First, Do No Harm: Building a Culture of Patient Safety at Novant Health Physician Education Part 2: Safety Behaviors for Error Prevention.

First, Do No Harm: Building a Culture of Patient Safety at Novant Health Physician Education Part 2: Safety Behaviors for Error Prevention

Goal and Objective Goal: Objective:
Understand the Novant Safety Behaviors and commit to making them personal work habits Objective: Provide an in-depth review of the five organization-wide Safety Behaviors here at Novant Health Today we have one objective - to give you an in-depth review of the five organization-wide Safety Behaviors here at Novant. These Safety Behaviors are evidenced-based, tied directly to your data that came out of a diagnostic assessment of past events of harm at Novant, and were chosen by your people – staff, leaders and physicians – folks from across the system who came together to in preparation for the second part of our CME program where we will explain how physicians can use those in practice with the overall goal of reducing harm in our hospital by 80% every 2 years.

Our Novant Safety Behaviors & Error Prevention Tools
Practice with a Questioning Attitude A. Stop, Reflect & Resolve in the face of uncertainty Communicate Clearly A. Use SBAR-Q to share information B. Communicate using three-way repeat backs and read backs C. Use phonetic and numeric clarifications Know & Comply with Red Rules A. Practice 100% compliance with Red Rules B. Expect Red Rule compliance from all team members C. If compliance with a Red Rule is not possible, STOP action until any uncertainty can be resolved Self-check: Focus on Task A. Use the STAR technique Support Each Other A. Cross-check and Assist B. Use 5:1 Feedback to encourage safe behavior C. Speak up using ARCC – “I have a concern” On April 27th, a group of over 200 Novant leaders, staff and physicians met in Statesville to go over these concepts and data in much greater detail, breaking up into discussion and focus groups to select Safety Behaviors and specific evidenced-based error prevention tools that can easily be adopted system-wide to help us make fewer errors. Here you see the outcome of their work that we now need to turn into practice habit across Novant. On the left are the five (5) safety behaviors that will help us dramatically reduce our error rates. The five safety behaviors are: Practice with a Questioning Attitude Communicate Clearly Know and Comply with Red Rules Self-check: Focus on Task Support Each Other There’s a specific reason we put them in this order. When we think about how we approach the many tasks that make up our day, we should think about building reliability through the adoption of low-risk safety behaviors in this process order: Practice with a questioning attitude (watch for those red flags) Communicate clearly (tell others, seek to understand) Know & comply with Red Rules (stick with what we know is right) Self-check (now check yourself) Support each other (and check others) On the right of the slide is a one-page handout that is in your packet. The bullets below each Safety Behavior are the specific evidenced-based Error Prevention Tools that we are now going to cover in much greater detail.

1. Practice with a Questioning Attitude
What should we do? Think critically by questioning information we hear and see if it doesn’t fit with what we know Why should we do this? To detect incorrect information and assumptions that can lead to erroneous decisions or actions To help ensure work activities are stopped when faced with uncertainty or unsafe conditions Error Prevention Tool Stop, Reflect and Resolve Here we see our first Safety Behavior: Practice with a Questioning Attitude. And you can see how well it aligns with our four Core Values, shown at the top right of the slide. For the remainder of our presentation, you will notice a green bar across the top of five of our slides. This green bar indicates it is a Safety Behavior. Think of each safety behavior as the Big Picture – the “Motherhood and Apple Pie” idea. Then, we’ll spend some time discussing the specific Error Prevention Tools that will help us achieve each Safety Behavior. Practice with a Questioning Attitude helps us improve our critical thinking skills. Critical thinking is the disciplined process of applying thought to a specific situation. Questioning attitude is not asking questions; it’s questioning the answers. In the simplest form, questioning attitude is detecting incorrect information and incorrect assumptions. People who lack critical thinking skills make errors because they: Make wrong assumptions Fail to note a condition that is unusual Use information that is obviously incorrect Misinterpret correct information Having a questioning attitude helps ensure that we correctly perceive the conditions around us and that we correctly choose the right response for the situation. Ask the audience if they can recall an example of an event that happened, because the individuals involved were not using critical thinking skills? There is one error prevention tool for this safety behavior: Stop, Reflect & Resolve Its not about asking questions – its about questioning the answers! 4

