Transcript
Timothy B McDonald, MD JD
Chair, Anesthesiology
Medical Director for Quality and Safety
Sidra Medical and Research Center
Weill Cornell Medical College - Qatar
October 28, 2014
Courageous Communication
And
Teamwork
I have no actual or potential conflict of interest in
relation to this presentation
http://www.youtube.com/watch?v=2h2Q_uTEckM
April, 1982 ABC 20/20 show: “The Deep Sleep – 6,000 will
die or suffer brain damage…from carelessness”
Overview of Patient Safety and Anesthesiology
April, 1982 ABC 20/20 show: “The Deep Sleep” – 6,000 will die or suffer brain
damage…from carelessness
1983 ASA Committee on Patient Safety and Risk Management created – closed
claims analysis
1984 Anesthesia Patient Safety Foundation
1986 Monitoring standards established
Overview of Patient Safety and Anesthesiology
Following the Human Factors Analysis of Harm Events and
the redesign of care delivery and focus on “courageous
conversations and teamwork:
Overview of Patient Safety and Anesthesiology
Following some Courageous Conversations and the Human
Factors Analysis of Harm Events
Anesthesia Mortality Risk
๏ 1982 - 1:2000
๏ 2011 – 1:400,000
๏ Substantial reduction in patients and families seeking legal action
Some more background
Institute of Medicine:
1999 report that
shook the medical
world
Some more background
Institute of Medicine:
1999 report that
shook the medical
world
Some more background
Institute of Medicine:
1999 report that
shook the medical
world
Making Matters
Worse
February 2012, Volume 31, Issue 2
Evidence of failure to communicate
courageously
“Bad Culture” Linkages to poor outcomes
Disruptive behavior – unsafe, increased risk
Poor communication – unsafe, increased risk
Poor design – unsafe, increased risk
Poor teamwork – unsafe, increased risk
Lack of standardization – unsafe, increased risk
IOM SUMMARY
Part 1: National Center for Patient Safety – in HHS’s Agency for
Healthcare Research and Quality (AHRQ) to research, establish best
practices.
Part 2: Mandatory and Voluntary Reporting Systems – Legislation to
protect the confidentiality of information to learn about and correct
problems before serious harm occurs – value placed on data
Part 3: Role of Consumers, Professionals, and Accreditation Groups
– “No outcome – no income” and establish NQF Safe Practices,
transparency, “never events”.
Part 4: Building a Culture of Safety – Create an environment in which
safety becomes a top priority with focus on communication, human
factors, medication safety, electronic health records, computer order
entry, team training
15
Students
What is Culture and What are Team
Dynamics and what is meant by
“courageous communication”?
A case to illustrate the need for candor, safe
culture and positive team dynamics.
60 y.o. for CABG
Case proceeds uneventfully
Chest closed, skin closure occurring
Plan for extubation
Surgeon leaves to speak with family
Perfusionist hands cell saver blood to anesthesiology resident
Put under pressure
Cardiac arrest
Only resident notices air in line
What next?
What about Candor, Professionalism and
Safe Culture? Barriers Benefits
What about Candor, Professionalism and
Safe Culture
Benefits ๏ Maintain trust
๏ Learn from mistakes
๏ Improve patient safety
๏ Improve culture
๏ Employee morale
๏ Psychological well-being
๏ Accountability
๏ Money
๏ Less legal involvement
Barriers
๏ Lack of leadership support
๏ Loss of job
๏ Reputation
๏ “Shame and blame” culture
๏ Loss of control
๏ Loss of license, deportation
๏ Fear of lawyers, legal system
๏ Money
Condition Predicate
Teamwork-related issues
Courage to speak up
Ask for help
Team response to crisis
Communication to system
Communication to family
It’s all about culture
Critical Competencies for Effective Teamwork
Teamwork-related knowledge
Teamwork-related skills
Teamwork-related attitudes
It’s all about culture
Air embolism outcome
2009 Sep; 136(3): 897-903
How did we break down the “wall of
silence” and support courage?
How did we do to break down the wall of
silence at the University of Illinois?
Convinced leadership to adopt the Seven
Pillars approach to harm
Goals of the Seven Pillars
Reduce harm thru transparency and learning
Reduce legal involvement through early, effective
communication [courageous] with all parties
Resolve inappropriate care cases early, efficiently
Support patient and family engagement
Support care professionals following harm events
Rapid
Support for patients and families
Support for care professionals
Credit to Albert Wu
Safe Culture approach to events
Credit to James Reason, David Marx
Seven Pillars: Response to patient safety events
Rapid
Support for patients and families
Support for care professionals
Credit to Albert Wu
Safe Culture approach to events
Credit to James Reason, David Marx
Seven Pillars: Response to patient safety events
Creating a Safe Culture and Team Environment
Peer to peer support: for physicians by physicians
Rapid
Support for patients and families
Support for care professionals
Credit to Albert Wu
Safe Culture approach to events
Credit to James Reason, David Marx
Seven Pillars: Response to patient safety events
Pillar 2 - investigation
What happened and why? Understanding the “science”
behind harm events… and the importance of culture and
team dynamics
Non-health care related event
37
Human Factors Engineering and Safety
Healthcare Related Event
Human Factor Issues in Healthcare
40
Putting it all together
October 7, 2011
The Power of Candor
October 7, 2011
Questions
top related