Slides from a webinar on designing, implementing, and monitoring a successful Care for the Colleague program, presented by Kit Hoffman with first-hand experience of setting up such a program at Confluence Health.
Good Stuff Happens in 1:1 Meetings: Why you need them and how to do them well
Care for the Colleague: Bringing Encouragement and Support in Difficult Events by Kit Hoffman, PsyD | BESIDE Program Coach, Confluence Health
1. BESIDE
Bringing Encouragement and Support in Difficult Events
Kit Hoffman, PsyD
September 27, 2018
Northwest Patient Safety Coalition – Patient Safety Webinar
2. Outline
• Brief Overview: Second Victim Phenomenon
• Overview of Care for the Colleague
• Psychologist’s Role in Care for the Colleague
• BESIDE: Design, Implementation, and Evaluation
– Future Directions
• How to support a traumatized healthcare professional
11. Potential Outcomes
• Reduced risk for burnout
• Retaining healthcare professionals in their role
• Finding joy and meaning in work
• Improvements in patient safety culture
12. Cost-Benefit Analysis: Cost Savings
• RISE at Johns Hopkins
Moran et al., 2017
• 1 year period
• 1,000 bed hospital
14. Clinician Support Model
ForYOU at University of Missouri Healthy System
Tier 3
Professional
Resources
Tier 2
Trained Peer Supporters
Tier 1
Department Supports and
Leadership Mentoring
ForYOU Three-Tier Structure. (Hirschinger, Scott, & Hahn-Cover, 2015)
18. Tier 3
External
Resources
Tier 2
Trained Peer Supporters
Tier 1
Psychologist – Support and Prevention
Organizational Awareness and Support
Confluence Health’s
Care for the Colleague Model
19. Psychologist’s Role: BESIDE Coach
• Coordinate Care for the Caregiver Program
• Immediate psychological interventions—Individual and Group
• Ongoing support, especially for litigation
• Evaluate fitness for duty
– Individual, supportive accommodations
• Design and conduct Peer Supporter Trainings—Ongoing support
• Organization-wide prevention
• Evaluate program effectiveness
23. Designing and Implementing Care for Colleague
• Clinician Support Toolkit for Healthcare via Medically Induced
Trauma Support Services (MITSS)
• Agency for Healthcare Research and Quality (AHRQ) Care for the
Caregiver Program Implementation Guide found in their
Communication and Optimal Resolution (CANDOR) Toolkit
• Building a Clinician Support Program, Assessment
Worksheet/Planner via Susan Scott at University of Missouri
Health Systems
• Second Victim Experience and Support Tool (SVEST)
– Pre- and post-test
24. How the BESIDE Program Works
Ongoing education and prevention workshops
At any time, staff and providers can self-refer
Safety Event or
Commission
Complaint is
Reported
Outreach to providers and
staff
Staff and providers can self
refer
Staff or provider
meets with BESIDE
Coach and/or Peer
Supporter and plan
for support is
devised
As needed, ongoing
consultation with
BESIDE Coach
and/or referral to
higher level of care
Group debriefings for crisis events, as needed
25. Activities: Inputs
Program Development
-Protocols for Inclusion in
BESIDE Program
Marketing/Outreach
Efforts
Recruiting and Training
Peer Supporters
Activities:
Outputs
(Products and
Services)
Individual
Coaching/Ongoing
support
Peer Support/Crisis
Intervention
Workshops
Short-Term
Outcomes
(Specific to
BESIDE)
Organizational support
(e.g., work
accommodations made)
Return to baseline
functioning
Increased perception of
social connection
Increased Knowledge (e.g.,
self-care, burnout)
Long-Term
Outcomes:
Culture of Safety
Reduced rates of
burnout/increased
resilience
