Quality and Safety: Are you creating an environment for safe, high quality care? Carolyn O’Brien, MSN, RN

Mayo Clinic International reputation for excellent patient care Long tradition of focus on quality care, putting the patient first Primary Value: “The needs of the patient come first”

Mission and Vision To inspire hope and contribute to health and well-being by providing the best care to every patient through integrated clinical practice, education and research Mayo will provide an unparalleled experience as the most trusted partner for healthcare In order to be trusted, we must be safe

How does Mayo define Quality? Service Outcomes Safety

Service Patient Satisfaction Awarded #1 hospital in patient satisfaction in 2010 and 2011 by Professional Research Consultants, Inc. (PRC) –patient satisfaction vendor Strong organizational focus and leadership involvement

Outcomes Quality Improvement (QI) Strongly woven into the fabric of our organization Improve outcomes by improving systems and processes Positive, healthy culture is determining factor in success or failure of performance improvement interventions

Safety Foundation of Quality Care Mayo’s Commitment to Safety Healthy culture, where staff speak up about safety concerns and work in an environment where we learn from and respond fairly to errors Safe behaviors Safe systems and processes How many of you have been practicing for more than 12 years? 1999 is when the IOM report “ To Err is Human” was published and gave birth to the patient safety movement. That report told the world that 100,000 people died every year from preventable medical errors. I’ve been practicing since 1981- we can all tell stories of things were when we started in nursing. My first job we used med cards, and poured our pills for the day into little white paper cups and kept them on a metal tray- that makes me really sound old! When I worked in the MICU/CCU at Boston University hospital in 1990, we mixed our own cardiac gtts, Ntg, Doobutamine, Heparin- things have changed tremendously. In 2000, I worked in risk Management for investigating sentinel events and conducting root cause analysis. As training for that role, I attended a seminar in Tampa that that opened my eyes to how medical errors happen- that systems and processes need to be improved to provide for better outcomes. We’ve learned that certain processes, certain drugs, certain transitions in care are high risk for errors to occur-

10 years about 44,000 to 98,000 people died each year as a result of preventable medical errors Today, the number of patients harmed in hospitals may be 10 times greater than was previously estimated What contributes to patient harm? Insufficient teamwork among clinicians Ineffective communication among clinicians and between clinicians, patients, and families Poor hospital safety cultures (cultural norms and behaviors that do not demonstrate a commitment to patient safety at every level of the organization (Pascal Metrics) 8

Culture and Patient Safety Required elements for a healthy culture Psychological safety Organizational fairness Transparency

Psychological Safety Definition: “people’s perception of the consequences associated with taking personal risks.” (TEM Field Manual, 2012) Present when people feel free to speak up and questions are welcomed Mutual respect is key Professional tone of communication Flattened hierarchy between disciplines Management of disruptive behavior

How do we know if we have psychological safety? Staff are not hesitant to speak about patient safety concerns Staff are treated with respect when concerns are expressed Concerns are acted on

How do we promote psychological safety? Unit and organizational leaders encourage staff to raise concerns and welcome it Encourage feedback and act on it Celebrate and praise new ideas

Organizational Fairness Historically- healthcare has been a culture of blame and punishment, a punitive culture A punitive culture discourages staff from speaking up Safety depends on people speaking up Reporting errors Reporting and identifying “near misses”

Just Culture “Leaders, managers and staff all value safety and create an environment where mistakes can be shared and learning occurs through identification of faulty processes and at-risk behaviors (J of Nurs Qual Vol 22, No.3 pp 210-212) Encourages staff to use their unique position on the “frontline” to identify safety issues and speak up

Fair and Just Culture Moving from culture of blame, to “fair and just” Responding to errors in a fair and consistent manner System of accountability Systems and behaviors are examined Not individuals and outcomes (Mayo Clinic and Pascal Metrics, Inc. 2012) A balance between punitive and blame-free culture

Individual Behavioral Choice Human error Inadvertent action Lapse, slip, mistake Often involve underlying system issues Increases with complexity of task

Individual Behavioral Choice Risky (Drift) Behavioral Choice that increases risk where risk is unrecognized or mistakenly believed to be justified Drift- “individual drifts away from what has been taught through the human desire to accomplish more or through a fading perception of risk as the individual becomes increasingly comfortable or competent in their work” (Outcomes Engineering, LLC, 2007)

Individual Behavioral Choices Reckless Behavioral choice to consciously disregard a substantial and unjustifiable risk Putting self-interest above that of the patient or organization

Management Response Thoughtful deliberation related to staff choices Human error Console and Learn Risky Coach/Learn Reckless Corrective Action

Transparency Leaders conduct rounds to seek out and discuss current processes and opportunities for improvement Outcomes, adverse event, near misses are openly discussed on regular basis and data is shared with all caregivers Learning is visible - Boards on units that show active work on process improvement

Behavioral Competency Diffusion of Best Practices This is Mayo Clinic’s Commitment to Safety System Competency Safe Care & Value Behavioral Competency Standardization & Diffusion of Best Practices Commitment to Safety in a fair & just culture Clearly Defined Behaviors Pay attention to detail Communicate clearly Have a questioning and receptive attitude Hand-off effectively Support each other Accountability for Behavior Handoffs and transitions Medication errors Rapid response team and deteriorating patient Mayo Clinic’s Commitment to Safety builds on the great work we are doing developing system competencies. Our work to standardize and diffuse best evidence-based practices - our system competencies – have shown substantial success over the past few years. We realize that even the best systems cannot work successfully if safe behaviors and a strong culture of safety are not in place. Through feedback received from the Culture of Safety survey, five clearly defined safe behaviors have been established that ALL Mayo staff must adopt. Along with the behaviors, we will begin using a more fair and just system of accountability when errors occur. Preventable Harm Approved by BOG/Management Team 1/24/2011 21

Pay Attention to Detail Intentional focus on specific task to avoid errors Mindful of task and ramifications Eliminate distractions-noise, interruptions, other thoughts (Mayo Clinic and Pascal Metrics, Inc.)

