Interprofessional Teamwork Collaboration Annette Bartley Director of The

Inter-professional Teamwork & Collaboration Annette Bartley Director of The Safer Patient Network Faculty for Healthcare Improvement Wales 1

Session Objectives �Appreciate the inherent clinical value of effective teamwork and communication in providing safe patient care �Understand how communication failures are at the root of the overwhelming majority of unanticipated adverse events �Understand the critical importance of Assertion /Critical Language so providers can speak up reliably when they perceive risk to a patient �Learn about the inherent limitations of human performance and the value of reliable systems to help insure safe care �Describe some tools/techniques that can help enhance 2

Let’s begin with a story �This is a story about 4 people named everybody, somebody, anybody and nobody. There was an important job to be done and Everybody was asked to do it. Everybody was sure somebody would do it. Anybody could have done it but nobody did it. Somebody got angry about that because it was Everybody's job. Everybody thought anybody could do it, but nobody realized that everybody wouldn't do it. It ends up that everybody blames somebody when nobody did what anybody could have done 3

Why is teamwork so important in healthcare? �A healthcare system that supports effective teamwork can improve the quality of patient care, enhance patient safety and reduce workload issues that cause burnout among healthcare professionals 4

Teamwork Matters �More responsive & patient –centered service �More clinically effective & cost effective care �Avoids duplication & fragmentation �Allows for improved organizational planning �Improves job satisfaction or cross-training �Improves admission, hand-off/ transfer of care & discharge planning 5

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“ Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects…. . Their part is that of adding the final garnish to a lethal brew that has been long in the cooking. ” James Reason, Human Error, 1990 7

Error is Inevitable Because of Human Limitations �Limited memory capacity – 5 -7 pieces of information in short term memory �Negative effects of stress – error rates • Tunnel vision �Negative influence of fatigue and other physiological factors • Cognitive performance after 24 hrs. without sleep equivalent to blood alcohol of. 10 ! Dawson et al, Nature, 1997 �Limited ability to multitask – cell phones and driving 8

Criteria for Healthcare Teamwork �Multiple disciplines are involved in care �Disciplines encompass a diversity of distinct knowledge and skills needed for patient care �Plan of care reflects an integrated set of goals �Team members share information and coordinate services Schmitt, Farrell and Heinemann; 1988 9

Cultivating Teamwork �People are any organization's most valuable assets, but for some reason we keep forgetting this simple point. Instead, we get caught up in the latest system that is going to make everything and everyone more efficient and economical, ignoring the fact that it is people who make systems work. 10

Teamwork- The Sum of the parts is greater than the whole Healthcare is an extremely complex environment �There are: �Surprises �Uncertainty �Incomplete Information �Interruptions �Multitasking 11

Getting to Goal 12

The Role of Leadership • Common goal – optimal care, optimal environment for caregivers • Engaging doctors • Understanding and engaging the culture • Effective teamwork and communication • Measurement – show people the benefit • Continuous cycles of improvement 13

Executive Perceptions vs. Frontline Perceptions: Executives overestimate: Teamwork Climate 4 X Safety Climate 2. 5 X Executive Confidence vs. Executive Accuracy: -Often wrong but rarely in doubt… -Currently no incoming data-streams -Halo Effects -Frontline data fills the gap

When is teamwork most effective �Clear purpose (shared vision) �Good communication; �Co-ordination �Supportive protocols and procedures �Effective mechanisms to resolve conflict when it arises. Active participation of all members is another key feature. 15

Teamwork video clip �http: //www. youtube. com/watch? v=lu. Lp. ITUkg. O 8 16

Patient at the centre �Patients and their families are important team members with an important role in decision-making. �To enable patients to participate effectively, they need to learn about how to participate in the team; how to obtain information about their condition; and how each healthcare professional will contribute to their care. 17

Barriers to Teamwork �Failure to appreciate the value of different roles �Power struggles inhibit communication �The ‘attitude virus’! �Frequent staff changes complicate staff learning �Conflict and compromise may be caused by predominance of less experienced workers �Poor communication Adapted from Opie, 1997 18

Barriers to Safety � Trained to be perfect - knowledge and competence are equated with the absence of error �Mistakes are seen as episodes of personal failure �Catastrophic events are rare-“It won’t happen to me” �Assuming safety, not assuring safety �Focus on individuals, not complex systems �- fix the person and the problem goes away 19

Familiarity with others is a critical component of effective teamwork: • 74% of all commercial aviation accidents happen on the first day of a crew flying together • Familiarity trumps fatigue • Highlights the importance of predictable patterns of behavior 20

