Académique Documents
Professionnel Documents
Culture Documents
Bedside Communication
Unit-Based Huddles
Teamwork Training
Preface
The Partnership for Patients (P.f.P.) initiative, a publicprivate partnership and its more-than 3,700
participating hospitals are focused on using effective
improvement and change strategies to make hospital
care safer, more reliable, and less costly.* Joint
Commission Resources, Inc., one of 26 Hospital
* Centers for Medicare & Medicaid Services. Partnership for Patients. Accessed May 30, 2013. http://innovation.cms.gov/initiatives/Partnershipfor-Patients/.
Positive
Patient
Experience
Reliable
Systems
Safe,
Patient-centric
Culture Strategy
Physician Leaders
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Page 2
Changing Expectations of
Leadership Team
The changing expectations for patient safety have
important implications for the expectations of hospital
leadership teams, as follows:
1. The board and corporate (C-suite) teams are
personally involvedthat they fully participate,
individually and collectively, in patient safety
initiatives. It has become conventional wisdom that
patient safety cannot be delegated. It cant be left to a
committee, function, or individuals, in which results
are reported up the chain of command. Although
organizational infrastructure is necessary for
accountability, the current best practice demands that
everyone participatethe board, the C-Suite, the
leadership team(s) at all levels, every clinical
practitioner; in fact, every employee or contract
service-provider of the organization in a committed
partnership with patients and their families.
2. The leadership teams learn from the best practices of
organizations outside health careincluding the
nuclear power industry, the commercial air travel
system, and the flight decks of aircraft carriers3that
who achieved high reliability. Even though health
care is, in the words of John Nance, a frequent
contributor to the practices of both aviation and
health care safety, an order of magnitude more
complex than any other enterprise,4 the lessons
learned can help health care make rapid progress. For
example, almost all sentinel events in health care have
poor communications and teamwork as their root
cause or at least as a strongly contributing cause. The
lessons about teamwork from other industries as they
Page 3
References
1. Chassin MR, Loeb JM. The ongoing quality improvement journey: Next
stop, high reliability. Health Aff (Millwood). 2011;30(4):559568.
2. CMS.gov. Partnership for Patients. Accessed May 10, 2013.
http://innovation.cms.gov/initiatives/partnership-for-patients/.
3. Reason J. Human error: models and management. BMJ. 2000;
320(7237):768770.
4. TMT National Research Test Bed. Nance JJ. Charting the Course:
Launching Patient-Centric Healthcare. Apr 18, 2013. Accessed
May10, 2013. http://www.safetyleaders.org/webinars
/indexWebinar_April2013.jsp.
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Board Engagement in
Patient Safety
One of the most important interventions for
hospital leadership in developing a hospital
safety program is to get the hospitals board
involved with safety and quality.1
Page 6
Safety Culture
Debriefing
The CEO and senior administrative leaders
should be directly involved in the application of
the knowledge that has been generated through
the measurement of culture.1
Page 7
Safety Leadership
Rounds
(also known as WalkRounds)
Organizations across the world are . . . using
the WalkRounds program as a mechanism to
engage senior leaders in efforts to improve the
reliability of care in their organizations.1(p. 46)
Page 8
Teamwork Training
and Skill Building
The CEO and senior administrative leaders
should be directly involved in ensuring that the
organization implements the activities detailed in
the specifications of the Teamwork Training and
Skill Building safe practice. This includes participating in the defined basic training program.1
Page 9
Reference
1. National Quality Forum. Safe Practices for Better Healthcare2009 Update: A Consensus Report. Mar 2009. Accessed May 10, 2013.
http://www.qualityforum.org/Publications/2009/03/Safe_Practices_for
_Better_Healthcare%e2%80%932009_Update.aspx.
2. The Joint Commission. Sentinel Event DataRoot Causes by Event Type.
Feb 7, 2013. Accessed May 10, 2013. http://www.jointcommission.org
/Sentinel_Event _Statistics/.
3. Risser DT, et al; the MedTeams Consortium. The potential for improved
teamwork to reduce medical errors in the emergency department. Ann
Emerg Med. 1999;34(3):373383.
4. Agency for Healthcare Research and Quality. TeamSTEPPS: National
Implementation. Accessed May 10, 2013. http://teamstepps.ahrq.gov/.
Page 10
1. Healthcare Performance Improvement, LLC. Best Practices in Implementing Leadership Methods. Pre-Summit Workshop, Sep 20, 2011,
Grand Rapids, MI. Safety Summit 2011: Navigating Toward Zero
Events of Harm. Accessed May 16, 2013. http://hpiresults.com
/safetysummit/docs/2011_breakout/Best%20Practices%20in%20
Implementing%20Leadership%20Methods.pdf.
Page 11
Senior Executive
Adopt-a-Work Unit
(Also known as Comprehensive
Unit-Based Safety Program)
Page 12
Best Practices of
Execution
The first discipline of execution is to focus your
finest effort on one or two goals instead of
giving mediocre effort to dozens of goals.1
From The 4 Disciplines of Execution, page 21
References
1. Bossidy L, Burck C, Charan R. Execution: The Discipline of Getting
Things Done. New York City: Crown Business, 2002.
