Executive Symposium

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Executive Symposium

• Surgical Patient Safety Creating a Culture of
  Perioperative Safety
• July 15 17, 2007
• Beaver Creek, Colorado

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Sunday July 15, 2007
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Mark Warner, MD
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Areas Where Change will have the Major Impact on
Perioperative Care

• Changing Demographics
• Human Genomics
• Improvement in Technologies

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Demographics

• Immigration 1st generation tend to have 3
  children vs. 1 child for the 2nd generation
• Implications for OB
• Children younger than 3 benefit from surgery in
  consolidated settings
• Aging population
• Americans 65 38 M in 2007
• Americans 65 85 M in 2040

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Changes in Anesthesia will offset some of these
changes

• Minimized procedures
• Patient targeted therapies
• Safer anesthetics

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Genomics

• Targeted therapies based upon genetic testing to
  ensure
• Drug efficacy
• Drug kinetics

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Nano Technology
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MondayJuly 16, 2007
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Stephen Harden, ATP
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When you have good hardware and good technical
processes, supported by good teamwork and
communication Systems, then you have a culture
that supports safe practices.
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Aviations Culture Changing Solution

• Understanding of the Human Condition
• Plus
• Teamwork Skills
• Plus
• Systems

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Stop being surprised when people make mistakes,
and start being prepared.
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Blueprint based on a Real Hospital Experience

• Corporate goals
• Dashboard
• Executive assessment and rewards
• Attached to credentialing
• Policies Procedures include teamwork and
  behavior
• Training Nursing and staff evaluations

• Capture and publicize successes
• Managers and admin round
• Collect data on communication teamwork
• Yearly refresher training on Patient Safety
  skills and programs

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Telling is not Training
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Team Challenge

• Team Mgt (leader) If you see anything that
  makes you feel uncomfortable or doesnt look
  right, bring it to my attention
• Recognize red flags
• Communication (members) Im uncomfortable and
  heres why
• Decision making process Seek input before
  stating your position
• Debriefing- 1-2 min What should we do
  differently next time?

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Geri Amori, PhD
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Basic Communication is

• Scaffolding for all effective communication
  hard-wired processes
• The nano technology of communication and
  teamwork

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Communication is either Effective or
Ineffective
Geris Principle 1
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All Communication Has 4 Parts

• Put Message Into Code (Symbolize)
• Send the Message (Transmission)
• Understand the Message (De-code)
• Show/Prove the Message was Received (Seekback)

Applicable in ALL Forms of Communication!
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No 2 people live in the same WORLD!
Geris Principle 2
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Assume that you are NOT understood until proven
otherwise!
Geris Principle 3
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Effective Communication Requires Asking the Right
Questions
Need to get more information to know

• What is going on
• What was understood
• How it was interpreted
• How it affects the recipient
• How the recipients perception of you is
  affecting your relationship

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The Organization Can Help

• Develop common vocabulary
• Develop signals to listen
• Build in feedback every process
• Ensure the rules of engagement are followed
• Work to drive out fear through a Just Culture
• Value honesty, and reinforce that value
• ULTIMATELY its up to the individual to SPEAK UP!

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Christine Zambricki, MS, CRNA
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Who is the C-Suite

• Mission
• Strategy
• Executive leadership
• Financial stewardship
• Quality of Care and Services
• CEO is most important determinant
• Boards are important

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What do we need to know about them?

