Incident Analysis Learning Program Module One Patient/Family Partnership Thursday, November 8, 2012

Welcome

Sandi Kossey Ioana Popescu Carrie-Lynn Haines Tina Cullimore

3 9-Nov-12 3

Be prepared to use: - Chat - Pen - Raise Hand - Other

The Virtual Classroom

Where are you from?

Use to place your name on the map

International: (type here)

About You

0 Familiarity with the Canadian Incident Analysis Framework 10

0 Familiarity with incident analysis / management 10

Agenda

1. Invited guests will share how they were included in the incident analysis & management process -highlighting the overall outcome of their lived experience.

2. Theory - practice leader/knowledge expert.

3. Facilitated discussion and virtual group exercise.

Learning Objectives

The knowledge elements include an understanding

of the following:

• What is patient engagement?

• What are the expectations of patients/families following an unexpected situation?

• Why is patient/family involvement an important part of incident analysis and making care safer?

Learning Objectives

The performance elements include the ability to:

• Use the checklist to plan a meeting with patients/ families .

• Describe ways in which patients/families can partner in the incident analysis process in order to build trusting relationships.

Sections of the Canadian Incident Analysis Framework were written by a group of patients and families, members of Patients for Patient Safety Canada (PFPSC). These sections provide the basis for this module, thus, the content is delivered from their perspective. It is the voice of the patient/family.

Canadian Incident Analysis Framework

Sections:

• Claire‟s story (John Lewis) (p. 5)

• 1.4 Incident analysis and management from a patient/family perspective (p. 14)

• Appendix F – Checklist for Effective Meetings with Patient(s)/Families (p. 87)

“Patients and families have important insights, information and experiences to share. There are many different ways that we can help. We are patients and families. We are committed partners in the safety and quality of our care.”

Patient / Family Partnerships in Incidents and Incident Analysis

Patient / Family Partnerships in Incident Analysis & Management

Raeline McGrath Sharon Nettleton

Patient/Family Partnership The Lived Experience – Claire’s Story

Raeline McGrath

Claire’s Story

To nurses, doctors and health care professionals

who give their all each day to improve and save

lives, and who feel humbled and privileged to be

part of life and death, but most of all to Claire.

A lifetime of happiness - that is our wish

Challenges

September 2006 - 12° October 2007 - 46°

The Big Day! Feb 27, 2008 - PICU Day 1

• Transferred to the PICU after surgery

…peaceful, settled, chest sounds good, Dad playing with and fixing Claire, child awoke…

• Successful posterior fossa decompression

• Intensivist and neurosurgeons are pleased

… Perfect!

“It Is Time” March 14, 2008 - PICU Day 16

• Oscillator withdrawn and placed on conventional mode of ventilation at 10:10.

• Claire died 50 minutes later at 11:00.

“Catastrophe”

…devastation - us and the PICU

Claire was gone… Now what?

• Devastation, desperation, a parent‟s guilt

• Return to nursing in the same division in which

Claire died – no book to guide me or the

organization

• After the dust settled

Confusion & questions

Instinct and intuition

Connecting the dots

…duty to Claire

Incident Analysis Process

• Preliminary file review – no findings

• Parents pose questions – internal case review completed

• External review - specialized area and parent an employee

• Worst possible outcome

…the edge of the cliff

Preventable Death

…Claire’s picture is removed from the „Memory Wall‟ in the PICU

…shock, anger, overwhelming for everyone

Important First Steps

• Apology and disclosure to family first – unexpected and appreciated

• Disclosure – candor and openness from reviewers and organization startling

• Disclosure to staff and physicians immediately following

• Action Plan developed to implement recommendations – given to us

• Commitment made to family to keep them engaged in the implementation process

… Silence from the PICU – devastating and antagonizing

Process Challenges

Review shared with Family before staff from PICU

Review read to everyone – no hard copy sharing

pushback from PICU – indignation and denial

no blame translates into no accountability

…devastation, isolation, anger

Rewriting the Literature

• New CEO arrives

• A new attitude to disclosure, quality reviews, patient safety – not fearing our motives

… relieved to move forward and to be included

What Works: CONNECT AND COMMIT

• Families must be given the information necessary to identify what happened, how it happened, and what is being done to ensure that it doesn’t happen again.

• Information to staff and families must be clear, factual, and above all, shared.

• Honesty and openness are crucial.

• Uniqueness of situations - flexibility.

