 1. Plan of Care: ____________________________________________________________________________ Lab/Imaging Tests: __________________________________________________________________________ Treatments/Procedures: _______________________________________________________________________ Consults: __________________________________________________________________________________ 60 2. To-Do List: _____________________________________________________________________________ 3. Red Flags: ______________________________________________________________________________
- 61. SBAR Film 7 MD-to-MD Medical Resident Sign Out 61
- 62. Debrief SBAR Film 7 MD-to-MD Medical Resident Sign-out 62
- 63. NCPS SBAR Hand-Off Guide RN-to-RN or MD-to-MD Change of Shift Situation: What is the situation with this patient? S Patient Condition? Patient Name: ______________________ SSN: __________ DOB: _________ Admit Date: ________ Clinical Service: _________________ Attending MD:________________ Resident MD:________________ Admitting Diagnosis: _____________________ Procedure(s): ____________________________________ Situation Brief Clinical Summary:___________________________________________________________________ _______________________________________________________________________________________ B Background: What is relevant in this patient’s past medical history? 1. Relevant Past Med/Surg History: ________________________________________________________ ________________________________________________________________________________ A Assessment Medications: ________________________________________ Allergies: ________________________ Code Status: __________________________ Health Care Proxy: _______________________________ 4. 1. 2. 3. Background Family/Social Support: _______________________________________________________________ Assessment: What is your assessment of this patient? 1. Nursing Assessment (choose relevant items only) BP _____/______ HR _______ Resp. Rate _________ Temp _________ SaO2 _______ Pain (1-10) _____ Cardiac: __________________________________________________________________________________ Respiratory: _______________________________________________________________________________ GI: ____________________________________________________________ Diet: _____________________ GU: ______________________________________________________________________________________ Musculoskeletal: ____________________________________ Fall Precautions: _________________________ Neuro: ____________________________________________________________________________________ Skin: ______________________________________ Wound(s):______________________________________ Psychosocial: ____________________________________________________________________________ 2. Rx Concerns: _______________________________________________________________________ 3. Lab/Imaging Data: _____________________________________________________________________ 4. Lines/Fluids:________________________________________ Tubes/Drains: ________________________ R Recommendation Recommendations: What is the recommended plan of care? 1. Plan of Care: ____________________________________________________________________________ ________________________________________________________________________________________ Lab/Imaging Tests: __________________________________________________________________________ Treatments/Procedures: _______________________________________________________________________ Consults: __________________________________________________________________________________ 2. To-Do List: _____________________________________________________________________________ 63 3. Red Flags: ______________________________________________________________________________
- 64. SBAR Film 3 RN-to-MD Change in Patient Condition 64
- 65. Debrief SBAR Film 3 RN-to-MD Change in Patient Condition 65
- 66. NCPS SBAR Hand-Off Guide RN-to-MD Change in Patient Condition S Situation Situation: What is the situation you are calling about? Relevant patient issues? I’m calling about… Patient Name: ______________________ SSN: __________ DOB: _________ Admit Date: __________ Clinical Service:___________________ Attending MD: ________________ Resident MD: ______________ Admitting Diagnosis: _________________________ Procedure(s): _________________________________ Problem(s) you are calling about: _____________________________________________________________ ______________________________________________________________________________________ B Background Background: What is relevant in this patient’s past medical history? 1. Relevant Past Med/Surg History: ________________________________________________________________________________________ ________________________________________________________________________________________ 2. Medications: __________________________________________ Allergies:_________________ 3. Code Status: ___________________ Health Care Proxy:__________________________________ 4. Family/Social Support: ___________________________________________________________ A Assessment Assessment: What is your assessment of this patient? 