Stop The Line Policy

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Stop The Line Policy Academic Medical Center
Initiative
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• Campus-wide Initiative
• Policy has been approved by WUSM, BJH, SLCH
• Policy is now being disseminated to all faculty
  and staff
• Stop The Line (STL) Advisory Panel formed
• Multi-disciplinary and inter-institutional group
  formed to evaluate effectiveness of the policy
  and review any case when STL is inappropriate or
  inadequate

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Stop the Line (STL) Team
WUSM Dr. Nikoleta Kolovos, PICU Dr. Chris
Carpenter, EDDr. Brian Nussenbaum,
OtolaryngologyDr. Jim Duncan, RadiologyDr.
Andrea Vannucci, AnesthesiaDr. Doug Schuerer,
TraumaDr. Mike Lane, Infectious DiseasesDr.
Robert McKinstry, RadiologySally OShea,
HRMary Taylor, Patient Safety

• BJH and SLCH
• Debbie Hendricks, BJH, Oncology
• Jody Woodward, BJH, Patient Safety
• Roz Corcoran, BJH, Patient Safety
• Mara Bollini, SLCH, Patient Safety
• Cathy Meyers, SLCH, HR
• Michael Miller, BJH HR
• April Kutheis, SLCH, OR
• Maria Fernandez, SLCH, PICU
• Betty Langin, SLCH, PACU
• Kathy Hughes, SLCH, SDS
• Advisory Panel members indicated in bold

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What is Stop the Line?
Originated from the Toyota Production
Systemtraditionally the industry standard for
excellence in production

• Built on the philosophy that every person is
  responsible for the process
• Shifts responsibility for quality into the hands
  of team members who are empowered/expected to
  speak up when problems are identified
• Operates on the belief that solving quality
  problems at the source improves safety and
  quality
• Providing a cultural shift so that every person
  feels responsible for the safety (of our patients)

Jeffrey K. Liker, The Toyota Way 14 Management
Principles from the World's Greatest
Manufacturer, McGraw-Hill 2004.
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Why Stop the Line? Inherent Human Limitations
Why Stop the Line? Inherent Human Limitations
Why Stop the Line? Inherent Human Limitations
Line? Inherent Human Limitations

• Limited memory capacity we can store 5-7 pieces
  of information in our short term memory
• Negative effects of stress error rates, tunnel
  vision
• Negative influence of fatigue and other
  physiological factors
• Limited ability to multitask ex cell phones,
  texting and driving

Courtesy Michael Leonard, MD Karen Frush, MD
Presentation at the SLCH UBJP Team Leaders
Workshop, EPNEC, May 12, 2009.
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Why Stop the Line in Our Academic Medical Center?

• Clinical medicine is an extremely complex
  environment with
• Surprises
• Uncertainty
• Incomplete information
• Interruptions and multi-tasking
• The overwhelming majority of untoward events
  involve communication failure
• e.g. wrong site surgery somebody knows theres
  a problem but cant get everyone in the same
  movie
• The clinical environment has evolved beyond the
  limitations of individual human performance

Courtesy Michael Leonard, MD Karen Frush, MD
Presentation at the SLCH UBJP Team Leaders
Workshop, EPNEC, May 12, 2009.
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Why Stop the Line? 25-40 of nurses at SLCH
reported on the Safety Attitude Questionnaire
they would be hesitant to speak up if they saw an
MD making a mistake
Concern Non-Supervisory Employees Confront the Person Supervisors Who Confront the Person
Competence of a Nurse or other Clinical Care Provider 3 16
Competence of a Physician Less than 1 Less than 1
Poor Teamwork 5 9
Disrespect or Abuse 2 5
page 7
Maxfield, D. et al. Silence Kills The Seven
Crucial Conversations for Healthcare,
VitalSmarts, 2005.
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Safety Leadership Behaviors

• It takes inclusive leaders who
• Invite input (name/role activation)
• Are accessible (present/approachable/all ears)
• Acknowledge the limits of current knowledge
• Go first (particularly in displays of
  fallibility)
• Inclusive leaders lower the psychological costs
  of voice and raise the psychological costs of
  silence

Courtesy Michael Leonard, MD Karen Frush, MD
Presentation at the SLCH UBJP Team Leaders
Workshop, EPNEC, May 12, 2009.
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SLCH and BJH Case Examples

• A circulating nurse respectfully insisted that
  the line be identified on an X-ray, obtained
  for a possible retained item.
• Respiratory therapist informed a fellow (after
  being up all night) that they were about to
  insert a chest tube in backwards.
• A nurse felt a patient who had been released from
  the PACU didnt look right. She worked with the
  physician to re-assess the patient and order
  further testing. The patient was taken back to
  the OR.
• A proceduralist was reminded of a patients
  allergy to heparin following a request for a
  heparin flush during the case.

