Stop The Line Policy Academic Medical Center Initiative

1. StopTheLinePolicy Academic Medical Center Initiative

2. Campus-wide Initiative: • Policy has been approved by WUSM, BJH, SLCH • Policy is now being disseminated to all faculty and staff • Stop The Line (STL) Advisory Panel formed • Multi-disciplinary and inter-institutional group formed to evaluate effectiveness of the policy and review any case when STL is inappropriate or inadequate

3. Stop the Line (STL) Team: • WUSM: • Dr. Nikoleta Kolovos, PICU Dr. Chris Carpenter, EDDr. Brian Nussenbaum, OtolaryngologyDr. Jim Duncan, RadiologyDr. Andrea Vannucci, AnesthesiaDr. Doug Schuerer, TraumaDr. Mike Lane, Infectious DiseasesDr. Robert McKinstry, RadiologySally O’Shea, HRMary Taylor, Patient Safety BJH and SLCH: Debbie Hendricks, BJH, Oncology Jody Woodward, BJH, Patient Safety Roz Corcoran, BJH, Patient Safety Mara Bollini, SLCH, Patient Safety Cathy Meyers, SLCH, HR Michael Miller, BJH HR April Kutheis, SLCH, OR Maria Fernandez, SLCH, PICU Betty Langin, SLCH, PACU Kathy Hughes, SLCH, SDS * Advisory Panel members indicated in bold

4. What is “Stop the Line”? Originated from the Toyota Production System—traditionally the industry standard for excellence in production • Built on the philosophy that every person is responsible for the process • Shifts responsibility for quality into the hands of team members who are empowered/expected to speak up when problems are identified • Operates on the belief that solving quality problems at the source improves safety and quality • Providing a cultural shift so that every person feels responsible for the safety (of our patients) Jeffrey K. Liker, The Toyota Way: 14 Management Principles from the World's Greatest Manufacturer, McGraw-Hill 2004.

5. Why Stop the Line? Inherent Human Limitations Why Stop the Line? Inherent Human Limitations Why Stop the Line? Inherent Human LimitationsLine? Inherent Human Limitations • Limited memory capacity – we can store 5-7 pieces of information in our short term memory • Negative effects of stress – error rates, tunnel vision • Negative influence of fatigue and other physiological factors • Limited ability to multitask – ex: cell phones, texting and driving Courtesy Michael Leonard, MD & Karen Frush, MD – Presentation at the SLCH UBJP Team Leaders Workshop, EPNEC, May 12, 2009.

6. Why Stop the Line in Our Academic Medical Center? • Clinical medicine is an extremely complex environment with: • Surprises • Uncertainty • Incomplete information • Interruptions and multi-tasking • The overwhelming majority of untoward events involve communication failure: • e.g. wrong site surgery — somebody knows there’s a problem but can’t get everyone in the same movie • The clinical environment has evolved beyond the limitations of individual human performance Courtesy Michael Leonard, MD & Karen Frush, MD – Presentation at the SLCH UBJP Team Leaders Workshop, EPNEC, May 12, 2009.

7. Why Stop the Line? 25-40% of nurses at SLCH reported on the Safety Attitude Questionnaire they would be hesitant to speak up if they saw an MD making a mistake page 7 Maxfield, D. et al. Silence Kills: The Seven Crucial Conversations for Healthcare, VitalSmarts, 2005.

8. Safety Leadership Behaviors • It takes inclusive leaders who: • Invite input (name/role activation) • Are accessible (present/approachable/all ears) • Acknowledge the limits of current knowledge • “Go first” (particularly in displays of fallibility) • Inclusive leaders lower the psychological costs of voice and raise the psychological costs of silence Courtesy Michael Leonard, MD & Karen Frush, MD – Presentation at the SLCH UBJP Team Leaders Workshop, EPNEC, May 12, 2009.

