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6/8/2011
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CUSP Step 5
Implementing Daily Goals and Other Teamwork Tools
Learning Objectives
• To understand the importance of having daily goals
• To understands basics of communication
• To learn how to implement daily goals in your unit
• To review other teamwork tools for possible implementation in your unit
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Comprehensive Unit-based Safety Program (CUSP) An Intervention to Learn from Mistakes and Improve Safety Culture
1. Educate staff on science of safety http://onthecuspstophai.org/
2. Identify defects
3. Assign executive to adopt unit
4. Learn from one defect per quarter
5. Implement teamwork tools Pronovost J, Patient Safety, 2005
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Examples
Work and Personal
• Wean
• Diurese
• Continue supportive care
• Meeting with no agenda
• I’ll do it later
• I will be home sometime this evening
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Importance of Daily Goals
• Communication defects common
• People and organizations who create explicit goals and provide feedback toward goals achieve more than those who do not
• Rounds generally provider rather than patient centered
• Discussion on rounds is divergent (brainstorming) rather than convergent (explicit plan)
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% o
f res
pond
ents
repo
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g ab
ove
adeq
uate
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k
ICU Physicians and ICU RN Collaboration
ICUSRS Data
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Communication Errors
• Communication errors most common contributing factor for all types of sentinel events reported to The Joint Commission
• Over 80% of staff responding to the question, “how will the next patient be harmed” list communication failure
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Science of Safety
• Understand System determines performance
• Use strategies to improve system performance– Standardize
– Create Independent checks for key process
– Learn from Mistakes
• Apply strategies to both technical work and team work
• Teams make wise decisions with diverse and independent input and when they alternate between divergent and convergent thinking
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Basic Components and Process of Communication
Elizabeth Dayton, Joint Commission Journal, Jan. 2007
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Daily Goals
• Standardizes communication and creates independent checks
• Helps ensure diverse input
• Adds convergent thinking to often divergent rounds
• Reduces encoding and decoding errors
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How to Use Goals?
• Be explicit
• Important questions– What needs to be done for discharge
– What will we do today
– What is patients greatest safety risk
• Completed on rounds and nurse reads back
• Stays with bedside nurse
• Modify to fit your hospital11
Percent UnderstandingPatient Care Goals
Pronovost PJ, Berenholtz S, Dorman T, et. al,. J Crit Care 2003;18(2):71-5
Implemented patient
goals sheet
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Impact on ICU Length of Stay
654 New Admissions: 7 Million Additional Revenue
Daily Goals
Pronovost PJ, Berenholtz S, Dorman T, et. al,. J Crit Care 2003;18(2):71-5
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Action Plan
• Present the idea to your CUSP team
• Draft a daily goals form
• Obtain support from one or more physicians
• Monitor number of time physicians are paged (WIFM)– Daily goals reduced pages by 80%
Timmel J, Kent PS, Holzmueller CG et al. Jt Comm J Qual Patient Saf. 2010 Jun;36(6):252-60.
• Pilot test on one patient
• Expand
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Other Teamwork Tools
• Morning briefing
• Shadowing
• Call list
• Culture check up
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Morning Briefing
On the CUSP: Teamwork Tools
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Morning Briefing
Who Participates:
1. The physician doing rounds who is responsible for the patients that day
2. The Night Charge Nurse
3. The Day Charge Nurse
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Morning Briefing Process
• Three simple questions:
– What happened overnight that I need to know about?
– Where should I begin rounds?
– Do you anticipate any potential defects in the day?
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What Happened Overnight That I Need to Know About?
• You should be thinking about…was there adequate coverage?
• Were there any equipment issues?
• Were new cases posted to the ICU?
• Unexpected changes in patient acuity?
• Were there any adverse events?
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Where Should Rounds Begin?
1. Is there a patient who requires my immediate attention secondary to acuity?
2. Which patients do you believe will be transferring out of the unit today?
3. Who has discharge orders written?
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As you continue planning rounds
4. How many admissions are planned today?
5. What time is the first admission?
6. How many open beds do we have?
7. Are there any patients having problems on an inpatient unit?
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Do You Anticipate Any Potential Defects in the Day?
