Welcome to CUSP Communication & Teamwork ToolsCoaching Call 1 The session will begin shortly. To access the audio for the session, Dial: 800-977-8002, Participant code 083842#.

The materials for this coaching call can be downloaded from the CUSP Communication & Teamwork Tools password-protected web page. Directions for how to access this web page can be found on each of the coaching call meeting notices (appointments) sent to you.

The phone lines will be open during the presentation. Please keep your phone on mute unless you are asking a question. If you do not have a mute function on your phone, you can press *6 to mute your phone (and *6 again to unmute if you want to ask a question). PLEASE DO NOT PUT YOUR PHONE ON HOLD!!!

If you experience any problems, please call Marilyn Nichols at the MOCPS office at 573-636-1014, ext 221 or mnichols@mocps.org.

CUSP Communication & Teamwork Tools

Pat Posa RN, BSN, MSA Kimberly O’Brien, MHASystem Performance Improvement Leader Project ManagerSt. Joseph Mercy Health System Missouri Center for Patient SafetyAnn Arbor, MI Jefferson City, MOpatposa@comcast.net kobrien@mocps.org

Coaching Call 1: Getting StartedLearning from Another Defect,

Assessing Current Rounding Practices, and Exploring Structured Huddles

June 21, 2011

Document 1

Participating Hospitals1. Barnes-Jewish St. Peters Hospital, St. Peters2. Capital Region Medical Center, Jefferson City3. Community Hospital – Fairfax, Fairfax4. Fitzgibbon Hospital, Marshall5. Jefferson Regional Medical Center, Festus6. Missouri Southern Healthcare, Dexter7. Ozarks Medical Center, West Plains8. Saint Louis University Hospital, St. Louis9. St. Luke’s Hospital, Kansas City10. St. John’s Mercy Hospital, Washington11. St. Luke’s Rehabilitation Hospital, Chesterfield12. St. Mary’s Health Center, Jefferson City13. Texas County Memorial Hospital, Houston

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Documents for this Session(All can downloaded from the CUSP Communication & Teamwork Tools password-protected web site. Detailed instructions are

located on each of the coaching call meeting notices/appointments emailed to you by Kimberly O’Brien)

1. This PowerPoint presentation2. Monthly Team Leader Checklist3. Sample Agenda for June/July CUSP Team Meeting4. MDR and Improving Teamwork Article5. MDR and ICU Mortality Article6. Lakeland Hospital Experience – daily rounds/goals7. SJMHS Interdisciplinary Rounds Checklist8. Henry Ford Health System Daily Goals Checklist9. Improving Communication Using Daily Goals Article10. Effective Communication Daily Goals Article11. An audio file recording of this session will be emailed to

you shortly after the call today4

Agenda• Describe the project organization and goals of CUSP

Communications & Teamwork Tools• Brief overview of CUSP• Review Learn from a Defect• Overview of Multidisciplinary Rounds with Daily

Goals• Overview of Structured Huddles• Identify next steps• Answer questions

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CUSP Communication & Teamwork ToolsProject Organization

• Monthly coaching calls will be held every third Tuesday of the month, from 12-1pm (beginning on 6/21/2011)

• Six coaching calls• Coaching calls will be recorded• Facilitated by Pat Posa, RN, BSN, MSA• Team leaders will be provided agendas and materials

for monthly unit team meetings (can be modified)• Project deliverables: At end of 6 months, each unit will

have implemented multidisciplinary rounds and/or huddles, and solved at least one defect– Submit Case Summary from Learning from a Defect Tool to

MOCPS by November 30, 2011

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CUSP Communication & Teamwork ToolsPrerequisites & Goals

• Prerequisites– The Basics of CUSP– Functioning CUSP team in place– Executive and physician support

• Goals– To implement multidisciplinary rounds (with daily goals) in

each participating unit– To implement structured huddles in each participating unit– To solve one defect, using the “Learning from a Defect”

methodology (introduced during The Basics of CUSP)

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Unit-Based Patient Safety Culture• Patient safety and quality happens at the local

level• Build capacity at unit level to tackle multiple

problems• Build capacity at the leadership level to

support unit-based safety culture• Raise the quality and safety bar on the units• Surviving the tsunami!

