1. Comprehensive Unit Safety Program (CUSP) David Thompson DNSc, MS, RN Kristina Weeks, MHS, DrPh(c) Teamwork Tools

2. Steps of CUSP 2 1. Educate staff on Science of Safety 2. Identify defects 3. Assign executive to adopt unit 4. Learn from one defect per quarter 5. Implement teamwork tools Pronovost J, Patient Safety, 2005

3. You got a problem, we’ve got an app for that 3 https://armstrongresearch.hopkinsmedicine.org/cs ts/cusp/resources.aspxhttps://armstrongresearch.hopkinsmedicine.org/cs ts/cusp/resources.aspx

4. Learning from Defects Joint Commission Journal Quality & Safety Feb 2006 What happened? Why? What will you do to reduce probability that it will happen again? How do you know risk is reduced? Share your learning throughout organization

5. Learning Invite all who touch process to attend Learn deeply from smaller number, rather than “re-educate” staff on a large number Learn at different levels –System/hospital: one per quarter –Department: one per quarter –Nursing unit: one per month Share your learning throughout organization

6. Familiarity with others is a critical component of effective teamwork: 6 74% of all commercial aviation accidents happen on the first day of a team flying together Familiarity trumps fatigue Highlights the importance of predictable patterns of behavior

7. 7 Intensive Care Unit (ICU) and Inpatient units Daily Goals

8. Goals 8 To learn how to implement daily goals in your ICU To discuss strategies for interdisciplinary rounds To fine tune daily goals to reflect your patient populations needs.

9. Background 9 Communication defects common People and organizations who create explicit goals achieve more than those who do not Rounds generally patient rather than provider centered

10. 10 % of respondents reporting above adequate teamwork

11. 11 Percent Understanding Patient Care Goals J Crit Care 2003,18, 71-75

12. 12 Impact on ICU Length of Stay Daily Goals 654 New Admissions: 7 Million Additional Revenue

13. Thoughts for Daily Goals 13 Leading question: Why is patient in ICU? Save teaching for a separate session (avoid pontification) Fellow/resident wrote note on each patient daily before attending reached patient for rounds – need to summarize this and convert into the work for the patient

14. How to use daily goals form? 14 Be explicit Ask the Important questions –What needs to be done for discharge –Safety risk –Scheduled labs Completed on rounds Stays with bedside nurse Modify to fit your hospital

15. Thoughts for Daily Goals 15 Is team on target with care plan for the day? –Sign out at end of shift for oncoming team Day rounds at 7am to include night shift Revisit goals as necessary- team huddle Modify patient’s plan of care -- physicians learn to use for benefit of frontline staff

16. Thoughts for Daily Goals 16 Physician buy-in, start with one physician and nurse team to demonstrate feasibility Long rounding time a problem –Patient care first –Facilitator a key person in moving discussions more quickly –Separate teaching and patient rounds

17. 17 Conducting a Morning Briefing (ICU) Conducting a Morning Huddle (OR) Improving Situational Awareness by

18. Situation Awareness An Overview 18 Members of the team have and understanding of “what’s going on” and “what is likely to happen next” Teams are alert to developing situations, sensitive to cues and aware of their implications.

19. Improving Situation Awareness 19 Know the game plan – through briefings and team management (e.g., workload & workflow management, task coordination) Anticipate next steps and possible events Follow known policies and procedure Cross-check and verify Provide ongoing updates – call-outs, cross- talk, and briefings

20. Briefing Defined 20 What a Briefing immediately does? 1.Map out the plan of care. 2.Identify Roles and Responsibilities for each team member. 3.Heightens awareness of the situation. 4.Allows the team to plan for the unexpected. 5.Team members needs, and expectations are met. A briefing is a discussion between two or more people, often a team, using succinct information pertinent to an event.

21. Effective Morning Briefings 21 Sets the tone for the day…… chaotic versus organized and efficient Encourages participation by all team members Owned by all team members Organized in thought regarding the procedure Establishes competence- who has what skills who performs what who knows what Predicts what will happen later Plans for the unexpected (include equipment, edications, consults)

22. Morning Briefing Process 22 Three simple questions 1.What happened overnight that I need to know about? 2.Where should I begin rounds? 3.Do you anticipate any potential defects in the day?

23. What happened overnight that I need to know about? 23 You should be thinking about…Was there adequate coverage? Were there any equipment issues? Were cases posted to the ICU? Unexpected changes in patient acuity? Were there any adverse events?

24. Where Should Rounds Begin? 24 1.Is there a patient who requires my immediate attention secondary to acuity? 2.Which patients do you believe will be transferring out of the unit today? 3.Who has discharge orders written?

25. As you continue planning rounds 25 4.How many admissions are planned today? 5.What time is the first admission? 6.How many open beds do we have? 7.Are there any patient having problems on an inpatient unit?

26. Do you anticipate any potential defects in the day? 26 Patient scheduling Equipment availability/ problems Outside Patient testing/Road trips Physician or nurse staffing Provider skill mix

27. When you identify defects/ problems 27 Want to assign a person to the issue- have them follow up. Identify actions taken to meet any patient or unit needs Report back to the staff what those actions were or will be. If ongoing- continue to report it during morning briefing until it is resolved.

28. 28 Shadowing another Provider

29. Why do we need to Follow? 29 To gain perspective of the other providers Practice, Responsibilities, Work environment, To identify issues that effect teamwork and communication that may impact patient care and patient outcomes.

30. Who should have this experience? 30 Patient care areas as part of the Comprehensive Unit Based Safety Program (CUSP) When there is a difference of > 20% in SAQ scores between provider types. As part of orientation to a new unit Units with little collaboration between disciplines.

31. Preparing to Follow 31 Review the tool prior to your shadowing experience Follow your health care provider through their daily activities. Review your list of communication and teamwork problems Discuss with the Provider Make a plan for resolution

32. Our Findings 32 Handoffs for 4 hour shifts not thorough, increased opportunity to forget key details as this increased the total number of people… Physician consults usually obtained but not always read by the requesting team… Nurse often most informed team member on the patient’s plan of care but does not always speaks up

33. Our Findings 33 Nurses did not realize how complicated sterile processing was, efforts made to keep trays together POE removed an important step- communicating to RN of stat order Physicians unaware of unit policies, depend on RNs to complete task.

34. 34 A fly on the Wall Observing Rounds

35. Observe and don’t participate 35 A method to add structure to interdisciplinary rounds. Improve collaboration and identify communication defects. Can be done by any discipline. Should be debriefed with the team afterwards.

36. 36 Setting priorities for improving the culture in your unit. Culture Check up Tool

37. Prioritize your weak areas 37 Pick the 3 lowest values from you HSOPS Identify a plan to address those areas where improvement is needed. Remember you are looking to improve your scores to the 75 percentile. Implement your strategy and reassess after the next HSOPS survey.

38. 38 Questions?