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All I could see from where I stoodWas three long mountains and a wood;I turned and looked the other way,And saw three islands in a bay./So with my eyes I traced the lineOf the horizon, thin and fine,/Straight around till I was comeBack to where I'd started from;/And all I saw from where I sto
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2.
All I could see from where I stood
Was three long mountains and a wood;
I turned and looked the other way,
And saw three islands in a bay./So with my eyes I traced the line
Of the horizon, thin and fine,/Straight around till I was come
Back to where I’d started from;/And all I saw from where I stood/ Was three long mountains and a wood.
Over these things I could not see:
These were the things that bounded me…
- Edna St. Vincent Millay
3. What will a major patient safety transformation look like? Make patient safety the #1 priority.
Embrace a new mindset.
Take a bold and brave leadership approach.
Collaborate rather than compete.
Create a culture of safety.
4. Make patient safety the #1 priority Sentinel events reported in 2005:
3,548
Most-frequently reported sentinel event:
Wrong-site surgery
(12.8% of events)
A root cause in 80% of reported wrong-surgery events:
Communication
5. How hazardous is healthcare?
6. Embrace a new mindset Acknowledging our vulnerability to make mistakes.
Unlearn what we learned in school. Reliance on professional/individual responsibility.
Human factors such as environment, stress, noise, etc. influence our work.
Flatten the hierarchy.
Communicate, communicate, communicate.
7. Transformational Leadership
“Adding wings to caterpillars does not create butterflies…it creates awkward and dysfunctional caterpillars. Butterflies are created through transformation.”
Stephanie Pace Marshal
8. Transformational Leadership Transformational change requires effective leadership: It’s about us!
Create an environment where the right questions/inner passion are allowed to emerge
We set the vision – they create the how
“New partnerships”
“Baseball Team” vs. “Basketball Team”
9. Transformational Leadership “Just” and “Accountable”
Minimize the chaos and unpredictability in the environment
Partnership with patients, vendors and community
“New Puppies” as well as “Old Dogs”
10. “A Jedi must have the deepest commitment, the most serious mind”. Team meetings will be scheduled based on a consistent timeline (i.e. every other Wednesday) – a team member will be scheduled for meeting days and must commit to not changing hours for those meeting days.
We’ll have to do what it takes. Team meetings will be scheduled based on a consistent timeline (i.e. every other Wednesday) – a team member will be scheduled for meeting days and must commit to not changing hours for those meeting days.
We’ll have to do what it takes.
11. “Try not. Do or do not, there is no try…” (Yoda) Work assigned is expected to be completed within the designated timeframe – all team members will be given homework at some point (i.e. gather 10 opinions on “x”) and must come prepared to discuss results/findings.
We will so!Work assigned is expected to be completed within the designated timeframe – all team members will be given homework at some point (i.e. gather 10 opinions on “x”) and must come prepared to discuss results/findings.
We will so!
12. Collaborate rather than compete Definition of
collaboration:
To labor together.
To work jointly with
others or together.
3. To learn from one another.
4. To trust, support, value one another.
13. Collaborate rather than compete
14. Definition:
All team members place the safety of the patient first by their shared values, attitudes, degree of effort,
and pattern of behaviors.
15. Culture is critical 25-40% of RNs told us they would be hesitant to speak up if they saw a physician making a mistake.
The chance of an orthopedic surgeon performing a wrong-site procedure during their career is 25%.
How we set the tone in the first 10 seconds in that room has a profound impact on whether people will comfortably voice concerns.
16. Correct-Site Surgery The old way of doing things: Relying on human vigilance
18. Safe Site Surgery Collaborative
19. Next steps Focus on culture
2007 Reliability-Centered Collaborative
Processes to improve teamwork, communication, and to address human factors research
Implementation of new surgical protocol regarding retained foreign objects
2. Spread of safe-site protocol in MN
Partnership with Minnesota Hospital Association and MN Dept of Health
20. High reliability principles Pre-occupation with failure
Reluctance to simplify
Commitment to resilience
Deference to expertise
Sensitivity to operations
21. High-reliability collaborative objectives To build a culture of safety in the surgical environment.
To improve communication and team practices resulting in high reliability teams.
To advance efficient surgical process flow by implementing standardized surgical protocols.
To create safe and reliable practices and reduce the number of adverse events in surgery.
22. Why communication? The overwhelming majority of untoward events involve communication failure.
Wrong site surgery – somebody knows there’s a problem but can’t get everyone in the same movie – often it’s hard to speak up.
The clinical environment has evolved beyond the limitations of individual human performance.
23. Effective communication requires: Structured communication – SBAR
(Situation, Background, Assessment, Recommendation)
Assertiveness/critical language – “Stop-the-Line” (the ability to speak up and stop the show)
Psychological safety
Effective leadership – an environment of respect
24. Assertion – What is it? “Individuals speak up, and state their information with appropriate persistence until there is a clear resolution.”
25. Why is Assertion / Critical Language Important? Because we know 25-40% of nurses tell us on the Safety Attitude Questionnaire they would be hesitant to speak up if they saw an MD making a mistake
Often people don’t speak up or do so quite indirectly
Knowing the plan – using SBAR – makes it much easier to speak up
How we set the tone in the first 10 seconds in a room has a profound impact on whether people will comfortably voice concerns
26. Where do Things Fall Through the Cracks? Systems – information, tests, diagnoses
Communication – hand-offs
Failure to plan
Failure to recognize
Failure to rescue
27. Error is Inevitable Because of Human Limitations Limited memory capacity – 5-7 pieces of information in short term memory
Negative effects of stress – error rates
tunnel vision
Negative influence of fatigue and other physiological factors
Limited ability to multitask –
cell phones and driving
28. Risk Factors of Surgical Error 2 or more physicians involved
Lack of expertise
Communication failures
Fatigue
Emergencies
Interruptions
Reliance of memory
29. Situational Awareness How do we keep everyone in the same movie as the case progresses?
It’s hard to speak up if you don’t know what’s supposed to happen
This requires initially sharing the plan and actively updating the team – active callouts
30. Red Flags – Loss of Situational Awareness Ambiguity
Reduced/poor communication
Confusion
Trying something new under pressure
Deviating from established norms
Verbal violence
Doesn’t feel right
Fixation / boredom / task saturation
Being rushed / behind schedule
31. Active Call-Outs We’re closing”
“I’m going to need X-ray in
about 20 minutes”
“We’ll be done in 30 minutes”
“We’re bleeding more than I like – we may need to open – we’ll decide within 5 minutes”
32. Our vision
