EHM: Teamwork, Communication and Culture

Make no little plans…..

Understanding Culture
• Why Culture Matters

• Methods to examine culture
– Team Check-up Tool

• Tools for changing culture

What is my Unit’s Culture?
The set of shared attitudes, values, goals, and practices that characterizes my unit…or an institution, organization or group

What is a Safety and Quality Culture?
“The enduring value and priority placed on a worker and public safety by everyone in every group at every level of the organization. It refers to the extent to which individuals and groups will commit to personal responsibility for safety and quality; act to preserve, enhance and communicate safety concerns; strive to actively learn, adapt and modify (both individual and organizational) behavior based on lessons learned from mistakes; and be rewarded in a manner consistent with these values.”

High Functioning Teams
• • • • • Positive Communication patterns Deceased levels of interpersonal conflict Increase collaboration Increase cooperation Increase participation

Lemieux –Charles, MacQuire, What do we know about health care team effectiveness? Review of the literature, Med Car Res Rev, 2006. 63:263-300 5

Safety, Quality & US Healthcare System
• Medication errors • Adverse events • Unnecessary infections and deaths
– Nearly 2 million HAIs in US hospitals each year – Nearly 100,000 deaths from HAIs – Cost of HAIs is $5-6 billion annually

Culture Matters: The Evidence
Safety Theme Unit Variation /Mgr + attitudes Author Huang 2007 Description Safety culture variation exists across ICUs of a single hospital. ICU nursing directors tend to overestimate their personnel’s attitudes, particularly for teamwork A clinical microsystem (unit) is an important level to focus safety interventions, where errors can be prevented or mitigated After team training, a 50% reduction in adverse outcomes was achieved

Units are key & Mohr , team training 2004 works Mann, 2006 Teamwork reduces nurse turnover

Di Meglio Organizations that have effectively implemented a 2005 medical teamwork system have a 27% reduction in nurse turnover

Antenatal Steroid Use in CA 2005-2007

Antenatal Steroid Use in CA 2005-2007

Communication Disconnection

Teamwork Disconnect


Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care

% of respondents within an ICU reporting good teamwork climate

90 80 70 60 50 40 30 20 10 0

No BSI = 5 months or more w/ zero No BSI 21% No BSI 31% No BSI 44%

Health Services Research, 2006;41(4 Part II):1599. 12

100 90 80 70 60 50 40 30 20 10 0

Teamwork Climate & Annual Nurse Turnover

% reporting positive teamwork climate

High Turnover 16.0%

Mid Turnover 10.8%

Low Turnover 7.9%

RN Teamwork Climate


Staff Physician Teamwork Climate

“Needs Improvement” Statewide Michigan CUSP ICU Results
• “Needs Improvement” means less than 60% of respondents reported good safety climate • Statewide in 2004 84% needed improvement, in 2007 23% • Safety Climate item that drives improvement: “I am encouraged by my colleagues to report any patient safety concerns I may have”

Team Check Up Tool
• Purpose: Monitor progress of project teams to increase breastfeeding rates • Team Use
– Identify activities that influence performance – Identify barriers – Identify opportunities – Communication: Senior leaders, nurse, physician, families

EHM Team Check Up Tool

Team Check Up Tool
• The TCT is your assessment and diagnostic tool for coaching your teams
– Identify where team struggles and successes

• Targeted interventions available in CUSP & CABSI toolkits • TCT data will support your communication with senior leadership
– “You have voiced your commitment to the CABSI project. This is where teams think the barriers are, and we need your assistance/resources to work through these barriers in order to move forward”

Other Teamwork and Communication Tools
• • • • Daily Goals Checklist Morning briefing or “Huddle” “Walk Rounds” Debriefing

TCT Time!
• 10 minutes to complete TCT at your tables • One representative report out

Make no little plans…
“Make no little plans; they have no magic to stir men's blood and probably will themselves not be realized. Make big plans; aim high in hope and work, remembering that a noble, logical diagram once recorded will not die.” Daniel Burnham (Master Architect and City Planner Chicago, DC, Union Station…)