1 / 38

Partnering for Safety

Partnering for Safety. Rose L. Horton, MSM RNC 2012 AWHONN President. Objective. Discuss the value of creating meaningful partnerships among the healthcare delivery team Discuss safety as a strategic imperative Identify key healthcare partners

aretha
Download Presentation

Partnering for Safety

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Partnering for Safety Rose L. Horton, MSM RNC 2012 AWHONN President

  2. Objective • Discuss the value of creating meaningful partnerships among the healthcare delivery team • Discuss safety as a strategic imperative • Identify key healthcare partners • Determine best practices in collaboration and communication

  3. Pregnancy- Related Mortality Ratio by Race

  4. Pregnancy ‐Related Mortality in the U.S.

  5. Maternal Mortality Rate

  6. When We Don’t Partner • When nurse staffing levels fell below target levels in a large hospital, more patients died, a new study discovered. • Some studies show that higher numbers of patients per nurse is correlated with increased risk of burnout among nurses • The association between increased mortality and high patient turnover was also significant • However, operational failures such as interruptions or equipment failures may interfere with nurses' ability to perform such tasks; several studies have shown that interruptions are virtually a routine part of nurses' jobs.

  7. When We Don’t Partner • For every patient added to the average hospital staff nurse’s workload, the risk of death following common surgical procedures increases by 7% • For every patient added to a nurse’s workload, rates of burnout and job dissatisfaction, rise by 23% and 15% respectively

  8. When We Do Not Partner • Compassion fatigue is a combination of secondary traumatic stress from witnessing the suffering of others and burnout. It can lead nurses to feel sadness and despair that impair their health and well-being • Compassion fatigue can reduce nurses' empathy and lead them to dread or even avoid certain patients, raising the risk of substandard care.

  9. Research reveals that nurses working through illness, injury and depression are more likely to make mistakes. One study surveyed more than 1,000 nurses and found that 20 percent had symptoms of depression, while almost 74 percent experienced pain from a sprain or strain while at work. When this data was correlated with medication errors and patient falls, the researchers discovered an incident increase of about 20 percent among nurses in pain or depression.

  10. Education Matters • Every 10% increase in the proportion of a hospital’s nurses holding a BSN degree or higher is associated with a 5% decline in mortality

  11. Johnson & Johnson Mosaic

  12. Key Strategic Partners • Providers • Lab • Dietary • Transport • Security • Case management • Admitting • Information Technology

  13. Photo by Adam Prince - Creative Commons Attribution-NonCommercial-ShareAlike License http://www.flickr.com/photos/25333063@N00

  14. “Systemic Disrespect” • Understaffing • Excessive workloads • Lack of administrative support & resources • Psychological intimidation Leape

  15. “Not Me !” Photo by AchimHering Creative Commons Attribution-Share Alike 3.0 Unported license http://commons.wikimedia.org/wiki/File:Who_is_responsible_not_me.jpg

  16. Silence is Permission • Not doing something = tacit assent • “When you see something, say something” • Aggressive and negative responses damage relationships • Damaged relationships impair patient safety (Rogers, Lingard et al., 2011; Lyndon, Zlatnik et al, 2014)

  17. Communication • Process Standardization • Systems Thinking • High Reliability Photo by sickmouthy - Creative Commons Attribution-NonCommercial License http://www.flickr.com/photos/32224133@N07 Created with Haiku Deck

  18. Effective Communication • Accurate • Timely • Patient-Centered • Clear, direct and explicit • Concise • Respectful • A Mutual Responsibility

  19. Tools Supporting Effective Communication • Situational Briefings • Concise briefing on situation and needs • Critical Language • Cues to attention • Handoff: SBAR • Structured format and prioritization • Team briefings • Developing a shared mental model (Lyndon, Zlatnik et al, 2014)

  20. Process Standardization • Protocols and checklists have been shown to reduce patient harm through improved standardization and communication • The use of checklists and protocols has clearly been demonstrated to improve outcomes and their use is strongly encouraged • Refinement and sophistication of checklists has shown decreased morbidity and mortality by meeting standards of care ACOG