2. McChesney C, Covey S, Huling J. The 4 Disciplines of Execution: Achieving Your Wildly Important Goals. New York City: Free Press, 2012.
* The practices in this section are based on the book, The 4 Disciplines of
Execution: Achieving Your Wildly Important Goals. Although we do not recommend or endorse any particular product or service from the authors or
their company, the principles and disciplines of execution contained in
the book have proven their effectiveness in health care settings and deserve careful consideration.
Page 13
Part 2. Physician
Leadership Strategies
Physician engagement and participation are critical
elements to any health care delivery organizations
efforts to improve the safety of care. However, as Taitz,
Lee, and Sequist suggested, most physicians are ill
equipped to lead patient safety initiatives, and many
physicians struggle to optimally contribute to patient
and quality improvement efforts that lead to safer, high
quality care for their patients.1(p. 722) Physicians represent
leadership in health care and help set the norms for an
organization.
As frontline providers, physicians patterns of behavior
and level of engagement influence the views and
expectations of nurses and other clinical care providers.
Thus, it becomes very important to have them
connected to any effort designed to improve clinical
care. Without engagement and alignment, variation in
care provision cannot be addressed and substantive,
lasting improvement cannot be guaranteed.
Physician engagement is one of the more difficult
aspects of safety culture to address because of the
inherent complexities of the physicians interactions
within a health care organization. Because of the
historically autonomous nature of physician practice, it
can easily become disassociated from the organizations
operational and strategic goals. With this in mind, we
often find that the lack of physician involvement in
quality endeavors reflects such factors as competing
demands, wariness of loss of autonomy to corporate
structures, an absence of compensation for participation, and lack of formal training and knowledge in
quality improvement work. Our goal is to provide
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Page 18
Used by permission of the publishers from Reasons Decision Tree of Culpability, in Managing the Risks of Organizational Accidents
by James Reason (Farnham, UK: Ashgate, 1997). Copyright 1997.
Page 19
Key Points
1. Draft a Code of Conduct that each physician on staff
would commit to in support of a just culture in
patient safety and quality improvement initiatives.
The Code of Conduct must be drafted with
direct input from physician leaders or members
of the Physician Leadership Advisory Group in
order to engender trust and support. The same
levels of leadership from other levels of care
provision should be directly involved as well.
2. Hold town-hall style meetings to obtain feedback
from physicians and other-level care providers and
tailor Code of Conduct to reflect input and to ensure
majority buy-in.
Page 20
Key Points
1. Change process and focus of departmental M&M
conferences to specific cases with actionable systembased, patient safety interventions
Consider shifting focus away from cases that are
of purely academic interest or involve inevitable
outcomes.
Consider renaming M&M (which has a heavy
historical context in shame and blame) to
Patient Safety and Quality Improvement
Conference to shift attention from the sharp to
the blunt end.
2. Create quarterly patient safety and quality
improvement conferences that focus on cases that
involve multidisciplinary groups of physicians to
encourage discussion of systemwide and
communication issues.
3. Create, on a widely accessed hospital and/or
department homepagea forum and space to
showcase and share best practices and patient
safety/QI initiative success stories.
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Page 22
Key Points
1. When convening physicians to discuss quality and
safety initiatives, use the opportunity to incorporate
and discuss relevant items from both medical and
industrial literature. Allow for discussion of these
concepts in order to reinforce how they are
connected with the organizations practice.
2. Create a system for reporting (both concerns and
actual events) that is both efficient and anonymous.
Ensure that this system uses multiple modes of
contact (online form, hotline, etc) for ease of use.
Page 23
Key Points
1. Create dashboards of quality and safety data that feed
back directly to individual departmental leadership.
2. Create accountability on the leadership level to
ensure that this reporting leads to improvement.
3. Allow the dashboards to become a natural part of the
organizations conversation on current process
improvement and patient safety. Refer back to them
as a method to measure effectiveness of interventions
4. Through iterative process, continue to measure
physician satisfaction with initiatives. Adapt and
expand the initiatives based on this feedback, and let
physicians be aware that their opinions are helping
shape directives.
Page 24
Key Points
1. Create quality-based incentives for physicians that are
in line with their clinical expectations. If routine
measures seem disconnected, allow the physician
body to help develop and contribute their own
additional measures.
Routinely obtain feedback on these measures to
ensure viability, congruency, and satisfaction.
2. Recognize physician leaders who take up the mantel
of safety/quality champion, and publicly
acknowledge their efforts. Incorporate the career
development of these individuals into your
organizations long-term strategic planning.
Page 25
References
1. Taitz JM, Lee TH, Sequist TD. A framework for engaging physicians in
quality and safety. BMJ Qual Saf. 2012;21(9):722728.
2. Birk S. Models of physician engagement: community hospital employs
physicians to address local needs. Fort Hamilton Hospital establishes a
structure to give physicians a clear voice. Healthc Exec. 2009
NovDec;24(6):3436, 38, 40.