Communicate Clearly Accurate exchange of information that ensures comprehension Communication is intentional, respectful Be aware of body language and tone Verify accuracy and understanding (Mayo Clinic and Pascal Metrics, Inc.)

Have a Questioning and Receptive Attitude Empowerment to speak up without fear in order to prevent harm Open and respectful to those asking questions Responsive and appreciative for concerns raised Mutual respect (Mayo Clinic and Pascal Metrics, Inc.)

Hand off Effectively Interactive process of passing on specific information from one person to another, transferring responsibility Watch body language, tone, respectful, non-intimidating (Mayo Clinic and Pascal Metrics, Inc.)

Support Each Other A spirit of teamwork, collaboration and cooperation across professions and at all staff levels Mutually supportive and respectful behavior- keeping a common goal first- the patient (Mayo Clinic and Pascal Metrics, Inc.)

Safe Behaviors = How we communicate Effective communication is integral part of a healthy, safe culture Communicate clearly- “speak up” Handoff effectively Questioning and receptive attitude Support each other

How do nurse leaders at every level contribute to safe, high quality care? Create environment and culture where staff feel empowered to: Speak up Question the way we do things Support one another Are accountable for choices/actions Learn from errors, don’t blame others

Leadership Unit and organizational culture is shaped by leaders attitudes and behaviors Effective leaders Set a positive tone on unit Share the plan, think out loud and elicit staff input related to their expertise, ideas and concerns Are approachable, encourage open communication

Teamwork and Communication The next steps in keeping our patients safe and preventing harm focuses on teamwork High performing, effective teams have Team Behaviors Structured communication “Hard-wire” performance improvement into everyday work Team Attitudes Ensure psychological safety Set expectation of excellence

A Team is a Group with: MAYO’S 5 SAFE BEHAVIORS ARE NORMS Common goals and a game plan Agreed upon behaviors Agreed upon attitudes MAYO’S 5 SAFE BEHAVIORS ARE NORMS What do teams do:   Teams have a common goal with a game plan in place and know where the team wants to go They have diverse roles that synergize They have agreed upon behavioral and attitudinal norms. 31 31

A Team: Plans Forward Briefings (huddle, pause, timeout, check-in) The associated behaviors: Plans Forward Briefings (huddle, pause, timeout, check-in) Reflects Back Debriefings Communicates Clearly Using Structured Critical Language In order to do this teams demonstrate certain behaviors:   Plan forward: by briefing or huddling Reflect forward: Debrief Communicate clearly: Using structured communication SBAR and Repeat Back Manage conflict: using structured and critical language. Ask: What types of critical language does your team use? Examples: Stop the line. We have a problem I need some clarity Let’s talk about each of these team components in a little bit more detail 32 32

Also known as: Huddle Pause Timeout Check-in Briefings COMPONENTS Everyone knows the game plan Psychological Safety is ensured Expectation of excellence is set 33 33

Debriefings Debriefings can be the best tool for learning Three Questions What did we do well? What could we do better? What do we want to do differently tomorrow or next time? When we are debriefing there are three questions that we should be asking:   What did we do well? We tend to look at the negative, but we should equally acknowledge what went well. What could we do better? There is always room for improvement What do we want to do differently tomorrow? What are the goals -- what can we do better for the patient and for ourselves As a team we should be doing this each day. 34 34

Critical Language: Positive Assertion A PHRASE THAT STOPS THE WORK “I just need a little clarity.” “I am concerned, unclear, this is unsafe.” SBAR Situation, Background, Assessment, Recommendation Structured, predictable method of communication Repeat Back Critical labs, medication dosages A team member uses critical language to indicate to their team that something is wrong or they don’t know the game plan. Using an agreed-upon phrase, it signals to the entire team that they need to stop work and re-evaluate. Some examples of critical language include:  I need clarity I’m concerned, I’m unclear This is unsafe 35 35

“Mayo’s Model of Teamwork” Team Training ID unit, collect data, share results, team training Ensure psychological safety Embed team behaviors Briefings, debriefings, critical language Improve processes Make work visible- transparent Learning boards Set goals PDSA Display knowledge gained Sustainable process to effect needed improvement

Implement Team Behaviors Display the Data (learning boards) Team-Based Engagement Implement Team Behaviors Identify Unit Collect Data Team Training 1 Culture & Teamwork 3 Display the Data (learning boards) Systems Improve Systems (based on debriefings) Eliminate Preventable Harm 2

Learning Board 3 North ©2011 MFMER | slide-38

Ongoing Work: Further shifting our culture Model of teamwork How we…. do our work communicate identify safety concerns improve safety improve outcomes improve quality It is a journey……

Questions?

References Mayo Clinic and Pascal Metrics, “Commitment to Safety Team-based Engagement Model (TEM)” PowerPoint, July 31, 2012. Mayo Clinic. (2012). Mayo Clinic Commitment to Safety. Retrieved July 28, 2012 from Mayo Clinic Web site: http://intranet.mayo.edu/charlie/commitment-to-safety/ Mayo Clinic and Pascal Metrics, Inc., Team-based Engagement Model (TEM) Field Manual, 2012. Outcomes Engineering, LLC. (2007). Just Culture Training for Healthcare Managers. Plano, TX: Outcome Engineering, LLC. Volgesmeier, A., Scott-Cawiezell, J. (2007). A Just Culture The Role of Nursing Leadership. Journal of Nursing Quality, Vol 22, No.3 pp 210-212.