Decreased “culture of
shame”/increased “Just
Culture”
Improved work/life
balance
Feels valued as an
employee
Effective Teamwork
27. BESIDE Implementation Progression
Marketing
and
Outreach
(Ongoing)
Phase One: Provide
Confidential
Coaching and
Support
-Offer and provide
education workshops
by request
Phase Two:
Implement Peer
Support Program
-Recruit, Select,
Train Peer
Supporters
Phase Three:
Ongoing education
and prevention
workshops
-Expand support to
include leadership
training
-Build Future
Directions
Current Phase of
BESIDE
29. Activities: Inputs
Program Development
-Protocols for Inclusion in
BESIDE Program
Marketing/Outreach
Efforts
Recruiting and Training
Peer Supporters
Activities:
Outputs
(Products and
Services)
Individual
Coaching/Ongoing
support
Peer Support/Crisis
Intervention
Workshops
Short-Term
Outcomes
(Specific to
BESIDE)
Organizational support
(e.g., work
accommodations made)
Return to baseline
functioning
Increased perception of
social connection
Increased Knowledge (e.g.,
self-care, burnout)
Long-Term
Outcomes:
Culture of Safety
Reduced rates of
burnout/increased
resilience
Decreased “culture of
shame”/increased “Just
Culture”
Improved work/life
balance
Feels valued as an
employee
Effective Teamwork
30. Input: Marketing and Outreach Efforts
• Tracking outreach
• Routinely asking,
– “How did you hear about
BESIDE?”
-COMPARE TO-
• Overall calls/identified
needs
• Interest in being Peer
Supporter
Calls for all BESIDE Services Requests
September 2017 through July 2018
0 1
8
5
12
24
15 15
22
18
12
8
0
5
10
15
20
25
30
Referrals and Requests for all BESIDE
Services
Total, n=140
31. Services Not
Provided, 66, 47%
Initial Services
Provided After 24
Hours, 47, 34%
Initial Services
Provided Within 24
Hours, 24, 17%
Pending Services, 3,
2%
Outcomes of Referrals And Requests For All BESIDE Services
Total, n=140
32. Products and Services: Number of Services Provided
• 94 sessions
• 43 individuals
Individual
Coaching
• 12 debriefings
• 95 individuals
Group Crisis
Debriefing
• 14 trained Peer Supporters
• 6 more will be trained this fall
Peer
Supporters
• 20 workshops
• 238 attendees
Workshops
35. Mean Workshop Scores
4.79
4.66 4.7
4.89
4.63
1
2
3
4
5
Satisfaction with
Presentation
Presenter's Ability to
Maintain my Interest
Learned One Thing I
Plan to Use
Presenter's Ability to
Answer Questions
Likelihood to
Recommend BESIDE
Responses from 11 workshops; 127 attendees
5-Point Likert Scale Questions
37. Activities: Inputs
Program Development
-Protocols for Inclusion
in BESIDE Program
Marketing/Outreach
Efforts
Recruiting and Training
Peer Supporters
Activities:
Outputs
(Products and
Services)
Individual
Coaching/Ongoing
support
Peer Support/Crisis
Intervention
Workshops
Short-Term
Outcomes
(Specific to
BESIDE)
Organizational support
(e.g., work
accommodations made)
Return to baseline
functioning
Increased perception of
social connection
Increased Knowledge
(e.g., self-care, burnout)
Long-Term
Outcomes: Culture
of Safety
Reduced rates of
burnout/Increased
resilience
Decreased culture of
shame/Increased
“Just Culture”
Improved work/life
balance
Feels valued as an
employee
Effective Teamwork
41. Future Directions
• Educating leaders across the organization
– What is 2nd Victim?
– What is BESIDE?
– What is leadership’s role in 2nd victim event?
• Increasing Peer Supporter presence
• Meeting identified needs
– Moved BESIDE from Incident Management to Behavioral Health
Department
43. Providing Support to a Traumatized Person:
General Guidelines for Anyone
• If in crisis
– Are basic and safety needs met?