Psychological Safety… Recognition that human error is inevitable • Complex systems • Inherent Human Limitations – stress, limited ● ● memory capacity, fatigue, & multitasking Safety is often ASSUMED, not ASSURED Culture of the expert of the individual Solution: Teamwork & Communication! 21

Fatigue � 24 hours without sleep is equivalent to a blood alcohol level of 0. 10 – a 30% decrease in cognitive processing �Nurses are 3 times more likely to make mistakes after 12 hours on the job �Junior doctors made 30% more errors in ICU patients when on traditional 24 hour call schedules �The best countermeasure for fatigue is teamwork – more people in the same movie 22

Multitasking, Interruptions, Distractions �Humans are poor multi-taskers �Drivers on mobile phones have 50% more accidents, 25% of traffic accidents are "distracted drivers” �Interruptions and distractions increase error rates �Humans need very formal cues to get back on task when interrupted and distracted 23

Failure of Recognition and Rescue �A very common theme in adverse outcomes �Someone has to recognize the patient is in trouble, AND �The patient has to be rescued from the problem in a timely fashion �Condition H 24

Conflict Resolution in the OR • Conflict was observed in 10% of flights and 10% of surgeries • Resolved in 80% of instances in cockpit • Resolved in 20% of instances in operating room

Psychological Safety… �Do you know all the names of the personnel you work with? �Safety Briefings= Level the playing field �“Hi, I’m ___. I’m sorry I missed your name. ” �“I don’t have any pride invested here. I just want to get it right, so if you think I am doing anything wrong, please let me know. ” 26

Psychological Safety… Environment of Respect • • “A fundamental, non-negotiable respect for every employee, everyday, by everyone” Their work is recognized and acknowledged 27

Effective Communication Requires �Structure Communication (SBAR) �Assertion/Critical Language (key words)- The ability to speak up and stop the show �Leadership �flat hierarchy �sharing the plan �continuously inviting other team members into the �Conversation �explicitly asking people to share questions or concerns using people’s names 28

Importance of Communication �Communication failure has been identified as the leading root cause of sentinel events over the past 10 years (Joint Commission) �Communication failure is a primary contributing factor in almost 80% of more than 6000 root cause analyses of adverse events and close calls (VA Center for Patient Safety) �The elevator speech 29

Effective communication �Have a plan �Hand-offs are dangerous �Recognise the value of a structured process �Structured language / clarity �Who owns the patient? �What are the parameters for increasing the intensity of care? 30

Different Communication Styles �National Culture �Gender �Roles (Physician, Nurse, Manager) �Nurses: narrative & descriptive �Physicians: problem solvers “just give me the facts” 31

Structured Communication: SBAR If the phone goes dead in 10 seconds – will the person on the other end know what is needed? Situation – State what you are calling about (5 -10 second punch line) Background – State what you are calling about (including objective date i. e. vitals, labs) Assessment – State what you think the problem is (diagnosis not necessary – include severity) Recommendation – State what you think needs to be done for the patient (get a time frame) 32

Structured Communication S –Mr. M has sudden onset of radiating chest pain & shortness of breath B – He has a history of MI’s, & his obs are 186/76, 180, 24 & he is on 5 L of O 2 per nasal cannula sats 84% A – I think Mr. M might be having an MI R – I need you to come evaluate the patient, how soon will you be here? 33

Structured Communication �CUSS to communicate concern �C – “I’m Concerned” or “I need clarity” �U – Uncomfortable �S – Stop the line/procedure �S – Patient Safety is at risk! 34

Assertion Speak up and state your information with appropriate persistence until there is a clear resolution What is it? Organized in thought and communication Valued by the entire team Looking for clarification & common understanding • • What is it not? Aggressive or hostile Ridiculing Confrontational Ambiguous * 35

Teamwork Improving Quality-How Do We Start? 1. 2. 3. 4. 5. 6. 7. 8. Create a sense of urgency Pull together the guiding team Formulate a change vision and strategy Communicate your vision for understanding and buyin Set aims & use the Model for Improvement Measurement and feedback loop Test ‘one’ communication tool on one shift with one team Test and Learn from it/build upon it and refine the process 36

What is TM Team. STEPPS ? �An evidence-based teamwork system �Designed to improve: �Quality �Safety �Efficiency of health care �Practical and adaptable �Provides ready-to-use materials for training and ongoing teamwork 37

Why Use Team. STEPPS? �Goal: Produce highly effective medical teams that optimize the use of information, people and resources to achieve the best clinical outcomes �Teams of individuals who communicate effectively and back each other up dramatically reduce the consequences of human error �Team skills are not innate; they must be trained 38

