The Nebraska Center for Rural Health Research

ENGAGE AND EDUCATE

Process mapping allows you to identify productivity opportunities, best practices, root causes of problems, create workflow consistency, and determine who owns an action item within the process and who is accountable for the process.
 

Marx, D. (2001). Patient Safety and the “Just Culture”: A Primer for Health Care Executives.  Prepared for Columbia University under a grant provided by the National Heart, Lung, and Blood Institute.

"To promote a culture in which we learn from our mistakes, organizations must re-evaluate just how their disciplinary system fits into the equation. Disciplining employees in response to honest mistakes does little to improve overall system safety. Yet, mishaps accompanied by intoxication or malicious behavior presents an obvious and valid objection to today’s call for blame-free error reporting systems."
 

Dana-Farber Cancer Institute.  Principles of a Fair and Just Culture.  Patient Safety Rounds Toolkit.
Example of how one organization has operationalized "Just Culture".
 

This website provides a guide to building an open, fair, and just culture, and a guide to the management of three distinct classes of behavior. By registering to become a community member you can gain access to online training and an interactive form of the unsafe acts algorithm.
 

For over a decade, communication has been the single greatest root cause of sentinel events reported to the Joint Commission. In 2006, leadership and procedural compliance were also among the top four root causes of sentinel events. Communication, leadership, and compliance with procedures reflect the knowledge, skills, and attitudes required for healthcare providers to effectively function as teams.
 

To function as part of a team, individuals must feel valued and be treated with respect.

Alan Rosenstein, M.D., M.B.A., is Vice President and Medical Director, VHA West Coast. He is a nationally-recognized expert in the prevalence and management of disruptive behavior in healthcare. Michelle O’Daniel, M.H.A., M.S.G., is Director of Member Services at VHA. Dr. Rosenstein and Ms. O’Daniel have published extensively on the topic of disruptive behavior. Rosenstein and O’Daniel advocate a strategy to address disruptive behavior that includes: raising awareness through surveys, developing policies and procedures for reporting, and education. This education links disruptive behavior to adverse events and identifies structured teamwork and communication skills such as those in the TeamSTEPPS™ curriculum essential to managing disruptive behavior.
 

Being a learning organization does not mean that senior leaders are eager to try each new idea that emerges from the literature, a workshop, or a consultant. Being a learning organization means:

	formal and informal safety reporting systems provide information about safety systems
	there is a just and straightforward way to decide if an event warrants disciplinary action
	structured communication in the context of teamwork ensures that an organization is flexible—authority gradients are not a barrier to effective communication
	the will exists to act—to execute and evaluate—the changes indicated by safety reporting systems
	a learning organization systematically makes sense of events that occur to achieve the goals of eliminating risks and hazards to patient safety and providing evidence-based reliable care

Kotter J, Rathgeber H. (2006). Our iceberg is melting: Changing and succeeding under any conditions. New York: St. Martin's Press.

This book is an enjoyable fable that explores the elements necessary to implement organizational change. The fable follows Fred, a particularly observant penguin, who realizes his colony lives on a melting iceberg. Once the colony understands the need for change, several penguins with varying personalities and leadership styles rise to the challenge of finding a new home using the eight-step framework for change. Beginning with the need to create a sense of urgency and ending with the creation of a new culture, the lessons the penguins learn are relevant to hospitals as they create a culture of safety. While the fable teaches valuable lessons about the process of change, it also keeps the reader engaged with endearing penguin characters that can remind us of people in our own organization. In the end, Our Iceberg is Melting will provide those involved in patient safety and quality improvement with a framework to learn about the role of teamwork and communication in managing organizational change.

EXECUTE

This website provides a guide to building an open, fair, and just culture, and a guide to the management of three distinct classes of behavior. By registering to become a community member you can gain access to online training and an interactive form of the unsafe acts algorithm.
 

Executing the TeamSTEPPS teamwork system should result in changing the knowledge, attitudes and performance of healthcare providers related to teamwork. Executing TeamSTEPPS requires an understanding of team structure and the skills to lead teams, monitor the situation, communicate effectively, provide mutual support to team members.

Executing leadership in the context of teamwork requires the following skills:

	Organize the team
	Articulate clear goals
	Make decisions through collective input of members
	Empower members to speak up and challenge, when appropriate
	Actively promote and facilitate good teamwork
	Skillful at conflict resolution

Executing situation monitoring requires actively scanning the behaviors and actions of those around you to assess elements of the situation or environment.

Executing mutual support is the essence of teamwork

	Protects team members from work overload situations that may reduce effectiveness and increase the risk of error
	Team members foster a climate in which it is expected that assistance will be actively sought and offered as a method for reducing the occurrence of error.

Executing effective communication requires that communication is

	Complete…all relevant information is communicated
	Clear…convey information that is plainly understood
	Brief…communicate the information in a concise manner
	Timely… - Offer and request information in an appropriate timeframe - Verify authenticity - Validate or acknowledge information

In flexible organizations that value reporting, authority patterns relax when safety information is exchanged because those with authority respect the knowledge of front-line workers. SBAR is a tool that structures communication (informal reporting) and ensures that healthcare providers exchange critical patient information in a manner that overcomes barriers to effective communication. These barriers include the traditional authority patterns in healthcare, gender, ethnicity, and differences in communication styles. By using SBAR, one provider systematically provides information about a Situation (what is happening) and the Background leading up to the situation, provides his/her Assessment of the problem, and his/her Recommendation to address the problem described in the situation. SBAR enables reporting information in a structured format that supports effective communication across authority gradients. As such, the SBAR technique is a practice that requires interaction between a reporting culture and a flexible culture.
 

Ineffective handoff of information can lead to delays in diagnosis, the wrong treatments, life-threatening adverse events, patient complaints, an increased cost and length of stay, and litigation. Patients are at particular risk for errors during transitions in care. Recognizing this risk, the Joint Commission has a specific National Patient Safety Goal 2E that addresses communication during hand offs and transitions in care: “Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.” Flexible organizations use structured communication tools to decrease the risk to patients during handoffs and transitions in care. During effective handoffs, information, authority, and responsibility are clearly transferred by including an opportunity to ask questions, clarify, and confirm information. The SBAR format is one tool to structure handoffs in care. The Department of Defense developed a tool to specifically transfer patient information, as well as responsibility and accountability for patient care. The mnemonic for this tool is “I PASS the BATON.”

Department of Defense Patient Safety Program. Healthcare Communications Toolkit to Improve Transitions in Care. (2005).  Retrieved December 28, 2007, from http://dodpatientsafety.usuhs.mil/files/Handoff_Toolkit.pdf 

I ntroduction—Introduce yourself and your role/job.
 

P atient—Confirm the patient’s name, identifiers, age, sex, location.

A ssessment—Provide your assessment of the patient’s chief complaint, vital signs, symptoms, and diagnosis.

S ituation—Describe the patient’s current status/circumstances, including code status, level of uncertainty, recent changes, response to treatment.

S afety concerns—Provide critical lab values/reports, socio-economic factors, allergies, alerts (e.g. falls, isolation).
 

THE
 

B ackground—Identify comorbidities, previous episodes, current medications, history.

A ctions—Describe actions that were taken or are required AND provide a brief rationale.

T iming—Explain the level of urgency, explicit timing, and prioritization of actions.

O wnership—Identify who is responsible for the next steps including patient/family responsibilities.

N ext—Confirm what will happen next. Anticipated changes? What is the plan?

EVALUATE

This report summarizes the medication error reports voluntarily submitted to MEDMARX in calendar year 2005 by the 25 Critical Access Hospitals in our project.