The Power of One The Patient Safety Skill that Changed One Family’s 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 responsibility to put into place systems to support safe practice. ” James Conway, IHI
The Power of One Stop-the-Line
1985
2015
17 years & 170 healthcare organizations
A patient’s story…
Jane 44 5 th Child
No We’ll see. C Section!
What Do You Think? • If this were an ultra-safe, ultra reliable hospital, what do you expect to happen? – What will Rebecca do? – What will Dr. K? • If something like this event happened in your hospital, with your version of Rebecca and your version of Dr. K, would Rebecca speak up? • How would you rate your culture? 0 10
Safety Climate Survey Results 89% Staff will freely speak up if they 52% see anything that will negatively affect patient care Before After Source: Piedmont Heart Institute
Safety Climate Survey Results 71% Staff feel free to question the 40% decisions or actions of those in more authority Before After Source: Piedmont Heart Institute
Safety Climate Survey Results 94% In this unit we 43% discuss ways to prevent errors from happening again Before After Source: Nebraska Medical Center
Reduction in teamwork/communication errors that contribute to Sentinel Events 90% Percentage of RCAs in which communication 40% and/or teamwork were listed as contributing factors Before TS After TS 2009 2012 Source: Missouri University Hospital
S e l f Others 200% Accountability
200% Accountability • We watch out for one another • We succeed, and we fail, as a team • We reinforce good behaviors • We correct perceived problems with patient care in a helpful, respectful manner
“How did that happen?” ANW story
How did that happen?
How did that happen?
How did I let that happen? The Power of One
Cross-Check & Assertion Team members Team members actively monitor speak up with situation for questions & potential problems concerns, and and concerns persist until there is a clear resolution
Cross-Check & Assertion Monitor the Situation Acknowledge, Recognize Decision, Adverse Situation & “ Thank you ” Communicate with Precise & Standard Comm
Cross-Check and Assertion is NOT… Doing someone else ’ s job A critique of your skills Usurping the leader ’ s authority
“ Cross-Check & Assertion ” in Action
How to Make an Assertive Statement Assertive Statement No response? Add “ Check ” No response? Relay Info
Assertive Statement Get attention Call them by name • Express concern “I statement” • State the problem Brief, objective & clear • Propose a solution • “ We ” or “ Let ’ s ”
“ A charge nurse in the cardiac cath lab (Nurse Danner) has received a patient named Morris, but has a patient named Morrison on the schedule. She questions the doctor. ” • Nurse Danner: • Nurse Danner: “ Doctor Smith, I need clarity about “ Doctor, we don ’ t our patient. We don ’ t have a have a patient named patient named Morris on the Morris on the schedule, but we do have a schedule. I ’ m Morrison. Let ’ s check her concerned there chart and call the floor to see might be a mix-up. ” if we have the right patient before we proceed. ” • Doctor: “ This is our patient. ”
Let’s Practice! • Split up into groups of two • Role play making an Assertive Statement from the Case Studies on the screen • After each practice session, conduct a debrief – “What did you do well?” – “What would you like to improve?” – “Here are my comments for you…” •
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. Dr. Minut tells the charge nurse, “I have another hour in my office and I will be there for a C-Section at 12:15 p.m.” Draft an Assertive Statement from the charge nurse to Dr. Minut: Get Attention Express Concern State the problem Propose Solution Dr. Minut, I ’ m concerned that this situation is deteriorating and the patient cannot wait another hour. We need to take action now . 32
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: 1. What did you do well? 2. What would you like to improve? 3. Here are my comments for you.
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 him. She responds, “I knew you were scheduled to come in and I didn’t want to bother you.” Draft an Assertive Statement from Dr. Kind to Nurse Timid: Get Attention Express Concern State the problem Propose Solution Debrief: 1. What did you do well? 2. What would you like to improve? 3. Here are my comments for you.
Stop-the-Line Challenge
What is the strongest predictor of clinical excellence? A. The experience (tenure) of the staff B. The educational background of the staff C. Nurse to patient ratio D. Willingness to speak up when a problem with patient care is perceived E. Margin ($$ - payor mix, reimbursement rates, profit line, resources, etc…)
3 Stop-the-Line Training Guides
What about Jane and her baby?
The Power of One "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
Thank you
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