Teams STEPPS- What Teams Learn? 39

What Can Team. STEPPS Do for Us? Emergency Department 1 After implementation of multiple medical team training programs: • Improved observed team behaviors. • Enhanced staff attitudes toward teamwork. • Reduced observed clinical errors. Clinical Units in a Medical Center 2 After implementation of SBAR to improve communication among clinical caregivers: • Reduced rate of adverse drug events (from 30 to 18 per 1, 000 patient days). • Improved medication reconciliation at patient admission from 72% to 88% and at discharge from 53% to 89%. 1. Morey, JC, Simon, R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: Evaluation results of the Med. Teams project. Health Serv Res. 37: 1553 -1581, 2002 2. Haig, K. , Sutton S, Whittington, J. SBAR: A shared mental model for improving communication between clinicians. JL Comm J Qual Patient Saf 32(3): 167 -75, March 2006. 40

Focus on the common goal �Anchor the work where we have common agreement (PFCC) �Avoid judgment and 1 st person / 2 nd person dialogue �Basic tenet of negotiation theory – it is much easier to have the 3 rd person conversation when discussing how to do the work 41

Doctor Engagement in Quality and Safety �Challenges: �Doctors are busy �They’ve been trained as individual experts �They are very goal oriented and want to see results �Traditionally, we haven’t taught them about human factors, teamwork and system error – a different way of thinking 42

Doctors & Nurses �Nurses are trained to be narrative and descriptive �Doctors are trained to be problem solvers �– “what do you want me to do? ” �– “just give me the headlines” �Complicating factors: gender, national culture, the pecking order, prior relationship �Perceptions of teamwork depend on your point of view 43

Understanding culture is essential �What are your social metrics? �How do people perceive teamwork in the �environment – are staff hesitant to speak up? �Safety climate? Do staff believe their �concerns would be acted upon? �What is their level of threat awareness? High �workload, fatigue, multi-tasking? 44

A Good Approach �SBAR to communicate �Assertion/ critical language �Psychological Safety / Effective Leadership �Rapid Response Teams �Leadership Walk Rounds 45

Putting the Pieces Together �Culture – leadership, safety culture, teamwork �Reliable Processes – embed teamwork practices in these �Cycles of Improvement – build a learning organisation with continual improvement 46

The Five Filters �What are the 5 medications that put our �patients at risk? Warfarin, insulin, narcotics etc. �What are the 5 lab tests we can’t afford to lose? �What are the 5 diagnoses we can’t afford to miss? �What are the 5 places things fall through the cracks? 47

Crew Resource Management �Focus on teamwork, communication, flattening hierarchy, managing error, situational awareness, decision making �Non-punitive reporting of near misses, 500, 00 reports over 15 years �Very open culture with regard to error and safety 48

High Reliability �Preoccupation with failure – When someone raises a concern, the problem exists until proven otherwise �Reluctance to simplify – Errors and close calls are �reflections of deeper system flaws �Commitment to resilience – Knowing there will be �problems and flaws, the job will get done �Deference to expertise – The person most qualified does the job �Sensitivity to operations – Flexing resources to deal with demand or workload 49

Red Flags – Loss of Situational Awareness �Ambiguity �Reduced/Poor communication �Confusion �Trying something new under pressure �Deviating from established norms �Verbal violence �Doesn’t feel right �Fixation / Boredom / Task saturation �Being rushed / Behind schedule 50

Debriefing -An opportunity for individual, team and organizational learning �The more specific, the better �What did we do well? What did we learn? �What would we do differently next time? �Take a minute or two to learn when it’s �fresh in everyone’s head 51

Teamwork & Vitality �Ideas generations- Snorkel together �Use data to motivate and drive teams for better results �STUDY RESULTS TOGETHER �Celebrate Successes �Star Awards/rewards 52

Key Take Home’s �Respect the wisdom of the front line workers �Culture is related to clinical and operational outcomes �Culture is local – work unit culture trumps hospital culture �Lots of variability across work units �Familiarity improves predictable patterns of behavior (improves performance) �Perceptions of teamwork differ by role, whereas perceptions of safety climate are consistent within a work unit �Senior leader contact with front-line workers is key to improving perceptions of safety climate �Frontline providers have demonstrated a striking ability to improve culture in an relatively short time, when they are leading the effort 53 �Answer the question: “Are We Safer than Last Year? ”

Remember every system is perfectly designed to get the results it get 54

The Blue Angels http: //www. youtube. com/watch? v=m. R 0_SK 1 K 8 x. Y