• They think things are better than they are
• Quality movement is confusing Almost 1000
  measures of performance!
• They dont understand our language
• They are concerned about the cost of healthcare

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Whats on their mind

• Cost of healthcare
• Who are we?
• Goofballs?
• Mistake waiting to happen?
• Mysterious at best
• Their focus Execution people, strategy,
  operations

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3 Kinds of Employees

• 30 - Actively engaged
• 54- Not engaged
• 16 - Actively not engaged
• (source cited on slides)

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What to Communicate

• Full data transparency
• Data AND stories
• Involve patients and families
• Set the expectations, adopt and report big,
  measurable aims
• Communication, disclosure, support resolution,
  learning

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(Talent Fit) x Investment Growth and Impact
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With the Right People
Source cited on slide in presentation
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John Paige, MD
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Teamwork Issues

• Differences in perception among members of the
  team about the efficacy of team functioning,
  roles, communication, and self-insight
• Differences in nurses and physicians perceive
  guidelines and rules
• Consequences
• Disruption
• Tension

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High Reliability Team Function

• Culture of Safety
• Human factors Engineering
• Decrease complexity
• Optimize information processing
• Automate intelligently
• Employ constraints
• Physical
• Procedural
• Cultural

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Role of Simulation

• Brings up systems issues when entire staff
  trained
• Improved team communication
• Disaster is the mother of invention!

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Lena Napolitano, MD
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Expansion of Use of Universal Protocol
Universal Time Out

• Correct patient, site, procedure
• Prevent surgical site infection
• DVT prophylaxis
• Beta-blockade if appropriate
• Blunt suture needles
• Double glove, neutral zone

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Contribution to wrong site surgery

• Human factors team training
• Patient factors -
• Procedure factors improved technology

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Problem Persists

• More reporting since Universal Protocol
  established in 2004
• Of 2,474 SE, 1 wrong-site surgery (n532)

Source cited on slide in presentation
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JCAHO Consensus Summit February, 2007

• Refinements to Universal Protocol that details
  expected process steps
• Zero tolerance for failure to follow universal
  protocol and long term, zero tolerance for these
  sentinel events

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www.wrong-side.orgpublic reporting site with
tools for your institution
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Wrong Site Surgery Highest Implicated Factors

• 53 activities of Surgeon in OR
• 34 Failure of Time Out

Source cited on slide in presentation
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Factors that Helped Correct a Near Miss

• Patient/family participation (23)
• Surgeon involvement (pre-operative before pt
  enters OR) (19)
• Consent (17)
• Patient information (16)
• Office records (13)

Source cited on slide in presentation
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Expanded Universal Time-Out

• Completion of any applicable patient-care/patient
  safety protocols
• Prophylactic antibiotics of SSi
• Does patient have infection or colonization with
  MDR-pathogens
• DVT prophylaxis
• Beta-blockade in appropriate patients
• OR team review of patients current medications

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More

• Pressure ulcer prevention
• Medications labeled properly on sterile field
• Clinical and physiologic alarms audible
• Patiently appropriately restrained to prevent
  falls
• Efforts to reduce surgical fires implemented
• Use of blunt suture needles when appropraite

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Lena and her Teams Vision

• Consolidated checklists among the disciplines
• Expanded time out that moves towards an expanded
  safety culture
• Using technology to help (e.g., Live Data OR
  Dashboard has checklist on it)

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What We Share

• How do we define time out (where does it begin
  and what does it include)?
• How do we deal with the dynamic tension between
  regulation, practicality, and what supports
  safety?
• Does more regulation and refinement support or
  deter safe care?

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Ajit Sachdeva, MD
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Creating a Culture

• Focusing on health care providers, patients and
  their families

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Lessons from HRA

• Culture that is supportive and yet emphasizes
  accountability

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Enhance PS trough Practice Based Learning and
ImprovementCycle of learning

• Gap analysis ID area for improvement
• Practice Based Learning System benchmarking tool
• Evidence based tools for benchmarking in Surgery

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• Engage in learning
• Simulated situations for learning using
  standardized patients for residents
• Simulation for learning at the CME level
• Apply new knowledge and skills to practice
• Check for improvement

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Need GREAT technical skills in addition to GREAT
communication and teamwork skills to improve
care!
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5 levels Verification

• Verification of Attendance
• Verification of Satisfactory Completion of Course
  Objective
• Verification of Knowledge and Skills (They want
  to go beyond current levels of measurement to
  where the faculty can verify actual skill)
• Verification of Preceptorial Experience
• Demonstration of Patient Outcomes

