The Power of One The Patient Safety Skill that Changed One Familys - - PowerPoint PPT Presentation
The Power of One The Patient Safety Skill that Changed One Familys Life Forever Capt. Stephen W. Harden Our systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time. We, as leaders, have a
The Patient Safety Skill that Changed One Family’s Life Forever
James Conway, IHI
The Power of One
Stop-the-Line
17 years & 170 healthcare organizations
No C Section! We’ll see.
reliable hospital, what do you expect to happen?
– What will Rebecca do? – What will Dr. K?
happened in your hospital, with your version of Rebecca and your version of Dr. K, would Rebecca speak up?
culture?
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Staff will freely speak up if they see anything that will negatively affect patient care
Before After
Source: Piedmont Heart Institute
Staff feel free to question the decisions or actions of those in more authority
Before After
Source: Piedmont Heart Institute
In this unit we discuss ways to prevent errors from happening again
Before After
Source: Nebraska Medical Center
Reduction in teamwork/communication errors that contribute to Sentinel Events Before TS
2009
After TS
2012
Source: Missouri University Hospital
Percentage of RCAs in which communication and/or teamwork were listed as contributing factors
S e l f Others
care in a helpful, respectful manner
Team members actively monitor situation for potential problems and concerns Team members speak up with questions & concerns, and persist until there is a clear resolution
Communicate with Precise & Standard Comm Monitor the Situation Recognize Adverse Situation
Acknowledge, Decision, & “Thank you”
Doing someone else’s job A critique of your skills Usurping the leader’s authority
Relay Info
Add “Check” No response? Assertive Statement No response?
Propose a solution •
“We” or “Let’s”
State the problem
Express concern
Get attention
“A charge nurse in the cardiac cath lab (Nurse Danner) has received a patient named Morris, but has a patient named Morrison on the
“Doctor, we don’t have a patient named Morris on the
concerned there might be a mix-up.”
patient.”
Smith, I need clarity about
patient named Morris on the schedule, but we do have a
chart and call the floor to see if we have the right patient before we proceed.”
Statement from the Case Studies
conduct a debrief
– “What did you do well?” – “What would you like to improve?” – “Here are my comments for you…”
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Stop-the-Line Situation # 1
The labor and delivery charge nurse calls Dr. Ina Minut and reports ruptured membranes, meconium [fetal feces] on vaginal exam, a breech baby on ultrasound, and a fetal heart pattern that shows minimal variability and variable decelerations.
12:15 p.m.” Draft an Assertive Statement from the charge nurse to Dr. Minut:
Get Attention Express Concern State the problem Propose Solution
situation is deteriorating and the patient cannot wait another hour. We need to take action now.
Stop-the-Line Situation # 2
The charge nurse, Con (short for Constance) Fuzed, noticed there was an extra bag hanging on the IV pole that wasn’t needed, and shouldn’t be administered IV. But Con knows the other staff member, Benear Longtime, is one of the most experienced in the department and is unsure if she should speak up and say something. Draft an assertive statement from Con to Benear Longtime:
Get Attention Express Concern State the problem Propose Solution
Debrief:
Stop-the-Line Situation # 3
While rounding on his patient, Dr. Kind notices on the strip that there was an indeterminate tracing an hour ago. Knowing that policy is that every RN is required to communicate, using SBAR, to the patient’s provider the patient’s status, he asks Nurse Timid why she didn’t call
want to bother you.” Draft an Assertive Statement from Dr. Kind to Nurse Timid:
Get Attention Express Concern State the problem Propose Solution
Debrief:
staff
problem with patient care is perceived
reimbursement rates, profit line, resources, etc…)
3 Stop-the-Line Training Guides
"The names of the patients whose lives we save can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would never have been.” Don Berwick, MD, MPP
Former President and CEO, Institute for Healthcare Improvement Former Administrator of CMS
The Power of One