– Remove from stressful environment
– What resources are available?
– 1-800-273-8255 Suicide Prevention Hotline
– Text to 741-741
44. Providing Support to a Traumatized Person:
General Guidelines for Anyone
• Following a crisis
– Trauma-informed conversations
– Use active listening—don’t jump to problem
solving right away
– Offer realistic support—don’t make promises
you can’t keep
• ALWAYS make sure the person has natural
supports in place
– Connect with resources or become their
support, if able
45. 4. Maintain Routine
5. Talk with Trusted Friends,
Family, Supports
3. Sleep/Rest
2. Physical Activity
1. Water and Healthy Foods
FiveEssentialSelf-CareSkills
46. Providing Organizational Support following a
Safety Event
• Develop a process for organizational support
1. Who will connect with healthcare professional?
– Managers, supervisors, etc.
2. A supportive statement
– e.g., “We value and trust you as a member our team.” or “We care about how you are
doing.”
3. Help with next steps
– Offer help with documenting and reporting event, if needed
– Offer to call in flex staff, if possible
4. Provide ongoing support
– Provide local resources (e.g., peer supporters, EAP, etc.)
– Check-in with staff member on ongoing basis (days, weeks later) until resolved
48. References
• Andrew, L. B., & Brenner, B. E. (2015). Physician suicide. Medscape Drugs &
Diseases.
• Burlison, J.D., Scott, S.D., Browne, E.K., Thompson, S.G. & Hoffman, J.M. (2014).
The second victim experience and support tool: Validation of an organizational
resource for assessing second victim effects and the quality of support
resources. Journal of Patient Safety.
• Christensen, J. F., Levinson, W., & Dunn, P. M. (2006). The Heart of Darkness:
The Impact of Perceived Mistakes on Physicians. Neonatal Intensive Care, 19(7),
48.
• Edrees, H., Connors, C., Paine, L., Norvell, M., Taylor, H., & Wu, A. W. (2016).
Implementing the RISE second victim support programme at the Johns Hopkins
Hospital: a case study. BMJ open, 6(9), e011708.
• Gold, K. J., Sen, A., & Schwenk, T. L. (2013). Details on suicide among US
physicians: data from the National Violent Death Reporting System. General
hospital psychiatry, 35(1), 45-49.
• Headley, M. (2017, October 4). Creating a Culture of Caregiver Support .
Patient Safety & Quality Healthcare.
• Hirschinger, L. E., Scott, S. D., & Hahn-Cover, K. (2015). Clinician support: five
years of lessons learned. Patient Saf Qual Healthc, 12(2), 26-31.
49. References
• Levy, S. & Kane, L. (2017). Medscape Malpractice Report 2017.
Medscape. Retrieved from
https://www.medscape.com/slideshow/2017-malpractice-report-
6009206
• Makary, M. A., & Daniel, M. (2016). Medical error—the third leading
cause of death in the U.S. BMJ: British Medical Journal (Online), 353.
• Moran, D., Wu, A. W., Connors, C., Chappidi, M. R., Sreedhara, S. K.,
Selter, J. H., & Padula, W. V. (2017). Cost-benefit analysis of a support
program for nursing staff. Journal of patient safety.
• Physician’s Weekly. (2016). Medical errors officially the third leading
cause of death in U.S. Physician’s Weekly. Retrieved from
https://www.physiciansweekly.com/medical-errors-officially-the-third-
leading-cause-of-death-in-u-s-study-finds
• Prins, J., van der Heijden, F., Hoekstra-Weebers, J., Bakker, A., van de
Wiel, H., Jacobs, B., & Gazendam-Donofrio, S. (2009). Burnout,
engagement and resident physicians' self-reported errors. Psychology,
Health & Medicine, 14(6), 654-666. doi:10.1080/13548500903311554
• Scott, S. D. (2015). Second victim support: Implications for patient
safety attitudes and perceptions. Patient Saf Qual Healthc, 12(5), 26-
31.
