Building a Culture of Safety: It Begins With Me
Cheri Constantino-Shor, MSN, RN, CRNI, CMSRN Director of Clinical Practice and Professional Development Virginia Mason Medical Center Seattle, WA [email protected]
November 2, 2018 Objectives
✓ Correlate how working together can improve patient outcomes ✓ Describe barriers to working together as a collaborative healthcare team ✓ Discuss ways in which healthcare workers can begin to break down the existing hierarchy and better function as an efficient interdisciplinary team TeamSTEPPS 2006
Increase in EMR use to 70% in last 5 years
2007 CMS changes reimbursement 2008 Nurses first included in Gallup Poll Affordable Care Act 1999 2010
1991 1991 1995 1999 2003 2007 2011 2015 2018
1991 1999 2004 2008 2013 Today IOM Computer-Based IOM To Err is Human IHI recommends HCAHPS public Journal of Patient Patient Record: An team huddle reporting Safety report Healthcare instability Essential Technology for Health Care Here lies the Kardex Seen and Heard But we’re SO busy and healthcare has Become SO Complex!
• Often need to switch from one task to a more urgent task (for all the right reasons!) • And we’re distracted… U.S. Statistics on Medical Errors
• 1999 Institute of Medicine: To Err is Human statistics: • Between 44,000-98,000 people die each year as a result of preventable medical errors • September, 2013 The Journal of Patient Safety: A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care: • Between 210,000-400,000 premature deaths per year associated with preventable harm in hospitals Leading Causes of Death in the U.S. (CDC, 2017 and Makary & Daniel, 2016) 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0
Heart Disease Cancer Preventable Medical Harm COPD Accidents Stroke Alzheimer's Diabetes Copyright The Seattle Times, used with permission Statistics
Commercial aviation statistics: Only one death per 1,000,000 flights
U.S. Hospital admission data: One preventable At least 1,000 deaths/day in death per 100-300 = the U.S. (or equivalent of 3 plane crashes per day hospital admissions Those that intend to downplay the role of heroic individuals and instead emphasize Three main the importance of teams and organizations types of aviation safety measures Those that seek to increase and apply group that apply knowledge of safety information and values to healthcare:
Those that promote safety by design What does TEAMWORK look like in healthcare?
Borrowing Healthcare workers concepts from the feeling comfortable aviation industry speaking up if they Decrease on the importance are concerned, Human of working uncomfortable, or Error together and have a safety building systems concern about a that account for patient situation human error Nurses Change Tasks Every 56 Seconds Pay Attention to Detail: Categories of Human Error
Skill-based Rule-based Knowledge- based Proportion in 25% 60% 15% healthcare Error Stop and think Refer to policy, Find an expert prevention before acting double check themes calculation, increase risk awareness Accountability and acceptance of feedback is how we’ll TRULY build a culture of safety! Components of Teamwork according to AHRQ and US Department of Defense
• Team leadership • Mutual performance Your patient will have monitoring better outcomes if you know the name • Back-up behavior of the person you are • Adaptability working with and what they like to do • Team/collective on the weekend. orientation • Shared mental models Even better • Mutual trust outcomes if you also have formalized • Closed loop team training. communication • Patient: James Peabody, 68 year old African American male with history of diabetes and hypertension is admitted with left lower extremity cellulitis secondary to a 5 cm ulcer on his ankle. • He is on PO metoprolol, SC insulin- Aspart AC and Lantus HS and today Case Study has been ordered Vancomycin 1000 mg IV q12h • He has a 22g peripheral IV in his right forearm and limited peripheral venous access • He has had multiple unsuccessful IV attempts prior to the placement of his current IV “You’re in a Hurry, so Slow Down” Make a connection and inspire confidence: It’s all about building relationships
Smile and greet
Pause and be present Express positive intent
Embrace equality
Footer 19 80% of Serious Medical Errors Involve Some Sort of Miscommunication
SBAR
Clarifying Questions
Closed Loop Communication
“CUS”
Footer 20 Advocate for a PICC INS, January/February 2015
“The evidence base has expanded significantly in the past decade, and clearly argues for the abandonment of the pH restriction as the sole consideration for delivery of peripheral intermittent IV medications.” Decision making, as it relates to the most appropriate vascular access device, should include:
• Drug or solution pH • Osmolarity of solution • Anticipated during of infusion therapy • Type and number of infusates • Location of the peripheral IV catheter • Catheter size • Condition of the patient’s veins • Patient preferences Some Nursing Truths
• 7.4% of nurses are absent from work during the week as a result of job burnout or stress/anxiety (this rate has been reported to be 80% higher than other occupations) • Nurses nationally have higher illness, disability, and absenteeism rates than all other healthcare workers • Nationally, 30-54% of graduate nurses change position (and some leave the profession) within the first year of nursing • It costs between $21,000-$88,000 to replace an experienced RN • A positive work environment is correlated with less turnover, fewer occupational injuries, increased job satisfaction, less burnout, and improved patient outcomes (such as lower mortality and fewer complications).
