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Patient Safety Curriculum Module 5 - National Patient Safety ...

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NPSF Professional Learning Series presents:<br />

<strong>Patient</strong> <strong>Safety</strong> <strong>Curriculum</strong> <strong>Module</strong> 5:<br />

Increasing <strong>Patient</strong> <strong>Safety</strong> Awareness and<br />

Practice Among Clinicians and Staff<br />

Pauline Robitaille, MSN, RN, CNOR<br />

Nursing Director, Operating Room<br />

Brigham and Women’s Hospital<br />

© Copyright 2011, <strong>National</strong> <strong>Patient</strong> <strong>Safety</strong> Foundation


Objectives<br />

• Upon completion of this module, participants will be<br />

able to<br />

‣ Explain the critical elements to effective teamwork and<br />

communication<br />

‣ Describe team training and communication techniques<br />

‣ Measure the impact of patient safety activities through the use<br />

of field-tested measurement tools and surveys<br />

‣ Analyze and interpret data to set goals and priorities for<br />

patient safety projects<br />

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NPSF Professional Learning Series


Teamwork and Communication<br />

• Failed communication has been identified as the root<br />

cause of nearly 70% of sentinel events.<br />

Sentinel event statistics, October 2007. The Joint Commission. http://www.jointcommission.org.<br />

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NPSF Professional Learning Series


Teamwork defined<br />

• Teamwork represents an interrelated set of cognitive,<br />

affective, and behavioral characteristics needed for a<br />

group of individuals to function as a cohesive collective.<br />

Salas E, DiazGranados D, Weaver SJ, King H. Does team training work? Principles for<br />

health care. Acad Emerg Med. 2008;15(11):1002–1009.<br />

• Cooperative effort by the members of a group or team to<br />

achieve a common goal. Free English Dictionary.<br />

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Team training tools and strategies<br />

• World Health Organization Checklist<br />

• Briefings<br />

• Time Out<br />

• Debriefing<br />

• Crew Resource Management<br />

• TeamSTEPPS®<br />

• MedTeams®<br />

• Education Seminars<br />

• Simulation<br />

Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JD, van Wijk KP. Interventions to<br />

improve team effectiveness: A systematic review. Health Policy. 2010 Mar;94(3):183–195.<br />

Gillespie, BM, Chaboyer W, Murray P. Enhancing communication in surgery through team training<br />

interventions: A systematic literature review. AORN Journal. 2010 Dec;92(6):642–657.<br />

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NPSF Professional Learning Series


World Health Organization (WHO)<br />

Checklist<br />

• 19-item checklist with 3 components<br />

‣ Before induction of anesthesia<br />

‣ Before skin incision<br />

‣ Before patient leaves the operating room<br />

http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html<br />

http://www.safesurg.org<br />

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Briefings<br />

• Often include but are not limited to<br />

‣ Introduction of team members<br />

‣ Verification of availability of supplies and equipment<br />

‣ Clarification of team member roles<br />

‣ Review plan for procedure/intervention and goal(s)<br />

‣ Identification of patient safety needs<br />

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Time Out<br />

• Completed immediately prior to the start of procedure<br />

or incision<br />

• Must be standardized<br />

• Initiated by a designated member of the team<br />

• Involves members of the team<br />

http://www.jointcommission.org<br />

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Debriefing<br />

• Often includes but is not limited to<br />

‣ Verification of surgical counts<br />

‣ Confirmation of correct labeling of surgical specimen(s)<br />

‣ Discussion of what went well and what should be changed in the future<br />

‣ Determination of who will take the lead on any action steps for changes<br />

identified<br />

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Crew Resource Management (CRM)<br />

• Modeled on aviation<br />

• Primary intent is to organize group to think and act<br />

as a team with goal of safety<br />

• Coordinated processes that enable team cohesion<br />

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TeamSTEPPS®<br />

• Evidence-based teamwork system<br />

• Based on Crew Resource Management<br />

• Designed to improve quality, safety, and efficiency<br />

• Customizable and adaptable<br />

• Provides materials<br />

http://teamstepps.ahrq.gov/about-2cl_3.htm<br />

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MedTeams®<br />

• Teamwork system based on CRM principles<br />

• System of teamwork training skills<br />

• Focuses on behavioral solutions<br />

• Delivered in 3 phases using a train-the-trainer model<br />

‣ Site assessment<br />

‣ Implementation<br />

‣ Sustainment<br />

• Designed to improve clinical and performance outcomes<br />

http://teams.drc.com/Medteams/Home<br />

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TOPS Project<br />

• Triad for Optimal <strong>Patient</strong> <strong>Safety</strong> (TOPS)<br />

‣ Multidisciplinary and multicenter teamwork training program<br />

‣ Aimed at improving unit-based safety culture<br />

‣ Incorporates communication skills and teamwork<br />

Sehgal et al. The TOPS Multidisciplinary Teamwork Training Program.<br />

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Education seminars and resources<br />

• Classroom-based training<br />

• Discussion<br />

• Scenarios<br />

• Video-based sessions<br />

• Role play<br />

• On-line training modules<br />

• Pod casts<br />

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NPSF Professional Learning Series


Simulation<br />

• Tool designed to improve<br />

‣ Team communication<br />

‣ Situational awareness<br />

‣ Teamwork<br />

‣ Decision making<br />

• Simulated scenarios to evaluate teamwork<br />

‣ Planned feedback sessions<br />

‣ Building trust<br />

‣ Working toward common goal of safety<br />

• Debriefing session<br />

‣ To reinforce appropriate performance<br />

15<br />

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Measuring the impact of patient<br />

safety activities<br />

• Hospital Survey on <strong>Patient</strong> <strong>Safety</strong> Culture<br />

• <strong>Safety</strong> Climate Scale (SCS)<br />

• <strong>Safety</strong> Attitudes Questionnaire (SAQ)<br />

• Strategies for Leadership Survey (SLS)<br />

• Hospital Unit <strong>Safety</strong> Climate Measure<br />

• Consumer Assessment of Healthcare Providers and<br />

Systems (CAHPS®) Survey<br />

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Analyzing and interpreting patient<br />

safety data<br />

• <strong>Safety</strong> or occurrence reports<br />

• Root cause analysis reports<br />

• Medical record documentation audits<br />

• Quality indicator monitoring<br />

• <strong>Safety</strong> rounds<br />

• <strong>Patient</strong> satisfaction surveys<br />

• Staff satisfaction surveys<br />

• AHRQ <strong>Patient</strong> <strong>Safety</strong> Indicators (PSI)<br />

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How can leaders support patient<br />

safety?<br />

• Garner support of senior leaders<br />

• Devote time, attention, and passion to patient safety issues<br />

• Avoid being defensive or explaining away patient safety<br />

irregularities<br />

• Create an environment that welcomes suggestions<br />

• Promote “bottom up” approach to patient safety<br />

• Encourage employees to speak up and share learning<br />

• Facilitate communication and teamwork<br />

• Take action when concerns are identified<br />

• Assemble patient safety information<br />

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How can leaders support patient<br />

safety?<br />

• Seek input from staff key stakeholders<br />

• Share results<br />

• Imbed changes into clinical work<br />

• Remember changes in culture take time<br />

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Summary<br />

• Safe care is a shared responsibility<br />

• Requires open and honest communication<br />

• Teamwork<br />

• Measurable goals and objectives<br />

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