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Improving Our NICU Culture of Safety Salem Hospital NICU, Salem, Oregon Primary Authors: Bobbi Kurronen NNP, Howard Cohen MD Email:
[email protected] Phone: 802-555-1111
Keywords Safety Pins Homeroom, patient safety, culture of safety, teamwork, huddles, error/ near-miss/ potential error reporting, handoffs, huddles, simulation, speaking up Background In 2013, we measured our culture of safety using the Teamwork and Safety Climate Survey as part of a multistate collaborative project focused on CLABSIs in the NICU. We repeated the survey in early 2014. Our overall scores on the survey and the safety climate portion were in the 80s and on the second survey only 77% of caregivers in our NICU reported that we had a positive safety climate. We believe that, in order to successfully implement and sustain practices that improve the safety of care for our patients, we needed to directly focus on improving our culture. Aim Improve our culture of safety as measured by the Teamwork and Patient Safety Climate Survey from an overall score of 85 to greater than 90; and 100% of NICU caregivers rate our safety climate as positive, by October 2015. Setting 27 bed NICU with an average daily census of 14 in a Community Hospital with ~3500 deliveries/year. Maternal and neonatal transports. 350-400 admissions/year. Babies down to 26 weeks gestation. Problem Description/Rationale Specific questions in the Teamwork and Patient Safety Climate Survey scored low and we hypothesized that these represented opportunities for improvement. These included a gap between the importance of handoffs compared to frequency and effectiveness, discomfort Text has disagreement been removedand fromquestioning this sectionthe since requirements have been updated for 2016. expressing neonatologists and neonatal nurse practitioners, Please see description of this section listed on 2016 Abstract Development Instructions. discomfort discussing errors and learning from errors of others. We brainstormed to identify contributing factors related to each of these hypothesized mechanisms. We also hypothesized that we had opportunities related to collaboration between the NICU staff and providers. Drivers of Change (see also Appendix slides 3, 4) We believe there are three important related areas of work related to providing the safest care for our patients and the safest workplace for our caregivers (slide 3: dots & PBPs). Much of the work that is done in the NICU can be standardized and we continue to develop and use protocols, guidelines, checklists, pre-briefings, training, our playbook, bundles and other safety tools to accomplish that. Certain emergent and rapidly changing clinical situations (e.g. difficult resuscitations, multiple nearly simultaneous admissions) don’t lend themselves to standard work. To handle these better, we rely on teamwork training, simulation, video review, debriefings. These have been areas of ongoing work in our NICU. For this collaborative, we chose to focus primarily on improving our culture of safety (slide 4: key drivers).
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Interventions/Tests of Change We identified our QI team and then created our charter. Using the VON patient-safety tool-kit, our own knowledge and previous work in patient safety and ideas from the NICQ/Next webinars and our on-site visit in 2014, we identified a number of potential better practices that could be tested and implemented. Our team met almost every Thursday morning to discuss our work and develop and review our action plans. We used I-Phone technology to allow everyone to participate either face to face or by conference call. Over the course of the collaborative work, we modified our charter several times to reflect changes as our work developed. Our first test of change was to try daily shift huddles. We scripted how the charge nurse would lead the huddle and what was to be included. All NICU staff and providers working the shift were to be present. During the day these were held at the start of multidisciplinary bedside rounds. On Tuesday, we included public health nurse and care manager. These huddles were immediately successful and have been done 100% of the days since inception. The hospital has an electronic proprietary Patient Safety Alert (PSA) system for safety issues to be submitted. To further increase reporting we had previously placed a box in the NICU where anonymous patient safety and practice related questions and concerns could be raised and those would be addressed by the neonatologists and nurse practitioners and reported back through a Patient Safety newsletter. We scripted the huddles to encourage reporting any patient safety concerns, which we then recorded and addressed as appropriate. We routinely discuss safety concerns and what was done to address previously raised concerns at our huddles and via email with staff and providers. We also have shared and discussed our data related to reporting and our Teamwork and Patient Safety Surveys at the huddles and email. Our initial approach related to handoffs focused broadly on the processes of neonatologist, nurse practitioner, nurse and charge nurse handoffs. As expected, we saw a lot of variability. Subsequently we narrowed the focus