Lessons for All from Labor and Delivery Joseph M. Montella, MD RN, MPH Keith Eddleman, MD Loraine ONeill, Lessons for All from Labor and Delivery: How leadership and team building make for successful huddles Joseph M. Montella, MD Associate Professor and Director of Quality and Safety Department of Ob-Gyn Jefferson Medical College What makes a good worker? Lucy and Ethel wanted to do well, but were intimidated by management and kept silent about the challenges of the job at hand They were obviously understaffed and realized it They knew they were fighting a losing game but kept on anyway, and used workarounds to accomplish the task, hoping that the boss wouldnt notice and everything would work out fine If the boss had listened to their comments about why this was an impossible task and how it could be made better, they would have accomplished more Perhaps of they worked as a team, they would have been able to
accomplish wrapping the candy What makes a good team? Willingness to work with others and listen to their opinion with an open mind Relinquishing autonomy among the members Information exchange as to best practices Capitalizing on the strengths of the individual members to advance the project for the good of the patient Team Members and Stakeholders Macrosystem Mesosystem Microsystem Pardini-Kiely, et.al (2010) Jt Comm J Qual Patient Saf. 36(9):387-98 Systems at Work System component Candy Factory Healthcare Organization
Macrosystem Owners C-suite (CMO, CFO, COO, CEO, CSO) Mesosystem Elvira Allman, Manager Department Chairs and Administrators Nursing supervisors and managers Microsystem Lucy and Ethel Physicians, nurses, residents, aides, techs Psychological Safety Allows for junior team members to speak up about
their ideas Physicians must relinquish autonomy as this is the only way this will work Ovretveit, J. et.al. (2009) Journal of Health, Organisation and Management. 23:581-596. Model for Improvement What are we trying to accomplish? Identify the problem How will we know if a change is an improvement? Systems theory states that a change in one process may affects others in a positive or negative waywe need a way to measure change What changes can we make that will result in this improvement? Model for Improvement Identify the problem--Sign-out was happening in silos: nurse to nurse, resident to resident, attending to attending. There was a lack of communication between obstetrics, anesthesia, neonatology, and nursing on all units which was measured through Pascal Metrics surveys How will we know if a change is an improvement?Pascal
metric surveys showed low scores on the communication component of the questionnaire. Raising these scores would be an improvement What changes can we make that will result in this improvement?A change in the way information was exchanged. Building a Team Team members were selected from each of the three system levels from the various departments A desire to be on the team was not the main criterionidentification of leadership qualities within those individuals was The team started with the problem then created the SMART goal SMART Goal Specific Measureable Attainable Relevant Time-Bound Ob Report (Huddle) SMART goal To improve the level of communication between
members of the obstetrics, anesthesia, nursing, and neonatology teams so that the communication portion of the worker satisfaction surveys (PressGaney) will show an improvement by 50% over the same time period in the last fiscal year within 6 months of starting the program. Ob Report Tool Implementation Introduced the plan at grand rounds, faculty meetings, nursing staff meetings Piloted the list with two attendings Received feedback from attendees at report about length, missing key information Revised form Expanded to all attendings Needed to change resident morning report time as this was a barrier to their education. Success and Sustainability Monthly report regarding attendance at twice a day Ob Reportafter 6 months, this report is done 100% of the time with attendance of at least one person from each of the clinical areas Preliminary survey of staff regarding communication issues demonstrated a 75% improvement in scores from a survey