1. Nursing Assessment (choose relevant items only) BP ____/____ HR ______ Resp. Rate _______ Temp _________ SaO2 _________ Pain (1-10 scale)_______ Cardiac: __________________________________________________________________________________ Respiratory: _______________________________________________________________________________ GI: ___________________________________________________________ Diet: _____________________ GU: ______________________________________________________________________________________ Musculoskeletal: ____________________________________ Fall Precautions: _________________________ Neuro: ____________________________________________________________________________________ Skin: ____________________________________ Wound(s):________________________________________ Psychosocial: ______________________________________________________________________________ 2. Rx Concerns: _______________________________________________________________________ 3. Lab/Imaging Data: _____________________________________________________________________ 4. IV Lines/Fluids: _______________________________ Tubes/Drains: _____________________________ R Recommendation Recommendations: What should be done? I suggest …or…request that you: • See the patient for medical evaluation ASAP / STAT • Order tests, treatments, consultations: __________________________________________________ If a change in patient care is ordered: • To-Do List: ______________________________________________________________________ • Red Flags: _______________________________________________________________________ • Guidelines for follow-up call to physician: _______________________________________________ 66
- 67. SBAR Film 9 RN-to-RRT Patient Hand-Off 67
- 68. Debrief SBAR Film 9 RN-to-RRT Patient Hand-off 68
- 69. Is Organizing Change Like Herding Cats? 69
- 70. “If you want to go quickly, go alone. If you want to go far, go together.” African Proverb 70
- 72. 72
- 73. Extra Slides 73
- 75. Debriefing • Facilitator • Team-based discussion • Review of a shared experience: – What went well? – What didn’t go well? – What lessons were learned? • Promotes situational learning 75
- 77. Debrief Code Scenario Debriefing Film 77
- 78. CARDIAC ARREST (CODE 4000) DEBRIEFING GUIDE Review Elements of a Good Code Did all members of the Code Team arrive at the bedside quickly? Was there an appropriate number of staff (or too many, few, etc)? Did the Medical Consult identify him/herself quickly and clearly? Were all necessary supplies/medications readily available/accessible? Was the cardiac rhythm determined quickly? Was the airway managed appropriately? Was the airway established timely? Was IV access established timely? Were emotional issues handled effectively? Were there futility issues? Was there effective leadership? Poor = 1 (explain) Good = 3 Excellent 5 Physician Satisfaction: 1 2 3 4 5 Nurse Satisfaction: 1 2 3 4 5 Resp. Ther. Satisfaction: 1 2 3 4 5 Safety Breech: Yes (explain) No Unanticipated Events: Yes (explain) No Did the post-code debriefing detect a problem? None Minor (explain) 78 Major (explain)
Notes de l'éditeur
- Acknowledge the challenges Ed’s story “Wrong size heart valve.” Had we been together as a team… 30 medical centers in the real world are doing this. Our expectation of participants is to apply CRM in the work place in the form of preoperative briefings and postoperative debriefings, and other MTT activities. Strategy for the day We will be sharing our own personal experiences about communication failures in health care today We will be showing you the evidence for the need to improve communication in health care – the fact that poor communication translates to poor outcomes of care that hurts patients We will introduce the principles of Crew Resource Management (CRM) from aviation and how they are applicable to health care We will move directly into applied CRM in Health Care – the essence of today’s training session This will be an interactive session throughout the day Clinical Vignette from Cardiac Surgery (my personal experience): Aortic Valve case – Where’s the right valve for my patient? … Surgical case in progress: Chest open on CP Bypass. Aortic valve area measured at surgery called for a #27 Carpentier-Edwards Bioprosthesis – the aortic root was more dilated than had been appreciated pre-op. There was no #27 CE in our inventory. We had not done a pre-op briefing. I had estimated the valve area as 23 to 25 mm pre-op via echocardiogram (average size for male patient who weighed 80 kg). Since we used so many CE valves on our cardiac surgical service in this hospital, I had failed to check the inventory with the Circulating Nurse pre-op. I had assumed that we had two valves each in sizes 19 through 27. Wrong assumption!! We had to search the city for the valve we needed and fortunately found a hospital with a #27 that they were willing to give to us. Close Call!! Additional OR/Anesthesia time waiting for the delivery of the correct bioprosthesis. *Our expectation of participants is to apply CRM in the work place in the form of briefings, debriefings, and communication behaviors in their respective workplaces.
- Has anyone seen the film, The Italian Job? Let’s see if you agree with Michael Caine’s description of teamwork.
- Do you agree with Michael Caine’s defiition of teamwork? Have you heard this before in healthcare? Ask the audience to identify the characteristics of a group of people that would uniquely define them as members of a TEAM? Common GOAL E.g. providing the best care possible to a patient Common ACCOUNTABILITY E.g. accountable to the patient, to each member of the team Common UNDERSTANDING E.g. complete understanding of the team plan and individual roles in the implementation of that plan
- Communication is inherently complex. So why is something that is human nature, innate in all of us, so difficult?
- Nursing school vs. medical school practices for communication training.
