Welcome
Georgia Medical Care Foundation’s Fall 2009
Regional Patient Safety Learning Session
This material was prepared by GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 9SOW-GA-PSF-09-74
• Breaking the Ice– Take a card but don’t look at it– Once everyone has a card, you
can look at your card– Group up into teams of card
holders that come closest to21 points without going over
– Face Cards = 10, Aces are either 11 or 1 and numbered cards are equal their value.
– You have 3 minutes
In Case of Emergency
Debrief
Agenda
• Change Management– Setting the Stage
• Where are we coming from, and what does it mean?
• Teamwork Wins!– Role of the leader and the team Member
• Deciding what to do– Survey says
– Improvement opportunities
– Knowing what works
• Power Tool Time• Making it stick• Envision the new culture
Objectives
• Better understanding of the issue• Discuss what is involved in creating a new
culture that will improve resident safety• How to create a culture to improve
– Communications– Mutual trust– Teamwork– Empowerment
• Begin planning for the change in your organization
CHANGE MANAGEMENT: HOW TO ACHIEVE A
CULTURE OF SAFETY
John Kotter
8 Steps of Change
Set the Stage and Create a Sense of Urgency
• Get people’s attention! • Sell the need for change … sell the pain
and the consequences of not changing• Immerse people in information about the
change • Discuss ways to solve the problems people
identify with the change – Empower people to solve the “problem”
How do we look?
Have we improved enough?
Three Cheers for GA Nursing Homes
Do you feel a little out of control?
• Statistics will only take you so far in changing your culture
• Vision, Passion and Pursuit of Excellence are the only things that will help you go the distance and change your world.
Share your Stories
Questions?
What is happening in your area?
What has worked for you?
Pull Together the Guiding Team
• Choose key players, especially staff-level managers
• Multidisciplinary
– Goal is informed; intelligent decisions are being made
• Credibility and integrity of change leaders
• Choose proven leaders who can drive the change process
– Strong position power, broad expertise, and high credibility
• Need both management and leadership skills
– Management skills control the process
– Leadership skills drive the change
…TeamSTEPPS initiative should have a designated executive sponsor
The Success of the Change Initiative Depends on
Having a Designated Executive Sponsor
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• Organize the team• Articulate clear achievable goals• Make decisions through collective input of
members• Empower members to speak up and challenge,
when appropriate• Actively promote and facilitate good teamwork• Are skillful at conflict resolution
Effective Team Leaders
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The Role of Each Team Member is to….
• Apply specific teamwork skills to accomplish and fulfill the responsibilities and tasks
• Communicate pertinent information to teammates and the patient/family efficiently and effectively
• Demonstrate desired behaviors and skills• Possess the attitudes necessary to develop mutual
trust and team orientation• Request clarification or additional information as
needed• Make adjustments to behaviors based on feedback
Deciding What to Do
Develop the Change Vision and Strategy
Senior Leadership is responsible for:• Establishing the definition of a “culture of safety”
aligned with expectations, core values, and shared beliefs
• Informing the organization of these values and evaluating the culture
• Leading the process of:– Translating values into expected behaviors– Establishing trust and accountability
• Communicating a commitment to shaping the culture
AHRQ Survey of Patient Safety – Nursing Homes
• 69 Nursing Homes completed survey
• Stats:– 4017 staff responded to survey– 7551 were employed by these homes– 53.2% completion rate
Difference in Perception
Improvement Opportunities
• Communication/Openness – staff’s ability to share ideas, concerns
• Teamwork – respectful support of one another where help is offered and given
• Staffing – adequate staff to perform work
• Handoffs – critical information is shared with staff both inside and out to ensure quality patient care
• Non-punitive Response to Mistakes – environment encourages reporting of error and support to prevent in future
What does this tell you?
How can we improve?
Stretch Break – 5 Minutes
Looking for Opportunities
• Why?– Loss of situational awareness– Change in conditions that impacts the team –
staffing, vitals, environment, behaviors, etc
• When?– Huddles are used in urgent situations– Should not be overused
• Who?– Try to create an environment where anyone, once
trained on huddles can “Stop the Line” and call one when they feel there is urgency or confusion that might cause patient harm
Call a Huddle
“Whiteboard” Huddle
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• When is it important Advocate for the patient?• Invoked when team members’ viewpoints don’t coincide with
that of a decision maker.