administered prior to the implementation of the Ob Report Executive walk rounds by members of the mesosystem (Chairs) and macrosystem (C-suite personnel) have reinforced to microsystem the importance of their work This report is now part of the cultureIts the way we do things around here. Conclusions A team is only as good as the individuals on iteach member must be made to feel that their contribution is important for the success and sustainability of the project. Everyone wants to do a good job Buy-in must start from the most senior levels who must allow the middle levels and boots and the ground the freedom to recognize problems and create their own solutions A SMART goal must be identified for each project so that success can be measured and sustained Even with checklists, huddles and read-backs, when all else fails to assure that things go smoothly in an emergency situation, thinking outside the box can create innovative ideas for safety such as Lessons for AllFrom Labor and Delivery SWOT TeamSTEPPS National Conference Wednesday June 12, 2003 Dallas, Tx
Loraine ONeill, RN, MPH Director of Quality Initiatives, Dept of OB/GYN & Reproductive Science The Mount Sinai Medical Center, New York, NY Objectives Define SWOT Identify 2 areas to apply this methodology SWOT Strengths Weaknesses Opportunities Threats Assessing organizational readiness Brainstorming Silos Groups
Prior to training OR After training Shift Towards a Culture of Safety Implementation planning addresses all phases UNFAVORABLE FAVORABLE STRENGTHS WEAKNESSES What are your strengths? What are your weaknesses? What can you do better than others? What can you improve given the
What unique capabilities and current situation? resources do you possess? What do your competitors do better What do others perceive as than you? your strengths? What do others perceive as your weaknesses? OPPORTUNITIES THREATS What trends or conditions may positively impact you? What trends or conditions may What opportunities are available to you?
negatively impact you? What impact do your weaknesses have on the threats you identified? Do you have the necessary resources? STRENGTHS What are your strengths? What can you do better than others? What unique capabilities and resources do you possess? What do others perceive as your strengths? WEAKNESSES What are your weaknesses? What can you improve given the current situation? What do your competitors do better than you? What do others perceive as your weaknesses? OPPORTUNITIES
What trends or conditions may positively impact you? What opportunities are available to you? THREATS What trends or conditions may negatively impact you? What impact do your weaknesses have on the threats you identified? Do you have the necessary resources? PARKING LOT Use one word that best described the current state of communication amongst the groups in the Dept:
good, OK, open, evolving, succinct,important and needs improvement chaotic, minimal, confusing, lengthy, frustrating, fragmented, lacking and unprofessional Words that would most definitely indicate the need for change EXECUTIVE SUMMARY Background: Methods: Findings: Summary: Next Steps: SWOT Evaluation Identify the strengths and weaknesses of the
area(s) in which you will implement TeamSTEPPS or Module Strengths (S): Weaknesses (W): SWOT Evaluation Identify the opportunities and threats in the area(s) in which you will implement TeamSTEPPS or Module Opportunities (O): Threats/Barriers (T): Shift Towards a Culture of Safety Implementation planning addresses all phases STRENGTHS Mutual Support
Leadership WEAKNESSES OPPORTUNITIES People know the right thing Speak up User friendly Group Diversity New nursing leadership Convince staff Silo culture (DESC) New nurse managers L&D
MBU New MDS (CUS) TeamSTEPPS training New staff Multidisc collaboration Situational awareness & respect Patient assessment New culture to be introduced- must relearn behaviors Have silos More people need to buy in Lack of computers & software that communicate with each other Some barriers to
assignment of roles THREATS/BARRIERS Multidisciplin e comm. level of staff comfortablen ess
Space confined Staff culture Familiarity Physical plant Staff Role changing People not speaking up or not being heard STRENGTHS Communica tion WEAKNESSES Part of EMR Structured language staff is knowledgeable Situation
Monitoring Rounds in MBU EMR (can write orders throughout the house) Difficult to learn /lack of cooperation Resistant to change, not receptive Neg. attitudes to change, resistant OPPORTUNITIES (SBAR) Identify when
to use/dev criteria Not all staff (STEP) Education available at the same time needs Lots of people resistant to change THREATS/BARRIERS Resist to change Resist change LEADERSHIP WHO WHAT
SITUATION MONITORING Nursing Manager NICU Rep 2 attending Senior Residents OB Anesthesia attending & Resident Charge nurse is brief Contest to name the team Use scripted rounds
COMMUNICATION Charge nurse Attending senior resident Would like to have Anesthesia Charge RN 2 attending anesthesiologist In acuity order SBAR Room to room
(acuity 1st) Scheduled events & triage Step process Ad hoc huddle Use a script MUTUAL SUPPORT RN/MD team LEADERSHIP WHE N (Room to Room proces s?)
