Collaborative Practice in Healthcare

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Collaborative Practice in Healthcare

Designing Systems for Quality and Safety WebEx

• Jeff Brown
• Klein Associates
• A Division of Applied Research Associates
• January 09, 2007
• Bloomington, MN

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How well do we do at teamwork in healthcare??

• 2007 Jeff Brown, Klein Assoc. Div. ARA

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JCAHO Sentinel Events
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Quality of Teamwork across 25 organizationsDiffe
rences between Physicians Nurses
Slide courtesy of Michael Leonard, MD
Quality of Teamwork Scale (1very low to 5very
high)
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Teamwork Climate Annual Nurse Turnover
Slide courtesy of Michael Leonard, MD
 
reporting positive teamwork climate
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I know the names of all the personnel that I
worked with during my last shift
Slide courtesy of Michael Leonard, MD
 
of respondents who agreed
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Second Curve
--Martin Merry
future
present
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How health care feels today depends on which
curve you are on
excitement
x
x
discouragement
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• This will require countercultural changes
• in professional practice
• Changes in patterns of interaction
• and communication among frontline
• personnel.
• Use of new technological aids
• Fundamental changes in
• administrative control.

• 2007 Jeff Brown, Klein Assoc. Div. ARA

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The Importance of Communication

• Outcome reliability is ultimately dependent on
  
• effective decision-making and coordination of
  
• action among members of small front-line
  groups.
• Safety is founded in speech exchange
• and social interaction.
• After reviewing nearly 3,000 deaths or serious
• injuries in hospitals, the Joint Commission
  found
• that communication failures were an element
  in
• essentially 100 of the cases reviewed, and
• were the primary root cause failed defense
  in
• over 60.

• 2007 Jeff Brown, Klein Assoc. Div. ARA

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Key Behavioral Safeguards of Team-based Safety1
Team Building
Planning
1Klinect, James (2000). CRM Lessons Learned
from LOSA. Bob Helmreichs LOSA Presentation
On-line slide show. University of Texas Human
Factors Research Project. http//www.psy.utexas.ed
u./psy/helmreich/nasaut.htm

• 2007 Jeff Brown, Klein Assoc. Div. ARA

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Structured Communication
Personnel with interdependent professional roles
communicate in consistent ways (briefings) that
optimize situation assessment, strategy
development and coordinated action. Patankar
and Taylor, 2000

• 2007 Jeff Brown, Klein Assoc. Div. ARA

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Elements

• Reduced hierarchy
• Communication Groundrules
• Briefings
• Shared Understanding/Situation Awareness
• Contingency Plans and Tolerances
• Monitoring and back-up
• Updating
• Adaptive action
• Debriefings
• Individual, team, task, technical, and
• organizational performance
• Hazards and error-provoking conditions

• 2007 Jeff Brown, Klein Assoc. Div. ARA

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Concord Collaborative Care Model Concord
Hospital, Concord, New Hampshire 2002 John M.
Eisenberg Patient Safety Award System
Innovation (JCAHO/NQF)

Courtesy of Paul Uhlig, MD, MPH
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Collaborative Care
NP/PA
Patient and family
Nursing
a true team
Surgeon
Pharmacist
Home Care
Social Worker
Nutrition
PT/OT/RT
Spiritual Care
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Patients and families as part of the care team
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• Concord Collaborative Care Model
• all disciplines present at one time
• patients and families are active participants
• ordinary language or immediate translation
• all information directed toward the patient
• strength-based not illness-based
  (dignity, respect, self-care)
• human factors science/HRO theory

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• Basic Principles of
• Human Factors Science/ CRM/ HRO Theory
• system rather than individual-centered approach
• consistent patterns of information sharing
  (structured communications methodology)
• overlapping roles/cross-checks/attentiveness
• reduced hierarchy full disclosure trust
• real-time glitch capture system learning

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Collaborative Communication Cycle
Review (closure and carry over)
Theory of Situation (discussion /
alignment)
Plan of Action (discussion /
alignment)
System Glitches?
Glitch Book
Special Roles?
Annenberg IV 2002
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Example GLITCHes

• Stop date on pepcid and raglan not entered
• Aortic dissection diagnosis missed--no echo in
  ER
• ICU not aware of second heart surgerycase
  booked for the day
• Doxepin recorded at BOT 25mg and 50 mg in chart
• Patient placed on oxygen after exposed care
  giver's perfume
• Surgeon's page inoperative when urgently needed
• Lipitor noted as started, but no order existed
• Swan catheter pulled back without discussion
  with surgeon
• Discrepancies in parameters for lopressor
  between surgeons
• Documented VRE, but no barrier precautions
• Three different disciplines took blood pressure
  on the same patient in one
• morning
• Patient not off coumadin before surgery--surgery
  delayed
• Patient asked to be taken back to bed, but was
  overlooked during shift
• change
• ID band with wrong name.
• Noise in CCU prevented sleep
• Patient concerned about the presence of
  construction workers in ICU
• Foley not maintained

