Team STEPPS Team Strategies Tools to Enhance Performance

Team. STEPPS Team Strategies & Tools to Enhance Performance & Patient Safety

Team. STEPPS “Tiered. STEPPS”: A Commitment to Address Behaviors that Undermine a Culture of Safety Gerald B. Hickson, MD Assistant Vice Chancellor for Health Affairs Associate Dean for Faculty Affairs Joseph C. Ross Chair in Medical Education & Administration Chair, Board of Governors, National Patient Safety Foundation Center for Patient & Professional Advocacy, Vanderbilt University School of Medicine Mod 1 05. 2 Page 2 TEAMSTEPPS 05. 2

Team. STEPPS Pursuit of Reliability n Safety Culture Willingness to report or act… § Psychological safety § Trust n “Behaviors that undermine a culture of safety” threaten trust, therefore must be addressed fairly, quickly, and in a measured way n Hickson, Moore, Pichert, Benegas Jr. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2 nd ed. Oakbrook Terrace, IL: Jt Comm Resources; 2012: 1 -36. Mod 1 05. 2 Page 3 TEAMSTEPPS 05. 2

Team. STEPPS Case: “Looks a Little Red” n 56 yo homeless man with frostbite to feet n Initial care in burn unit. . . to Psych unit. Nurse and Psych Resident (Dr. PR) concerned. . . redness, mild fever, tachycardia? n Burn Unit resident, Dr. Surg. Res, examines. . . "on right abx. . . wounds OK, vitals stable. . . see 1 st thing in A. M. . call with any concern. ” Mod 1 05. 2 Page 4 TEAMSTEPPS 05. 2

Team. STEPPS Case: “Looks a Little Red” n 2 nd call to Dr. SR, 2 hours later… n Psych Chief Resident to Dr. SR: "please have the Burn Fellow come now and examine this patient. " n Shortly thereafter the phone rings in the Psych unit…“Let me speak with Dr. PR” Mod 1 05. 2 Page 5 TEAMSTEPPS 05. 2

Team. STEPPS Case: “Looks a Little Red” n Dr. Burn. Fellow: "is this Dr. PR or whoever the #%&! is questioning my #%&! resident’s judgment. . . ” n Dr. BF continues, “You guys in psych get so worked up. . I bet you consult critical care every time a patient sneezes. . . " n Dr. BF then hangs up. . . Mod 1 05. 2 Page 6 TEAMSTEPPS 05. 2

Team. STEPPS Consider the microsystem where you work… What % of the time would the professionals report Dr. BF’s conduct to either a supervisor or through an event reporting system? 1. 0 – 20% 2. 20 – 40 % 3. 40 – 60% 4. 60 – 80% 5. 80 – 100% 10 Countdown Mod 1 05. 2 Page 7 TEAMSTEPPS 05. 2

Team. STEPPS If reported, what % of the time would a medical leader have a conversation with Dr. BF? 1. 2. 3. 4. 5. 0%-20% 20%-40% 40%-60% 60%-80% 80%-100% 10 Mod 1 05. 2 Page 8 TEAMSTEPPS 05. 2

Team. STEPPS A Few Questions n From Reason’s “Unsafe Acts” algorithm (1997): n n Is the team member intending to cause harm? Is the team member impaired? Is the team member knowingly and unreasonably increasing risk? Is another team member in the same situation likely to act in a similar manner? Reason J. T. : Managing the Risks of Organizational Accidents. Aldershot, UK: Ashgate Publishing, 1997. Mod 1 05. 2 Page 9 TEAMSTEPPS 05. 2

Team. STEPPS Definition of Behaviors That Undermine A Culture of Safety Include but are not limited to, words or actions that: § Prevent or interfere w/an individual’s or group’s work, academic performance, or ability to achieve intended outcomes (e. g. intentionally ignoring questions or not returning phone calls or pages related to matters involving patient care, or publicly criticizing other members of the team or the institution); § Create, or have the potential to create, an intimidating, hostile, offensive, or potentially unsafe work or academic environment (e. g. verbal abuse, sexual or other harassment, threatening or intimidating words, or words reasonably interpreted as threatening or intimidating); § Threaten personal or group safety, aggressive or violent physical actions; Violate VUMC policies, including conflicts of interest and compliance. It’s About Safety Vanderbilt University and Medical Center Policy #HR-027, 2010 Mod 1 05. 2 Page 10 TEAMSTEPPS 05. 2