8:30 a.m. 8:30 p.m. 9:30 a.m. 9:30 p.m. April 1st HOW Implement team round Get message out to all to get running Documentation/ Sign in sheets Unit see to rally the group (paging, etc
SITUATION MONITORING COMMUNICATION MUTUAL SUPPORT Weekly 8:30 a.m. Weekly & 8:30 p.m. W/E W/E Committee meetings with Rollout
Color coding on boards for high priority Name tags/ magnetic boards Interdisciplinary rounds Organize functions on the unit Text page reminder Overhead page Teaching @ Briefs (more frequent) Nurse staff meetings PA meetings Peds/OB conference Policy Revision
UTUBE CLIPS E-mail BARRIERS to SWOT Time Understanding Buy In from Leadership Take staff meeting or lunch.
Educate as you go Present If you feed them they will come Sometimes it has to be Logistics Silos Thanks Pat Kischak, RN Michael Brodman, MD David Feldman, MD Raymond Z. Sandler, MD Our teams back in NYC
Which format? Case presentation of Corrective action plan in a fictional unit: Outline how to assembly the local teammembers,meeting schedule, format Define elements of an overview of TeamSTEPPS Essentials Course Explain SWOT Practice use of SWOT analysis for Leadership and communication Create executive summary Discuss barriers Q&A
Findings: Strengths: Each discipline indicated that communication amongst their unique group was generally good. Communication between RN and BAs was identified as good. The residents noted that the communication with the attending staff, due to their accessibility, was good. Weaknesses: Limited multidisciplinary communication. Lack of structured flow of communication across the Dept and with those floor teams with admitted patients who remain in the Dept (due to lack of beds). Lack of coordinated team formation. Multiple handoffs. Multiple interruptions and noise therefore vital information can be missed. Minimal respect between physicians, nurses and support staff . Very limited use of SBAR. No common language to ensure level of understanding. Opportunities: Most felt that the time was right to review communication other issues aside such a space and volume-if structured processes were in place. They suggested Team Rounding. Threat/Barriers: Change can be difficult. Personalities and hierarchy could impinge on sustainability. Format of educational
session would be important to ensure success. RN L&D RN POST PARTUM STRENGTHS Rounds Feel free to speak up or get assistance from a colleagues EMR Nurse cares for mom & baby = consistency in care Hosptl purchased
phones communication Emergency beepers Designated morning rounds Access to Attendings SBAR already in place WEAKNESSES OPPORTUNITIES Lack of advocating Implement for self team STEPPS Hand off
communicatio difficulties n tools Practice Hand-off Phones do not always function (especial EMR lose face to breaks) Group report face communication to increase SA Need SBAR coaching/use in simulation Interdisciplinary communication gaps Variation in use of debriefs Overhead paging system fails
STRENGTHS WEAKNESSES PAs/ CNMs Easy to huddle Small/carrying cell phones provides for increase communication NICU Communicates status well
ANES Familiarity OPPORTUNITIES Attitude Resistance Need ownership of patient provider may not be available Leadership decisions made without input from staff Communication between staff and leaders