24 Image permission obtained from alligatortek.com, October 2017 ✓ In January 2009, TJC issued leadership standards that require hospital leaders American to create and maintain a culture of Nurses safety and quality, acknowledging that “behavior that intimidates others and Association affects morale or staff turnover can be and harmful to patient care” The Joint Commission ✓ “A strong link exists between the Weigh In professional work environment and the registered nurse’s ability to provide quality healthcare and achieve optimal outcomes.” ANA (2010). What is lateral violence in nursing?
Acts in the nursing workplace that “can be covert or overt acts of verbal or non-verbal aggression. Behaviors include gossiping, withholding
information and ostracism.” (ANA, 2011).
Lateral violence: Refers to acts that occur between colleagues Bullying: Described as acts perpetrated by one in a higher level of authority and occur over time Behaviors associated with lateral violence in the nursing workplace
• Ostracism • Gossip • Isolation • Passive-aggressive • Sarcasm communication • Undermining work • Innuendos • Setting up to fail • Criticism • Withholding info • Belittling • Pressure to overwork • Rolling eyes in disgust • Condescending • Sneering communication • Threats • Threats of repercussions for • Physical abuse speaking out Imbalance of Power
Oppression Theory
Right of Passage
Low self esteem
Caretakers
Saying “yes” when we mean “no”
Female-dominated profession
There are some theories…
What are the impacts?
Increased absenteeism
Attrition of staff (some nurses even leave the profession, contributing to the nursing shortage!)
Nurses stop asking questions or seeking validation for knowledge
Deterioration in the quality of patient care! What are the impacts?
Gradual impact on the confidence and self-esteem of the bullied person
40% of clinicians report having “kept quiet” due to an intimidating colleague, contributing to impaired communication in the workplace
Unmanaged anger contributes to hypertension, coronary artery disease, depression, psychological problems, and other health problems
Low morale Republished with permission from The Online Journal of Issues in Nursing from Using Maslow’s Pyramid and the National Database of Nursing Quality Indicators to Attain a Healthier Work Environment, Paris, L. & Terhaar, M.,16, 1, 2011; permission conveyed through Copyright Clearance Center, Inc. Peer Accountability: 5:1 Feedback
Think about giving feedback Feedback ratio in the ratio of 5 positive to 1 negative (called the magic ratio) ✓ Builds trust ✓ Creates supportive environment ✓ Focus on how to improve and develop ✓ People grow faster than you think is possible! Positive
A Team with Depth- “bring everyone up so that you can count on anyone” Building Trust through Sliding Door Moments Responsibility of all nurses to shift the culture
“One preceptor acting in a welcoming way has the power to change the experience from negative to positive for one her hire. A new hire who is welcomed and supported will respond to others in the same way. Sustained acts of kindness can change the world.” (Modic, 2012, p. 300).
BUT HOW???????????????????????? Nurses’ control over practice
• Control over practice: • Organizational structures that promote empowerment are a characteristic of Magnet hospitals • An individual nurse’s value for self-determination and psychological belief, or self-efficacy, that he/she can and should change practice • Nurses’ control over practice is: • Essential to nursing care quality • Fosters teamwork at the point of care delivery • High control over practice exerted a statistically significant relationship with effective teamwork!
39 Pressure to ‘Do No Harm’
✓49-80% of nurses suffer from burnout –can lead to depression, detachment and at extreme, suicidal ideation
✓8% of nurses have or have been involved in substance abuse in the past year.
✓Average suicide rate for nurses 0.11 deaths per 1,000 (national average 0.07).
✓Nurses are 39% more likely to live longer than the average person How can I help myself to help others?
What am I doing/feeling? Self- Am I avoiding? Re-experiencing? Awareness Is this stress, a type of grief, compassion fatigue or burnout?
