Flexible Culture

A Flexible Culture Changes Work Processes to Minimize Risks to Patients

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Engage and Educate a Flexible Culture  

Joint Commission Website - Sentinel Event Statistics

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.

TeamSTEPPS Overview

As Carolyn Clancy, MD, Director of the Agency for Healthcare Research and Quality indicates, "Communication failures and lack of teamwork are major contributing factors to patient injury and harm. There is a growing body of evidence from military, civilian, transportation, and healthcare settings that confirms the fact that effective team skills can be developed." TeamSTEPPS® is an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and other teamwork skills among health care professionals. It includes a comprehensive set of ready-to-use materials and training curricula necessary to integrate teamwork principles successfully into your health care system. TeamSTEPPS® was developed by the Department of Defense (DoD) in collaboration with the Agency for Healthcare Research and Quality (AHRQ).

Foundation for Teamwork: Managing Disruptive Behavior

Disruptive behavior is any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse to physical or sexual harassment. Disruptive behavior causes strong psychological and emotional feelings, which can adversely affect patient care (Rosenstein & O'Daniel, 2008). On July 9, 2008, The Joint Commission issued a Sentinel Event Alert regarding disruptive behavior: and stated that, "Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team."

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.

Execute a Flexible Culture  

TeamSTEPPS Teamwork System

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

Structured Communication: SBAR

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.

Handoff Communications Tool - "I PASS THE BATON"

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).


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?

Department of Defense Video Link

Sample Disruptive Behavior Management Policy

Survey of Staff Relations to Increase Awareness of Disruptive Behavior