THREATS/BARRIERS Create moraleboosting opportunities (outside work environment) Facilitate communicatio n flow up and down Hierarchy Training and education Feedback Hand-offs Perception of midline leaders STRENGTHS
RN NICU SAFETY Work well in emergencies Skill/ Knowledge Comradery & cooperation Resources
OPPORTUNITIES Inconsistent communication I first vs. We first Silo Hands-offs Communication with Attending THREATS/BARRIERS Improved communication Education
Resolution w/ empowering MD Safety team allocate resource Hierarchy culture Compliancy Communicatio n structure Consistency /Resistance Communicatio n Professionalis m Silo Communication (Hands-Off) Resistance to
changes Improve communication with team re: DR plans Medical team hand off Time Personalities Staffing Resources CommunicationMultidisciplinary Simulation Interdisciplinary meetings
Culture Staffing Patient safety initiative Senior staff Buy In Leadership Time-Out process weak MD apathy toward changes
Improved communication Standardization of issue identified Broad scope of issue Skepticism ANES WEAKNESSES
EMBEDDING TEAM STEPPS ````````````````````` Keith A. Eddleman, MD Professor Director of Obstetrics Department Ob/Gyn and Reproductive Medicine Icahn School of Medicine at Mount Sinai New York, New York OBJECTIVES Describe the elements of Team STEPPS as it relates to a patients experience. Describe the process of embedding Team STEPPS into our obstetrical service. Labor & Delivery Mini-Hospital: Triage
Delivery.. PACU ICU O/R Outcomes of Team Competencies Knowledge Shared Mental Model Attitudes Mutual Trust Team Orientation Performance
Adaptability Accuracy Productivity Efficiency Safety 48 Barriers to Team Effectiveness BARRIERS OUTCOMES Brief Inconsistency in Team Membership Huddle Lack of Time
Hierarchy STEP Cross Monitoring Defensiveness Conventional Thinking Complacency Varying Communication Styles Conflict Lack of Coordination and Follow-Up with Co-Workers Distractions Fatigue Advocacy and Assertion
Two-Challenge Rule CUS DESC Script Collaboration SBAR Call-Out Check-Back Misinterpretation of Cues Lack of Role Clarity Shared Mental Model Adaptability Team Orientation Mutual Trust
Team Performance Patient Safety!! Feedback Workload Debrief Lack of Information Sharing TOOLS and STRATEGIES
Handoff 49 Patient to Physician Scenario Rear ended! LIE! Home from a party! Bag deployed! Side and front! wet down below! Neck hurts! Speeding teenagers! Baby moving?! Scared Attending to Resident Mount Sinai / Presentation Slide / December 5, 2012 52 Information Exchange Strategy (SBAR) Situation Background Assessment
Recommendation 53 Process How did we do it...? Every attending (67) attended a communication workshop approx 10 at a time Scenarios and training Barriers to Team Effectiveness BARRIERS TOOLS and STRATEGIES Inconsistency in Team Membership
Lack of Time Lack of Information Sharing Hierarchy Defensiveness Conventional Thinking Complacency Varying Communication Styles
Conflict Lack of Coordination and Follow-Up with Co-Workers Distractions Fatigue Workload Misinterpretation of Cues Lack of Role Clarity
SBAR 55 OUTCOMES Shared Mental Model Adaptability Team Orientation Mutual Trust Team Performance
