Patient Safety Advance

The Toxicity of Silence

It’s hard to imagine a hospital as a silent place—but there are many instances within the routine hospital day when silence, the absence of communication, can lead to medical mishaps. As the practice of medicine is a team sport, silence, including the failure to hold several critical types of conversations, can be deadly.

Based on studies in aviation and the military, we know that differences in professional hierarchy can result in reluctance to speak up. These studies also show that previous experience upon speaking up—a rude, sarcastic or demeaning response—can quell future efforts. We’ve all also experienced the silence of a person in power as a demonstration of that power. However, newer studies help us to learn more about the nature and effect of silence in healthcare. Here we’ll explore one such study and then cite seven crucial conversations that all too often DON’T happen in hospitals, and give a few hints about how to break these silences.

According to a study reported in “Silence, power and communication in the operating room,” (Gardezi et al. (2009) Journal of Advanced Nursing 65(7), 1390-1399), problematic “silence” can include absence of communication, non-responses to requests, and quiet or hesitant speech. These “silences” were interpreted to be defensive or strategic. The article states that “many of the instances of nurses having difficulty in obtaining responses… relate to brief, seemingly mundane, skirmishes that occur in the domains of nursing responsibility, including monitoring sterility in the OR, the instrument count, and the surgical pause.” Obviously the surgical pause, for example, is not at all mundane if it allows for the team to obtain a shared mental model and avoid harm. What is intriguing (and alarming) about this observational research is the effect of social interplay, power, and passivity that is at work in the OR—and much of it is unnoticed but has potentially harmful repercussions.

Another study done by the American Association of Critical Care Nurses and Vital Smarts (Silence Kills, 2005) enumerates seven conversations that people in healthcare just don’t seem to have” and the lack of these conversations puts patients at risk. These “Crucial Conversations™” were identified through a comprehensive survey of nurses, physicians, administrators and other clinical care staff in a variety of hospitals in 2004. The study found that more than half of all respondents had occasionally witnessed mistakes, broken rules, poor teamwork, etc., and yet fewer than one in ten broke their silence about what they saw.

These crucial conversations—in which silence is indeed toxic—are:

1. Broken rules
2. Mistakes
3. Lack of support for team members
4. Incompetence
5. Poor teamwork
6. Disrespect
7. Micromanagement

For example, 75% of survey respondents indicated that they had long standing concerns about problematic teamwork on the part of a colleague, some to the point of considering changing their place of employment, yet fewer than one-fifth of these respondents had spoken directly with their peer to voice their concerns.

When teams function poorly, when rules are broken, when there are concerns about competence, patients are at risk. So how can hospitals learn from the example of the minority—those who actually do speak up when they see these safety red flags? The authors of the Silence Kills study suggest that this problem is serious enough for hospitals to take on as a strategic priority; to assess and measure these behaviors (surveys are available); to focus training on problem areas with high impact (perhaps the OR?); and to implement training in effective ways. There are many ways to improve the effectiveness of training—one example they cite is to use emotionally compelling stories and examples that will motivate trainees to recognize behaviors and acknowledge that change needs to occur.

There is free content as well as proprietary material about Crucial Conversations™ available on the website www.dialogueheals.com; and as always please be sure to contact Qualis Health for additional information, assistance and training as you work toward stopping the silence!

Case Study: Puget Sound Healthcare

Improving Physician-Nurse Communication and Teamwork Using SBAR

Leadership at Puget Sound Healthcare, a nursing home in Olympia, Washington, identified physician-nurse communication and teamwork as an important focus for their quality improvement efforts. Commonly, physicians are off-site when nurses contact them about an emerging medical issue, making communication and collaboration especially challenging.

Qualis Health facilitated a leadership session on how structured communication and flattened hierarchy can improve communication effectiveness. Using a “learning conversation” structured communication approach (format: what I observe, think, feel and want), the physicians wanted to see nurses more effectively communicate patient status. Nurses reported delays and inefficiencies with the current communication system, sometimes spanning into the next shift. All felt frustrated and wanted to improve teamwork.