- And you are adaptable communicators; you’ve been taught to communicate with patients who vary from ailment to personality. We’ve learned that nurses learned how to communicate in nursing school with other healthcare professionals and medical schools are now making the advances to teach communicate to young medical students. Absence in professional school curricula re: communication between health care professionals
- Gawande…as a resident…wrote about adverse events for the New Yorker Magazine…he compiled and published in a book title, “Complications.” Sutcliffe’s article – Residents described themselves embedded in a complex network of relationships, playing a pivotal role in patient management vis-à-vis other medical staff and healthcare providers from within the hospital and from the community. “Communication” and “Patient Management” were the two most commonly cited contributing factors to adverse patient events that they observed. Sutcliffe concluded that recurring patterns of communication difficulties occur within these relationships and appear to be associated with the occurrence of adverse events.
- 80% of sentinel events involve communication failure.
- SPOT database search on January 18, 2008
- Shortell found effective caregiver interaction was associated with: Lower risk-adjusted length of stay and nurse turnover Higher technical quality of care Greater ability to meet family member needs. All improved with collaboration and teamwork. Pronovost- study showed marked reduction in line sepsis and ventilator acquired pneumonia in ICUs where daily briefings and checklists were utilized.
- IOM in its 5 year review re-emphasized the benefits of team training.
- At its foundation, communication is the transfer of information from one person to another. But what makes communication so complex is the dynamic process individuals go through in order to process and interpret the information. Communication is not a one-person, one-way street. There are several types of communication, but the three types used most frequently by healthcare professionals are verbal, non-verbal and written communication. First, verbal and non-verbal communication. Most people think they communicate with others verbally most of the time. But in fact, we communicate with each other non-verbally 80% of the time, which means that we are only physically talking with each other 20% of the time. Unfortunately, that 80% of non-verbal communication can cause us to not really listen to the actual message. (Select a physician or nurse for this activity) For instance, let’s say that you are taking care of my father and you have some good news and some bad news for me regarding my father. At some point in the conversation, I cross my arms (cross arms here). What does that mean? If the participant doesn’t answer, say: Does that mean I’m so upset with the conversation that I’m physically shielding myself from you and message? Does it mean that I’m in denial about what you are saying and disagree with your assessment? 65% of the time when an individual crosses their arms during a conversation they are cold. It’s important when communicating to really listen to the message; don’t pay so much attention to every non-verbal, which we do, and try to create your own interpretation of what the individual is “really” saying. Face-to-face communication, in real time, is the best way to communicate. Now, let’s test this theory with our faculty. Ed and XXX are going to do a role play for you. Describe the scenario here. Ask the participants to pay particular attention to the verbals and non-verbals in the scenario. Debrief after the role play is finished. *Major point of this slide is that communication involves the sender and the receiver of a message. The communication mode can be verbal, written, and non-verbal. Don’t assume your message was effectively communicated without confirmation by a response from the receiver. In order to produce quality change, you must open a dialogue. Speaking up and out is the only way that conversation can begin and continue to grow. Without it, there will be no change. A dynamic interaction is more than physical action on a day to day basis. It consists of dialogue, respect, understanding, and an attitude that denotes change. Briefings and debriefings are wonderful springboards to start an interaction. These tools are interactive in nature and allow everyone an opportunity to learn, explain, and listen to others. Using a white board for written communication allows for an interaction two different levels – it is a physical reminder of the task ahead and can include notations from all team members, as well as another opportunity to open discussion for improved patient safety
- Who is the loser in this scenario? Role Play Scenario #1 – A surgeon is walking through a med-surg unit after completing rounds and heading to his office. A staff RN stops him to request more analgesic coverage for one of his post-op patients who is experiencing breakthrough incisional pain. Nurse: “Dr. Dunn, Mr. Jones is having incisional pain that is occurring only 1 ½ to 2 hours from his last administration of Percocet. I think he will need additional analgesic coverage to get him through the next day or two.” Surgeon: “I can’t believe you are bothering me with this. He has orders in the chart to take care of his pain. Have you read them? I would suggest that you do your job by getting the patient up and walking him down the hall. That will distract him enough that he will probably not be asking for pain medication so frequently. I wish you would pay attention to what the patient really needs for a successful recovery rather than asking for more pain medication all of the time.” (exhibiting aggressive behavior) Nurse: “Well…. (hesitating) OK, Doctor.” (the nurse is exhibiting a submissive response, choosing not to push the issue any further despite the fact that she fully knows that the patient’s pain will prevent him from being able to walk or do his breathing exercises) The surgeon abruptly walks away from the nurse mumbling something about “the state of post-op care these days.” After completing the role play, debrief with participants for 5 minutes. Ask them: Who suffers in this scenario? The patient suffers uncontrolled pain. the nurse suffers the ignominy of being addressed in a demeaning and hostile manner. Her submissive response only reinforces her low self esteem. the surgeon suffers for isolation because no one will want to work with him, and nurses will be hesitant to call him in the future for fear of eliciting his angry, demeaning and hostile reaction. Role play version 2: Operating Room – conversation between surgeon and scrub nurse nearing the conclusion of a Coronary Artery Bypass case after the 1st count of sponges, sharps and instruments has been completed. There is a missing Raytec 4x4 sponge after the 1st count had been completed. The Surgeon is frustrated by missing sponge and refuses to look for it in the surgical field. Scrub nurse will not give him the sternal wire he is requesting to begin closing the surgical wound. Lot’s of “YOU,” “NEVER,” “ALWAYS,” “SHOULD” statements that raise a barrier to communication between the surgeon and scrub nurse in 1st scenario.
