Perinatal Patient Safety An interdisciplinary approach to improve performance J. Chris Carey MD Director, Obstetrics and Gynecology, Denver Health Professor, Obstetrics and Gynecology

**High reliability organizations are those that operate highly complex and hazardous technological systems essentially without mistakes over long periods of time. High reliability patient care units are built on a solid foundation of timely communication and collegial teamwork to maintain patient safety as a top priority. ** “Managing the Unexpected: Assuring High Performance in an Age of Complexity” K. Sutcliff, MSN, PhD San Francisco: Jossey-Bass; 2001

In these units………… Concise, real-time and constant communication is valued Teamwork and collegiality characterize the professional relationships Hierarchy is minimized Safety is the hallmark of the organizational culture Their operations are viewed as potentially dangerous Emergencies are rehearsed and the unexpected practiced

Partnering Relationships Are……………….. Collaboration and teamwork that is an authentic partnership in which power on both sides is valued Each recognizes and accepts spheres of activity and responsibility Each mutually safeguards the interests of each other Each recognizes a commonality of goals Based more on respect and contribution than power and dependency

Partnership is evidenced by …… Communicating with patient’s family and healthcare providers regarding patient care and all providers’ role in the provision of that care Collaborating in creating a documented plan, focused on outcomes and communication with families and others Partners with others to effect change and generate positive outcomes through knowledge of the patient or situation

Strategies to achieve a strong partnership ethic include: Thinking expansively Being flexible Challenging assumptions Abandon the comfort zone Redefine boundaries Realize the vision

Think Expansively, become a “Totalist” Always learning and supporting the changes that benefit the patient Thinks beyond the confines of own experiences or knowledge Sees the whole picture Sees how people and processes work together

Be Flexible Adapt to change When situations are not controllable, your reaction to it is Work together to manage the surprises, ambiguity, conflict or disorientation that are part of every change

Challenge Assumptions Never blindly trust assumptions Build on knowledge and understanding Mistakes, errors, wrong turns and confusion are often built on assumptions Knowing your partners is essential Believing assumptions to be true encourages a lose-lose situation that fosters resentment, confusion, delays and waste. Stop Making Stuff Up – check it out!

Abandon the Niche Step outside of your personal comfort zone Understand your team Cannot continue to do things in the old way Be willing to trust others Be willing to stretch and share our expertise Be willing to work on projects that involve others in the organization Be willing to take risks

Redefine Boundaries Let go of traditional roles Eliminate “turf protection” Remove barriers to cross-functional interactions Think big and out of the box Focus on patient needs

Key Elements for success Partnership Equity Outcomes Benefits Barriers Accountability Ownership

Why Effective Communication and Teamwork ? The overwhelming majority of untoward events involve communication failure Somebody knows there’s a problem but can’t get everyone in the same movie The clinical environment has evolved beyond the limitations of individual human performance

MD –RN: Different Communication Styles Nurses are trained to be narrative and descriptive Physicians are trained to be problem solvers - “what do you want me to do” – “ just give me the headlines” Complicating factors: gender, national culture, the pecking order, prior relationship Perceptions of teamwork depend on your point of view

Effective Communication Requires: * Structured communication – SBAR * Assertion/ Critical Language – key words, the ability to speak up and stop the show * Psychological safety – an environment of respect

Situational Briefing Model S-B-A-R * Situation * Background * Assessment * Recommendation

SBAR in OB * S – Impending uterine rupture * B – VBAC, dense epidural, persistent breakthrough pain, complete * A – I’m concerned, something’s wrong * R – I think she needs a C-S. I need you now

SBAR * Situation – the punch line 5-10 seconds * Background – the context, objective data, how did we get here * Assessment – what is the problem ? * Recommendation – what do we need to do ?

Assertion Model to guide and improve assertion in the interest of patient safety *

The Difficult Conversation * Focus on the common goal – high quality, safe care * 3 rd person – depersonalize the conversation – it’s not about you and me * Avoid judgment; who’s right, who’s wrong is a loser * What needs to happen for us to do the right thing here? “Difficult Conversations”: Stone, Patton, Heen; Viking (1999)

Sustaining SBAR Use “Give it to me in SBAR” Use prompts and ticklers –Checklists –Phone labels –Pocket cards “Thanks for using SBAR” Reward and recognize