• Assert a corrective action in a firm and respectful manner
• The Assertive Statement should:– Respect and support authority– Clearly assert concerns and suggestions– Use a structured assertive statement (nonthreatening and ensures that
critical information is addressed)• Make an opening• State the concern• State the problem• Offer a solution• Reach an agreement
Advocacy and Assertion
Seems different than usual
Talks or communicates less than usual
Overall appears much different
Participated less than usual in activities
Ate less than usual (not because of dislike of food)
NDrank less than usual
Weight change
Agitated or nervous more than usual
Tired, weak, confused or drowsy
Change in skin color or condition
Help with dressing, toileting, transfers more than usual
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Please Use CUS Wordsbut only when appropriate!
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Conflicting Information
Information Conflict(We have different information!)
CUS
Invoked when an initial assertion is ignored…•It is your responsibility to assertively voice your concern CUS if you need to ensure that it has been heard•The member being challenged must acknowledge•If the outcome is still not acceptable
– Take a stronger course of action
– Use supervisor or chain of command
Power Tool Time
• Group into 3’s• Read over all 3 Scenarios consider application of Stop
and Watch, Calling a Huddle, and CUS to be assertive• Round 1,
– Observer critiques Coach/Staff Role Play
• Round 2 – 1st Observers becomes 2nd Coach, 1st Staff becomes 2nd Observer, and 1st Coach becomes 2nd Staff– Observer critiques--Coach/Staff Role Play
• Round 3 – 2nd Observers becomes 3rd Coach, 2nd Staff becomes 3rd Observer, and 2nd Coach becomes 3rd Staff– Observer critiques--Coach/Staff Role Play
• Communicate for Understanding and Buy-In– Provide supportive actions for fear, anger, and resistance
– Encourage discussion, dissent, disagreement, debate … keep people talking
– Tell people what you know―and what you don’t know
– Acknowledge people’s pain, perceived losses, and anger
– Value resisters
• They clarify the problem and identify other problems that need to be solved first
• Their tough questions can strengthen and improve the change
• They may be right―it is a dumb idea!
Making it Happen
…communicate, communicate, communicate…
• Empower Others to Act– Develop a shared sense of purpose
– Align structures with vision and goals
– Train employees so they have the desired skills and attitudes
– Confront high-level resisters
Making it Happen
An organization cannot be improved from the top only
Produce Short-Term Wins
• Provide further impetus for change
• Provide positive feedback
– Further builds morale and motivation
• Lessons learned help in planning next goal
• Create greater difficulty for resisters to block further change
• Provide leadership with evidence of success
• Build momentum
– Helps draw in neutral or reluctant supporters
Don’t Let Up
• Acknowledge hard work
• Celebrate successes and accomplishments
• Reaffirm the vision
• Bring people together toward the vision
• Acknowledge what people have left behind
• Develop long-term goals and plans
• Provide tools and training to reinforce new behaviors
• Reinforce and reward the new behaviors
• Create systems and structures that reinforce new behaviors
• Prepare people for the next change
Making it Stick
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TOPIC
Communication clear?
Roles and responsibilities understood?
Situation awareness maintained?
Workload distribution?
Did we ask for or offer assistance?
Were errors made or avoided?
What went well, what should change, what can improve?
Don’t forget to Debrief
Debrief Checklist
Create a New Culture
• Develop action steps for stabilizing, reinforcing, and sustaining the change:
• Develop performance measures to continually monitor the results from the change and to identify opportunities for further improvements
• Make adjustments to the change vision and strategy to reflect new learning and insights
• Challenge people to be open to new challenges, forces, and pressures for the next change
John Kotter
8 Steps of Change
• Please fill out your evaluations and educational credit cards, your evaluation and ideas are important to us.
• If there are others that would benefit from this program, send them to one of the other regional meetings at:
Feedback
• Don’t forget to find out about the upcoming Cross-Setting meetings in your area.
• Have a Safe Trip Home
• See you in the Spring of 2010 if not before!
Thank You!