3. Walsh KE, Ettinger WH, Klugman RA. Physician quality officer: A new
model for engaging physicians in quality improvement. Am J Med Qual.
2009;24(4):295301.
4. Reason J. Managing the Risks of Organizational Accidents. Farnham, UK:
Ashgate, 1997.
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Page 27
Physician
Communication
at the Bedside
Common to all such interactions is the desire
for trustworthy information (often from an
individual clinician) that is attentive, responsive, and tailored to an individuals needs.1 (p. 50)
Page 28
Physician Involvement
in Unit-Based Huddles
Patients want to be treated like responsible
adults capable of assimilating information, asking informed questions, and having reasonable
expectations.1
1. Spath PL, editor. Engaging Patients as Safety Partners: A Guide for Reducing Errors and Improving Satisfaction. Chicago: Health Forum, Inc, 2008.
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Page 30
Harm-Reduction
Rounding Checklists
and Evidence-Based
Guidelines
A checklist is a type of informational job aid used to reduce failure by compensating for
potential limits of human memory and attention. It helps to ensure consistency and
completeness in carrying out a task. Evidence-based guidelines use the best available
evidence regarding the effectiveness, risks, and cost of a medical procedure before
implementing the procedure in clinical practice.1(p .688)
Page 31
Date: _________________
Purpose: To eliminate patient harm that is preventable. This tool will be designed by physicians within hospitals to reflect
their priorities for harm reduction during daily rounds with the multidisciplinary team within their service specific area.
Category
Checklist Options
Notes: Action
Infection Prevention
Medication Safety
Bedside Safety
Physiologic Safety
Transfer Plan?
Care team in place for handoff?
L.T.A.C. candidate?
Provided courtesy of Benjamin Taylor, MD, MPH, Assistant Professor, and Chief Quality and Patient Safety Officer, University Hospital,
University of Alabama at Birmingham School of Medicine. The checklist may be adapted for use with acknowledgement.
Page 32
Date: _________________
Purpose: To eliminate patient harm that is preventable. This tool will be designed by physicians within hospitals to reflect
their priorities for harm reduction during daily rounds with the multidisciplinary team within their service specific area.
Category
Checklist Options
Notes: Action
Infection Prevention
Medication Safety
Bedside Safety
Physiologic Safety
Vital Sign Stability past 24 hours: If S.B.P. < 90, M.A.P. < 65,
or H.R. > 130, shock workup been considered?
Have we started nutrition and are we at tube feeding goal?
Glucose control less than 180?
Code Status Addressed?
Adapted by Joint Commission Resources from ICU Rounding Checklist (Figure 1, page 32) .
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Multidisciplinary
Teamwork Training
Teams perform better than collections of individuals. In any situation requiring a real-time
combination of multiple skills, experiences, and
judgment, teamsas opposed to individuals
create superior performance.1(p.381)
Page 35
Physician Leadership
of Post-Adverse Event
Debriefs
An adverse event is defined as an injury caused
by medical management rather than by the
underlying disease or condition of the patient.
A potential adverse event carries the potential for
injury. Many, but not all, adverse events are preventable. Those that are preventable, or those
that are preventable and result only in the potential for harm, are considered errors.
Thus, errors may or may not result in adverse events, and adverse events may or may not be
the result of errors.1 (p. 2)
References
1. Regenstein M. Understanding the First Institute of Medicine Report and Its
Impact on Patient Safety. In Youngberg BJ, Hatlie MJ, editors. The Patient Safety Handbook. Burlington, MA: Jones & Bartlett Learning,
2004, 116.
2. Pratt S, et al. How to develop a second victim support program: A
toolkit for health care organizations. Jt Comm J Qual Patient Saf. 2012
May;38(5):235240.
Page 36
Managing Challenging
Behavior
A major challenge in transitioning to the health
care system of the 21st century . . . is
preparing the workforce to acquire new skills
and adopt new ways of relating to patients and
each other.1(p. 19)
Reference
1. Institute of Medicine. Crossing the Quality Chasm: A New Health System
for the 21st Century. Washington, DC: National Academy Press, 2001. .
Page 37
7. Rice JA, Sagin T. New conversations for physician engagement. Five design principles to upgrade your governance model. Healthc Exec.
2010;25(4):66, 6870.
8. Walsh KE, Ettinger WH, Klugman RA. Physician quality officer: A new
model for engaging physicians in quality improvement. Am J Med Qual.
2009;24(4):295301.
9. Szent-Gyorgyi LE, et al. Building a departmental quality program: A patient-based and provider-led approach. Acad Med. 2011;86(3):314320.
10. Taitz JM, Lee TH, Sequist TD. A framework for engaging physicians in
quality and safety. BMJ Qual Saf. 2012;21(9):722728.
11. Hockey PM, Bates DW. Physicians' identification of factors associated
with quality in high- and low-performing hospitals. Jt Comm J Qual Patient Saf. 2010;36(5):217223.
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