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Moving toward Interdisciplinary Learning Programs
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ACS Closed Claims Study

• 90 of 460 (19.8) filed entirely or largely
  because of communication failures
• Communication failures occurred in 70 of 414
  claims (16.9) involved surgical procedures
• Communication failures occurred in 20 of 46 (43)
  of non surgical encounters

Source cited on slide in presentation
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Barriers to Safe Hand-offs

• Physical setting
• Social setting
• Language barriers
• Medium of communication
• Influenced by time limits for Residents

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Creative Programs

• Disclosure CD-Rom Immersion
• Professionalism CD-Rom
• Grumpy surgeon
• Disruptive surgeon
• Age impaired surgeon
• Acknowledging error
• Fatigued surgeon
• Its All about Me
• Demoralized,etc

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TuesdayJuly 17, 2007
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Joseph Grenny
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We learn early on that we have to limit truth to
spare relationships.
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The process that impedes the flow of information
to those who need it is critical to change for
patient safety
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Top MD Crucial Conversations

• Family problems
• MD Accountability issues
• Needing clarity on roles and responsibilities
• Peer problems Negotiating partnership terms
• Strategic issues Where is the organization
  going?

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Lack of Crucial Conversations -Derailleur of
Quality and Safety
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Best predictor of quality is the stability of
the learning environment
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4 out of 5 people who leave your company will
not talk fully about why they are leaving.
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Any time you find yourself having recurring
problems, concerns, etc. you need to ask yourself
what conversation are you NOT having. What causes
problems to persist is frequently the inability
to discuss the issue.
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Real Examples of How People Avoid Crucial
Conversations

• Leave and start their own business
• Work from home rather than go to office
• Throw pencils
• Give up medical practice
• Blind copy and forward e-mails
• Have a heart attack
• Write an obituary for the offender (then tear it
  up)

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Silence Killswww.silencekills.com
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Common Concerns w/Colleagues(at least 10 of
their colleagues)

• 50-80 report concerns Competence
• 75 - Work Ethic Issues
• 49-85 - Mistakes
• 85 - Broken Rules
• 53 - Lack of Support
• 75 - Disrespect
• (couldnt see this one.)

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About 25 of the time the problem has persisted
more than 5 years!
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3 ways to know if you are not holding the right
conversation

• If during the conversation you are getting
  increasing frustrated
• If youre having the same conversation twice
• If youre stuck at one level of conversation, you
  need to move to a deeper level

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3 Types of Conversation CPR

• Content
• Pattern
• Relationship

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Keys to Success

• Start with Heart
• Learn to look
• Make it safe
• Master my stories
• State my path
• Explore others paths
• Move to action

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The Main one Make it Safe
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The first 30 seconds determine whether you will
conduct that discussion effectively.
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How to Create the Psychological Safety

• Make sure the person knows you care about their
  interests and their problems
• Make sure that you not only care about their
  problems but that you respect them

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To see how this can workDelancy RestaurantSan
Francisco
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Creating a Culture of Mutual Respect at
Maimonides Medical Center

• David Feldman, MD
• Kathryn Kaplan, PhD
• Pamela Mestel, RN, MSN

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Its like psychic surgery to change a culture!
- Kathryn
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Steps to Change respect

• Part of Leadership Development initiative
• Research
• Pilot

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Pilots

• Leaders as champions
• Mediated Conversations
• Tracking of Systems issues
• Skills training
• Measurement- Respect Survey

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Mediated Conversations

• The involved parties
• Someone who supports their point of view
• Mediator

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We are going to hold people accountable to
respect each other. - The CEO Maimonides
Medical Center
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Vision

• The Medical Staff encourages all members of the
  hospital community to work together in a
  collaborative fashion such that unfavorable
  interactions can be either avoided, or addressed
  by the parties involved in a professional,
  productive manner.