to nurse shift change handoffs including several tests of change related to developing standard handoff information and process. After changes were made during those tests, we implemented a standard nurse shift change handoff in May, 2015. We also developed a scenario related to parents being at the shift change handoffs and held discussions at staff meetings about preparing parents for shift change handoffs and doing the handoff with them present. We did several tests related to increasing comfort speaking up and expressing concerns including one simulation and a subsequent discussion at staff meetings. We also continued to encourage speaking up during shift huddles. We also did a number of tests of change leading up to implementing nurse led multidisciplinary daily bedside rounds and additional iterative changes after. Lastly we began asking parents about any safety concerns during our weekly multidisciplinary discharge rounds. Measurement Teamwork and Safety Climate Survey Scores (June 2013, March 2014, September 2014, June 2015) 1. Number of Patient Safety Reports/ month including annotation of specific reports 2. Monthly Rate of shift huddles (number done/number of days x 100). Quickly stopped this measure as it was 100% from first day. 3. Monthly Rate of correctly done RN shift reports (handoffs) (number done correctly/number done x 100). 4. Rate of nurse led daily bedside multidisciplinary rounds. Quickly stopped as a measure as it was 100% from first day
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5. Preventable errors in care because of incomplete shift report (Qualitative) Results (See appendix slides 5-9) We have done shift huddles during all (100%) shifts since we started doing in spring 2014. We have seen a gradual increase in the number of patient safety issues raised per month. We started daily nurse led bedside multidisciplinary rounds in March 2015. These have happened daily (100%) though we’ve made some adjustments in the process to increase rounding efficiency and support individual RN needs (breaks, breast pumping) and family participation. Discussion Our outcomes, based on the Teamwork and Safety Climate Surveys reflect the processes we changed and ongoing transparent discussions regarding importance of reporting through whatever venue feels most comfortable as well as errors themselves and ways that we have addressed them to improve safety. The Survey continues to show we still need to improve nurses’ and others’ comfort speaking up and expressing disagreement with the neonatologists and/or neonatal nurse practitioners. We’ve made a number of process changes in our NICU to successfully increase patient safety and our culture of safety. In terms of reporting, we’ve created multiple avenues for reporting. Verbal reports come up during our shift huddles where errors and other safety concerns are also discussed daily. Errors can also be reported anonymously. Recently, we’ve had several individuals self-report, which we take as an indication of increasing psychological comfort with error reporting/discussions. Though we always started with small tests of change, several process changes were very quickly adopted including daily shift huddles and nurse-led rounds, which now always happen. In part, we attribute this to already having a process in place (daily multidisciplinary rounds) and a non-threatening flexible implementation. Our most difficult change has been related to doing simulations focused on speaking up, questioning, having difficult conversations. This is related to some discomfort doing the simulation and not having a good forum such as staff meetings in which to do them. We will continue to work on this aspect of our culture. We believe our nurse-led rounds will empower our bedside nurses to speak up and question more by flattening the professional hierarchy. Next steps: As noted we continue to see that it is difficult for staff to express disagreement with the neonatologists and nurse practitioners. As the team reviewed this result together and brainstormed we have already identified several ways to try and understand more about the mechanisms of this discomfort so that we can develop and test hypotheses to address it. • Discussions at our huddles after sharing the results of the survey • Survey monkey with the staff to allow more anonymous feedback regarding the barriers • Reading the book “Crucial Conversations” to improve our own knowledge, identify other possible mechanisms we can test and education we can provide to the staff and providers We will also use the Model for Improvement approach to addressing this. In order to know if we are sustaining our improvement related to our culture of safety, we will continue ongoing measurement of our NICU Safety Culture using the Teamwork/Safety Climate Survey every 6-9 months.
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Team acknowledgment: Our outstanding team included Howard Cohen MD, Bobbi Kurronen NNP, Kacy Bradshaw NNP, Andrea Bell RN, Alyssa Scheler RN, Heather Austin RN, Julie Cox RN, Jill and Nathan McClenny- Parent Advisors Other participating Neonatologists: Robert Schelonka, Brian Jordan, Dmitry Dukhovny, Daniel Morrow, Trang Huynh, Brian Scottoline, Magda Petriniak
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