During the session, the group discussed differences in communication styles. Physicians are trained to be problem solvers, and nurses are trained to be narrative and descriptive. Dr. Kirk Dawson, Medical Director, noted, “In medical school, physicians learn to use SOAP to communicate case facts, assessment and patient plan of care. I can see SBAR as a parallel approach for nursing staff.”

The traditional model of communication might have been “I’m calling about Mr. Smith, he’s short of breath.” Then the conversation becomes a game of 20 questions until they come up with a plan that may or may not be mutually acceptable. SBAR requires problem solving, organization of information before communicating, and collaboration.

Why SBAR?

• Ensures completeness of information
• Sets expectations that flatten hierarchy—makes it okay for staff to say what they think is going on and make a recommendation
• Standardization makes communication less “random” or person-dependent
  
  

The team conducted a small test. Allison Paquette, the director of nursing, asked Qualis Health to provide an in-service to the three nurse managers on day shift. All nurse managers strongly agreed that the SBAR training was valuable, well organized and could be applied to their work. A huddle at the end of shift indicated that nurses successfully applied their training. Wendy Wincewicz, RN, used SBAR on a call to Dr. Laura Lindsay, Medical Director, who declared, “You’re using SBAR!” Puget Sound is now implementing SBAR facility-wide with all nurses, all shifts to receive training in February. SBAR is appropriate for any situation in which background is shared and a decision is to be made:

• Critical conversations requiring immediate action
• Problem situations
• Telephone communication between clinical professional and MD
  
  

Communication effectiveness at Puget Sound Healthcare is monitored through structured interviews with staff, observations and formal satisfaction surveys. The team is evaluating the current system for contacting physicians off-site for possible improvements in efficiency as well.

The Institute of Healthcare Improvement has a free webinar “IHI on Demand: Effective Teamwork as a Care Strategy—SBAR and Other Tools for Improving Communication between Caregivers” at www.ihi.org (type “on demand sbar” in the search box). You will be asked to set up a user account and password.

Qualis Health seeks applications for our Awards of Excellence in Healthcare Quality in Washington

The annual Awards of Excellence in Healthcare Quality recognize organizations in Washington State for outstanding and innovative work to improve healthcare quality during 2009. Does your organization have a compelling story to tell about a project that measurably improved effectiveness, efficiency, safety, access, the use of health information technology, patient-centeredness or healthcare transitions? If so, please consider submitting an application.

Providers from all healthcare settings (hospitals, clinics, home care agencies, extended care facilities, health plans and others) are encouraged to apply, regardless of size or resources.

To apply: Download an application from our website at www.qualishealth.org/qualityaward/wa.cfm.

The application deadline is February 26, 2010. Award winners will be notified by April 9 and recognized in a special ceremony at the Washington Patient Safety Coalition’s Northwest Patient Safety Conference on May 4, 2010, at the Hilton Seattle Airport & Conference Center.

For more information about the conference and how to register, please visit www.wapatientsafety.org. See how the Qualis Health Idaho team did this year.

Questions? Please contact Paula Parsons at paulap@qualishealth.org or call 206.288.2470.

Patient Safety Roundup

SCIP

National SCIP Expert Visits Idaho and Washington Providers

In January, Dr. Dale Bratzler, DO, MPH, & CEO of the Oklahoma Foundation for Medical Quality, visited both Idaho and Washington to meet with SCIP providers. Dr. Bratzler, a nationally recognized expert in SCIP who represents the program to various national committees including the National Quality Forum, led educational sessions focused on SCIP successes, culture and practice challenges, and addressing problematic measures. Please see below for list of hospitals.