  21. Bingham, D. (July/August 2012) Applying GEMS to OB Hemorrhage, JOGNN. Risks Maternal Risks (Physiologic and Iatrogenic) Monitoring Errors Problem Solving Errors Errors Skill-Based Errors Strong but wrong routines Rule-Based Errors Strong but wrong routines Knowledge-Based Errors Increased Rates of Preventable Maternal Injuries and Deaths Injuries Death RECOGNITION– QBL* Accurate assessment of blood loss regardless of: 1. Clinician skill 2. Perceptions of expertise 3. How blood loss data are linked and communicated Error Reduction Strategies READINESS- Drills Each team** member knows how to respond: 1. What to do and when to do it 2. Where supplies are 3. How to work together during a high-risk, high-stress emergency situation RESPONSE- Debriefs The plans (policies and procedures) are: Adequate Comprehensive Decided in advance 4) Include methods for maintaining a state of readiness, e.g., equipment available and working,

  22. High Reliability Organization • Maintain a sensitivity to operations • Reluctant to accept ‘simple’ explanations for problems • Track and scrutinize all failures, even small failures • Defer to expertise, not titles • Resilient Studer Group

  23. AWHONN SmartBrief Presentation highlights importance of team-based approach for health care delivery June 27, 2014 LOS ANGELES — A team-based approach to health care is critical for improving patient care and outcomes, according to a presentation given by Robin J. Trupp, PhD, RN, ACNP-BC, CHFN, FAHA, at the American Association of Heart Failure Nurses Annual Conference.

  24. AWHONN SmartBrief “We have an urgent need [for team-based care] based on ineffective communication in our current model,” Trupp, of the University of Illinois at Chicago, said here. “We have uncoordinated care, which results in a lot of waste and duplication of services and is quite costly to our system. Ineffective communication, especially at times of [patient] hand-offs when providers are changing, or when the setting of care is changing, has been attributed to 41% of in-hospital errors that are largely avoidable if we could communicate better on what we’re doing.”

  25. AWHONN Partners • ACOG • SMFM • HRSA • CMS • ACNM • AAP • Vitalsmarts • But wait…there’s more!

  26. reVitalize Obstetric Data Definitions

  27. reVitalize Obstetric Data Definitions

  28. reVitalize Obstetric Data Definitions Menard MK, Main EK, Currigan SM 2014

  29. What’s Trending? The 761 hospitals likely to face penalties for patient harm • The last of the ACA's three penalty programs launches in October

  30. With a red light, Hopkins' new checklist app may prevent harm New tool is linked with hospital's EHR system The program—called Emerge —was developed by a team of patients, nurses, physicians, engineers, data analytics experts, and bioethicists who identified 200 potential patient harms. The group narrowed the list to seven harms: • Delirium due to improper medication dosage; • Weakness acquired in the ICU; • Issues arising from ventilator use; • Blood clots; • Central-line associated bloodstream infections; • Loss of dignity; and • Patients' treatment goals and preferences not being respected.

  31. Nurse Family Partnership The Nurse Family Partnership is a free, voluntary program that partners first-time, low income or vulnerable pregnant women, with registered nurses who make ongoing home visits starting early in pregnancy and continuing until the child is two years old. The program serves over 25,000 babies and their moms each year.

  32. Nurse Family Partnership Studies reveal that for families enrolled in the program: • There are 79% fewer preterm deliveries • At 21 months, there is a 50% reduction in language delays • At age 6, there is a 67% reduction in behavioral and intellectual problems • There is a 48% reduction in child abuse and neglect • By age 15, fewer arrests • And by age 18, a 69% reduced use of cigarettes, alcohol or marijuana

  33. Nurse Family Partnership • This program reminds me of something that I have known my entire career: when nurses partner with patients and families, the nurses’ power of influence is magnified to a degree that is immeasurable. You are powerful, a force to be reckoned with. In partnership, nurses have the ability to influence families for generations to come and improve communities on a grand scale.

  34. 100% Accountability Photo by Project On Government Oversight - Creative Commons Attribution-NonCommercial-ShareAlike License http://www.flickr.com/photos/27617792@N06 Created with Haiku Deck

  35. Lessons From the Geese • The importance of achieving goals • The importance of team work • The importance of sharing • The importance of empathy and understanding • The importance of encouragement

More Related