– On Boarding Call Schedule –9/25 @ 2:00 Tuesdays 8/21

On Boarding Call Schedule –
Tuesdays 8/21–9/25 @ 2:00
Armstrong Institute for Patient
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Safety and Quality
Learning Objectives
• To understand the basics of communication
• To understand the importance of having daily goals
• To learn how to implement daily goals in your ICU
• To understand that daily goals is a tool to improve
teamwork and communication AND supports interventions
to reduce VAP
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Implementing Daily Goals
Nishi Rawat , M.D.
Johns Hopkins Community Physicians
Armstrong Institute for Patient Safety and Quality
CUSP & VAP Interventions
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Armstrong Institute for Patient Safety and Quality
Basic Components and Process of
Communication
Elizabeth Dayton, Joint Commission Journal, Jan. 2007
Armstrong Institute for Patient Safety and Quality
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Six Factors of Communication Risk
Woods. Pt Saf Qual Healthcare May/June 2006
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Communication and Health Care
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Lawton et al. BMJ Qual Saf 2012;21:369-80
Communication and Health Care
• 65% of all sentinel events occur due to breakdowns in
communication (JCAHO 2005)
• Nurses: communication with physicians is a leading
contributing factor for medical errors (NCSBN)
• 7% of respondents involved in medication error in past
year in which intimidation played a role (ISMP 2003)
• High performing ICUs: team-oriented, shared beliefs,
education, collegiality, informal but direct
communication, collaborative problem-solving
(Zimmerman et al. 2003)
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ICU Physicians and ICU RN Collaboration
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Huang, DT et al. Crit Care Med 2007 jan 35(1): 165-76 S Data
ICU Physician Rounds
• Should include a multidisciplinary group of
professionals as applicable:
– Physicians, nurses, pharmacists, respiratory
therapists
• Should be conducted at bedside if at all
possible
– Allows patient and/or family involvement
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Crew Resource Management (CRM)
• Safety training program focused on effective
team management to improve performance
• Targets cognitive and interpersonal skills
• Goal: improve situational and self-awareness,
communication, flexibility, assertiveness,
adaptability
• Create a culture where there is freedom to
question authority
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Communication and Aviation
Accidents
Aviation Safety Network
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Armstrong Institute for Patient Safety and Quality
Conventional rounds
• Communication defects are common
• Rounds are generally provider rather than patient centered
• Discussion on rounds is more divergent (brainstorming) rather
than convergent (explicit plan)
• Prevents effective real-time or future feedback regarding plan
of care
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Armstrong Institute for Patient Safety and Quality
Rounds with Daily Goals
• Creates explicit goals and enables feedback toward goals to
achieve more for the patient
• Standardizes communication to reduce encoding and
decoding errors, and creates independent checks
• Adds convergent thinking to often divergent rounds
• Helps ensure diverse input
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Armstrong Institute for Patient Safety and Quality
Structure of Daily Goals Tool
• Items organized by organ system
• Medication review section
• To Do, Disposition, Family meeting and Code
status sections
• What can we eliminate? Lines, labs, abx…
• Safety item
• Include VAP process measures
• Check boxes vs open-ended vs combination
• One column vs second column for night goals15
Armstrong Institute for Patient Safety and Quality
How to Use Goals?
• Be explicit
• Important questions
– What needs to be done for discharge?
– What will we do today?
– What is the patient’s greatest safety risk?
• Completed on rounds and nurse reads back
• Stays with bedside nurse
• Modify to fit your hospital
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Percent Understanding Patient Care Goals
Implemented patient
goals sheet
Pronovost J Crit Care 2003;18(2):71-5.
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Impact on ICU Length of Stay
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Recent Data in Support of Daily Goals
• Narasimhan et al. 2006: MICU
– Provider understanding of goals improved
– Improvement in communication scores
– LOS decreased from 6.4 to 4.3 days
• Agarwal et al. 2008: PICU
– Provider understanding of goals improved
– Trend toward decrease in LOS, not significant
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Comprehensive Unit-based Safety Program
(CUSP)
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Action Plan
• Present the idea to your ICU team
• Draft a daily goals form
• Obtain support from one or more ICU
physicians
• Pilot test on a couple of patients on rounds
• Get feedback from nurses and physicians
• Revise and expand
• Monitor physician paging, track LOS….
• Share your tool with the other teams
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Armstrong Institute for Patient Safety and Quality
Questions
– Karol G. Wicker, MHS
Senior Director, Quality Policy & Advocacy
Maryland Hospital Association
kwicker@mhaonline.org
– Mary Catanzaro RN BSMT CIC
Project Manager HAIs
Hospital and Healthsystem Association of Pennsylvania
mcatanzaro@haponline.org
Armstrong Institute for Patient
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Safety and Quality
What Should you do NOW?
CUSP Preparation:
1) Assemble team
2) Schedule meetings
CUSP Implementation:
1) Science of Safety Training for all staff
2) Identify Defects: How will the next patient be harmed?
3) Use elements of Toolkit, including Daily Goals
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Armstrong Institute for Patient Safety and Quality
References - 1
Slide 5
Dayton E, Henriksen K. Jt Comm J Qual Saf. 2007 Jan;33(1);34-47.
Slide 6
Woods MS. How Communication Complicates the Patient Safety
Movement. 2006 May/June. http://www.psqh.com/mayjun06/dun.html.
Slide 7
Lawton R, McEachan RR, Giles SJ, Sirriyeh R, Watt IS, Wright J.
Development of an evidence-based framework of factors contributing to
patient safety incidents in hospital settings: a systematic review. BMJ Qual
Saf. 2012 May;21(5):369-80. Epub 2012 Mar 15.
Slide 9
Huang DT, Clermont G, Sexton JB, Karlo CA, Miller RG, Weissfeld LA,
Rowan KM, Angus DC. Perceptions of safety culture vary across the
intensive care units of a single institution. Crit Care Med. 2007
Jan;35(1):165-76.
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References - 2
Slide 12 Aviation Safety Network
Slide 17 and 18
Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden
C. Improving communications in the ICU using daily goals. J Crit Care.
2003 Jun;18(2):71-5.
Slide 19
Narasimhan M, Eisen LA, Mahoney CD, Acerra FL, Rosen MJ. Improving
nurse-physician communication and satisfaction in the intensive care unit
with a daily goals worksheet. Am J Crit Care. 2006 Mar;15(2):217-22.
Agarwal S, Frankel L, Tourner S, McMillan A, Sharek PJ. Improving
communication in a pediatric intensive care unit using daily patient goal
sheets. J Crit Care. 2008 Jun;23(2):227-35.
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Armstrong Institute for Patient Safety and Quality