During the sessions Dr. Bratzler covered all of the current measures, discussing the evidence base behind each measure as well as techniques used nationally for success. He also reviewed national progress on the measures since the beginning of the program in 2002 and a peek at future plans for SCIP. These fruitful sessions led to some major take-aways:

1. Antimicrobial prophylaxis for surgery needs to be administered in accordance with patient weight”larger patients need larger doses (sometimes 3 or 4 grams of cefazolin, for example) in order to attain appropriate bloodstream levels.
2. Antimicrobial prophylaxis may need to be redosed during lengthy surgical procedures. The half life of cephalosporins is around 4 hours, so if a surgery is still going at 3 hours, redosing should be done. Vancomycin and other medications have longer half lives and may not require redosing.
3. The SCIP glucose control measure requires that cardiac surgery patient serum glucose levels be maintained below 200, which gives a reasonable amount of leeway to avoid the problems associated with very tight control while still providing the evidence-based level of control shown to decrease SSIs.
4. VTE (venous thromboembolic events) are very common and very dangerous to hospitalized patients. Indeed almost every Medicare patient has at least one risk factor for the development of VTE. In order to adequately protect patients, hospitals should approach VTE prophylaxis as a “rule out” proposition rather than “rule in.”
5. CMS and the Joint Commission are working together on the SCIP measures to help hospitals meet the requirements that Congress has specified for reporting.

Some possibilities for future SCIP work include:

• the probability that additional measures will be extracted directly form electronic medical records wherever possible
• an ongoing effort on the part of the national SCIP Steering Committee to develop outcomes measures that will be meaningful.
  
  

Dr. Bratzler presented much more valuable information in the presentations and if you would like copies, please contact Jennifer Palagi at jenniferp@qualishealth.org in Idaho and Paula Parsons at paulap@qualishealth.org in Washington.

Participating Idaho SCIP Hospitals

Cassia Regional Medical Center
Madison Memorial Hospital
Portneuf Medical Center
Mountain View Hospital

Participating Idaho non-SCIP Hospital

Eastern Idaho Regional Medical Center

Participating Washington SCIP Hospitals

Cascade Valley Hospital
Kennewick General Hospital
Harrison Medical Center
Samaritan Healthcare
Southwest Washington Medical Center
United General
Yakima Valley Hospital

Pressure Ulcers

Hospital Pressure Ulcer Initiative Discontinued by CMS

Effective January 31, 2010, Centers for Medicare and Medicaid Services (CMS) has asked QIOs to refocus their efforts with the hospital acquired PrU initiative. As a result, Qualis Health will scale down the number of hospital in the project to a selected few hospitals with the best opportunity to continue to address the challenges of pressure ulcers in their community and with specific participating nursing homes. Qualis Health is committed to supporting activities that will help sustain the forward momentum created by the work of all of the participating PrU hospitals and will continue to work with nursing homes and hospitals on community of practice (CoP) activities. Qualis Health will continue to periodically provide PrU conference calls for both hospitals and nursing homes.

CMS and Qualis Health are grateful to the hospitals that have been part of the PrU initiative in 2008 and 2009. Qualis Health commends the participating hospitals and nursing homes for stepping up to the challenge of addressing the important issue of ulcer prevention and asks all of our participants to continue to monitor and address this important issue, as warranted in their facility and community. It matters to the patient!

VTE

Qualis Health Joins VTE Prevention Collaborative Project

Qualis Health has joined the AHRQ-QIO Learning Network’s VTE Prevention Project, which runs January-July 2010, to help providers reduce hospital-acquired venous thromboembolism (VTE). Using resources from AHRQ’s VTE toolkit, Preventing Hospital-Acquired VTE: A Guide for Effective Quality Improvement, hospitals reach breakthrough levels in care by participating in a multi-state, accelerated learning collaborative. The AHRQ VTE Toolkit is available publicly online www.ahrq.gov/qual/vtguide/#acknow.

Jennifer Palagi at jenniferp@qualishealth.org in Idaho and Paula Parsons at paulap@qualishealth.org in Washington.

Qualis Health Idaho receives record number of Quality Award nominations

The Qualis Health Award of Excellence in Healthcare Quality is given to providers to recognize and reward outstanding work in improving healthcare. This year Qualis Health Idaho received a record number of nominations (22), up 28% from last year’s record breaking (16) nominations! A wide variety of project topics were submitted such as clinical care practices, data and communications and patient safety culture. The nominations were evaluated in early February by a non-partisan review committee. Awards will be given for patient safety, quality of care, patient/family involvement and communications at the 2010 Annual patient Safety and Quality Improvement Conference on April 15-16 at the DoubleTree Riverside in Boise, Idaho.

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