- The third type of commonly used communication technique is written communication. But you have to be careful using written communication because often-times, the content or the message will get diluted by the context, they way it was sent. For instance, look at CPRS. CPRS was created to distribute patient information is timely and efficient fashion. But the content, the patient information, is often tainted when individuals don’t know how to use CPRS or don’t know how to use it to its greatest advantage. Let me give you another example: I often send emails with content underlined and bolded because I want to emphasize certain points. But society has contextualize the idea that if something is bolded or underlined, the sender of the message is angry or upset. So I get messages back asking if I’m alright or asking why I’m upset. My message is destroyed by the context that has sent it. Instead of questioning why someone underlined or bolded something in an email, use the opportunity to really read the message. But again, face-to-face communication is real time is the best way to communicate.
- There are other barriers to communication that have can break down messages and contextualize situations/messages. This is a very abbreviated list of barriers. One that stands out for me is language barrier. The patient was a woman who didn’t speak English very well; she spoken Spanish. On her prescription bottle, it said “take X number of pills once a day”, which means that you take the prescribed number of pills one time a day. In Spanish, the word “once” is eleven. The women took the prescribed number of pills eleven times a day. She overdosed and died. Those four little letters caused a patient her life. Remember to communicate, in real time, as much as physically possible. *We should think about additional examples for each of the bullet point items on this slide These phenomena are barriers to successful communication that are about the context rather than the content of what we are communicating. The “how” we communicate is just as important as “what” we communicate. Spend some time going over these items and invite participants to comment. In considering our communication failures, we too often focus on content and not much on context.
- One way to communicate is the use of assertive statements. Assertive statements are direct and clearly communicated statements to facilitate decision-making on an issue. Remember in the role play,… Remember that assertive statements are not a license to be rude. By using “you” statements instead of “I” statements you take responsibility for the communicate in the situation. You cannot control the communicate style of others, but you can make sure that you communicate to the best of your ability. Discuss difference between the following: “You” statements – eg. “You don’t care about your patient” or “You are not listening to me” These statements put people on the defensive because they are being attacked. This approach will place barriers to communication, and you will usually will not achieve your goals with “you” statements “I” statements – eg. “I am concerned that your patient is not having his needs met” or “I am concerned that you did not hear my message” These statements allow you to safely raise an issue of concern without putting people in the immediately defensive posture. These statements are less confrontational. Sun Tzu was an ancient military strategist who said “you should always build a golden bridge for your opponent to retreat across.” i.e. give people options to allow them to cooperate with you without the appearance of a retreat from their own interests – allowing them to save face. Sun Tzu also said “the best general is the one who never fights.”
- Reference: The Power of a Positive No by William Ury (Bantam Books, 2007), pp. 101-121.
- “Say what you mean, mean what you say, but don’t say it mean.”