Patient Safety!! Initial Fetal Heart Tracing Category I Category I Baseline 110 160 beats per minute Moderate variability No variable or late declerations Early decelerations may be present Accelerationss may be present or absent
Resident to Attending Barriers to Team Effectiveness BARRIERS TOOLS and STRATEGIES OUTCOMES SBAR Inconsistency in Team Membership Check-Back Lack of Time Lack of Information Sharing Hierarchy
Defensiveness Conventional Thinking Complacency Varying Communication Styles Conflict Lack of Coordination and Follow-Up with Co-Workers
Distractions Fatigue Workload Misinterpretation of Cues Lack of Role Clarity Shared Mental Model Adaptability
Team Orientation Mutual Trust Team Performance Patient Safety!! Handoff 59 EFM WORKSHOP Nurses (104) and MDs (67) in groups of 10
The nomenclature of NICHD taught with scenarios Briefs, Huddles and Debriefs Barriers to Team Effectiveness BARRIERS TOOLS and STRATEGIES OUTCOMES SBAR Inconsistency in Team Membership Check-Back Lack of Time
Brief Hierarchy Huddle Defensiveness Conventional Thinking Complacency Varying Communication Styles Conflict Lack of Coordination and Follow-Up with Co-Workers
Distractions Fatigue Workload Misinterpretation of Cues Lack of Role Clarity Shared Mental Model Adaptability Team Orientation
Mutual Trust Team Performance Patient Safety!! Handoff Lack of Information Sharing Debrief 61 10:00
11:41 TOOLS FOR CONFLICT RESOLUTION TWO-CHALLENGE RULE SAME PERSON/DIFFERENT PERSON INVOKES CHAIN OF COMMAND CUS: ANOTHER FRAMEWORK FOR CONFLICT RESOLUTION CONCERNED UNCOMFORTABLE THIS IS A PATIENT SAFETY ISSUE DESC-IF CONFLICT HAS BECOME PERSONAL IN NATURE (HOSTILE, HARRASSING) DESCRIBE THE SPECIFIC SITUATION
EXPRESS YOUR CONCERNS ABOUT THE ACTIONS SUGGEST OTHER ALTERNATIVES CONSEQUENCES SHOULD BE STATED Mount Sinai / Presentation Slide / December 5, 2012 64 Nurse Intervention Situation Awareness, Advocacy, Escalation CUS.. Clarity Weekly meetings , nurse manager/perinatal safety officer scenarios and vignettes constantly reinforcing Team STEPPS. Mutual Support .Feedback, Cross monitoring etc
ongoing Barriers to Team Effectiveness BARRIERS TOOLS and STRATEGIES OUTCOMES SBAR Inconsistency in Team Membership Check-Back Lack of Time Brief Hierarchy
Huddle Defensiveness Varying Communication Styles Conflict Lack of Coordination and Follow-Up with Co-Workers Distractions Fatigue Workload
Misinterpretation of Cues Lack of Role Clarity Adaptability Team Orientation Mutual Trust Team Performance Patient Safety!!
Debrief Conventional Thinking Shared Mental Model Handoff Lack of Information Sharing Complacency Feedback Advocacy and Assertion CUS Collaboration 66 13:15 6cm dilated, Tachy HUDDLE
Attending, resident, nurse, charge nurse, anesthesiologist 13:50 Pre-op assessment Brief, huddle debrief The Mount Sinai Hospital One Gustave L. Levy Place New York, NY 10029 SURGICAL SAFETY CHECKLIST Pre Procedure Verification Before Leaving Holding (RN, Anesthesia, Surgeon) Has the patient confirmed his/her identity, site, procedure and consent with each team member using name and DOB? Yes Was the consent verified against the schedule? Yes Is the site/side correctly identified and marked with the surgeons initials?
