Timothy B McDonald, MD JD

Chair, Anesthesiology

Medical Director for Quality and Safety

Sidra Medical and Research Center

Weill Cornell Medical College - Qatar

October 28, 2014

Courageous Communication

And

Teamwork

I have no actual or potential conflict of interest in

relation to this presentation

http://www.youtube.com/watch?v=2h2Q_uTEckM

April, 1982 ABC 20/20 show: “The Deep Sleep – 6,000 will

die or suffer brain damage…from carelessness”

Overview of Patient Safety and Anesthesiology

April, 1982 ABC 20/20 show: “The Deep Sleep” – 6,000 will die or suffer brain

damage…from carelessness

1983 ASA Committee on Patient Safety and Risk Management created – closed

claims analysis

1984 Anesthesia Patient Safety Foundation

1986 Monitoring standards established

Overview of Patient Safety and Anesthesiology

Following the Human Factors Analysis of Harm Events and

the redesign of care delivery and focus on “courageous

conversations and teamwork:

Overview of Patient Safety and Anesthesiology

Following some Courageous Conversations and the Human

Factors Analysis of Harm Events

Anesthesia Mortality Risk

๏ 1982 - 1:2000

๏ 2011 – 1:400,000

๏ Substantial reduction in patients and families seeking legal action

Some more background

Institute of Medicine:

1999 report that

shook the medical

world

Some more background

Institute of Medicine:

1999 report that

shook the medical

world

Some more background

Institute of Medicine:

1999 report that

shook the medical

world

Making Matters

Worse

February 2012, Volume 31, Issue 2

Evidence of failure to communicate

courageously

“Bad Culture” Linkages to poor outcomes

Disruptive behavior – unsafe, increased risk

Poor communication – unsafe, increased risk

Poor design – unsafe, increased risk

Poor teamwork – unsafe, increased risk

Lack of standardization – unsafe, increased risk

IOM SUMMARY

Part 1: National Center for Patient Safety – in HHS’s Agency for

Healthcare Research and Quality (AHRQ) to research, establish best

practices.

Part 2: Mandatory and Voluntary Reporting Systems – Legislation to

protect the confidentiality of information to learn about and correct

problems before serious harm occurs – value placed on data

Part 3: Role of Consumers, Professionals, and Accreditation Groups

– “No outcome – no income” and establish NQF Safe Practices,

transparency, “never events”.

Part 4: Building a Culture of Safety – Create an environment in which

safety becomes a top priority with focus on communication, human

factors, medication safety, electronic health records, computer order

entry, team training

15

Students

What is Culture and What are Team

Dynamics and what is meant by

“courageous communication”?

A case to illustrate the need for candor, safe

culture and positive team dynamics.

60 y.o. for CABG

Case proceeds uneventfully

Chest closed, skin closure occurring

Plan for extubation

Surgeon leaves to speak with family

Perfusionist hands cell saver blood to anesthesiology resident

Put under pressure

Cardiac arrest

Only resident notices air in line

What next?

What about Candor, Professionalism and

Safe Culture? Barriers Benefits

What about Candor, Professionalism and

Safe Culture

Benefits ๏ Maintain trust

๏ Learn from mistakes

๏ Improve patient safety

๏ Improve culture

๏ Employee morale

๏ Psychological well-being

๏ Accountability

๏ Money

๏ Less legal involvement

Barriers

๏ Lack of leadership support

๏ Loss of job

๏ Reputation

๏ “Shame and blame” culture

๏ Loss of control

๏ Loss of license, deportation

๏ Fear of lawyers, legal system

๏ Money

Condition Predicate

Teamwork-related issues

Courage to speak up

Ask for help

Team response to crisis

Communication to system

Communication to family

It’s all about culture

Critical Competencies for Effective Teamwork

Teamwork-related knowledge

Teamwork-related skills

Teamwork-related attitudes

It’s all about culture

Air embolism outcome

2009 Sep; 136(3): 897-903

How did we break down the “wall of

silence” and support courage?

How did we do to break down the wall of

silence at the University of Illinois?

Convinced leadership to adopt the Seven

Pillars approach to harm

Goals of the Seven Pillars

Reduce harm thru transparency and learning

Reduce legal involvement through early, effective

communication [courageous] with all parties

Resolve inappropriate care cases early, efficiently

Support patient and family engagement

Support care professionals following harm events

Rapid

Support for patients and families

Support for care professionals

Credit to Albert Wu

Safe Culture approach to events

Credit to James Reason, David Marx

Seven Pillars: Response to patient safety events

Rapid

Support for patients and families

Support for care professionals

Credit to Albert Wu

Safe Culture approach to events

Credit to James Reason, David Marx

Seven Pillars: Response to patient safety events

Creating a Safe Culture and Team Environment

Peer to peer support: for physicians by physicians

Rapid

Support for patients and families

Support for care professionals

Credit to Albert Wu

Safe Culture approach to events

Credit to James Reason, David Marx

Seven Pillars: Response to patient safety events

Pillar 2 - investigation

What happened and why? Understanding the “science”

behind harm events… and the importance of culture and

team dynamics

Non-health care related event

37

Human Factors Engineering and Safety

Healthcare Related Event

Human Factor Issues in Healthcare

40

Putting it all together

October 7, 2011

The Power of Candor

October 7, 2011

Questions