Frush, Karen, MD, BSN

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Interprofessional Training and Practice at Duke Karen Frush, BSN, MD Chief Patient Safety Officer .,. . Duke University Health System' . January 7,2011 ' [51 DukeMedicine Duke Medicine Duke University Health System, School of Medicine and School of Nursing •  Duke University Hospital, 2 community hospitals, primary care network, ambulatory services, home health and hospice Duke University Hospital - 1000 bed academic flagship hospital, Magnel designation - 8,650 nurses 1,500 physicians GME training lor 950 residents and fellows in 74 programs Over 1 ,600 volunteers [51 OU.... M.d,cine  PageJ Framework for Safe, High Quality Care UADERSHIP CULTURE· COlLABORATiVE LINK TO U>lIT LEVEL...... " Ai• TfiliUng isconlin\JOO\K Rapid cyC1& omp'OIIemen! , f>!.ychoklqlca1 safely ... • C<>m!f<JnlCltl...... "e:I<)ilFll'6ured C,","'_                              faMlIe AiI:;oocer'lSare mponM'l !X)(I'murucalion . S!Jf'IX"1lte_ 1Ba<n"'!l                                                           clIo",""s                            , Coo(Oc«;rueresololM Crnicallangl.sge ClVtialCO!'IYl!fsaholl Overview Provide an overview of "Duke Medicine" Describe a framework for providing safe and reliable care Discuss the importance of interprofessional collaboration and high-performing teams in healthcare Review case studies at Duke Share challenges and successes of interprofessional education and training for healthcare professionals [51 DukeMedicme Duke Tradition •  Traditional culture of AMC - Described by D Kirch, AAMC President's Address 2007 - Autonomous. expert-centered, hierarchical - High-achieving, competitive Punitive Human factors: fatigue, burn-out Leaders - the best and brightest clinicians Medica' directors - Charge nurses, Clinical operations directors - No training; figure it out Clinica! science - Major research center: randomized control trials - Quality department responsible for "improvement" [51 OU....M.dicin. Starts with Leadership:  Attributes of the Right Stuff  Most important factor in predicting success of safety improvement initiatives was quality of leadership Organizations highly successful in safety were also successful in operational performance What does it take to be a good leader? - Engage at all levels of the organization - Understand crucial aspecls of human performance and relationships - To continuously improve performance and achieve superior results, evlture must change - meaning behavioral change [51 OukeMedidne 1 ------Achieving Safe & Reliable Care Culture: collaboration and teamwork - Healthcare is highly complex - Clinical environment has evolved beyond limitations of individual performance - Effective teamwork and communication are essential, yet not taught in school - Many assumptions regarding effective communication and teamwork 131 DukeMp.didnF. Kootlausesot lIysm"'reatment Root (auses orSentmel Events .....-- Root CllUlItfii or Venlilil.tor [\lents (1"5-21104) _,--== Communication Breakdowns are frequently          the root cause of ..          -_._-undesirable outcomes . " ............... ..  Root Causes ofMed;cahon Errors RooICa",,<:I;ClflnfeClion-DSSoclntcd E,ell!! ...        --::::        _._--- ----,-- _.._-....,.....   ...-            -               Communication breakdowns and adverse events at Duke Hospital Root Cause of Sentinel events at Duke Hospital similar to that reported to T JC Communication failures have resulted in harm to: - Patients undergoing surgery: wrong site - Patients on our medical floors and ICUs • Wrong medication, wrong procedure - Wrong newborn infant received vaccine Need for knowledge and tools to improve communication, collaboration and teamwork behaviors 131 Duke-MediCinE' Pallell Greenberg et ai, J Am Coli Surg 2007 Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients 444 surgical malpractice claims - 4 liability insurers 60 cases with communication breakdowns resulting in harm to patient - Pre-op, intra-op and post-op - 74 verbal commu nications (1 transmitter, 1 receiver) -                       to notify someone, i.e. an attending, of critical - 59 responsibility ambiguity - 35 handoff breakdowns "Serious communication breakdowns occur across the continuum of care." 131                            Teamwork Climate is the consensus of  Frontline Care Provider assessments  Related to Collaboration Example Teamwork Climate Scale Items: - In this clinical area, it is difficult to speak up if I perceive a problem with patient care - Disagreements in this clinical area are resolved appropriately (i.e. not who is right, but what is best for the patient) - The physicians and nurses here work together as a well-coordinated team 131 DukeMf'dlClne "  ..  II!' .< "  ..  "  ..  II  II  JII' ..  II' " II!'  I>  ... a, 2 '"    Teamwork Climate Across 33 Clinical Areas NOTE: iHmworK                     negatively CD""';StwJ with IMnuft! nll,..e lUmover rates, abHntHlsm, 851, PElDV'f', delajl$. and burnout Teamwork Climate and BSIAcross Michigan ICUs: No BSI is;;:: 5 Consecutive Months without a BSI 100 Hudson at al., 2009. Contemporary Critical Care Vol 7 N05 The strongest item level predictor of clinical excellence: caregivers feel comfortable speaking up If they perceive II problem with patient cate Case Studies at Duke: Interprofessional Practice and Training to improve Patient Care • Teamwork training and handoffs TeamSTEPPS in PICU • Healthcare acquired infections  - CA-BSls in Critical Care Units  • Next-generation Healthcare Professionals Interprofessional training, education -'I,  f);,."1 !            