What Works: CONNECT AND COMMIT

• Ongoing discussions with program staff and physicians.

• “Big Picture Thinking” - challenging the status quo.

• Working together with the family is much better than

working around them - inclusiveness.

• Use of outside consultants for support and to effect

change.

Follow-Up

Families must feel and observe a commitment and

acceptance of responsibility, accountability and of

steps being taken to prevent a reoccurrence.

Theory Burst – Patient/Family Partnerships in Incident Analysis & Management

Sharon Nettleton

Patient Engagement

• Thank you Raeline and so many other patients/families for staying engaged and for your work as partners in helping to make care safer.

Patient Engagement

• What is it?

• Why is it important?

• Why is it even more important when unexpected things happen?

Engagement

What is it?

“ The feeling of being involved in a particular activity.”

Macmillian Dictionary (English)

Patient Engagement

What it feels like

• I‟m able to share what I know, how I feel • Someone is listening to me • I‟m able to talk openly • Someone understands me • I‟m treated with respect • Someone cares about me • I‟m included in the team • I feel safe • I feel I have a partner(s) in my care

Patient Engagement

• An exchange of ideas, experiences and expertise

• Different perspectives / new thinking / other possibilities, actions and solutions

• Innovations, improvements are possible

Patient Engagement

A relationship between

Person requiring health care

(patient, client and/or family or loved one)

AND

Person(s) who can provide health care services

(providers, clinicians, staff, administrators)

Patient Engagement

When patients or family feel disengaged

• Left out, isolated, betrayed

• Unacknowledged, not listened to

• Not respected

• Unimportant

• Knowledge or expertise wasn‟t valued

• Not cared for

• Not safe

Patient/Family Centred Care

The provider or health organization perspective:

Dignity & respect Access to information Open communication

Involved in decision-making

Patient Patient/Family Engagement Centred Care

What it feels like to the What it feels like to

the patient/family the provider

I feel heard I listen

I feel understood I try and understand

I feel cared for I show I care

I am helped I provide help

I feel safe I provide safe care

Patient Patient/Family Engagement Centred Care

Partnerships or relationships between the patient/ family & care providers and principles of:

Involvement

Respect

Honesty

Trust

Safety

Patient Engagement & Incidents

When unexpected things occur during our care, these principles are even more important:

Involvement

Respect

Honesty

Trust

Safety

Healing/Learning/Improving

Words and Actions Matter

From OUR perspective…

• We often see you (care providers) for only minutes at a time

• But we remember our encounters (what you say, what you do, how you treat us, how you make us feel) it has a lasting impact

When Unexpected Things Occur

Being unprepared

Being (somewhat) prepared

When Something Unexpected Occurs

First minutes, first words, first actions really matter Often set the stage for everything that happens

next Ongoing connection

Framework

When Something Unexpected Occurs

Normal Human Reactions

• Surprise, shock • Guilt, feeling „let down‟ • Feeling frozen (not knowing what to say & how to act,

who to turn to, what happens next) • Fear

• Avoidance • Anger • Name, blame, shame • “Get past it”, “Move on” • Grief

When Something Unexpected Occurs

Reflective & Emerging Questions

• What happened?

• How/why did it happen?

• What (if anything) can be done to prevent this from happening again?

• What happens next?

Learning, improving, rebuilding trust & relationships, healing

When Something Unexpected Occurs

1. Being (somewhat) prepared for the unexpected.

2. Knowing immediately what to do.

(Care & empathy for the patient/family AND the providers directly involved).

3. Knowing where to access resources and people to help.

Framework

Three Essential Questions

1. Who is going to look after the patient/family?

2. Who is going to look after the providers/staff directly involved?

3. Who is going to coordinate/be accountable for the management of the incident?

This is engagement!

Immediate Response

Engage with the Patient/Family

• Immediate Care for the people directly involved (patient/family AND providers)

• Assign people to Stay Connected to those directly

involved (patient/family AND providers)

Framework

Preparing for Analysis

Engage with the Patient/Family

• Inquire and plan for patient/family involvement in the analysis process

• Using the Checklist for Effective Meetings with Patients/Families (Appendix F, p.87)

Framework

Analysis Process

Engage with the Patient/Family

• Involve the patient/family

• Begin with the patient/family perspective

• Include a patient/family advisor(s) on the review team

Framework

Follow Through and Close the Loop

Engage with the Patient/Family

• Include (even begin) with the patient/family

• Include as part of the team to re-establish trust, partnership/relationship

Demonstrates honesty, commitment, learning, improvement and helps with healing

When Something Unexpected Happens

Connect with the people involved

• Timely acknowledgement / empathy / apology • Caring about the people & relationship(s) • Includes patient/family

Commit to analysis • Includes patient/family

Follow-Up • Includes patient/family

Evaluating Patient Engagement

• How are „we‟ engaging patients/families when incidents occur?