Team. STEPPS The Balance Beam Competing priorities Not sure how lack tools, training Leaders “blink” “Can’t change…” Fear of antagonizing Do nothing Staff satisfaction and retention Reputation Patient safety, clinical outcomes Liability, risk mgmt costs Do something June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Center for Patient and Professional Advocacy; Hickson GB, Pichert JW. Disclosure and Apology. National Patient Safety Foundation Stand Up for Patient Safety Resource Guide, 2008; Pichert JW, Hickson GB, Vincent C: “Communicating About Unexpected Outcomes and Errors. ” In Carayon P (Ed. ). Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety, 2007 Mod 1 05. 2 Page 11 TEAMSTEPPS 05. 2

Team. STEPPS Professionalism and Self-Regulation • Professionals commit to: • Technical and cognitive competence • Professionals also commit to: • Clear and effective communication • Modeling respect • Being available • “Self awareness” • Professionalism promotes teamwork • Professionalism demands self and group regulation • You have a critical role Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2 nd ed. Oakbrook Terrace, IL: Joint Commission Resources; 2012: 1 -36. Mod 1 05. 2 Page 12 TEAMSTEPPS 05. 2

Team. STEPPS Infrastructure for Promoting Reliability & Professional Accountability (PA) 1. 2. 3. 4. 5. 6. 7. 8. Leadership commitment (will not blink) Goals, a credo, and supportive policies Surveillance tools to capture observations/ data Process to guide graduated interventions Processes for reviewing observations/data Multi-level professional/leader training Resources to address unnecessary variation Resources to help affected staff and patients Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring and addressing unprofessional behaviors. Academic Medicine. 2007; Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2 nd ed. Oakbrook Terrace, IL: Joint Commission Resources; 2012: 1 -36. Mod 1 05. 2 Page 13 TEAMSTEPPS 05. 2

Team. STEPPS “So, is this Team. STEPPS stuff required? ” What about: – Hand hygiene – Handoffs/documentation – Time outs – Arriving on time – Answering pages – Refraining from jousting – Practicing EBM Mod 1 05. 2 Page 14 TEAMSTEPPS 05. 2

Team. STEPPS Our organization has Leadership Commitment to address behaviors that undermine Team. STEPPS… 1. Strongly agree 2. Agree 3. Uncertain 4. Disagree 5. Strongly disagree 10 Mod 1 05. 2 Page 15 TEAMSTEPPS 05. 2

Team. STEPPS I am committed (act, report) to address behaviors that undermine safety… 1. Strongly agree 2. Agree 3. Uncertain 4. Disagree 5. Strongly disagree 10 Mod 1 05. 2 Page 16 TEAMSTEPPS 05. 2

Team. STEPPS Policies and programs will not work if behaviors that undermine a culture of safety go unobserved, unreported and unaddressed Mod 1 05. 2 Page 17 TEAMSTEPPS 05. 2

Team. STEPPS What Are “Surveillance Tools”? n Risk Event Reporting System n “Dr. __ entered the room without foaming in… proceeded to touch area with purulent drainage…I offered gloves…took and dropped them into trash. ” n Patient Relations Department n Record pt/family concerns: Father: “Son had surgery so I asked Dr. XX to explain plan. Dr. XX said, ‘I drew a picture. If you don't get it, you just don't get it. ’“ n Compliance hotline; Equal Opportunity, Affirmative Action, and Disability Services (EAD) Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2 nd ed. Oakbrook Terrace, IL: Joint Commission Resources; 2012: 1 -36. Mod 1 05. 2 Page 18 TEAMSTEPPS 05. 2