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Components of CUSP

1. Form a unit CUSP team with executive sponsorship

2. Measure unit culture3. Educate staff on Science of Safety4. Identify defects using the Staff Safety

Assessment; prioritize defects5. Learn from one defect per quarter6. Implement team/communication tools

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How is CUSP different?• CUSP identifies problem areas –

– what staff think are impeding patient care vs. what managers/directors think are priority areas

• CUSP improvement tools are designed for bedside caregivers – easy for busy staff to use– unit drives its own quality

• Lean/Six Sigma/CQI – focus more on streamlining the process than identifying the problem areas

• CUSP can complement other quality improvement methods – must use multiple tools!

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Learn from a Defect• Designed to rigorously analyze the various

components and conditions that contributed to an adverse event and is likely to be successful in the elimination of future occurrences.

• Tool can serve to organize factors that may have contributed to the defect and provides a logical approach to breaking down faulty system issues

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Learn from a Defect• Select a specific defect

– What happened?

– Why did it happen (system lenses) ?

– What could you do to reduce risk ?

– How do you know risk was reduced ?

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Learn from a Defect ToolDivided into three sections:• Section 1 asks the users to identify what happened or the

defect they want to investigate • Section 2 is a framework provided for the investigators to

identify any contributing factors. These factors include: patient, task, caregiver, and team related, training and education, local environment, information technology and institutional environment.

• Section 3 asks participants to develop an action plan with assigned responsibility for task completion and follow up dates for each item.

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Identifying a Defect

AHRQ HSOPS results Staff safety assessment—how will the next patient be

harmed? Non-compliance with a core measure Event/incident reports Issues identified on Executive patient safety rounds

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Learning from Defects Tool

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CUSP Communication & Teamwork Tools Interventions

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Multidisciplinary Rounds with Daily GoalsStructured Huddles

• A strategy to assemble the patient care team members to review important patient care and safety issues and improve collaboration on the overall plan of care for the patient

• Improve communication among care team and family members regarding the patient’s plan of care

• Goals should be specific and measurable• Documented where all care team members have access• Checklist used during rounds prompts caregivers to focus on

what needs to be accomplished that day to safely move the patient closer to transfer out of the ICU or discharge home

• Measure effectiveness of rounds—team dynamics, communication, quality measure compliance, LOS

Multidisciplinary Rounds with Daily Goals – What is it?

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Evidence For Impact Of MDR Rounds

• Research studies on the effect of structured interdisciplinary rounds show:– Earlier identification of clinical issues– More timely referrals– Improved ratings by nurses and physicians on teamwork, communication and

collaboration.

• Research also indicates variable effects on LOS and cost, with some studies showing improvement and others having no impact.

Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. O'Leary KJ, et. al, Journal Of General Internal Medicine [J Gen Intern Med], ISSN: 1525-1497, 2010 Aug; Vol. 25 (8), pp. 826-32; PMID: 20386996

(Document 4 of your materials for this coaching call)

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The Effect of Multidisciplinary Care Teams on Intensive Care Unit Mortality

Arch Intern Med Feb 22, 2010

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• Retrospective cohort study (using state discharge data from Pennsylvania Health Care Cost Containment Council)• 112 hospitals• Non-cardiac, non-surgical ICUs• 30 day mortality• Looked at 3 types of multidisciplinary care models

•multidisciplinary care staffing alone•intensivist physician staffing alone•interaction between intensivist physician staffing

and multidisciplinary care teams

The Effect of Multidisciplinary Care Teams on Intensive Care Unit Mortality

Arch Intern Med Feb 22, 2010

Association Between Intensivist Physician Staffing and 30-Day Mortality for All Patients

Variable OR (95% CI) P Value

Model 1: multidisciplinary care staffing alone– No multidisciplinary care 1 [Reference]

– Multidisciplinary care 0.84 (0.76-0.93) .001

Model 2: intensivist physician staffing alone– Low intensity 1 [Reference]– High intensity 0.84 (0.75-0.94)

.002

Model 3: interaction between intensivist physician staffing and multidisciplinary care teams

– Low intensity+ no multidisciplinary team 1 [Reference]– Low intensity + multidisciplinary team 0.88 (0.79-0.97) .01– High intensity + multidisciplinary care 0.78 (0.68-0.89) .001

