Chain of Command - MCIC Vermont Patient Safety Documents

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4 Healthcare Risk Control • The process for handling clinical disagreements allows me to bypass the prescriber or my supervisor if necessary. If the underlying milieu is found to be unsupportive of teamwork and interprofessional communication, leadership should make efforts to improve communications and enhance the culture of safety. Leadership backing is crucial to such efforts and may involve a unit-specific approach. 15 Culture-of-safety survey results that indicate a need to improve communication and teamwork can garner leadership support and, thus, allocation of the resources necessary to improve the culture of safety. Crew resource management, an approach to team building and assertive communication in healthcare that was adapted from a military model, is being used to enhance communication and improve the culture of safety in hospitals. (See “Crew Resource Management Encourages Assertion in Healthcare.”) The risk manager can also gain leadership support for clear chain-of-command policies by providing information on liability claims that exemplify how the lack of (or failure to invoke) chain-of-command policies affected patient outcomes and/or ability to defend the claims. The risk manager would also play a key role in conducting safety culture surveys and in providing education about Crew Resource Management Encourages Assertion in Healthcare One approach to breaking down hierarchies, fostering assertive communications, and building teams currently being tested in healthcare came from the U.S. Department of Defense. Instituted by the U.S. military after numerous aircraft crashes, crew resource management (CRM) makes everyone responsible for flight safety and focuses on communication, stress management, and other human-factors concepts to prevent aviation mishaps. 1 With CRM, if a problem is detected, all team members are held accountable for fixing the problem or, if the problem is not within their realm, for notifying someone who can fix it. CRM has been adapted for use in military medicine and renamed “Medical Team Management.” 2 Other adaptations of the CRM concept include the Operating Room Human Factors Project 3 and emergency department MedTeams. 4 One important and similar aspect of these programs is that all team members are urged to speak up when there is a problem, and the leader(s) are expected to listen. Everyone is taught respectful assertion. Other features of these programs include education in team building and communication through role playing and implementing “briefings.” A briefing is the direct communication between physicians, nurses, or other care givers on patient status that includes transfer of important patient information at critical times such as prior to before the start of a procedure, at the change of shift, or during morning rounds. The crux of good communication skills that forms the foundation of CRM is for all team members to use and understand well-defined language. 5 Using a predetermined way of communicating that there is a problem reduces misunderstandings and increases appropriate interventions to correct the problem. Everyone on the team recognizes that with this type of communication, they must pay attention, listen, and act. CRM can prevent communication breakdowns through team building, reducing the need to invoke the formal chain of command to obtain necessary patient care. Clear communication and improved patient safety can be the most direct benefits of CRM. 6 Notes 1. Stone FP. Medical team management: using teamwork to prevent medical errors [online]. Legal Medicine 2001 [cited 2004 Jun 9]. Available from Internet: http://www.afip. org/Departments/legalmed/legmed2001/medical.htm. 2. Ibid. 3. University of Texas Center of Excellence in Patient Safety Research. Research into medical human factors and human error in medicine [online]. [cited 2004 Jun 11]. Available from Internet: http://homepage.psy.utexas.edu/ homepage/group/HelmreichLAB/Medicine/medicine. html. 4. Dynamics Research Corporation. MedTeams products and services [online]. [cited 2004 Jun 11]. Available from Internet: http://www.drc.com/TrainingAnalysis/ products.htm. 5. Crew resource management promises adverse events. Healthc Risk Manage 2003 Sep;25(9):103-5. 6. Ibid. ©2004 ECRI. May be reproduced by member institution only for distribution within its own facility.
Risk and Quality Management Strategies 19 5 the benefits of open communication and the importance of chain of command to managers, providers, and staff. Chain-of-Command Policies The lack of a proper chain-of-command policy and/or the failure to follow an existing chain of command is often among the allegations in negligence cases. When patient care issues cannot be resolved between the individuals involved, a clear administrative process must be available to resolve the conflict(s) in the interest of safe patient care. This administrative process should be outlined in a chain-of-command policy, communicated to physicians and hospital personnel, and supported by facility leaders who demonstrate its importance through their interactions with providers, patients, and staff. A sample policy on chain of command is reprinted in the Appendix. In reality, communication flows in both directions, as well as back and forth between departments and disciplines, in the process of resolving issues and clarifying exactly what actions should be taken. Often depicted in a bottom-up diagram, the chain of command depicts positions or personnel in a hierarchical flow of communication. (See “Sample Chain-of- Command Schematic.”) In reality, communication flows in both directions, as well as back and forth between departments and disciplines, in the process of resolving issues and clarifying exactly what actions should be taken. For example, suppose a physician orders that a drug be given to a patient but the nurse knows that the drug is contraindicated or could be dangerous if given to the patient. The nurse has a professional duty to question the drug order and convey his or her concerns to the physician. Upon notification, if the physician does not change the order and/or insists that it be administered to the patient, according to the specified chain of command, the nurse should notify the appropriate supervisor or other clinical manager. The onus is then on the manager to intervene with the physician about the drug order. If the situation cannot be resolved at that level, the manager or primary nurse must continue up the chain and contact the medical director, department chairperson, or other designated clinician as necessary to ensure the patient’s safety. All the while, there should be ongoing communication between the primary nurse and the responsible managers. Policies on chain of command should also set forth the conditions under which the policies should be initiated. Such conditions include those that jeopardize patient care and safety, such as • conflicts concerning the plan of care, • unclear or potentially unsafe orders, • unavailability or unresponsiveness of the care provider(s), and • unprofessional behaviors. An example of how the chain of command can be used to prevent a potential adverse outcome is illustrated in the following situation. 16 An order for an abdominal computed tomography (CT) scan was placed around 8:30 a.m. for an elderly patient with abdominal pain when previous test results were inconclusive. The patient’s nurse knew that according to policy, the scan should be performed that day. When it had not yet been completed by 5 p.m., the nurse called the CT department and was informed that the scanner had malfunctioned, resulting in a backlog. Because the patient was still in pain, and the nurse knew the physician was waiting for the CT scan, he attempted to call the CT manager, but she was unavailable. At 6 p.m., the nurse called his supervisor and explained the situation. The supervisor called the CT manager, who was still unavailable, and then called the director of imaging services. Within 15 minutes, the patient was undergoing the CT scan, which revealed an obstruction; the patient was subsequently taken to undergo surgery. Had the nurse not been persistent in following up and using the chain of command, the patient’s condition may have deteriorated. By following the chain of command, he fulfilled his duty to advocate for the patient by ensuring that the physician’s order was carried out in a timely manner and in the process protected himself and the hospital from possible liability. Documentation of the steps taken and the communication that takes place between caregivers is also crucial to following the chain of command. Medical record documentation should include patient assessments and observations, along with the date, time, the names of individuals contacted, any orders received and carried out, and other factual information. Along with its importance in patient care, accurate documentation in the record can assist in the defense of a liability claim by providing written evidence of actions taken to meet the standard of care. As noted in the case summarized in “Failure to Pursue Physician Bedside Evaluation,” a lack of documentation contributed to the inability to defend the case. Documenting non-responsiveness of the physician or others should be done factually and objectively. It is important not to use the medical record to attack the physician or assign blame. Jousting in this way only ©2004 ECRI. May be reproduced by member institution only for distribution within its own facility. September 2004
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