9. SLCH and BJH Case Examples: • A circulating nurse respectfully insisted that the “line” be identified on an X-ray, obtained for a possible retained item. • Respiratory therapist informed a fellow (after being up all night) that they were about to insert a chest tube in backwards. • A nurse felt a patient who had been released from the PACU didn’t look right. She worked with the physician to re-assess the patient and order further testing. The patient was taken back to the OR. • A proceduralist was reminded of a patient’s allergy to heparin following a request for a heparin flush during the case.

10. Stop the Line: What does it mean? • Stop the Line: • The request of any team member for clarification or interruption of a process when s/he perceives a significant potential threat to patient safety. • When staff or health care providers are engaged or are about to engage in an action believed to be a significant threat to patient or staff safety; or • A staff member or health care provider requests clarity regarding a non-emergency clinical situation that may pose a significant impending threat to safety.

11. Stop the Line: When to use it? When a patient’s safety is thought to be at risk, examples of which may include: • Incompatible blood is sent from the OR while an operation is in progress. • A respiratory therapist notices that a fellow, who had been up all night, was about to insert a chest tube backwards. • A proceduralist requests a heparin flush in a heparin allergic patient. • A disagreement between members of the care team during a time-out prior to a procedure. • The wrong side or wrong site is being prepped/draped for an operation or procedure. • A collected pathology specimen is not in the collection cup anymore

12. Stop the Line: When to use it? Department/Unit-Specific Examples • …………………………..

13. How to Stop the Line • Step 1: When a significant patient safety risk is perceived, communicate in a respectful manner the need to “Stop the Line” and re-evaluate or restore patient safety: • Sample Language: “Could we please “Stop the Line” because I have an important question and want to make sure we are delivering safe care to this patient”

14. How to Stop the Line Step 2: If the response to step one is inadequate to restore patient safety, repeat your request to stop the line: Sample Language “(Caregiver Name), please stop – we need to review the plan/procedure/situation together before proceeding to make sure we are delivering safe care.”

15. How to Stop the Line Step 3: If the response to Steps One and Two are inadequate to restore patient safety, immediately invoke the chain of command by contacting the appropriate immediate supervisor. • Once the immediate needs of the patient are resolved, the supervisor shall contact the appropriate AMC Patient Safety Departments regarding the incident and the inadequate response to stopping the line. • The AMC Patient Safety Departments will notify the appropriate AMC leadership and begin the process of investigation.

16. Step 3, Continued • The AMC organization’s CMO will be notified, and, in the event a WUSM Physician is involved, the appropriate WUSM Department Chair. Inadequate responses will be investigated promptly and thoroughly as directed by the appropriate Department Chair. • In the event that remedial measures are necessary, they will be determined based on the severity of the behaviors and according to the AMC organization’s existing policies or Code of Conduct.

17. Monitoring Stop the Line The Stop the Line AMC Advisory Panel will evaluate the effectiveness of the policy and identify needs for further education and modification to the system. The advisory group can then use that knowledge to refine the initiative.

18. Case Examples of Interest to Your Unit/Department

19. Discussion

20. Appendix

21. One Physician’s Perspective Dr. Peter Pronovost lost his father to a misdiagnosis…..In a March 2010 New York Times interview, he said, …A few years later, when I was a physician, I met Sorrel King, whose 18-month-old daughter, Josie, had died at Hopkins from infection and dehydration after a catheter insertion. The mother and the nurses had recognized that the little girl was in trouble. But some of the doctors charged with her care wouldn’t listen. So you had a child die of dehydration, a third world disease, at one of the best hospitals in the world. Many people here were quite anguished about it. And the soul-searching that followed made it possible for me to do new safety research and push for changes. What exactly was wrong here? As at many hospitals, we had dysfunctional teamwork because of an exceedingly hierarchal culture. When confrontations occurred, the problem was rarely framed in terms of what was best for the patient. It was: “I’m right. I’m more senior than you. Don’t tell me what to do.”

23. Effective Communication and Teamwork: How? Courtesy Michael Leonard, MD & Karen Frush, MD – Presentation at the SLCH UBJP Team Leaders Workshop, EPNEC, May 12, 2009.