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Two Final Points from David Feldman

• Safety efforts will not succeed without mutual
  respect
• Physicians must be leaders

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Team Training at Beth Israel Deaconess

• Donald Moorman, MD
• Elena Canacari, RN, CNOR

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How to Change Culture

• Alter our perceptions of problems to be solved
• Alter perception of our effectiveness
• Alter understanding about how we integrate and
  externally adapt
• Change assumptions
• Change some core values
• Over time

Taken from their slides
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Keys to their Success

• Interdisciplinary teams to manage problems
• Didactic team training (4 hours)
• Whole team simulation

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Team Metrics

• Adverse Events
• Disruptive behavior episodes
• Work Satisfaction Inventory
• Patient Safety Attitude Survey
• OR Staff Vacancies
• Events to be celebrated
• Liability exposure
• OR Performance Metrics

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Business Case OR Metrics

• Start Time Efficiency Increased from 45-89!
  (Focus on Pre-op hold area)
• Intraoperative Pathways -
• OR Staff Turnover/Cost of New Hires 5(?)
  reduction in RN turnover
• Supply Budget Reductions Major Savings!
• Employee Survey Results Improved

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Red-Green Cards in Pre-op

• Placed in front of chart
• When red it means there is something missing
• Green Good to Go
• Huge Cost savings per year 20 minutes per case
  _at_ 48 per minute!

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OR RN New Hire Cost

• Inexperienced 131,918
• Experienced 45,192

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Total Cost Savings based on metrics is about 3.5
Million Dollars
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Spin-offs beyond the OR!

• SICU
• Triggers RRT
• Nursing Huddles
• Whole Team simulations
• And more

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Patient centricity and mutual respect are core
valuesDonald Moorman
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Human Factors in the OR 1 Year Follow-up

• Nadeem R Abu-Rustum, MD
• Eric Kelhoffer, MD
• Aileen Killen, RN, PhD
• David Marshall

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Process

• Took advantage of new OR Platform so closed OR
  for 3 days Incorporated team training with
  physical layout training
• Champions
• Lesson MD buy-in is not the same as a champion
• Designed Wall of Knowledge Leverage
  technology to help w/ Team Behaviors

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Things they notice that affect the team

• Have problems when the team plan changes
  (negative)
• Trouble getting briefings off the ground
  (negative)
• Using team members names (positive)

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Its hard to be self-actualized when you cant
find a Foley!
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Summary Report of 1 Yr Eval

• Safety and Teamwork scores improved on 11 of 12
  measures
• Training Effectiveness Areas needing
  improvement
• Frequency of events reported
• Non-punitive report to error
• Feedback and communication of error

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Quality and Safety in the ASC

• Becky Small, RNC, MS
• David Zarin, MD

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USPI EDGE

• Every
• Day
• Giving
• Excellence

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Todays Proven Processes

• Best practices gathered by team
• Staff puts them together
• Starts from the time a patient enters the center
  until they leave the center

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Edge Methodology

• What is the problem? (Plan)
• What is the solution? (Plan, contd)
• How do we implement change?( Do)
• How do we know if it worked? (Study/act)
• What can you share with others?
• Mirrors the PDSA model

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Edge On-line

• Weekly and monthly clinical audits (reportable
  incidences)
• Leadership
• Monthly reports for outcome metrics
• Facilities can trend data to track areas to need
  improvement
• Benchmark with other USPI like facilities

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USPI Encourages

• Fair and just culture
• Embraced by leadership
• Ensuring every employee is accountable for
  assuring the safety of every patient

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Common Themes from the Symposium
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Themes

• Change is tough
• Change requires articulating what you vision for
  the outcome
• Change requires understanding the human condition
• Change requires interpersonal respect
• Change requires standards for behavior, training
  on appropriate behavior, and holding people to
  that behavior

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Themes

• Interpersonal skills are essential but not the
  sole skills required to improve safety
• Processes must be in place
• Use technology to help support teamwork
• Never ever give up!