Duk<>Med'Clne  {I    Duke PICU First 6 months ... no traction End of year one: good results Decrease in infection rates (3% to 1%) Decrease LOS (0.6 days) and increased throughput (1 0%) - Work Culture survey score increased by 16% End of year three: fantastic results - Decrease in infection rates «0.5%; >300 days with no BSI) - Improved handoffs (more efficient and effective) •  Consistent sustainment - New staff and new residents oriented each month "The way we work here", nol a separate initiative anymore - Tools and strategies are embedded into workflow   DukeMed,cire DukePICU Started team training in 2005, using earliest versions of TeamSTEPPS •  Transformational change model:  Strong leadership support  - Trained everyone over a few weeks time in Interprofessional groups Hired consultants to train, coach and observe Chose several practice changes at once: sterile cockpit for rounds, morning huddle. SBAR nursing report, structured han doffs Consistent metrics measured frequently: sUlVeys. observation, outcomes [!;I DukeMediCine Cardiothoracic Surgical Hand-Off Oporallt'l!J 1<:(!()UIj{l l'elmllne C;l<:d<ac inle<!51'le Care \,.!ru: {poe',)) 3 OR -ICU Hand-Off Turnaround Time Mistry K, et al. AHRQAdvancesin PatientSafely; 2008 [g OukeMedidne Improving Collaborationto Decrease CA-BSI •  ImplemenllT safely syslems 'M1y we need checklists - Computerized SRS - CPOE,EHR  Automated Surveillance  Bar Coding, Smart Pumps  Patient Portal •  Standardize, align processes  Implement best practices  Use of checklists  • CA·BSI Bundle [g DukeMedicine "  Interprofessional Education for  Students in the Health Professions  • Growing body of evidence to suggest interprofessional collaboration and teamwork are important for patient safety, outcomes •  How are we training next generation  healthcare professionals?  • Personal experience" [g OUkaMedKioe OR -ICU Hand-Off Improvements MiSlryK, el al. AHRQ Adv.ncesin Patient Safety, 2008 • Tum-around lime was reduced from 15.3 minules to 9.6 minutes (p<0.001) • Critical lab draw time reduced from 13.0 minutes to 2.4 minutes (p<0.001) • Percent of chest radiographs completed within 15 minutes of arrival to PCICU increased from 60% to 94% (p<0.01) • Most importantly, decrease in serious safety events  related to handoffs from OR to PCICU  [g DukeMe-dIClne. Duke University Hospital Catheter Associated Primary Bloodstream .-Infections      J (32 c o o Top Perfonner FYOS FY09 FY10 FYII --Internal TGT -- NEMJ Bencbmark [g OukeMedicmE ." .. " .. .. ,. .. r .' .. *' '" It< .-• .. ., 4 '" ., I nterprofessiona I Education • 2007 grant funded interprofessional, inter-institutional study • Duke/UNC SoN and SoM •  Using TeamSTEPPS in lecture, ARS, role play and high fidelity simulation ..   Teamwork Knowledge Results knowledge test results Training condition [51 DukeMedidne Conclusions of Study Training Significantly improved student  knowledge ofTeamSTEPPS curriculum  attitudes toward interdisciplinary teamwork  No significant difference between four different educational delivery methods Students reported positive experiences and asked for more opportunities for interdisciplinary education Hobgood, Frush, et ill. Teamwork traimng with nurSing and medica! students Does the methOd matte!! Results of an inter/flstitutionaJ, inierfiiscipilnar'j coffaboratmn QSHe Jato Apr 21-[51 Duk&Medicine TEAM TRAINING EVALUATION  KIRKPATRICK'S EVALUATION MODEL  Teamwork Attitude Survey Results Level 4 - Results whether the traming has affected process or outcomes such as Increased production, Improvedquallty; reduced adverse events, decreasedcosts, or return on Investment Level 3 - Behavior, whether partIcipants change thEHrbehavlOr back In the workplace as a result oftralfllng Level 2 - Learning whetherthe traIning results-tO an Increase In knowledge,skilis or attitudes Level 1 - Reaction how did partu:lpantsreactto the trammg? • Heafthcare acqutredinfection rates. • AHRQ Patient Safely Indicators. •Adverse drug events. • Lengl/1 of stay. • Patient satisfaction. • Staff satisfaction. • Nurse tumoverrates. Observation ofteamwork behaviors during routine patient care. .. Teamworkknowledge test.  .. Survey of attitude towardsteamwork  • Survey of self-percejved  communication skills  .                           reacnonsurvey Pili-e27 5 Interprofessionai Education Duke interprofessional sessions during Capstone - Scheduling difficulties: evening sessions - Team based learning; key Interaction of medical and nursing students in small groups •  UNC Interprofessional Teamwork and Communication (IPT) Course Semester long course; SaM, SoN, SoPh lecture, simulation, TBl; Faculty development Emory - Interprofessional team training: SoM, SoN, PA, PT - 460 students, 88 facilitators - Communication, Role Identity, Team Identity [51 DukeMedicine Summary Growing evidence to link effective teamwork behaviors and collaboration with good patient outcomes, safe patient care Duke, others' experience supports focus on inter-professional training in healthcare •  Important to understand culture survey results and assess need for teamwork training •  AMCs have great opportunity to "mold" behavior and create new norms, rather than changing old patterns •  Challenges to IPE in healthcare professions include scheduling logistics, faculty development and role models ..  ..  11" '" i>' ..  Ii ..  II> ..  II> ..  iii' ..  ... ..  ..  ..  6 11\ II< II 

Crossing the Boundaries: Achieving Interprofessional Collaboration and Care

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Crossing the Boundaries: Achieving Interprofessional Collaboration and Care

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