Stop, Reflect and Resolve
Stop: Review the plan – do not proceed in the face of uncertainty Reflect: Does it make sense to me? Patient Technology Professionals Medical Record Documentation Procedures & References Stop, Reflect and Resolve is the number one critical thinking tool. It’s a is a three-step technique for processing raw information into fact. As an overview, we first need to recognize situations or information that don’t seem quite right and not proceed in the face of uncertainty. The raw information can be from any source: Direct observation (seeing, hearing, touching, etc.) Results of tests (lab values, images, etc.) Displays from monitors and devices (monitors, gauges, indicators, etc.) Verbal and spoken (orders, patient history, etc.) Verbal and written (orders, progress notes, etc.) Guidance documents (policy, protocols, etc.) Reflect is an internal check – does this situation or the information that has been given to me make sense with what I know to be true or right. It takes seconds to do and is sometimes called the gray matter check because it occurs in your brain. Resolve is an external check of the information with an independent and credible source to corroborate our thinking. It takes minutes to do – sometimes many minutes – and as opposed to occurring in the gray matter, this occurs with the shoe leather, because you have to get on your feet and do some work to track down the right answer. Here are a couple of quick scenarios where you can see it coming into play: * A new graduate RN starts work on July 1st. His patient is having trouble breathing and he is concerned that the patient may soon have a respiratory arrest. He tells the intern (who just started 1 week ago) about his concern, who tells the nurse that this is nothing to worry about as the patient has a history of this. A physician calls radiology to order a specific test for his patient. The Attending Radiologist taking the call asks, “Are you sure you want this test? I think an alternate test is the one you want.” Resolve: Check it out with an independent, expert source 5

Reflect - An internal check
Expectation Current Situation Does this make sense to me? Is it right, based on what I know? Is this what I expected? Does this information “fit-in” with my past experience or other information I may have at this time? Get in the habit of asking these questions all the time… it takes only seconds. Our internal smoke detector… Reflect is an internal check – think of it like an internal smoke detector. The smoke detector in your home is always on. When an alarm sounds, you check to determine what made the alarm sound. Was it smoke from a dangerous fire, from a piece of bread that got caught in the toaster oven, or the smoke from birthday candles? Or is the battery getting weak? Reflect is your internal detector, and it should always be on. Whenever you receive information or observe a situation, you should be asking yourself the questions shown on this slide. Its about comparing a situation or information to what you know to be correct and true. The key is that you do it before you act. It’s a comparison of a situation or information to what you already know – a consistency check. So you’re asking yourself questions like – “Does this make sense to me?”, “Is this right based on what I know about those types of situations or this case specifically”. You’re asking yourself things like “Is this what I expected based on the name of the case, the diagnosis, the plan of care, or things we talked about yesterday.” And that third bullet is really the bottom line – “Does this fit in – is it consistent with what I know and expect? You don’t have to say you know for a fact its true, you just have to say, “Yes, its seems likely and possible”. Take the time to Reflect on every situation and information that you encounter. It takes just a few seconds to run this check in your head. Always think…does it make sense to me? Just like the smoke detector, reflecting costs very little and can save thousands of lives each year. 6

Resolve - An external check
When should you resolve? When your detector goes off In every high-risk situation When there is a change in the patient condition or plan of care While Reflect is an internal check that you perform with your grey matter (Brain power!), Resolve is an external check that you perform with your shoe leather (GOYA – Get Out of Your Armchair!) So it naturally takes longer to do – minutes as opposed to seconds. Resolve by finding an independent, qualified source to verify the situation or information is correct. What are some qualified sources you rely on to resolve information? Policies, procedures, and job aids Clinical protocols and guidelines of care Reference manuals (PDR, Lippincott’s nursing manual) Expert individuals (Supervisors, Clinical Nurse Specialists, Pharmacists) Points to emphasize: When using other professionals as your source, make sure the person really is an expert. Coworkers are not always the best expert, as people who work closely together tend to share the same perspectives and understandings of situations and information. We should Reflect on most of the situations or information we see in healthcare since it only takes seconds to do. But since Resolving takes longer – minutes – we need to pick and choose the times when we to should apply it so as not to become inefficient. There are 3 specific instances, when you must resolve information: Any high-risk situations When the plan of action changes When you note an inconsistency (the Reflect detector goes off) It may feel uncomfortable to ask about something you think you should know… but think about how you will feel if you don’t ask and you make a mistake or error. It’s okay not to know… It’s NOT okay not to find out. 7

Our Novant Safety Behaviors – Communicate Clearly

Ensure that we hear things correctly and understand things accurately
Approximate Time At This Point – 1 hour 50 minutes 2. Communicate Clearly What should we do? Ensure that we hear things correctly and understand things accurately Why should we do this? To prevent wrong assumptions and misunderstandings that could cause us to make wrong decisions Error Prevention Tools SBAR-Q to Transfer Information 3-Way Repeat Backs and Read Backs Ask and Encourage Clarifying Questions Phonetic & Numeric Clarifications Here is our second Novant Safety Behavior (as indicated by the green bar) - Communicate Clearly. And you can see how well it aligns with our four core values shown up in the top right side of the slide. We can’t display those core values unless we communicate clearly – to each other and to our patients. Communicate Clearly is about making sure we give and receive accurate and complete information. We act on information others give us, and our coworkers act on information we give them, so we need to make sure the information exchange occurs correctly to prevent wrong assumptions and misunderstandings. When we communicate poorly, inaccurate and incomplete information can lead us to make decision-making errors, or poor choices. Can you recall an time when you were involved in an error that resulted from poor communication? There are four error prevention tools for this safety behavior that we are going to discuss now in more detail: 1. SBAR-Q to transfer information 1. 3-Way Repeat Backs and Read Backs 2. Ask and encourage Clarifying Questions 3. Phonetic & Numeric Clarifications 9