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• Should be done in ICUs and all units in hospital• Hard initiative to implement, especially if you have an open unit

and/or no intensivists or in non-ICU area– Standardize the structure and process for all units– Benefits seen even if physician can not attend consistently or at all– Second rounds should be done in afternoon—include at least

physician and bedside nurse• Evaluate if goals for day have been met; readjust if necessary• Identify if patient can be discharged (or transferred ) the next

day and if so, what needs to be accomplished• Focused first on defining daily goals and recording those either on the

white board in the room or on a sheet of paper• Then standardize rounds—who should attend and what is discussed• Implemented checklist or nursing objective card

Multidisciplinary Rounds with Daily GoalsChallenges and Opportunities

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Multidisciplinary Rounds with Daily GoalsSteps to Implementation

1. Commitment by all that MDR with daily goals is a strategy that will be implemented to improve communication and patient outcomes

2. CUSP team takes on initiative—identify if there are any additional team members needed

3. Evaluate current rounding process4. Identify gaps between current process and what you want it

to look like5. Define the standard work of rounds, roles and

responsibilities of each member and develop checklist and goal process

6. Define metrics to evaluate MDR

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Standardized Work Paradigm

Old Paradigm - I know you’ll be able to figure it out. Just get it done the best way you can.

New Paradigm - In order to have consistent results we must do things the same way every time.

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Standard Work System

• Standardized Work is a system for achieving a stable baseline for a process in order to systematically improve it.

• Standardized Work Systems are the basis for Continuous Improvement.

“What you permit, you promote”

“We deserve what we tolerate”

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Current State AssessmentResults of this assessment should be entered into Survey Monkey by July 8th using this URL: http://www.surveymonkey.com/s/Z3KVYSQ

What is the state of rounds on your unit?1. Describe the structure of the participating unit(s). For example, the type of unit (i.e.

ICU, Med Surg, Ancillary), whether the unit is open or closed, whether or not the unit has intensivists or hospitalists, how many beds the unit has, etc.

2. Are rounds currently held on the participating unit(s)?3. How often are rounds held?4. Who usually attends rounds?5. What are the roles of each member?6. Where do rounds usually take place?7. Is there a defined structure/process for rounds? If so what is it? Or does it depend on

who is running them? 8. Are daily goals part of the rounding structure/process?9. How have rounds made a difference during the past year in improving the

performance on your unit?10. What is the major barrier for multidisciplinary round implementation on your unit?

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Patient Daily Goals Form(Document 6 of Coaching Call Materials)

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Daily Goal Sheet

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(Information in parentheses is the standard patient goal – check in daily column whether specific need identified)

Date: Initials: Date: Initials: Date: Initials: Date: Initials:

Activity – Skin – Mobility (Adequate activity progression, no skin breakdown) “If Braden < 18 at risk for skin breakdown”

Yes No PT consult ROM DVT prophylaxis Consult ET RN Dressing, wound, incision Pressure ulcer prevention standard Impaired skin management standard

Yes No PT consult ROM DVT prophylaxis Consult ET RN Dressing, wound, incision Pressure ulcer prevention standard Impaired skin management standard

Yes No PT consult ROM DVT prophylaxis Consult ET RN Dressing, wound, incision Pressure ulcer prevention standard Impaired skin management standard

Yes No PT consult ROM DVT prophylaxis Consult ET RN Dressing, wound, incision Pressure ulcer prevention standard Impaired skin management standard

VAD

Yes Temp No Readiness to DC Arterial Line Day # ER/Elective Central Line Day # ER/Elective

Peripheral IV Day # ER/Elective

Yes Temp No Readiness to DC Arterial Line Day # ER/Elective Central Line Day # ER/Elective

Peripheral IV Day # ER/Elective

Yes Temp No Readiness to DC Arterial Line Day # ER/Elective Central Line Day # ER/Elective

Peripheral IV Day # ER/Elective

Yes Temp No Readiness to DC Arterial Line Day # ER/Elective Central Line Day # ER/Elective

Peripheral IV Day # ER/Elective

Safety / Restraints Yes No Assess need every 2 hours Order obtained

Yes No Assess need every 2 hours Order obtained

Yes No Assess need every 2 hours Order obtained

Yes No Assess need every 2 hours Order obtained

Family – Psychosocial – Spiritual (No ethical concerns, e.g., end of life issues, financial issues) Spokesperson DPOA Living Will

Yes Code Status No Family Conf. (LOS>3 Days) Plan of care reviewed with pt/family Yes No Financial Services Consult Social Services Consult

Yes Code Status No Family Conf. (LOS>3 Days) Plan of care reviewed with pt/family Yes No Financial Services Consult Social Services Consult

