The half-day conference brought together acknowledged experts from the national movement for quality in health care for a discussion of Stanford University Medical Center's strategy to excel in patient safety and clinical excellence. One common theme permeated the day: communication. When done correctly, patient experience and quality of care improve dramatically. When communication fails, disastrous outcomes occur. Nearly every speaker acknowledged one poignant fact: most medical errors arise from miscommunication or incorrect assumptions.
Christopher Dawes, president & CEO of Lucile Packard Children's Hospital, brought this point home in a profound way by showing the audience a re-enactment of the Canary Islands airline tragedy, the worst in aviation history. Watching two 747 airplanes collide on a foggy runway is a powerful way to depict how communication errors can lead to disastrous results.
Other speakers shared examples of creating a culture where providers at every level feel safe to speak up, implementing a zero-tolerance policy for patient harm, becoming more patient-centric in communications, training teams of providers together under stressful situations and sharing mistakes openly so others can learn from them.
Becoming patient centric
Keynote speaker, Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement (IHI), was quick to point out that the health care system in its current state is far from optimal. Seventy-five percent of the health care budget is spent on chronic disease, and all indications are that this problem will only get worse as diabetes, cardiac disease and obesity continue to rise.
"As health care professionals, we need to understand our obligation to focus on the health of the population in general," she said. She believes that change must occur at three levels: the patient, the organization and the community. "On the patient level, we need to change how we interact in a deep and profound way," said Bisognano. She counseled providers to become more patient-centric, to ask, "What matters to you?" rather than "What's the matter?"
On an organizational level, Bisognano recommends adopting a team-based approach. "When people learn to work as a team, there's a dramatic difference in the culture," she said, citing an example from Packard Hospital where family-centered rounds were implemented two years ago. During rounds, a patient's entire team is there, including the patient's family members, doctors, residents, students, pharmacists, nurse, case manager, social worker, dietician, etc. Rather than taking longer to round, the team-based program actually reduced the time per patient, while also decreasing miscommunication. Everyone heard the same message and shared in the decision-making. "It's so exciting when the patient’s voice can be heard, and the whole team is there to hear it," said Bisognano.
On a community level, she shared a care strategy being used in New Zealand to work with the Maori population. Providers there are going back to seeing patients together with their families, so that all members can be educated and trained to care for the sick patient. They are teaching the wife to cook healthy meals, for example, and teaching children to care for their sick parent. "They are seeing chronic diseases melt away in this population," says Bisognano.
In another part of New Zealand, a pastor and his wife offer Zumba classes at their parish and teach parishioners how to prepare healthy foods. They are getting people in their community to change behaviors, and are having a great impact on chronic disease.
Simulation training is essential
In the second keynote presentation, David Gaba, MD, associate dean for Immersive and Simulation-Based Learning, used a number of correlations from the airline industry to show the clear similarities between these two high-stakes fields. "Expert knowledge and skill is not enough," he contested. "You need optimal team skills and decision making."
Simulation-training engages providers in scenarios with clinical challenges, it allows them to deploy and practice teamwork skills, it tests how people react to pressure and uncertainty and it allows cross training. He encourages teams to bring in the whole hierarchy for simulation training because subordinates often have difficulty challenging the decisions of those in a higher position.
How can we improve communication?
The second half of the conference focused on strategies for improving communication across multidisciplinary teams and between care teams and patients. Standardizing communication among team members and using checklists and tools such as SBAR and IPASS are instrumental in decreasing hand-off errors.
Critical language is another key for reducing miscommunication. Deborah Franzen, MD, clinical associate professor at Packard Hospital described how the ICU staff at Packard went through a three-day training with coaches from IHI to use critical language and role-playing to decrease hand-off errors. Before the intervention, the ICU team had a 33 percent rate of errors, but just two percent after the training.
Another important area to tackle is the environment. Does the patient care staff feel safe speaking up? Is their mutual respect between team members? Anita Honkaren, MD, chief, Pediatric Anesthesia Division at Packard, discussed ways to break down what she referred to as the "Authority Gradient." "Everyone needs to feel empowered and responsible to intervene when quality/safety appear compromised," she said. She counseled those in attendance to be clear and concise, and to speak up.
Bisognano shared some stories that exemplified this point. In one case, an intern stubbornly kept her hands on an OR patient's knee, preventing the attending surgeon from making an incision on the wrong knee. In a starkly different scenario, an intern observed something amiss during a routine Cath Lab procedure, but was too intimidated to call attention to her superior's error. Later that day, a relatively healthy patient died.
Halfway through the conference, Chief of Staff Ann Weinacker, MD, conducted an on-the-spot poll of attendees, gauging Stanford's culture of communication. Using an instant survey tool, she reported that 77% of the audience said they would be afraid to question the care provided by a superior and 57% had discounted the opinion of a subordinate. "We have a lot of work sill to do," she said.
"A safety culture exists when each employee takes an active role in harm prevention and is supported by the organization," said Bryan Bohman, MD, associate chief medical officer. He discussed the Stop the Line philosophy, which builds a culture of safety through empowerment of front line clinical teams. "Our culture of safety at SHC is not where we want it to be. We need to get over being perfect and have the courage to send out reports about our mistakes and learn from these stories."
In the day's final presentation, Nancy Szaflarski, RN, PhD, FCCM, program director, Clinical Effectiveness Innovations, and Clarence H. Braddock III, MD, MPH, FACP, professor of medicine and associate dean for graduate medical education at Stanford, shared results from Project TRANSFORM. This yearlong research study showed that a simulation-driven patient safety program can improve clinical outcomes through enhanced teamwork, training and process. The key to Project TRANSFORM was that simulation training occurred on patient care units where nurses and residents who ordinarily work together trained together, noted Braddock.
He and Szaflarski also discussed a number of organizational strategies to promote effective communication and decrease adverse events. These include conducting daily interdisciplinary rounds, using the Goals of Care form to communicate care plans, standardizing hand-off communication, creating psychological safety for staff by holding informal social events, reliably identifying the responsible physician so nursing staff know who to call and making adverse events transparent by sharing lessons learned.
By Grace Hammerstrom