Promoting Professionalism Pyramid Adapted from Hickson GB, Pichert JW, Webb LE, Gabbe SG. Acad Med. Nov 2007. © 2011 Vanderbilt University Mandated Reviews No ∆ Level 3 "Disciplinary" Intervention Pattern persists Level 2 “Guided" Intervention by Authority eg Egr Single “unprofessional" incidents (merit? ) Level 1 "Awareness" Intervention iou s Apparent pattern "Informal" Cup of Coffee Intervention Mandated Vast majority of professionals - no issues provide feedback on progress

Team. STEPPS 3 Conversations for Professionals and Leadership to address unnecessary variation Authority: EDICTS Conversation Awareness: An Awareness Intervention Informal: Cup of Coffee Conversation and Espresso Conversation Mod 1 05. 2 Page 20 TEAMSTEPPS 05. 2

Team. STEPPS But are “awareness” interventions effective? Mod 1 05. 2 Page 21 TEAMSTEPPS 05. 2

Patient Advocacy Reporting System® (PARS®) The CPPA Tool: Analyzes existing pt complaint data to identify unnecessary variation/outlier performance (Risk): a) Evidence-based PARS Risk Score b) Local and/or national comparisons a. Promote complaint collection and Service Recovery best practices* b. Unsolicited pt/family complaints collected/recorded by Pt Relations c. Transmitted to CPPA *Hayden et al, 2010; Moore et al, 2006; Pichert et al, 2004 a. Reliably coded* b. Data aggregated & analyzed** c. PARS Risk Score*** d. Local & nat’l comparisons**** * Hickson et al, 2002; ** Hickson et al, 2002; 2006; ***Mukherjee et al, 2010; ****Stimson et al, 2010 22

Team. STEPPS Does it work? PARS® Progress Report Total # high complaint physicians Departed after initial intervention First follow-up in 2012 - 2013 810 59 149 Total with follow-up results 602 Results for those with follow-up data: Good – Intervention Visits suspended Good – Anticipate suspension in 2012 - 2013 Some Improvement—still needs tracking 302 93 43 (50%) (16%) (7%) Subtotal 438 127 37 (73%) (21%) (6%) Unimproved/worse Departed Unimproved Total with follow-up results 602 Pichert JW, Moore IN, Hickson GB. Professionals promoting professionalism. Jt Comm J Qual Patient Safe. 2011; 37(10): 446. Mod 1 05. 2 Page 23 TEAMSTEPPS 05. 2 This document is confidential and privileged pursuant to the provisions of State Statutes

Malpractice Claims (per 100 MDs) FY 1992 – 2011* ** **TN Certificate of Merit 24 * Data used with permission, State Volunteer Mutual Insurance Company, a mutual insurer of 10, 500 TN non-VUMC physicians of all specialties, 29% to 33% who practiced in Middle TN during the target date.

Team. STEPPS Infrastructure for Promoting Reliability & Professional Accountability (PA) 1. 2. 3. 4. 5. 6. 7. 8. Leadership commitment Goals, a credo, and supportive policies Surveillance tools to capture observations/data Processes for reviewing observations/data Model to guide graduated interventions Multi-level professional/leader training Resources to help address unnecessary variation Resources to help those affected Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring and addressing unprofessional behaviors. Academic Medicine. 2007. Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2 nd ed. Oakbrook Terrace, IL: Joint Commission Resources; 2012: 1 -36. Mod 1 05. 2 Page 25 TEAMSTEPPS 05. 2

Team. STEPPS CPPA Conferences n Promoting Professional Accountability: Addressing Behaviors That Undermine A Culture of Safety n The How and When of Communicating Adverse Outcomes and Errors n For details, please visit our website: http: //www. mc. vanderbilt. edu/centers/cppa/courses. htm Mod 1 05. 2 Page 26 TEAMSTEPPS 05. 2

Team. STEPPS Let Us Hear Your Comments, Questions Now or Later www. mc. vanderbilt. edu/cppa Mod 1 05. 2 Page 27 TEAMSTEPPS 05. 2