Set balanced Take a time out, know limits, regular vacations, Balance of ‘yes’ and ‘no’ boundaries
Self Care Rest, Health, Exercise, Play, Meditation/Mindfulness, Body work,.
Personal Nurture curiosity, creativity, play, spirituality Growth Learn a new way to manage stress Image used with permission from Wespire.com
Image used with permission from the Employee Engagement Group, 2017 Image used with permission from the Employee Engagement Group, 2017 Image used with permission from the Employee Engagement Group, 2017 Image used with permission from the Employee Engagement Group, 2017 Under- ____
Image used with permission from the Employee Engagement Group, 2017
References
• American Nurses Association (2015). Position Statement: Incivility, Bullying, and Workplace Violence. Retrieved from: http://www.nursingworld.org/HomepageCategory/NursingInsider/Archive-1/2015- NI/Aug15-NI/New-ANA-Position-Statement-Incivility-Bullying-and-Workplace-Violence.html • American Nurses Association (2014). Professional Role Competence. Retrieved from: http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/NursingStan dards/Professional-Role-Competence.html • Balevre, P., Cassells, J., & Buzaianu, E. (2012). Professional nursing burnout. Journal for Nurses in Staff Development, 28(1), 2-8. • Centers for Disease Control and Prevention (2017). Leading Causes of Death. Retrieved from: https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm • Christie, W. & Jones, S. (2013). Lateral violence in nursing and the theory of the nurse as wounded healer. The Online Journal of Issues in Nursing, 19(1), 1-13. DOI: 10.3912/OJIN.Vol19No01PPTO1 • Fennessey, A. (2016). The relationship of burnout, work environment, and knowledge to self-reported performance of physical assessment by registered nurses. Journal of the Academy of Medical Surgical Nurse, 25 (5), 346-50. • ISMP (2016). ISMP Medication Safety Alert: Reporting and second-order problem solving can turn short-term fixes into long-term remedies, 21(10), 1-4. • Lewis, G. et. al. (2011). Counterheroism, common knowledge, and ergonomics: Concepts from aviation that could improve patient safety. Milbank Quarterly, 89 (1), 4-38. References
• Lindokuhle, P, et. al. (2014). Nurses’ lifestyle behaviors, health priorities and barriers to living a healthy lifestyle: A qualitative descriptive study. BMC Nursing, 13 (1), 38. • McNamara, S. (2012). Incivility in nursing: Unsafe nurse, unsafe patients. AORN Journal, 95(4), 535-540. • Makary, M. & Daniel, M. (2016). Medical error-The third leading cause of death in the US. British Medical Journal, 353 (1). • Matt, Susan. (2012). Ethical and legal issues associated with bullying in the nursing profession. Journal of Nursing Law, 15(1) 9-13. • Mijakoski, D., et. al. (2015). Burnout, engagement, and organizational culture: Difference between physicians and nurses. Journal of Medical Science, 3 (3), 506-13. • Modic, M.B. (2014) Clinical judgment: Developing skills in reflection. Journal for Nurses in Professional Development. Retrieved from www.jnpd.com. DOI: 10.1097/NND. 0000000000000054 • Moran, R. (2012). Retention of new graduate nurses. Journal for Nurses in Staff Development, 28(6), 270-73. • Nance, John (2008). Why hospitals should fly: The ultimate flight plan to patient safety and quality care. Second River Healthcare Press; Skokie, IL. References
• Press Ganey Associates. (2015). The influence of nurse work environment on patient, payment, and nurse outcomes in acute Care Setting. Retrieved from: http://images.healthcare.pressganey.com/Web/PressGaneyAssociatesInc/%7Bb352868 c-885f-4834-a6a4-05368fd2ed55%7D_2015_PG_Nursing_Paper.pdf • Robert Wood Johnson Foundation. (2014). Civility Tool-kit: Resources to Empower Healthcare Leaders to Identify, Intervene, and Prevent Workplace Bullying. Retrieved from: http://stopbullyingtoolkit.org/ • Sabzevar, A., et. al. (2016). The effect of emotional intelligence training on employed nurses. Journal of Nursing and Midwifery Sciences, 3(3), 46-53. • The Institute of Medicine. (2010). The Future of Nursing, Leading Change, Advancing Health (Education brief). Retrieved from: http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of- Nursing/Nursing%20Education%202010%20Brief.pdf • Truglio-Londrigan. (2016). Shared decision making through reflective practice. Journal of the Academy of Medical Surgical Nurses, 25 (5), 341-45.