SBAR-Q Situation: What is happening right now?
An outline for planning and communicating information about a patient condition or any other issue or problem Situation: What is happening right now? Background: What are the circumstances leading up to this situation? Assessment: What do I think the problem is? Recommendation: What should we do to correct the problem? Questions: Follow up questions? SBAR-Q is a communication tool that helps structure a communication, when you have a request to make. It can be used for a problem in both clinical and non-clinical situations. It can be used verbally, by phone or in writing, such as in an . Each letter stands for information that is important to communicate: Situation – Who or what you’re calling about and the immediate problem: the headline Background – A brief description of relevant history related to the condition Assessment – Your view of the situation (“I think the problem is…” or “I’m not sure what the problem is.”) and your perception of the urgency of action (“The patient is deteriorating rapidly” or “We won’t be able to continue service with out more supplies”) Recommendation – Your suggestion about the action that should be taken to solve the problem, or your request for guidance on what action to take Questions – Does anyone have any follow up questions It is best to gather information about the problem and plan what you’re going to say before you make the call. When communicating, specifically use the words – Situation, Background, Assessment, and Recommendation - so that the listener knows the nature of the information your giving. History of SBAR SBAR as a communication protocol was developed by Kaiser Healthcare but has also been credited to the nuclear Navy, where submariners have used it for years to clearly and accurately transfer information in a time-critical manner. SBAR is built around the simple idea that physicians, being trained as problem solvers, want the problem first then the back-story. Unfortunately, nurses, being trained to be the patient historian, prefer to communicate in a chronology beginning with the history, through recent signs and symptoms, and finishing with the assessment. This often means that the physician has interrupted or lost interest by time the relevant information is presented. SBAR is the best compromise between the physician and nurse communication style, but is also effective from one care provider to another. 10

Top 3 Statements to Encourage Critical Thinking1
SBAR-Q: Questions Encourage questions by inviting questions and positively reinforcing questions when asked Asking a question is primarily an emotional security issue. We can foster a culture of critical thinking by encouraging questions. Invite questions, and use positive reinforcement when questions are asked. In addition to ensuring good communication, both the hospital staff and the medical staff want to foster a culture of critical thinking. Critical thinking is not what one knows but how well one uses what they know. Critical thinking is using our cognitive skills to interpret information correctly and choose the best plan of action based on this information. The Q at the end of SBAR-Q is intended not only to help ensure information is transferred effectively, it is also to help develop a questioning attitude, which is the single most important critical thinking skill. Asking a question is primarily an emotional security issue. If you think and feel that it is okay to ask a question (even a basic question), then you will ask. If you think that asking only shows your ignorance or that others will think less of you, you will be less likely to ask. Top 3 Statements to Encourage Critical Thinking1 “What do you think?” “That is an interesting question” “Let’s explore this” A great way to help break down perceived Power Distance! 1Rubenfeld, “Critical Thinking Tactics for Nurses” If we want our peers to think critically, we need to encourage questions (as well as ask questions ourselves). The best positive reinforcement for asking a question is to receive an immediate and useful reply. The slide lists the top 3 things that physicians can say or do to invite questions. For a listing of all 20, refer to the One Page Patient Safety lesson “20 Things to Say or Do to Encourage Questions.” This listing is excerpted from Rubenfeld’s book “Critical Thinking Tactics for Nursing.” A Case in Point A 56 yo F is admitted to regain control of diabetes. The physician writes an order for 5 Units Lantus. Physician uses U for Units and writes poorly such that order reads 50 Lantus. Both pharmacist and nurse notice the missing unit (thinking the U is a 0) and consider 50 Units too much for the pt. Neither asks the physician because she is well known for harsh responses to “idiots who can’t do their jobs” who ask “stupid questions.” Had either the Nurse or the Pharmacist asked a simple question, the Physician would have realized she made an error and a hypoglycemic event would have been prevented.

Repeat Back / Read Back Sender initiates communication using Receiver’s Name. Sender provides an order, request or information to Receiver in a clear and concise format. Receiver acknowledges receipt by a repeat-back of the order, request or information. Sender acknowledges the accuracy of the repeat-back by saying, That’s correct! If not correct, Sender repeats the communication. 1 2 3 By now many of you have heard about how we should be applying this concept to healthcare. The sender initiates the communication, the receiver acknowledges the information by repeating it back, and then the sender acknowledges accuracy by closing the loop with the phrase “That’s Correct!”, which is like the pilots in our previous example saying “Roger” to the Air Traffic Controllers. Here is what a 3-way repeat back sounds like in a hospital setting: Sender (Nurse): “I’m calling because Jane Elgin’s blood pressure has dropped to 78 over 50.” Receiver (Physician): “I understand, Jane Elgin’s blood pressure is now 78 over 50.” Sender (Nurse): “That’s correct.” That third step in which the Sender acknowledges the accuracy of the repeat back is so important. The Receiver must listen for the words, “that’s correct.” If the information is not correct, the Sender must repeat the communication. A bad practice is to say “that’s right” because right goes with left and there could be confusion at times in terms of procedures involving laterality. So the official answer and one of our verbal indicators of safety culture here at Novant will be in hearing people say “That’s correct”. Since Repeat-Backs are not a common practice in our normal lives, sometimes you have to invite yourself in, so shown at the bottom left of the slide is a good safety phrase to know – “Let me repeat that back”. That’s your way of saying “I need a second and want to make sure I have this perfectly clear by repeating it back to you”. Invite yourself in: “Let me repeat that back…” Train our ears to listen for “That’s Correct!” – it’s a codeword for “we understand each other”