• Wu, A. (2000). Medical error: the second victim: the doctor who makes
the mistake needs help too. BMJ: British Medical Journal, 320(7237),
726.
Continued
Notes de l'éditeur
BESIDE = care for the colleague; CH program to support second victims
Susan Scott and colleagues defined 2nd victim: someone who experiences a medical error, patient-related injury, or other unanticipated, adverse patient event and feels traumatized by the event
-key factors: FEELS traumatized
That traumatization includes….
Mostly beh & psychological symptoms, some professional issues
Traumatization generally occurs when our concept of the world is threatened (“the world is a safe place”). 2nd victims often feel traumatized b/c the experience has threatened their identity (healer identity)
Sxs are normal, to a degree. But 2nd victims who’s symptoms persist can end up having another adverse patient event, because of these symptoms, or leaving the profession altogether. 2nd victims can, however, come through this experience and grow from it.
Med errors are most commonly discussed as causing 2nd victim experience
more than 251,000 care teams.
(Numbers don’t include other stressful patient events, like near misses, other kinds of patient deaths, or traumatic codes in the hospital.)
Ongoing litigation = opportunity for support (med error = initial trauma, reminders of error = retraumatization)
Medscape Report that surveyed over 4,000 physicians
Consider factors at play. (must understand for program to be successful)
Mediators:
-Societal standards for perfectionism in medical providers
-competitiveness created in medical training
(enforce) culture of shame
Individual personality factors and effective coping skills can help or hurt
The implication here for us is that BESIDE addresses both individual resilience and organizational culture. We are defining our success as making an impact in both of those areas.
Bronfrenbrenner approach multiple concentric systems, with individual at center
These programs = support to traumatized medical providers
In 2000, the physician Albert Wu coined the term “second victim” to describe the experience of the physician who makes a medical error. Matter of patient safety.
consists of: organizational support and psychological first aid
Began August of 2017. Collaboration among our Risk Management and Behavioral Health departments (Leslie Robinson and Julie Rickard).
Why we chose “care for colleague”
Support: me, the BESIDE Coach, and peer supporters.
In addition to improved psych outcomes and pt safety cultures. Cost savings
good messaging for getting buy in for “bottom-line-focused” individuals in organization
----------------------------------
RISE (Resilience in Stressful Events) is a care for the caregiver program through Johns Hopkins. Albert Wu (who coined the term second victim) and Cheryl Connors created the program
Moran and colleagues conducted a cost-benefit analysis. They looked at a 1-year period in a 1000-bed private hospital where RISE Program was implemented. Using a statistical model to compare nurses who used the RISE program and those who didn’t, Moran and colleagues determined that the hospital potentially saved over $22,000 per nurse who made a call to the RISE program. That amounts to a potential savings of $1.81 annually. Their analysis took into consideration the cost of running the program (including the time that peers responders take off to provide support), nurse turnover, and nurses taking time off.
In designing our program-took all of this into consideration along with what was currently being done
Most popular model
Sue Scott, ForYOU team U of Missouri, successful, particular in terms of number of people reached and improvements in patient safety culture
theoretical framework: Theory of Transpersonal Caring and Critical Incident Stress Management
3-Tier Model for increasing level of needs
------------------------------
In this model, Leadership and Dept Supports are trained to be aware of 2nd victim phenomena and to offer initial support. They may refer the 2nd victim for peer support or, more often, peer supporters see a need and reach out. Both Peer supporters and leadership are also trained on when to refer to a higher level of care. They have established pathways to professional support, such as an Employee Assistance Program.
Peers have team leaders in their department. Tries to match roles with peers, when possible
Nationwide Children’s Hospital in Columbus, Ohio has also adopted this structure for their Peer Support Program
2nd victim experience = psychological and professional otucomes
Literature highlights psychological impact of a 2nd victim event.