Yes Silver armband required? Yes Not applicable H&P completed within 30 days, 24 hour surgical confirmation present, signed, timed, dated and dictation number? Yes Radiologic and diagnostic test available and labeled with patient name, DOB & Laterality (if applicable) Yes Not applicable Does the patient have any known allergies and allergy band? Yes No Blood products required? Yes No Blood type and Screen Blood Ordered Blood Available Are the correct implant(s)/Special equipment available (if applicable or requested)? Yes Not applicable Not requested Intra-Operative OR Team Huddle(RN, ST, Anes, Attending) Have all team members introduced themselves by name, role and confirm the patient name, procedure, allergy and where the incision will be made? Yes Has antibiotic prophylaxis been given within the last 60 minutes? Yes
Not applicable DVT prophylaxis? Yes Not applicable Patient pressure points reviewed to minimize potential for pressure ulcer injury TIME OUT RN, Anesthesia, Surgeon, Surgical Technologist RN initiates and states planned procedure from consent. Yes Surgeon confirms the procedure and estimates the time to perform the procedure? Verifies Image and confirms laterality/site markers with Surgical Team Surgeon reviews with the team the risk of blood loss > 500ml (7ml/kg in children) Anesthesia and the surgeon confirm what are the triggers for blood transfusion? Patient position is confirmed for type of procedure Anesthesia states any airway specific concerns and addresses airway fire safety? Are there any safety (fire safety), equipment, supplies, instrument or implant (if applicable) concerns? Yes No Surgical instrumentation sterility confirmed? Yes Surgical Technologist verifies site mark is visible for all team members and patient is in the correct position Yes Not applicable 1409 8cm dilated30 min Terbutaline given 1422
Pause for the gauze tools Post Procedure Debriefing (RN, ST, Anesthesia, Attending) Circulating Nurse verbally confirms with attending surgeon: Post operative diagnosis Name of the procedure performed Specimen(s) identified, reviewed, solution confirmed and form signed by attending surgeon? Yes Not applicable Completion of Surgicount, manual count verified, and final count reported to surgeon prior to skin closure Yes and correct Surgeon performs wound sweep (if applicable). Yes and correct Not applicable Surgical instrument accounted for and intact Yes Reconciled correct count stated by RN Yes Were there any equipment, instrument or supply opportunities for improvement to be addressed? Yes No What are the key concerns for recovery and disposition of patient? Yes No What are the key concerns for recovery and disposition of patient? Yes No
What are the key concerns for recovery and disposition of patient? Yes No Back into PACU HAND OFF Physician decision making TASK FIXATION DESC STANDARDIZATION DRILLS Shoulder: huddles, briefs, debriefs, call out, read back
Hemorrhage: huddles, briefs, debriefs, call out, read back Team Effectiveness BARRIERS OUTCOMES Brief Inconsistency in Team Membership Huddle
Lack of Time Hierarchy STEP Cross Monitoring Defensiveness Conventional Thinking Complacency Varying Communication Styles Conflict Lack of Coordination and Follow-Up with Co-Workers Distractions Fatigue
Advocacy and Assertion Two-Challenge Rule CUS DESC Script Collaboration SBAR Call-Out Check-Back Misinterpretation of Cues Lack of Role Clarity Shared Mental Model Adaptability Team Orientation
Mutual Trust Team Performance Patient Safety!! Feedback Workload Debrief Lack of Information Sharing
Leone Lattes - 1915. Blood testing - used technique developed by Dr. Karl Landsteiner. Bloodstains - developed method to determine blood type from dried blood. Discovered that blood typing could be used as a means of identification
the vertebrates well-developed brain to nerves that carry information to and from every part of the body . Types of Vertebrates . Fish. Amphibians. Reptiles. Birds. Mammals. Fish. The first vertebrate with a backbone was a fish. Fish are the...
Critical Discourse Analysis. CDA is consolidated here as a 'three-dimensional' framework where the aim is to map three separate forms of analysis onto one another: analysis of (spoken or written) language texts, analysis of discourse practice (processes of text production,...
The product classification to be used is the CPC 1.0 . The 2-digit level of CPC should be used. The activity code should be the activity carried out by the enterprise according to ISIC Rev.3.1. The code within the BR...
Route r (not visible to all) Route s (visible to all) CP Tester: ... Trie. IP Forwarding. ACL. QoS. Safe Table. m3 paths. 3 m + 2 paths. ... the chance to change the way large networks are operated. The...
Syllabic Scramble In this experiment, you will be presented with 10 syllables. Instructions: Step 1: Play all ten syllables at least once time. Step 2: Arrange the syllables in the correct order to reveal a birthday wish to Peter.
How to Count Atoms Coefficient If an element or molecule has a LARGE number in front of it, this is how many atoms of each element there is. Example: 4Na -FOUR Sodium atoms 2HCl -TWO Hydrogen atoms and TWO Chlorine...
Ready to download the document? Go ahead and hit continue!