“Let me ask a clarifying question…”
Clarifying Questions Ask one to two clarifying questions: In all high risk situations When information is incomplete When information is not clear Why… How… Clarifying Questions probe for understanding. Questions can be asked by the Sender or by the Receiver. Do you always have to ask clarifying questions? No. Pick your spots. Most certainly ask clarifying questions in these situations: When in high-risk situations When information is incomplete When information is ambiguous Studies have shown that the probability of making a wrong assumption is reduced 2½ times when you ask clarifying questions. 1 to 2 clarifying questions is the right number. One question usually isn’t enough, but more than 3 clarifying questions can become a bit annoying. Point to emphasize: Recall that the 3-Way Repeat Back technique does not ensure that the Sender sent accurate information or that the Receiver understood the information. So it’s always a good practice to use the 3-Way Repeat Backs and Clarifying Questions together. When you receive information, repeat it back and then ask 1 or 2 clarifying questions to make sure that you understood the information. The Sender may also ask clarifying questions to confirm understanding of the information. A good way to telegraph your need for understanding in the interest of patient safety by saying “Let me ask a clarifying question”. People then are much more receptive of the questions. If you just ask the question directly it sounds like you’re challenging them or their knowledge, when in reality you just want to help understand the situation. Asking clarifying questions can reduce the risk of making an error by 2½ times! Use the Safety Phrase: “Let me ask a clarifying question…” 13

Numeric Clarifications
For sound alike numbers, say the number and then the digits… 15…that’s one-five 50…that’s five-zero 45…that’s four-five 425…that’s four-two-five 4 to 5…that’s the range four dash five …and ALWAYS use leading zeros – as in 0.9 The second recommended best practice in oral communications is Numeric Clarifications. This is where we say the number and then say the digits to avoid confusion with the sound-alike numbers like fifteen and fifty. So if a nurse is given a verbal order to give a patient 15 mg of morphine, in his or her mind they may wonder was that 15 or 50? A best practice is to commit to saying 15 mg…that’s one-five Verses 50 mg…that’s five-zero. Clear and concise, and we use the separating word “that’s” to avoid any confusion between the number and the digits. The best times to use numeric clarifications are when communicating the following: Medication doses Critical lab values Equipment set points Patient identification numbers Additionally, we need to commit to using those leading edge zeros where the decimal point is a place holder. This situation is so important because if we mess this one up we automatically get an order of magnitude error in our communications. So we see pretty good commitment to the written use of leading zeros in front of decimal points, but overall there is still room for improvement in the verbal use of leading edge zeros. So the correct way to say that example at the bottom is zero-point-nine which helps train the tongue to say, the ear to hear and the eye to see, each and every time, drastically reducing those instances where an error around an order of magnitude miscommunication can have tragic outcomes. 14

Phonetic Clarifications
For sound alike words and letters, say the letter followed by a word that begins with the letter… A Alpha B Bravo C Charlie D Delta E Echo F Foxtrot G Golf H Hotel I India J Juliet K Kilo L Lima M Mike N November O Oscar P Papa Q Quebec R Romeo S Sierra T Tango U Uniform V Victor W Whiskey X X-ray Y Yankee Z Zulu The next tool is called Phonetic Clarification, which is an outstanding best practice in oral communications in three instances: Patient name, procedure name and medication name. Those three instances tend to be long, spelling is difficult and there’s a lot of sound-alikes. So a best practice would be to spell, especially over the telephone, and when we go to spell, we realize that some of the letters are sound alike as well. The B sounds like the C which rhymes with the D. So in phonetic clarification you say the word, then spell it with the letter in addition to saying a word that starts with the letter. You see here a standardized phonetic alphabet – used by the U.S. military in addition to other NATO countries that speak English, civilian radio operators, commercial aviation and nuclear power. While there is no overriding reason to memorize the alphabet, you’ll find in practice its more efficient to learn it and use it consistently across the organization, plus it serves as a good indicator that we’re all onboard with a commitment to safety culture. Hearing Lima Mike November is not a common practice, so when we hear that, we say to ourselves, “Wow, that person must be taking this patient safety stuff seriously”. And once the initial adapters learn the phonetic alphabet, its passed down as part of “the way things are done around here,” so ensuing generations simply absorb it as part of the culture. Of course, you can make up the words as you go - for example – you can say A as in apple, but as you go you’ll be surprised how often people get stuck on simple letters – like, what’s a word that starts with N? And that avoids some common missteps like N as in pneumonia and Z as in Xylophone. So an organizational commitment to learning and memorizing a single phonetic alphabet reduces mental effort over time. 15