I can’t tell you PTSD #s b/c no one is measuring
Why is that important? Why would we care about how many 2nd victims experience PTSD or another MH Dx?
One reason not studied=MH Stigma among healthcare professionals. We want to avoid the topic. Let’s look at what happens when we avoid the topic
related to job stress (Gold, Sen, & Schwenk, 2013) and evidence that physicians are undertreated for MH Dx (postmortem =less psychotropic meds compared to gen pop).
Implication: Physicians--do not seek support for mental health issues,
-stigma and state licensing boards / past mental health diagnoses (Headly, 2017)
If this # is accurate and a large portion of these people are experiencing PTSD/other MH diagnosis and not getting adequate Tx, that is a problem.
Other 2nd victim programs don’t measure things like trauma, depressive, or anxiety symptoms. Their concern is that it will prevent people from using the program. Who is going to use a service that is going to give them a stigmatizing mental health label? The problem with this is that many of these people ARE experiencing significant trauma, depressive, and anxiety symptoms. We didn’t want to avoid that issue because we knew we would be reinforcing the stigma.
Case example: Outreach---people with PTSD who wish that they had this program then. Thought they were going crazy. Not only told not to talk about the incident, but no acknowledgment that they were traumatized either, which made them feel more isolated and even crazier.
Not labeling, not assigning a diagnosis-exploring the psychological phenomena
Describe our model and rationale.
With my involvement, we are able to explore important questions like:
-how many 2nd victims experience PTSD?
-what are the risk factors for developing PTSD in the 2nd victim population specifically?
-how many 2nd victims recover fully?
-how long does it take to recover with and without support?
-what parts of BESIDE or organizational support are most helpful?
Case example: 2 providers experiencing almost identical symptoms-1 medical error, 1 not. Maybe med-error would have gotten peer support, but where would non-med error have gone?
She likely would have suffered in silence. Perhaps left the profession.
Unique constellation of skills that psychologists posses
Support for litigation, peer support may not be sufficient. (psych first aid versus ongoing addressing Sxs)
-Also, outside MH support-less legal protection (detailed notes and potential for added legal protection if part of our Coordinated Quality Improvement Program [CQIP]).
Now, take you through our process of designing, implementing, and evaluating BESIDE
Getting organizational buy-in. Starts with C-suite buy-in.
Two basic areas. Remember: individual resilience and organizational culture are important
1-individual level=program components that reach individuals
2- organizational and cultural context
-Culture of safety and a Just Culture (Communication and Resolution Program.)
-Organization-wide understanding of the 2nd victim phenomena
-Policies and procedures that need to be in place
Thinking about Unique needs of the organization
Confluence – many things already in place
-Culture of Safety Committee
- Wellness newsletter, Employee Wellness Program
-CRP – CRP certification; care for the colleague is essential component for CRP certification. Process for sharing relevant information that we built into our CQIP
1. Confidential Consultation and support
2. Peer support program
3. Research on burnout/2nd victim experience -- We made educational workshops a central element of the BESIDE Program.
-paired down representation. mountain of considerations in each part.
It can be a daunting task to sort through everything….here’s some help
Luckily, there is some low-hanging fruit to help you.
MITSS (Medically Induced Trauma Support Services) comprehensive toolkit. extensive resources and links
The CANDOR toolkit and the University of Missouri Worksheet mostly map onto MITSS. somewhat simplified/ user friendly / get visual snapshot
Rec: use MITSS toolkit for initial research and getting exmaples for policies and procedures for your own program. The CANDOR and university of Missouri versions: to assess your own organization.