- CALL OUT: Have conversation around what you’re thinking so others can verify/and team members can all receive the same information. Film Examples COPD film #2: Linda calls out dislodgement of O2 Oximetry probe and places back on patient’s index finger Respiratory Therapist calls out disconnection of patient’s O2 mask from wall flowmeter 2) OR case film: Circulating nurse calls out sudden increase in blood draining into the vacuum drainage container Physician Assistant calls out air observed in the right coronary artery graft and later calls out bleeding from the circumflex coronary artery graft Planned Call Out – “The antibiotic is in!” “Starting/ending time” “We are coming off bypass…. We are off bypass, BP systolic is 100 and HR 85.” Emergent Call Out – “The patient’s BP is_60/40 and heart rate 120. What’s happening up there? (anesthesiologist asking the surgeon what is happening in the surgical field)… “We need another unit of blood now!” (to the circulating nurse)
- Step back or pause/stop in the action. Fixation error: Become so intently focused on one aspect of care you become unable to see the whole picture. “Unable to see the forest through the trees.” Film Examples COPD film #2: Dr. Wakefield says “Maybe we are missing something here. Perhaps we should step back and reassess this situation here.” Cardiac Surgical OR case film – after coming off the bypass machine the heart is not contracting well, and the surgeon says “Let’s step back and go back on bypass to give his heart a rest.” Code Scenario film: Dr. Wakefield persists in his struggle to intubate the patient and dismisses Linda’s concern about the prolonged time of greater than 2 minutes when no oxygen had been given the patient. Wakefield was fixated on intubating the patient when it may not have been necessary since mask ventilation subsequently administered by Jennifer had restored the oxygen level to normal
- Three steps to read-back: write it down, read it back and verify (confirm). Role Play with a volunteer in the audience to demonstrate the 3 important principles in Read Back. I use the scenario of a nurse calling an on-call physician in the evening about a patient who had been admitted for congestive heart failure 24 hours ago. The patient is more dyspneic, and his auscultatory exam shows bibasilar rales with a drop in his O2 Sat to 88%. He takes Lasix every morning, and the nurse will ask the physician for an order of an additional 40 mg Lasix to be given now. Film Examples Code Scenario – Kyle, the RN scribe in this scene, repeats back the order he received from Dr. Wakefield: “You want to give the patient 0.6 mg of Atropine? … (as he begins infusing the drug) 0.6 mg of Atropine is infusing… 0.6 mg of Atropine is in.” 2) COPD film #2 – Linda, the nurse in the scene, takes Dr. Gaba’s order to schedule a chest CT Scan ASAP as she writes the order into CPRS from her hand held device: “Chest CT Scan ASAP, the order is in.” 3) Surgical case film – the perfusionist repeats back orders from the surgeon on changing the flow level on cardiopulmonary bypass: “Flow down to 1500 milliliters… now at 1000 milliliters… down to 500 milliliters… and the patient is now off bypass.” There are various tools and techniques to make sure the appropriate communication and actions are taken. Lessons from catastrophic adverse events highlight a need for having a system of repetition or redundancy. Redundancy is an important characteristic of safe systems. These tools build repetition and redundancy into the system. Using these may feel awkward at first – but to build a culture of patient safety, we cannot treat medical interactions in the same way as social interactions.
- If you’re skeptical does it mean you don’t trust someone? Redundant communication does not mean you don’t trust someone. Get over it! Focus on the patient, not our own personal egos. Characteristics of high reliability organizations…like nuclear power plants…or ORs or ICUs…is an attitude that things are always potentially about to go down the tube. Film Example Code Scenario – Kyle, RN scribe on the code team, looks skeptically upon what he is observing (zoom in shot) as Dr. Wakefield is struggling to intubate the patient.
- Birthday cake story. Don’t wait until you are 100% sure of what you are observing – it will be too late, and the patient will suffer the consequences.
- <number> Per recent IOM report, 44000-98000/yr die in US hospitals because of errors Australian study of 28 hospitals found communication errors leading cause of adverse events (2x more than clinical inadequacy) 2005 study found 70% of preventable hospital mishaps occurred because of communication problems Two of three RCAs list communication problems as a cause of the adverse event.
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- <number> Rationale
- <number> 2/3 of all RCAs identify specific communication issues as one of the causes of the particular adverse event under review.