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Stop the Line What does it mean?

• Stop the Line
• The request of any team member for clarification
  or interruption of a process when s/he perceives
  a significant potential threat to patient safety.
  
• When staff or health care providers are engaged
  or are about to engage in an action believed to
  be a significant threat to patient or staff
  safety or
• A staff member or health care provider requests
  clarity regarding a non-emergency clinical
  situation that may pose a significant impending
  threat to safety.

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Stop the Line When to use it? When a
patients safety is thought to be at risk,
examples of which may include

• Incompatible blood is sent from the OR while an
  operation is in progress.
• A respiratory therapist notices that a fellow,
  who had been up all night, was about to insert a
  chest tube backwards.
• A proceduralist requests a heparin flush in a
  heparin allergic patient.

• A disagreement between members of the care team
  during a time-out prior to a procedure.
• The wrong side or wrong site is being
  prepped/draped for an operation or procedure.
• A collected pathology specimen is not in the
  collection cup anymore

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Stop the Line When to use it?
Department/Unit-Specific Examples

• ..

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How to Stop the Line
Step 1 When a significant patient safety risk
is perceived, communicate in a respectful
manner the need to Stop the Line and
re-evaluate or restore patient safety   Sample
Language
Could we please Stop the Line because I have
an important question and want to make sure we
are delivering safe care to this patient
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How to Stop the Line
Step 2 If the response to step one is
inadequate to restore patient safety, repeat
your request to stop the line Sample Language
(Caregiver Name), please stop we need to
review the plan/procedure/situation together
before proceeding to make sure we are delivering
safe care.
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How to Stop the Line
Step 3 If the response to Steps One and Two are
inadequate to restore patient safety,
immediately invoke the chain of command by
contacting the appropriate immediate supervisor.

• Once the immediate needs of the patient are
  resolved, the supervisor shall contact the
  appropriate AMC Patient Safety Departments
  regarding the incident and the inadequate
  response to stopping the line.
• The AMC Patient Safety Departments will notify
  the appropriate AMC leadership and begin the
  process of investigation.

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Step 3, Continued

• The AMC organizations CMO will be notified, and,
  in the event a WUSM Physician is involved, the
  appropriate WUSM Department Chair. Inadequate
  responses will be investigated promptly and
  thoroughly as directed by the appropriate
  Department Chair.
• In the event that remedial measures are
  necessary, they will be determined based on the
  severity of the behaviors and according to the
  AMC organizations existing policies or Code of
  Conduct.

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Monitoring Stop the Line
The Stop the Line AMC Advisory Panel will
evaluate the effectiveness of the policy and
identify needs for further education and
modification to the system. The advisory group
can then use that knowledge to refine the
initiative.
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Case Examples of Interest to Your
Unit/Department
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Discussion
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Appendix
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One Physicians Perspective

• Dr. Peter Pronovost lost his father to a
  misdiagnosis..In a March 2010 New York Times
  interview, he said,
• A few years later, when I was a physician,
  I met Sorrel King, whose 18-month-old daughter,
  Josie, had died at Hopkins from infection and
  dehydration after a catheter insertion.
• The mother and the nurses had recognized
  that the little girl was in trouble. But some of
  the doctors charged with her care wouldnt
  listen. So you had a child die of dehydration, a
  third world disease, at one of the best hospitals
  in the world. Many people here were quite
  anguished about it. And the soul-searching that
  followed made it possible for me to do new safety
  research and push for changes.
• What exactly was wrong here?
• As at many hospitals, we had dysfunctional
  teamwork because of an exceedingly hierarchal
  culture. When confrontations occurred, the
  problem was rarely framed in terms of what was
  best for the patient. It was Im right. Im
  more senior than you. Dont tell me what to do.

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Effective Communication and Teamwork How?
Structured Communication SBAR
Language Key words, the ability to speak up in a respectful manner and stop the line (or ask for clarification)
Psychological Safety An environment of respect
Effective Leadership Flat hierarchy, sharing the plan, continuously inviting other team members into the conversation, explicitly asking people to share questions or concerns, using peoples names
Courtesy Michael Leonard, MD Karen Frush, MD
Presentation at the SLCH UBJP Team Leaders
Workshop, EPNEC, May 12, 2009.