SVEST: 29-item measure to evaluate 2nd victim experience and perceptions of recourse available (content and construct validity; internal consistency)
Logic model—program matrix for hypothesized program impact. Important for design, implementation, and evaluation
Informs what needs to be prepared for successful implementation (processes, training materials, documentation)
Informs measures to be used or developed for short- and long-term evaluation
This is BESIDE logic model based on what we’ve identified as important; yours will be specific to your organization’s needs and values
Return to in evaluation
Creating a timeline; tentative and flexible
Manual that I developed for providing peer psychological first aid (Other programs use their own curriculum and/or Critical Incident Stress Management, but geared toward first responders following acute critical incident)
Numbers: 14 peer supporters
Point of Comparison: ForYOU at University of MO (~10 yrs): 300 trained peers, 185 active for 6500 staff, 1200 providers in a 600 bed facility
We are hospital, primary care, and specialty care across 4 counties. ~400 providers (2016) and close to 4,000 staff, just over 200 hospital beds
Back to logic model
Every one of these areas is an opportunity to evaluate
Highlight some things we are finding in each of these columns
Outreach efforts=marketing materials, going to leadership meetings, going to staff meetings, participating in committee events
Since Sept 2017
As of July 30, 2018
Coaching services: primary utilizers are nurses and physicians, followed by techs, Mas and Physician Assistants
Products and Services: Peer Services Provided
Track overall encounters, actions taken in time of crisis, and interventions used.
The CRP certification form asks if peer support was given within 72 hours following adverse event. This form will help us track this.
DO NOT DOCUMENT CONTENT OF PEER SUPPORT DISCUSSIONS
Survey monkey
Things learned- daily life use
Evaluating long-terms outcomes
Each Organization will define
What is the low-hanging fruit?
Culture change can take 5-7 years.
You can add two questions to things you are already measuring (e.g., burnout, patient safety culture, employee engagement, measures of wellness); Sue Scott did this for culture of safety, Hospital Survey on Patient Safety
Were there patient safety events within the last 12 months that impacted you personally or professionally?”
If yes, did you receive support from our Care for the Colleague Program? 3 groups
SVEST Tool, especially if used initially, could be appropriate to use over time to look at possible changes in 2nd victim response and
Some of these LT outcomes create feedback loop: e.g., Perceptions of patient safety culture can have a direct impact on severity of second victim experience. The more positive and less-punitive the patient safety culture is perceived, the better outcomes for second victims.
___________________
Short-term outcomes are what keep me going and inspire me. Seeing the nurse of 30 years who was burned out and ready to quit following a series of negative events, but they decided to ask for help and now they enjoy their job again. The medical providers who trust me enough to advocate for them to take time to heal when they are really suffering following a medical error. When I see them later in the hallway they stop me and they are so grateful. It’s true that if we referred these people to external psychologists, they may have had good outcomes as well. But people seem to appreciate the fact that I’m embedded at the hospital. They know that I understand the world they are living in; they believe me when I tell them that I think they can heal from their experience because I’ve seen others do it.
Market the program, and don’t stop
Be prepared to address unidentified needs
In recruiting Peer Supporters, we realized that there is a need for non-clinical staff as well
E.g., kitchen and security
We decided to include them—won’t be matched with clinical staff
LT goals: impact on culture change
Also, other situations that are not typical second victim experience
-multiple non-med-error events that were stressful
Not every unmet need=2nd victim. Distinguish from management/HR/EAP issues
-employee conflict (management/HR)
-life stressors that impact work (I may meet with initially b/c this can become 2nd victim issue if not addressed)
Balancing educating leaders with training Peer Supporters and developing program
Too much prog dev w/o leader buy-in => unsupported processes
Too much leader buy-in before prog dev => high need w/o enough resources
-need to have program in place, but also need leaders to support process.
Trauma Informed Care: Understanding the impact of Trauma
EMPATHY
Normalize the second victim experience (earlier slide)
Brene Brown, a research professor who is known for her work on vulnerability, wrote, “Grace means that all of your mistakes now serve a purpose instead of serving shame.” May you grant yourself grace, in all of your endeavors. If you are embarking on this particular path, may your journeys be full of meaning and growth.