• 2005 System Safety Group

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Patient/Family Satisfaction
(97-99th percentile nationally) Concord Hospital
open heart surgery patients are happier than
mothers having babies
Source Concord Hospital Press-Ganey Surveys
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Quality of Work Life
Not True
Very True
1 2 3
4 5
Sense of common purpose Sense of
personal/collective power Listen actively to
each other Share responsibility for
leadership Problem-solving process
apparent Feel respected Feel good about team
membership Sense of cohesion and team spirit
collaborative rounds traditional rounds
(February 2001, n16) Karen Reagan, RN BSN
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Expected Observed
Institution of collaborative rounds and other
changes at green arrow
(4.8)
(2.1)
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North Shore Medical CenterCardiac Surgery

• Salem, Massachusetts

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(No Transcript)
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Collaborative Care Rounds

• Patient
• Family Members
• Physician
• Physician Assistant
• Pharmacist
• Chaplain

• Primary Nurse
• Clinical Nurse Specialist
• Nurse Practitioner
• Respiratory Therapist
• Exercise Physiologist
• Case Manager

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HIPAA Compliance
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All Case Operative Mortality Concord Expected
(NNE Risk Model) Concord Observed Salem
Observed
(Onset of collaborative care at red arrow)
(Onset of collaborative care at green arrow)
All Case Mortality (percent)
(4.8) Concord Expected
(2.1) Concord Observed
(0.3) Salem Observed
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Where to Begin?

• 1. What are your goals?
• 2. Do you have clinical and administrative
  champions?
• a. Is leadership ready for Rocks to be Lifted?
• Examples
• The example of OB crisis team development
• The vertical safety audit
• 3. Care transitions
• Information and knowledge flow during transitions
• Transitions of the patient among clinical units
• Transitions in staff at shift turnover other
  transitions in authority and responsibility for
  care of the patient.
• 4. Hows the relational infrastructure in your
  organization?

• 2007 Jeff Brown, Klein Assoc. Div. ARA

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Where to Begin?, continued

• Build team performance from existing strengths of
  communication and interaction, consistent with
  behavioral safeguards against error and accident.
• Pilot teamwork initiative where there are
  clinical championspassionate leaders who will
  model team work behaviors with inclusion and
  respect.

• 2007 Jeff Brown, Klein Assoc. Div. ARA

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Highly Reliable Systems

• Are organized around highly functional teams.
• Support work processes wherein team members
• develop overlapping role and task knowledge.
• Enable individual team members to exercise joint
  
• accountability for all elements of the process
  to
• which they contribute.
• Are organized to optimize information processing
• and decision-making among front-line personnel.
• Continuously monitor and improve system
  performance
• based on evolving front-line experience.
• Leadership skills are a critical reliability
  factor in
• complex systems.

• 2007 Jeff Brown, Klein Assoc. Div. ARA

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We Are Never Out of the Woods
The safety of socially and technically complex
systems is shaped dynamically, by people and
technology within and among organizations,
across varied and geographically distributed
environments, and over time. The ability to
reliably manage complex, high-consequence work is
a property of highly effective
(adaptive) frontline teams.

• 2007 Jeff Brown, Klein Assoc. Div. ARA

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References

• Berwick, D., A Users Manual for the IOMs
  Quality Chasm Report. http//www.healthaffairs.o
  rg
• Corrigon, J., Kohn, L.T., Donaldson, M.S.
  (Eds.). (2000). To Err is Human. Building a
  Safer health System. Washington, DC, National
  Academy Press.
• Corrigon, J., Kohn, L.T., Donaldson, M.S.
  (Eds.). (2001). Crossing the Quality Chasm, a
  New Health System for the 21rst Century,
  Washington, DC, National Academy Press.
• Helmreich, R.L. Merritt, A.C., Culture at Work
  in Aviation and Medicine National,
  Organization, and Professional Influences,Ashgate,
  1998
• Klinect, James (2000). CRM Lessons Learned from
  LOSA. Bob Helmreichs LOSA Presentation On-line
  slide show. University of Texas Human Factors
  Research Project. http//www.psy.utexas.edu./psy/
  helmreich/nasaut.htm
• Patankar, Manoj Brown, Jeffrey, Treadwell,
  Melinda, Safety Ethics Cases from Aviation,
  Healthcare, and Occupational and Environmental
  Health, Ashgate, 2005.

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References

• Nelson, E., Batalden, P., Huber, T., Mohr, J.,
  Godfrey, M., Headrick, L., Wasson, J.
  Microsystems in Health Care Part 1. Learning
  from High-Performing Front-Line Clinical Units.
  Joint Commission Journal on Quality, September
  2002.
• Patterson, E., Render, M., Ebright, P. ,
  Repeating Human Performance Themes in Five
  Healthcare Adverse Events, Proceedings of the
  Human Factor and Ergonomics Society 46th Annual
  Meeting.
• Roberts, K. and Bea, R., When Systems Fail From
  the Titanic to the Estonia, 2001,
  Organizational Dynamics, Volume 29, pp. 179-191
• Rasmussen, J. (1982). Human errors A taxonomy
  for describing human malfunction in industrial
  installations. Journal of Occupational Accidents,
  4, 311-333.
• Reason, J. (1990) Human Error, Cambridge
  University Press
• Reason, J. (1997) Managing the Risk of
  Organizational Accidents, Ashgate

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Jeff Brown 603-924-7983 jpbrown_at_ara.com