Improving Patient Safety Culture to Provide Safer Care

Improving Patient Safety Culture to Provide Safer Care August 10, 2016

Improving Patient Safety Culture Team. STEPPS® Rules of Engagement n Audio for the webinar can be accessed in two ways: 1. Through the phone (*Please mute your computer speakers) 2. Through your computer n A Q&A session will be held at the end of the presentation n Written questions are encouraged throughout the presentation and will be answered during the Q&A session n Mod 1 05. 2 Page 2 Slide 2 To submit a question, type it into the Chat Area and send it at any time during the presentation TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Upcoming Team. STEPPS Events n Online Course Availability n Not able to travel? Training through the Team. STEPPS 2. 0 Online Master Trainer Course is available. n Register at: https: //tslms. org n Learn more and register for all events at www. Team. STEPPSportal. org Mod 1 05. 2 Page 3 Slide 3 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Help Line (312) 422 -2609 Or email: AHRQTeam. STEPPS@aha. org Mod 1 05. 2 Page 4 Slide 4 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Today’s Presenter Adam Novak, MA Project Coordinator Michigan Health & Hospital Association Mod 1 05. 2 Page 5 Slide 5 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Objectives n Provide an overview of MHA's overall program of work to improve patient safety culture n Discuss the role of Team. STEPPS and other teamwork interventions within the CUSP framework n Describe specific implementation efforts focused on improving teamwork, communication, and safety culture n Discuss the importance of the engagement of both leaders and front-line staff in this work n Present MHA's efforts to assess intervention effectiveness Mod 1 05. 2 Page 6 Slide 6 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® About the MHA n 293 members n 166 hospitals n Keystone Center (PSO) n CUSP 4 MVP – VAP n On the CUSP: Stop CAUTI Mod 1 05. 2 Page 7 Slide 7 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® The MHA Culture Program n SCORE – Culture Survey n CUSP Workshops n Culture Orientation Material (Business Case) n Speak-up! Award n Culture Roadmap n Improvement toolkit Mod 1 05. 2 Page 8 Slide 8 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Comprehensive Unit Based Safety Program (CUSP) n An intervention to learn from mistakes and improve safety culture n n n n Mod 1 05. 2 Page 9 Slide 9 Evaluate culture of safety Assemble team Educate staff on the Science of Safety Identify defects Assign executive to adopt unit Implement teamwork tools Evaluate culture of safety TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® CUSP: The Short Version q Identify • Who is on your team? (physician champion, nurse champion, pharm, executive) q Meetings • Monthly (work with executive assistant, piggy-back off of existing meetings) • Review data (culture, process, outcomes) q Science of Safety • All staff should watch this video • Complete Staff Safety Assessment (SSA) – dot voting • What is your aim and plan for improvement? (reduce possible opioid dependence/abuse rates, increase risk assessment compliance) q Mod 1 05. 2 Page 10 Slide 10 Use Tools to Improve • Daily Goals Checklist • Learning from Defects (LFD) • Morning Briefings • SBAR TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Team. STEPPS, CUSP, and Culture n CUSP – (Team, culture primer, meetings, test) n Morning Briefing n Staff Safety Assessment (SSA) n Learning From Defects (LFD) n Team. STEPPS n SBAR n CUS n Check-Back n Other n STOC/PDSA n Culture Orientation Material (business case) n Speak-up! Award Mod 1 05. 2 Page 11 Slide 11 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® CUSP Tool #1: Morning Briefing n Structured communication n Focus on safety in real time n Integrated into routine care n Easy to use, little training, quick n Can be adapted to other areas Mod 1 05. 2 Page 12 Slide 12 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® CUSP Tool #2: Staff Safety Assessment n Asks two questions: n How will the next patient be harmed? n What can we do to prevent it? Mod 1 05. 2 Page 13 Slide 13 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® CUSP Tool #3: Learning From Defects n What happened? n Why? n What will you do to reduce probability that it will happen again? n How do you know risk is reduced? n Share your learning throughout organization Mod 1 05. 2 Page 14 Slide 14 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Team. STEPPS Tool #1: SBAR n Situation, Background, Assessment, Recommendation n Offers standardized method of concise, direct communication n Doesn’t need to be formal Mod 1 05. 2 Page 15 Slide 15 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Team. STEPPS Tool #2: CUS n Concerned, Uncomfortable, Safety Issue n Progression in magnitude of meaning n Allows for a “safe” way to speak-up n Will “stop the line” if necessary Mod 1 05. 2 Page 16 Slide 16 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Team. STEPPS Tool #3: Check-Back n Sender initiates message n Receiver accepts message and feeds back n Sender confirms that message is correct Mod 1 05. 2 Page 17 Slide 17 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Other Tool #1: STOC/PDSA n Small Test Of Change/Plan, Do, Study, Act n Plan: Test or observation, data collection, prediction n Do: test on small scale (how did someone react? ) and record what happened n Study: How do the results compare to your prediction? n Act: Use what you learned to make changes, how can you improve your STOC for the next cycle? Mod 1 05. 2 Page 18 Slide 18 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Other Tool #2: Culture Orientation n Provides a “business case” for safety culture n Pulls from peer reviewed journal articles and white papers from experts n Gives the “why” and the “how” Mod 1 05. 2 Page 19 Slide 19 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Culture Orientation Continued… Mod 1 05. 2 Page 20 Slide 20 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Culture Orientation Continued… Mod 1 05. 2 Page 21 Slide 21 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Other Tool #3: Speak-up! Award n 80 nominees n First quarterly awardee officially announced on July 13, 2016 n Engage staff, recognize and reward patient safety efforts n Align organizational reporting with nomination timeline Mod 1 05. 2 Page 22 Slide 22 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Engagement is Key! n Include staff early n When developing a program/QI initiative, ask for feedback, opinions (tip: use the SSA) n Be Transparent n Show your data to staff, embrace and improve n Use patient stories n Couple with your data, tell the story to make it real n Reduce burnout n Celebrate even small successes Mod 1 05. 2 Page 23 Slide 23 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Does it Work? Measuring Impact Mod 1 05. 2 Page 24 Slide 24 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Measuring Impact Continued… Mod 1 05. 2 Page 25 Slide 25 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Benchmarked Culture Data Mod 1 05. 2 Page 26 Slide 26 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Benchmarked Culture Data (Cont’d) Mod 1 05. 2 Page 27 Slide 27 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Benchmarked Culture Data (Cont’d) Mod 1 05. 2 Page 28 Slide 28 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Why Teamwork and Communication? n You can achieve more n Orcas, wolves, ants, bees n Layers of protection n Swiss Cheese Model n Essential for functionality n What if your sensory and motor nerves stopped communicating with your brain? n Historical implications Mod 1 05. 2 Page 29 Slide 29 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Questions and Answers Mod 1 05. 2 Page 30 Slide 30 TEAMSTEPPS 05. 2

Improving Patient Safety Culture Team. STEPPS® Thank You! For more information, please contact our team at: AHRQTeam. STEPPS@aha. org Mod 1 05. 2 Page 31 Slide 31 TEAMSTEPPS 05. 2