Yes Code Status No Family Conf. (LOS>3 Days) Plan of care reviewed with pt/family Yes No Financial Services Consult Social Services Consult

Yes Code Status No Family Conf. (LOS>3 Days) Plan of care reviewed with pt/family Yes No Financial Services Consult Social Services Consult

Discharge / Transfer Plans Long term discharge goal

Yes No Ready to discharge from CCU? Yes No ECF Planning Yes No Social Services Consult

Yes No Ready to discharge from CCU? Yes No ECF Planning Yes No Social Services Consult

Yes No Ready to discharge from CCU? Yes No ECF Planning Yes No Social Services Consult

Yes No Ready to discharge from CCU? Yes No ECF Planning Yes No Social Services Consult

Medication Review (no concerns re: IV to PO, home med, renal adjustments, sedation requirements, new allergies, adverse reaction, unnecessary medications)

Yes No Can any be discontinued? IV to PO

Yes No Can any be discontinued? IV to PO

Yes No Can any be discontinued? IV to PO

Yes No Can any be discontinued? IV to PO

Other patient specific issues / Other needed consults

AMI / ACS Indicators Cardiac Cath ACE for EF < 40%

Yes Plavix No Aspirin Beta Blocker ACE / ARB Lipid lower

Yes Plavix No Aspirin Beta Blocker ACE / ARB Lipid lower

Yes Plavix No Aspirin Beta Blocker ACE / ARB Lipid lower

Yes Plavix No Aspirin Beta Blocker ACE / ARB Lipid lower

CHF Indicators ACE for EF < 40%

Yes ACE No ARB

Yes ACE No ARB

Yes ACE No ARB

Yes ACE No ARB

RN Signature Date: Time:

Date: Time:

Date: Time:

Date: Time:

Intensivist Signature Date: Time:

Date: Time:

Date: Time:

Date: Time:

Physician PCM RN Physician PCM RN Physician PCM RN Physician PCM RN Pharmacy RT SS Pharmacy RT SS Pharmacy RT SS Pharmacy RT SS PT Dietary Chaplain PT Dietary Chaplain PT Dietary Chaplain PT Dietary Chaplain Palliative Care Other Palliative Care Other Palliative Care Other Palliative Care Other

Daily Goal Sheet (continued)

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Nursing Card(see Document 7 of the Coaching Call materials – SJMHS Interdisciplinary Rounds Checklist)

VAP

DeliriumSepsis

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• Enable teams to have frequent but short briefings so that they can stay informed, review work, make plans, and move ahead rapidly.

• Allow fuller participation of front-line staff and bedside caregivers, who often find it impossible to get away for the conventional hour-long improvement team meetings.

• They keep momentum going, as teams are able to meet more frequently.

Structured Huddles

Use this strategy to begin to recovery immediately from defects---IE: falls, sepsis and daily to focus on unit outcomes

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Components

Metric 1: Quality/SafetyMetric 2: Patient SatisfactionMetric 3: Operations

Daily Critical Communications

Information

Ideas in Motion

How to do it?

•Beginning or mid shift•5 minutes•Lead by member of unit leadership team

SICU Huddle Board

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CUSP Communication & Teamwork ToolsNext Steps

• Multidisciplinary Rounds– Complete Current State Assessment (See Slide 25)– Submit answers through Survey Monkey: http://www.surveymonkey.com/s/Z3KVYSQ– Due by Friday, July 8th

• Learning from a Defect– Identify next defect to solve – Make any additions/deletions to team membership

• Structured Huddles– Review the concept with unit leadership and CUSP team, gather questions– Questions will be answered/discussed during Coaching Call 2 on July 19th

• CUSP Team Agenda (see Document 3 of Coaching Call Materials)– Choose next defect to take through the Learning from a Defect Tool– Review multidisicipnary rounds slides; complete current state assessment– Review structured huddle slides; get feedback/questions from CUSP team and unit

leadership for next Coaching Call– Ensure that concepts of Multidisciplinary Rounds and Structured Huddles are vetted by

executive sponsor for unit and VPMA/CMO

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We Are On a Continuous Journey

• We have toolkits, manuals, websites, and monthly calls to learn from and with each other.

• Your job is to join the calls, share with us your successes and more importantly the barriers you face.

• Commit to the premise that harm is untenable.

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Questions?

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