A Repeat Back Failure 27 527 29 “The Same”
Here’s an example of how clear communications could have avoided a safety event at one hospital in Florida. A patient was admitted through the ED to the ICU after being found unconscious with diabetes not well controlled (the pt was a homeless person who had been in the hospital before). The patient was not alert nor oriented throughout the event. The nursing aid measured the blood sugar using a glucometer and found a reading of 27. She immediately reported to the patient’s nurse who, for some reason, heard the report as 527. There was no repeat-back, clarifying questions, or numeric clarification. The nurse asked for a second reading. The second reading was 29, but reported as “the same.” Again, there was no repeat-back or clarification. The nurse obtained a telephone order for insulin. The nursing aid, seeing no D50 running, thought something wasn’t right and approached the charge nurse with her concerns. The charge nurse is the one who recognized the problem. There was no requirement by the Joint Commission to write down and Read Back the value in this case, but you can see that by some consistent commitment to 3-way communications and numeric clarifications, this event could have easily been avoided. The nursing aids actions when she didn’t see D-50 hanging and went to the Charge Nurse – an expert source – also are a good demonstration of our first Safety Behavior and Error Prevention Tool at work. Can you say what those are and how the aid used them? Questioning Attitude and Reflect and Resolve! “The Same”

Our Novant Safety Behaviors – Know & Comply with Red Rules

3. Know and Comply with Red Rules
What Is A Red Rule? An act having the highest level of risk or consequence to patient or employee safety if not performed exactly, each and every time By now you may be asking, “What is a Red Rule?” First, we need to recognize that all rules are not created equal. So a Red Rule is an act having the highest level of risk or consequence if not performed exactly, each and every time. Although the term Red Rule is new to Novant, safety-critical rules are not. Red Rules are existing rules that are recognized as safety-critical – we designate them as RED to highlight the need for exact compliance. The Red Rule label focuses our attention on the importance of the rule to safety and elevates the rule to a consistent work habit. Successfully implemented, Red Rules should be viewed by employees as an important part of our safety culture at Novant, and non -compliance with safety-critical acts should be a minimal problem. If you want to relate these to examples from everyday life, think about the following: Stop sign on a school bus: everybody knows to stop without exception. And if we see someone else violating this Red Rule (by driving around the bus with the stop sign out), we get upset – maybe honk our horns, take down the license plate number, or even call the police Wearing your seatbelt while driving – especially for babies and toddlers As we think about improving overall compliance with Red Rules, seatbelt usage provides a good analogy. The number one motivator for improving seatbelt compliance is not posters or ad campaigns, its whether the person sitting beside you puts on their seatbelt. And especially if they ask you to buckle up before they go, then we see compliance go through the roof. In the same way, we should model, expect and ask for compliance with our Novant approved Red Rules. “Red” designates the rule as a safety absolute with the highest priority for exact compliance 18

Red Rules…For Times When There Are No Do-Overs
Comair Flight 5191 crashed in Lexington, KY on Sunday August 27, Of the 47 passengers and 3 crew, 49 people died. The plane cleared for take off on Runway 22 but taxied on the shorter Runway 26 instead. Not having enough distance to take off, the plane crashes after hitting a berm at the end of the runway. Violation of a Red Rule can lead to tragic consequences. Here’s how it didn’t work out so well in another industry. Before the crash in February 2009 in Buffalo of a regional jet due to icing, the last major airline crash in the United States was in August of 2006 in Lexington, KY. On that morning the pilots were taxiing out from the terminal before sunrise as they knowingly violated a Red Rule known as “Sterile Cockpit”. Sterile Cockpit is an FAA Red Rule where on the ground and airborne below feet, the pilots in the cockpit are supposed to only talk about those issues relating to the safe flight and navigation of the aircraft. Well, here the aircrew were discussing their families, pets and jobs and became so distracted they turned early onto the runway highlighted in red rather than continuing on to the longer runway highlighted in blue. They failed to achieve sufficient flying speed on the much shorter runway and crashed off the departure end, killing everyone onboard with the exception of the co-pilot who was violating the Red Rule. As they were turning onto the shorter runway in the pre-dawn hours, one of the pilots remarked “I wonder why the runway lights are not on?”, which is an example of a failure of one of the safety behaviors we already discussed, Practice with a Questioning Attitude. Stop, Reflect and Resolve those issues that don’t seem quite right in the face of uncertainty. Among the facts revealed by a January NTSB release was the violation of the "sterile cockpit" rule by the pilots, who talked about their families, pets, and jobs during taxi and takeoff. 19