• Ask us (patients/families) what else could be done.

• Engage patients/families as advisors in helping to improve.

What worked What needs improvement • Nurse‟s immediate response

(regret, empathy, apology)

• Sharing of findings with family

• Verbal report to family

• Heartfelt apology, caring

• Opportunity to continue improvements

• Reaction of PICU

• Removal of Claire‟s picture from wall

• No paper copy to family

• Meeting with whole team

Observations • Pushback from PICU

• Leadership change

• Communication & follow-up

Evaluating the Incident Management Process

Preparation Begins with Discussions & Sharing of Resources

Canadian Incident Analysis Framework • Claire‟s Story (John Lewis) • Patient/Family Perspective • Checklist for Effective Meetings with Patients/Families Other Resources • “Claire‟s Story” (Raeline McGrath) Canadian Nurse Oct. 2009 Vol.

105, No. 8 • Beware the Grieving Warrier (Larry Hicock & John Lewis, 2004) • After Harm (Nancy Berlinger, 2005) • “Harm to Healing: Partnering with Patients Who Have Been Harmed”

(Trew, Nettleton, Flemons) www.patientsafetyinstitute.ca • Canadian Disclosure Guidelines www.patientsafetyinstitute.ca • Literature on Patient Engagement, Grief, Healing & Forgiveness • Policies/Procedures/Practices within your own organization, other

organizations

A Safety Culture

In healthcare settings where there is a safety culture, the people (providers, staff, administrators AND patients/families) are engaged, encouraged and supported to make care safer.

Patient/Family Partnerships in Incident Analysis & Management – A Provider’s Experience

Paula Beard

Partnering with Patients and Families

• Involving patients/families in incident analysis

• Engaging with patients/families as members of analysis teams

• Practical examples of ways to involve patients and families in analysis

Applied Learning

1. The technical host has randomly assigned half of the participants to a breakout room

2. If prompted, click YES to both popup screens to join

Breakout Session

Learning Objectives

Performance Element

Use the checklist to plan a meeting with

patients/families.

The checklist has been developed to help prepare healthcare leaders and providers for meetings with patients/families when a patient safety incident is being discussed. The most important attributes that leaders and providers can bring to these meetings are compassion, a willingness to listen and understand, and the ability to be supportive.

• Virtual Group Exercise – Checklist Review the “Checklist for Effective Meetings with Patient(s)/

Families” on page 87 of the Canadian Incident Analysis Framework. * What are some of the barriers and enablers to meeting with patients and families? * What are some strategies to overcome the identified barriers?

Performance Element

Describe ways in which patients/families

can partner in this process in order to build

trusting relationships.

Learning Objectives

Virtual Group Exercise – Gap Analysis What would your preferred future state look like in relation to key steps in the Canadian Incident Analysis Framework, specifically: * What are we doing well? * What do we need to improve? * What are our next steps?

Write a goal: “Tomorrow I/we will….”

Next Steps

• Evaluation

• Follow up survey

Incident Analysis Learning Program

1. Patient/ family partnership – November 8, 2012

2. The essentials: principles, concepts and leading practices – November 29, 2012

3. Incident analysis as part of the incident management continuum – December 13, 2012

4. Comprehensive analysis – January 10, 2013

5. Concise analysis – January 31, 2013

6. Multi-incident analysis – February 21, 2013

7. Recommendations management – March 7, 2013

8. Follow-through and share what was learned – March 28, 2013

Additional CPSI Resources

• “Harm to Healing: Partnering with

Patients Who Have Been Harmed” (Trew, Nettleton, Flemons, 2012)

• “Canadian Disclosure Guidelines: Being Open with Patients and Families” (2011)

• Learning Opportunities – information about workshops, training, and learning sessions

• Tools – a collection of documents, templates, guidelines, and examples

www.patientsafetyinstitute.ca

www.patientsforpatientsafety.ca

Thank you!

Contact us at: analysis@cpsi-icsp.ca