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- <number> Started 9 years ago in Indy – Center for Applied Informatics and Research Organization (VISN 11) * Paper describes attributes of good physician shift-changes, and implementation efforts at Indianapolis VAMC. Staff contacted by NCPS and information acquired on locally-developed software tool for physician shift-change handoffs. Additional 4 sites: Altoona/Denver/San Antonio/Puget Sound Specify class 3 vs. class 1 – homegrown vs. nationally released / nationally available
- <number> Bright yellow are free text/modifiable fields (can have auto delete or character limits) Pale yellow are retrieved from CPRS
- <number> Medication – summary/detail. IV or not Printing options Sorting option Additional boxes can be added (total 6) – consults/labs Patient demo – some mandatory/some optional DNR – site specific
- <number> Titles can be modified at sites – ex) consults/labs/radiology Auto-delete feature if fields not modified within set amount of days Can set character limit if desired
- <number> Can site specify identifiers etc. Pale yellow are retrieved from CPRS
- <number> Patient toggle – was on ONE/now on SIX CODE STATUS clarification Dosages/administration of medications
- <number> landscape
- <number> Handoff talk on W at 10:45 – I’m Covering…what do I do now Temporary Data Fields – JCAHO does not mandate making part of chart/documenting/audio tapes Compliments CPRS chart – does NOT replace CHART DNR issues – lack of standardization…
- Patient location, identifying information, medical Hx, Px, lab and imaging data, plan of care, code status, family support How should this information be delivered? Is technology, like the CAIRO program the answer to this challenge?
- SBAR creates a common language. SBAR can be described as a dialog between the ship’s captain and the harbor captain. The harbor captain knows the local geography best. (Nurse= harbor captain as she/he spends 8-12 hours/day with the patient. Provider=ship’s captain).
- Principles of safe and accurate patient hand-offs: 1. Communication in real time 2. Face to face communication 3. Include patient in the hand-off 4. Use standardized checklist template 5. Medical record with pertinent lab and imaging data
- SBAR is a tool which aids clinicians in clearly communicating the critical elements of a case to another clinician during a patient hand-off or transfer. It provides a framework for conversations so that important information regarding a patient’s condition and plan of care is communicated in a focused and effective manner.
- <number> SBAR Guide: RN-to-RN or MD-to-MD Patient Transfer SBAR film example: Patient Discharge to PCP or Patient ED admission to medical unit
- <number> SBAR Guide: RN-to-RN Change of Shift or MD-to-MD sign-out
- SBAR Film 3RN-to-MD Change in Patient Condition 6 minutes, 55 seconds
- <number> SBAR Guide: RN-to-MD Change in Patient Condition
- CODE is medical jargon used when a patient’s life is in danger and immediate assistance is needed. In this case, the nurse finds her patient in his hospital bed unresponsive, not breathing, with low blood pressure, and a lethal cardiac rhythm.
- The debriefing process can be employed after codes, meetings, surgical cases, and at end of shift. A Debriefing will promote learning from experiences. It’s important for debriefings to occur immediately after the event while team members are still there…or within 24 hours as memory fades. The issue may determine how soon a debrief can occur. If there are technical issues…items missing from the code cart, right away is good. If there are communication issues, some calming down time may be needed. It may help to have a facilitator present. Unless we take action, we simply complain about issues and nothing is done to address them. When the responsibility for action is diffused to a department, clinical unit, of a general group of people, it is unlikely that anything will be done. “When everyone is responsible, no one is responsible.” Remember the tragic case from New York in the 1960s? Kitty Genovese was murdered in the courtyard of her apartment building in Kew Gardens, Queens, NY on March 31, 1964 while 38 onlookers did nothing.
- Here’s an example of a Code Team Debriefing. Notice how the rules are set. After a code we don’t want to waste people’s time.
- The value of debriefing is enormous. Debriefing is a way to …learn from experiences and the knowledge of others, grow as a team, and get concerns out in the open. Information gathered can be productive in improving future code responses. It must be depersonalized! A good way to start is…debrief when things go well…learn the process and then apply it to when things don’t go well. When things go wrong in your area…would a discussion like this make a difference? What are your thoughts? Story (Seattle): Interventional Radiology. Patient had an anaphylactic reaction to Protamine…was coded for 3 hours…and died 2 days later. The nurse telling the story had administered the medication. No debriefing ever occurred. She carries this memory with her to this day. Luckily this nurse was friends with her coworkers and eventually felt safe sharing feelings over margaritas. As this nurse told her story, weight visibly lifted form her…If you had seen this nurse while she told this story, you would debrief every event forever. Re: Speaking Up (the bottom line of this code debriefing film)….. “Our lives begin to end the day we become silent about things that matter.”Martin Luther King
- <number> Code Debriefing Guide