Novant Red Rules I will always verify patient identity using 2 identifiers prior to any treatment, therapy, transport, procedure or specimen draw. 2. I will always perform “double checks” as specified by my department*. *Note: Refer to your department “Double-Check” poster for your safety-critical double-checks Red Rules are a communication tool for our leaders to let us know those things that are so important to them – and to the organization – that they need us to comply 100% of the time. Red Rules are few in number and written to be specific. Here at Novant, based upon input from staff, physicians and leaders, we have identified 2 Red Rules: I will always verify patient identity using 2 identifiers prior to any treatment, therapy, transport or procedure. Can anybody name the two forms of patient ID here at Novant? Our second Red Rule is …... Corporate HR is still considering the sanctions for Red Rule violations, but it will be in line with the current progressive discipline policy. People always ask “what will be the punishment for Red Rules violations. Well, instead of thinking about punishment we should all think about choices. Going back to the beginning of this presentation, we should remember that everybody makes mistakes – and so unintended human error will be treated differently than choices to not comply with our expectations. For those choices to not comply there will be fair consequences consistently applied in line with our progressive discipline policy. But the response to honest human mistakes is not automatic termination.

Our Novant Safety Behaviors – Self Check: Focus on Task

4. Self Check – Focus on Task
Approximate Time At This Point – 2 hours 55 minutes 4. Self Check – Focus on Task What should we do? Focus on the task at hand to avoid unintentional skill-based errors Why should we do this? To avoid those slips or lapses where the hand is operating before the head To reduce the chance that we’ll make an error when we’re under time pressure, distracted or stressed Error Prevention Tool – Self Check Using STAR This is an introductory slide: no need to discuss the details of the error prevention tools Here we have our fourth Safety Behavior – Self Check – Focus on Task. You can see it aligns with 3 of our 4 core values. As a self-checking behavior, it’s not as much focused on Teamwork, but it aligns nicely with the other three. This behavior is designed to prevent us from making skill-based errors – those unintended slips and lapses when we perform familiar, routine acts that we do on auto-pilot without even thinking. These errors are so simple that we are very much surprised when we make them. When we make a skill-based error, we slap our forehead in disbelief – the international sign of a skill-based error. Slips and lapses are unintended errors. The intent of the action was correct, but the execution and the outcome of the action was not consistent with the intent. Can you recall a skill-based error that you experienced recently? There is one error prevention tool for this safety behavior: Self Checking Using STAR 22

Self-Check Using STAR Stop Pause for 1 to 2 seconds to focus your
attention on the task at hand Think Consider the action you’re about to take Act Concentrate and carry out the task Review Check to make sure that the task was done right and that you got the right result STAR is an acronym for Stop, Think, Act, and Review. In STAR, you pause for 1-2 seconds, consider your action, concentrate and carry out the task, and then, if you have time, review for consistency of outcome with intention. STAR was developed in the early 1970s in the California school system to help prevent school children from acting impulsively. The children were coached to stop and think about the consequences before acting. Two professional groups then adopted STAR - aircraft pilots and nuclear power operators. These are professions where pressing the wrong button without thinking about can result in very bad consequences very quickly. These industries developed simulators to help people use the STAR technique. You have actually have a good simulator here in the hospital – its called the candy machine. People will put their money into the machine, point to the candy bar they want, point to the letter and number for the slot, and right before pushing the final number they will pause for a second to ensure they’ve got it right, hold their breath and only exhale when the correct item drops to the bottom of the machine. Great example of the STAR technique – if its good enough for snack time its good enough for our daily safety-critical healthcare tasks! People who develop a good habit using STAR use the technique as many as 500 times per day. This amounts to less than 10 minutes per day. While a human performs over 10,000 skill-based acts per day, use STAR – a one-to-two second pause to think before you act - at the most important points. While there are times when we need to work fast or hurry throughout our day, we need to pause at the most critical points of no-return to make sure that our acts are the right ones. The best times to use STAR are when going from thought to action – identifying a patient, entering data into a device or computer, documenting a thought or value, connecting tubing or leads, and anytime before taking action with a patient. Point to emphasize: STOP is the most important part of STAR, to give your brain a chance to catch up with your hands. Sometimes people say or think that when you are in an emergency situation, this is when you can bypass the “rules”. This is the time when use of these tools are the most critical. STOP is the most important step. It gives your brain a chance to catch up with what your hands are getting ready to do. 23

Our Novant Safety Behaviors – Support Each Other

5. Support Each Other What should we do? Why should we do this?
Approximate Time At This Point – 3 hours 15 minutes 5. Support Each Other What should we do? Look out for one other to catch each other’s mistakes while building a greater sense of accountability for our actions Why should we do this? To help everyone perform at their individual best To help our team perform at it’s best Error Prevention Tools Cross Check and Assist Encourage Safe Behavior Using 5:1 Speak Up for Safety Using ARCC – “I have a Concern” Our fifth and final Safety Behavior is Support Each Other and it aligns with all of our Core Values. Support Each Other means we look out for each other in order to catch each other’s mistakes (which, by now, we know all humans make!) while at the same time building a greater sense of accountability across the organization . No need to go into detail: the tools will be discussed on the next slides! This is all about helping others do the right thing and expecting that they will help us to do the right thing, too. There are three error prevention tools for this safety behavior: Cross Check and Assist Encourage Safe Behavior Using 5:1 3. Speak Up for Safety Using ARCC 25

