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Culture of Teamwork and Safety in Healthcare

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Limited memory capacity 5-7 pieces of information in short ... Suits meet Scrubs: Executive Partnership & Executive WalkRounds. 21. Improving Safety Climate ... – PowerPoint PPT presentation

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Title: Culture of Teamwork and Safety in Healthcare


1
Culture of Teamwork and Safety in Healthcare
  • J. Bryan Sexton, Ph.D.
  • Johns Hopkins University

2
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

3
Perceptions Drive Reality
4
What of frontliners agree?
  • The administration of this hospital is doing a
    good job
  • Hospital administration supports my daily efforts
  • Hospital management does not knowingly compromise
    the safety of patients

5
  • We tend to over-rely on technology

6
Teams and Technology
Hi-tech band-aids dont replace teams
7
  • 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

8
Culture at Work in Medicine
9
Annual US Health
Research Funding
Millions of Dollars Spent
Sources ACP-ASIM Observer, 2001,
http//www.acponline.org/journals/news/feb01/clinr
esearch.htm Federal Funding and
Priorities for Health Services Research,
AcademyHealth, March 10, 2003.
10
Learning to embrace the wisdom of the frontline
caregiver
11
What is Culture? The way we do things around
here
1 attitude opinioneveryones attitude
culture
aka Climate
12
(No Transcript)
13
Comparing Culture Surveys
SAQ 22 out of 23 characteristics
Qual. Saf. Health Care 200514364-366
14
Executive Perceptions vs. Frontline
Perceptions Executives overestimate Teamwork
Climate 4X Safety Climate 2.5X
Executive Confidence vs. Executive
Accuracy -Often wrong but rarely in
doubt -Currently no incoming data-streams -Halo
Effects -Frontline data fills the gap
15
Hospital Wide Culture
  • Interesting
  • Not the best unit of analysis masks variability
    between work units

16
 
of respondents reporting positive safety climate
17
 
of respondents reporting positive safety climate
18
2005 Safety Climate across Clinical Areas
Goal 80
 
of respondents that agree safety climate is
positive
Needs improvement 19
27. My suggestions about safety would be acted
upon if I expressed them to management.
 
of respondents that agree
20
Suits meet Scrubs Executive Partnership
Executive WalkRounds
21
Improving Safety Climate
  • Executive Partnership
  • Select the executive for the unit carefully
  • Level of executive
  • Clinical vs. non-clinical
  • Ability to connect with front-line workers
  • Long-term commitment

22
 
of respondents reporting positive safety climate
EWRExecutive Walk Rounds
23
Teamwork Climate Perceived quality of
collaboration between personnel in this unit
24
 
of respondents reporting positive teamwork
climate
25
80 or higher is climate goal 23 reached it
 
of respondents reporting positive teamwork
climate
26
Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence
caregivers feel comfortable speaking up if they
perceive a problem with patient care
of respondents within an ICU reporting good
teamwork climate
27
Teamwork Climate across 250 ICUs from the past 18
months
28
Teamwork Climate Across
ICUs
 
of respondents within an ICU reporting good
teamwork climate
29
3. Nurse Input Is Well Received In This ICU.
 
of respondents within an ICU that agree
30
3. Nurse Input Is Well Received In This ICU.
 
of respondents within an ICU that agree
31
Heeding input from others
32
32. Disagreements In This ICU Are Resolved
Appropriately (i.e. not who is right, but what is
best for the patient).
 
of respondents within an ICU that agree
33
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

34
40. The Physicians And Nurses Here Work
Together As A Well-Coordinated Team.
 
of respondents within an ICU that agree
35
Teamwork Climate Annual Nurse Turnover
 
reporting positive teamwork climate
36
 
of respondents reporting above adequate teamwork
ICU RN/MD OR RN/Surgeon
CRNA/ Anesthesiologist
37
Teamwork Disconnect
  • RN Good teamwork means I am asked for my input
  • MD Good teamwork means the nurse does what I say

38
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39
Have you ever..
40
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

41
I know the names of all the personnel I worked
with during my last shift
Agree
 
42
Does it get better?
43
CUSP at work in MI
  • BSI from 50th percentile to the 10th percentile
    in first year
  • Safety Climate improved 20 statewide

44
(No Transcript)
45
Safety Measures
  • How often do we harm patients?
  • BSI and VAP
  • How often do we do what we should?
  • Vent bundle sepsis bundle
  • How often do we learn from defects?
  • Learn from one per month
  • How well do we improve culture?
  • SAQ

46
JHH Surgery and ACCM August Safety Dashboard
47
The Johns Hopkins Comprehensive Unit-based Safety
Program (CUSP)
  • Engage- make harm real
  • Execute- standardized interventions that includes
    tools for culture change
  • Evaluate- scientifically sound measures

48
The Johns Hopkins Comprehensive Unit-based Safety
Program (CUSP)
  • Evaluate culture of safety
  • Educate staff on science of safety
  • - http//www.jhsph.edu/ctlt/training/patient_saf
    ety.html
  • Identify defects
  • - survey and incident reports
  • Assign executive to adopt unit
  • Learn from one defect per month
  • - measure how often we learn from defects
  • - tool www.safetyresearch.jhu.edu/qsr/
  • 6. Evaluate culture

49
Keystone ICU CUSP Statewide Michigan Improvement
50
80 Reduction in BSI in One Year
433 prevented infections 108 deaths
51
Safety Climate Across Michigan ICUs
 
of respondents within an ICU reporting good
safety climate
52
Safety Climate Across Michigan ICUs
 
of respondents within an ICU reporting good
safety climate
53
Safety Climate Across Michigan ICUs
 
of respondents within an ICU reporting good
safety climate
54
OR Briefing Intervention to Improve Teamwork
Climate
55
 
Agree
56
 
Agree
57
 
Agree
58
 
Agree
59
Kaiser Permanente LD Unit Scores
 
60
Take Home
  • 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
  • Answer the question Are We Safer than Last
    Year?

61
Questions?
Hey whats a mountain goat doing way up here in
a cloud bank?
62
Culture Tools Modules of CUSP
  • Daily Goals
  • Executive Partnerships with Units
  • Analyze a Defect Root Cause Light
  • Multi-Disciplinary Shadowing
  • AM Briefing About Last Night
  • T-List for Effective Communication
  • Observe Rounds
  • In-service culture results highlight the
    culture conversation with data
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