• Patient scheduling
• Equipment availability/ problems
• Outside Patient testing/Road trips
• Physician or nurse staffing
• Provider skill mix
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When You Identify Defects / Problems
• Want to assign a person to the issue - have them follow up
• Identify actions taken to meet any patient or unit needs
• Report back to the staff what those actions were or will be
• If ongoing - continue to report it during morning briefing until it is resolved or alternatively use Appendix E Status of Safety Issues.
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Shadowing Another Provider
On the CUSP: Teamwork Tools
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Why Do We Need to Shadow?
• To gain perspective of the other providers– Practice
– Responsibilities
– Work environment
• To identify issues that affect teamwork and communication that may impact patient care, patient care delivery and outcomes
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Who should have this experience?
• Patient care areas as part of the Comprehensive Unit Based Safety Program (CUSP)
• Staff involved in the delivery of patient care in units where culture score indicate a poor score in teamwork and safety
• When there is a difference of > 20% in culture scores between provider types
• As part of orientation to a new unit
• Units with little collaboration between disciplines
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How To?
• Review the tool prior to your shadowing experience
• Follow your health care provider through their daily activities.
• Review your list of communication and teamwork problems
• Discuss with the Provider
• Make a plan for resolution
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Review the Shadowing Another Professional Tool
• Set up with questions and prompts
for the personnel using it.
• You should make changes that are specific to your unit!
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Section 1
1. Were any health care providers difficult to approach?
– Things to think about:
– How did that impact the health care provider you followed? (obtained an order, ignored etc.)
– What was the final outcome for the patient? (delay in care, etc.)
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Section 2
2. Did one provider get approached more often for patient issues?
– Things to think about:Was it because another health care provider was difficult to work with?
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Section 3-5
3. Did you observe an error in transcription of orders by the provider you followed?
4. Did you observe an error in the interpretation or delivery of an order?
5. Were patient problems identified quickly?
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If You Were Following a Nurse:
1. Did you observe that in a crisis or when there was an important issue, a nurse’s page or phone call was not returned quickly?
2. What was the outcome for this patient?
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If You Were Following a Physician
1. If you are following a physician, what were the obstacles that a physician faced in returning calls or pages?
2. What other factors impacted their ability to see
patients?
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How Would You Assess
• Handoffs
• Communication During a Crisis
• Provider Skill
• Staffing
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III. What will you do differently in your clinical practice?IV. What would you recommend to improve teamwork and
communication
Specific Recommendations Actions taken
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Our Findings
• Handoffs for 4 hour shifts not thorough, increased opportunity to forget key details as this increased the total number of people…
• Physician consults usually obtained but not always read by the requesting team…
• Nurse often most informed but does not always speak up
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Our Findings
• Nurse is the provider most often left with patient information to pass on to another provider - few conversations from MD to MD.
• Pharmacists did not realize how critical supplying Pyxis and stock drugs were.
• Some providers avoided…
• EMR was not accessed…
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Our Findings
• Nurses did not realize how complicated sterile processing
was, efforts made to keep trays together.
• POE removed an important step - communicating to RN of
stat order.
• Physicians unaware of unit policies, depend on RNs to
complete task.
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Our Findings
• Some nursing practice should be used hospital wide such as labeling.
• Isolation policies not adhered to - primarily physician personnel, consults -Required RNs to speak up.
• Assertiveness training indicated.
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References
• Pronovost PJ, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care 2003;18(2):71-5.
• Schwartz JM, Nelson KL, Saliski M, Hunt EA, Pronovost PJ. The daily goals communication sheet: A simple and novel tool for improved communication and care. Jt Comm J Qual Patient Saf 2008;34(10):608-13.
• Dayton E, Henriksen K. Teamwork and Communication: Communication Failure: Basic Components, Contributing Factors, and the Call for Structure. Jt Comm J Qual Patient Saf 2007;33(1):34-47.
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