Effective Teamwork and Communication 7-19-07

EffectiveTeamworkandCommunicationNPSFStandUpForPatientSafetyJanetNagamine,RN,MDMichaelLeonard,MDJuly19,2007OverviewI.TheNatureofClinicalPerformanceII.CommunicationFailures:HowandWhyDoTheyOccur?III.TheRoleofSBARinOneonOneandHandoffCommunicationsIV.HelpfulHintsonImplementationTheNatureofClinicalPerformanceComplexOftenTask-orientedMulti-taskingInterruptions,DistractionsRelianceonHumanMemoryFatiguePoorCommunicationWhereDoThingsFallThroughtheCracks?FailuretoPlanFailureofRecognitionFailuretoRescueCommunicationfailures–handoffsSystemfailures–losinginformation,look-alikedrugs,etc.FoundationalElementsofSafetyStructuredcommunication–SBARCriticallanguage–“Ineedalittleclarity.”PsychologicalsafetyEffectiveleadershipWhyDoesThisHappen?IndividualandInterpersonal•hierarchy•disconnectincommunicationstyles•cultureofperfection•individualagencyEnvironment/System•nodefinedstandardsofcommunication•poorhandoffsacrosscontinuum•lackofsystemsapproachandreliabledesign•departmentsilos,poorcoordinationofcare•timepressureCaseStudy:HierarchyIndividual•RN-Attendingrelationship•Residentattitudetowards•nursesconcern•callingforhelpEnvironment/System:•Handoffcommunicationnorms•Residentattitude•Hierarchy•IndividualagencyandcultureofperfectionWhatStudiesShow...•25-40%ofnurseswouldbehesitanttospeakupiftheysawanMDmakingamistake•Oftenpeopledon’tspeakupordosoquiteindirectly•Seeminglyobliquecommentsbecomethe“Itriedtotellhim/herthat...”AnalysisofMalpracticeClaimsinSurgeryFourinsurers,threeregions•444surgicalclaims•“Systemsfactors”contributedin82%ofcases•Communicationbreakdownsin1/4ofcases•inadequatehandoffsorpersonnelchanges(11%)•miscellaneous(11%):RN-MDcommunication,inabilitytoreachattendingsurgeon•failuretoestablishclearlinesofresponsibility(9%)RogersSOetal.Surgery2006;140:25-33.TeamworkFailuresNotedinMalpracticeClaims“Medicalstudents,residents,nurses,andsupportstaffoftenholdacriticalpieceofinformation,havea“gutfeeling”,orobserveapatternthattheyhaveseenbefore.Unfortunately,ifthestageisnotsetforcollaborativepracticeandgoodteamcommunication,thatimportantpieceofinformationisnotshared.”A“badfeeling”aboutafetalheartrate...GroffH.ForumJuly2003;23(3).(RiskManagementFoundationoftheHarvardMedicalInstitutions)TheMissingComponentsRespectforeachother’sclinicalassessmentOpencommunicationandasenseofsafetyinassertinganideaUseofconflictresolutionresourcesAsharedplanofcare(ambiguity)GroffH.ForumJuly2003;23(3).(RiskManagementFoundationoftheHarvardMedicalInstitutions)TwoFundamentalIssuesHierarchyandlackofPsychologicalSafety•Recognizedifficultiesinassertion•HierarchiesexistbetweenandwithindisciplinesLackofstructureanddefinedstandards•Nocleardefinitionofhowwecommunicatetoeachother,whenwemustcommunicate,andwhatinformationtoincludeCaseStudy:StructuredCommunicationHe’salloutofbreath...Hierarchyandlackofpsychologicalsafety•Whydidn’tthenursequestionme?Lackofstructureanddefinedstandards•Incompletepicturefromthenurse•Incompletepicturefromsignout•UsedtooperatingwithlimitedinformationHowWouldSBARHelpStructureTheConversation?Situation-thepunchlinein5-10seconds.Background-thecontext,objectivedata,howdidwegethere?Assessment-whatistheproblem?Recommendation-whatdoweneedtodo?TheIdealConversationS-I’mworriedaboutMr.Jonesbecausethere’sbeenadramaticchangeinhiscondition.B-He’sa74y.o.malehereforafungalinfection,hxRF.Ijustwalkedhimtothebathroomandhewassoweakhecouldbarelywalk.Lastnightherequiredminimalassistancebuttonightittooktwoofusandwewerepracticallycarryinghimbacktobed.A-I’mnotsurewhat’sgoingonbutI’mworriedaboutthisbigchangeinhiscondition.R-Couldyoucomeevaluatehim?•Afterevaluation,additionalRecommendations?TheValueofSBARTooltohelpovercomesteephierarchyanddifferentcommunicationstyles•Createscommonexpectationssopeopledon’tfeel“outofline”Givesafullpicture,reducesambiguitySynthesisofinformationandredundancyWhytheDisconnectinRN-MDCommunicationStyles?Nursesaretrainedtobenarrativeanddescriptive“youdon’tmakediagnoses”•reportdatavs.synthesizedinformation,conclusionsPhysiciansaretrainedtobeproblemsolvers“whatdoyouwantmetodo–justgivemetheheadlines”Theresult---frustrationonbothends•docskeepwaitingforthepunchline•nursesfeelinterrupted,notlistenedtoTwoTakeHomePointsOurtrainingputsusondivergentpaths•Nursingschoolvs.Medicalschool•WherehintandhopecomesfromUnderstandingthe“rootcauses”ofcommunicationfailureshelpsreducethefrustrationandpromotecollaboration•MDs:activelyengagepeopleforinput•“teachingmoment”ifyourrecommendationrejected,otherwisethatNurse/RT/Pharmacistwillhesitatetospeakupagain•RNs,otherdisciplines:communicatemoredirectlyTheValueofStructure:OrganizationandFlowofContent“Excuseme,butIthinkthatcontinuingyourpatient’sToradolforfourmoredosesmighthelphergetabetterhandleonherpain---Inoticedthatherpainworsenedaftertheorderexpired.CanwecontinuetheToradol?”“Thepatient’spainisn’twell-controlled.”“ShewasdoingwellonToradolbuttheorderexpired.”“Ithinkfourmoredosesmighthelphergetabetterhandleonthepain.”“CanwecontinuefourmoredosesofToradol?”FromBartholomewK.