Piloting the Physician Relationship, Improvising, and Sense-making - - PowerPoint PPT Presentation

McCombs Healthcare Initiatives Symposium April 9th, 2015

Luci K. Leykum, M.D., MBA, MSc., Nadia Silva, MPH, Meghan A. Crabtree, M.S., Holly J. Lanham, Ph.D., MBA, Jacqueline A. Pugh, M.D., and Reuben R. McDaniel, Jr., Ed.D.

Piloting the Physician Relationship, Improvising, and Sense-making Intervention

Presentation Outline

• PRISm – Background and Purpose
• Intervention setting, participants, and context
• Preliminary Results – Team Observations

and Attending Interviews

• Preliminary Conclusions

PRISm: Background & Purpose

• How do we systematically improve

hospitalized patient care?

• By improving how providers:

–Relate to each other –Make sense of what is happening –Improvise in uncertain situations

Intervention Setting

Audie L. Murphy Memorial VA Hospital

San Antonio, TX

• 220-bed acute care facility
• Part of the South Texas

Veterans Health Care System

• Teaching Hospital affiliated

with UTHSCSA

• Four Inpatient General Medicine

teams, consisting of:

– 1 Faculty Attending Physician – 1 PGY-2/3 Resident – 2 PGY-1 Interns – 2 to 3 Medical students – Pharmacist and/or pharmacy students

Intervention Participants

Intervention Context

Daily Attending Rounds

Rounding Pattern Pattern Description Gravity Starting at the highest floor and moving down Geography Starting on a particular unit and moving to contiguous units Intern by Intern Rounding on one intern’s patients first and then the

• ther’s

Running the Board Rounding in the team room, going down the list of patients in the order they are listed Patient-driven Based on patients’ clinical needs

Intervention Context

Daily Attending Rounds

Rounding Pattern Pattern Description Gravity Starting at the highest floor and moving down Geography Starting on a particular unit and moving to contiguous units Intern by Intern Rounding on one intern’s patients first and then the

• ther’s

Running the Board Rounding in the team room, going down the list of patients in the order they are listed Patient-driven Based on patients’ clinical needs

Intervention Context

Daily Attending Rounds

Rounding Pattern Pattern Description Gravity Starting at the highest floor and moving down Geography Starting on a particular unit and moving to contiguous units Intern by Intern Rounding on one intern’s patients first and then the

• ther’s

Running the Board Rounding in the team room, going down the list of patients in the order they are listed Patient-driven Based on patients’ clinical needs

Intervention Context

Daily Attending Rounds

Rounding Pattern Pattern Description Gravity Starting at the highest floor and moving down Geography Starting on a particular unit and moving to contiguous units Intern by Intern Rounding on one intern’s patients first and then the

• ther’s

Running the Board Rounding in the team room, going down the list of patients in the order they are listed Patient-driven Based on patients’ clinical needs

Intervention Context

Daily Attending Rounds

Rounding Pattern Pattern Description Gravity Starting at the highest floor and moving down Geography Starting on a particular unit and moving to contiguous units Intern by Intern Rounding on one intern’s patients first and then the

• ther’s

Running the Board Rounding in the team room, going down the list of patients in the order they are listed Patient-driven Based on patients’ clinical needs

Physician Relationship, Improvising and Sensemaking intervention

• 3 Key Components:

– Briefings before rounds – Debriefings after rounds – STICC for individual patient discussions

STICC element Definition Situation “What are we dealing with?” Task “What do we think we should do?” Are specific steps explicitly discussed? Intent “Why are we doing it?” Explicit discussion of why team is deciding on a plan Concern “What are we watching for?” Discussion of potential complications, things to consider Calibrate “What don’t we know?” “What do we do if…?” Includes contingency statements and more-than-1-step-ahead thinking.

The STICC Framework

PRISm: Implementation & Assessment

PRISm: Implementation & Assessment

PRISm: Implementation & Assessment

PRISm: Implementation & Assessment

PRISm: Implementation & Assessment

PRISm Preliminary Results

Rounding Patterns and Patient Load

PRISm Preliminary Results

Percent Patient Discussions containing STICC

PRISm Preliminary Results

Attending Interviews

Preliminary Conclusions

• Integrating PRISm into rounds:
• Is feasible and easily adaptable
• Encourages patient-driven rounding patterns
• Enables mindful patient discussions
• May benefit from a more structured orientation
• Can augment other tools, e.g. SOAP