Cross-Checking in Healthcare
High Reliability Organization (HRO) Lesson: Together we are Six Sigma quality (3.4 dpmo*) On your own, a person is only as reliable as a human can be: 1 defect per thousand opportunities Cross-checking multiplies the error probability: 0.001 x = 1 defect per million opportunities The effect that we’re looking for is to multiply the error probabilities. Let’s say I’m doing something very simple – like washing in or washing out with a hand cleanser for infection control when I enter or exit a patient’s room. When I’m committed to doing that idea of hand hygiene, the probability that I’ll make experience a skill-based lapse and not do it is about 1 out of every 1000 entries. Now if you’re with me and you care about the patient and you care about me enough to watch out for me, your error probability is similarly 1 out of 1000, we then multiply those two together, so together we’re 1 out of a million. So while 1 out of a thousand is not even close that six sigma quality that you talk about, if you care enough to say “Are you going to wash in?”, then suddenly we go to 1 out of a million, which is six sigma quality – defined as 3.4 defects per every million opportunities. Malcolm Baldrige National Quality Award * defects per million opportunities

Encourage Safe Behavior Using 5:1
Encourage and praise others when they use safe and productive behaviors Constructively correct and give advice to others when they use unsafe and unproductive behaviors Ask the participants if someone has coached a sports team and ask them to share how they coached that team. If nobody speaks up, explain how you may have coached someone, or were coached by someone. This leads into how encouraging safe behavior at Novant is not any different: Encouraging safe behavior is different from checking. Encouraging safe behavior follows observation of behaviors and performance of our coworkers. The goal is to encourage good behaviors and constructively correct poor behaviors. 5 to 1 describes the proper ratio for providing feedback to peers and coworkers. Research shows we all need to give a greater volume of feedback on the job and it needs to be in the ratio of 5 positives for every 1 negative. That doesn’t mean you give 5 goods followed by 1 bad. Its more of an idea over time. Look for the good things people are doing and recognize them on the spot with the lightest touch possible – and they will be more likely to repeat the good, productive behaviors in the future. Point to emphasize: That last one – correcting unsafe and unproductive behaviors – can be challenging because it requires approaching a coworker about something they are not doing right – but by using the lightest touch possible it can be done. And, by establishing a collegial environment where we are willing to be checked, its OK to say “thanks for the crosscheck” when on the receiving end of constructive correction. 27

Speak Up for Safety Using ARCC
Something I do to help our team prevent a safety event Ask a question Make a Request Voice a Concern Use the lightest touch possible… If no success… Use Chain of Command This next tool is something we should use only if we observe a situation that we believe compromises safety. Speak Up Using ARCC is a communication technique that can help us assert a concern in a non-threatening way to avoid coming on too strong when a simple question would have sufficed. ARCC helps escalate the concern if it is not addressed. ARCC is a very specific and effective error prevention tool when Crosschecking and Assisting. Normally, when we Crosscheck and Assist, it looks somewhat informal and can involve information, head nods, tips, teaching. In the case where you see a situation that concerns you, or you’re asked to do something that concerns you, the ARCC technique exists to resolve that concern without creating offense. ARCC can be especially helpful if we feel hesitant or intimidated to raise a concern to someone we perceive to be in a position of higher authority (a nurse speaking with a physician, a transporter speaking with a nurse). In the following example, a nurse speaks up for safety using ARCC when a physician walks into an isolation room without protective barriers: Ask a Question: Dr. Jones, aren’t we supposed to put on a gown and gloves when entering an isolation room? (Dr. Jones says he is not going to touch anything) Make a Request: Dr. Jones, could you please put on a gown and gloves as per isolation precautions. (Dr. Jones says he doesn’t have time.) Voice a Concern: Dr. Jones, I am concerned about the safety of our patient and other staff – we use barriers to prevent the spread of infections. (Dr. Jones goes on in.) Chain of Command: Dr. Jones, I am not comfortable with this, I need to speak with my supervisor. POINT TO EMPHASIZE Every organization should have a safe word and the safe word at Novant is CONCERNED. So whenever somebody says they’re Concerned, that should set off bells and whistles in our heads causing us to stop and address why this person has this genuine worry that we’re about to harm a patient. A Safety Phrase – “I have a Concern…” 28

A Speak up for Safety Failure
DC-8 from Denver to Portland with 189 people While preparing to land, indications of unsafe landing gear extension National Transportation Safety Board (NTSB) findings Captain failed to properly monitor fuel state Captain failed to respond to crewmember’s advisories regarding fuel state Crewmembers failed to successfully communicate fuel concern to Captain Here’s an example from another industry where they should have used ARCC. In1978 a DC-8 was preparing to land in Portland when it couldn’t lower its landing gear. The aircraft circled southeast of the airport at a low altitude for about 1 hour while the crew coped with a landing gear malfunction and prepared the passengers for an emergency landing. The crew was so distracted by the emergency that the plane eventually ran out of fuel and crashed 6 mi from the airport, killing 11 people. The National Transportation Safety Board determined that the cause of the accident was the poor teamwork in the cockpit where the captain failed to monitor the aircraft's fuel state and to properly respond to the crewmember's advisories. The two co-pilots were cited for failing to fully comprehend the criticality of the fuel state and successfully communicating their concerns to the captain. At one point as they were delaying during the troubleshooting, the flight engineer said, "Fifteen minutes is gonna -- really run us low on fuel here,” but he never REQUESTED a change in plan or voiced a CONCERN in an assertive manner. He was one of two crew members killed in the accident.

Speak Up for Safety Using ARCC
Something I do to help our team prevent a safety event Ask a question Make a Request Voice a Concern Use the lightest touch possible… If no success… Use Chain of Command This next tool is something we should use only if we observe a situation that we believe compromises safety. Speak Up Using ARCC is a communication technique that can help us assert a concern in a non-threatening way to avoid coming on too strong when a simple question would have sufficed. ARCC helps escalate the concern if it is not addressed. ARCC is a very specific and effective error prevention tool when Crosschecking and Assisting. Normally, when we Crosscheck and Assist, it looks somewhat informal and can involve information, head nods, tips, teaching. In the case where you see a situation that concerns you, or you’re asked to do something that concerns you, the ARCC technique exists to resolve that concern without creating offense. ARCC can be especially helpful if we feel hesitant or intimidated to raise a concern to someone we perceive to be in a position of higher authority (a nurse speaking with a physician, a transporter speaking with a nurse). In the following example, a nurse speaks up for safety using ARCC when a physician walks into an isolation room without protective barriers: Ask a Question: Dr. Jones, aren’t we supposed to put on a gown and gloves when entering an isolation room? (Dr. Jones says he is not going to touch anything) Make a Request: Dr. Jones, could you please put on a gown and gloves as per isolation precautions. (Dr. Jones says he doesn’t have time.) Voice a Concern: Dr. Jones, I am concerned about the safety of our patient and other staff – we use barriers to prevent the spread of infections. (Dr. Jones goes on in.) Chain of Command: Dr. Jones, I am not comfortable with this, I need to speak with my supervisor. POINT TO EMPHASIZE Every organization should have a safe word and the safe word at Novant is CONCERNED. So whenever somebody says they’re Concerned, that should set off bells and whistles in our heads causing us to stop and address why this person has this genuine worry that we’re about to harm a patient. A Safety Phrase – “I have a Concern…” 30 30

Current event rate, set at 100%
Our Goal – 80% Decrease in Serious Safety Events 20% Event Rate Awareness Skill Acquisition Habit Formation Performance Time 100% 80% Decrease In Event Rate Over 1-2 Years 2 Years Current event rate, set at 100% One myth in safety culture is that educating staff on safety culture reduces human error rate and thereby reduces the number of events involving harm to patients. This is simply not true. Education does not improve culture. But, if the staff return to their jobs and incorporate the ideas from education into their practice habits, the error rate improves quite a bit. (Recall that this culture change is designed to lower the event rate by 80% every two years.) The results that we achieve will only be proportional to our implementation. If we implement half, then our results will only be one-half (or a 40% reduction in event rate). The most important thing for you to take away from this presentation is that First, Do No Harm does not end with this training session! In fact, it just begins. This is all about practicing new behaviors that will help us make fewer errors – AND making those behaviors become our habits. This graph shows the stages of an effective error prevention program: Awareness – That’s what our training session is all about. We’ve educated you on our behavior expectations and tools for error prevention. But as you can see on the graph, awareness will drop our event rate only a small amount. Skill Acquisition – When we leave this training session, we’ll begin to practice our behaviors and use our error prevention tools. We won’t have it down perfectly – sometimes we’ll forget, and we may apply a tool incorrectly every once in a while. During this phase we’ll be counting on leaders and coworkers to reinforce our behavior expectations and help build our accountability for practicing them. Habit Formation – “Practice makes…habits!” At first, we’ll have to consciously remember to practice our safety behaviors. But over time, they will indeed become our work habits. Most likely, you’ll find yourself practicing them at home, too, and you’ll see a reduction in the errors that you make outside of work. Our goal is to make these best practices become our common practices. Performance – As our safety behaviors become our common practice, we will begin to see a reduction in the number of errors we make as individuals and in the number of events that occur at our hospital. As the graph demonstrates, we can expect to see an 80% reduction in our event rate within 2 years.

Novant Contact Information Sue DeCamp-Freeze Senior Director Clinical Improvement (704) Catherine Fenyves Patient Safety Manager (704)

First, Do No Harm: Building a Culture of Patient Safety at Novant Health Physician Education Part 2: Safety Behaviors for Error Prevention.

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First, Do No Harm: Building a Culture of Patient Safety at Novant Health Physician Education Part 2: Safety Behaviors for Error Prevention.

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