1. LEARN FROM A DEFECT Emily Pasola RN, MSN, CNL Clinical Nurse Leader Surgical Intensive Care Unit Saint Joseph Mercy Hospital Ann Arbor, Michigan

2. Learn From a Defect Supporting a culture of safety Easy to use efficient Structured Method Continuity Non-punitive Ownership collaborative, multidisciplinary Improve Quality

3. Creating a Culture of Safety Identifying Defects- Creating a Culture of Safety Patient Safety Rounds Interdisciplinary Rounds Clinical & Communication Unit Care Team Quality Dashboard Daily Shift Huddles VOICE: anonymous reporting system Patient/Family feedback MHA score card Staff Safety Survey HCAHPS results/Press Ganey

4. Surgical Intensive Care Unit- LFD topics HAPU CAUTI VAE CLABSI Infection Control Delirium Screening Falls Septic Shock Bundle Medication Errors Mobility Self Extubation Communication defects

6. “How will the next patient be harmed?” Staff Safety Survey “How will the next patient be harmed?” Multiple Answers Common Responses Pressure Ulcers Fall CAUTI Major Themes Drift from common & standard practices Physican/Nurse Communication Patient acuity related to staffing RN to RN shift handoff RN to RN shift handoff

7. RN to RN Handoff The Defect: RN to RN Handoff

9. RN to RN Shift Hand-off Survey n=20 #1: The nurse that provided me hand-off used a hand written card, unit report card or other tool as the primary source of information. (19/20=95%) #2. After report, during my shift, I learned about pertinent information that should have been handed-off during report but it was not. (07/20=35%) #3. While taking report, the off going nurse and I used the Safety Page or other parts of the EMR to talk about the patient. (17/20=85%) #4. After receiving report the off going nurse and I went in to the patient room to do a bedside introduction. (17/20=85%) #5. After report, the off going nurse and I went in to the patients room and checked bags to pumps. (18/19=94%)

10. RN to RN Shift Hand-off Survey cont… n=20 #6. I would describe today’s hand-off as: “Outstanding, no missing information.” 10/20=50% “Informative, most information provided, missing a few points.” 9/20=45% “ Not helpful, disorganized, I had to seek out missing information after report.” 1/20=5%

11. Staff Engagement: Make tools easily accessible

12. Next Steps Continue with LFD action plan Provide on the spot feedback Wait for updated report tool Develop audit tool for hand-off spot check Re-administer hand-off survey Larger sample size Daily Huddle Continuity: How are things going? Insight from all shifts Can catch new drift

13. LFD: Patient Outcome Measures Learn from a Defect performed on ALL… Unit Acquired Pressure Ulcers Skin Huddle using LFD format Was it preventable? Did we perform all prevention interventions? Staff perspective of patient’s course of care Multidisciplinary, different units Falls Falls Huddle using LFD format Were all appropriate steps followed after fall? What can we do differently for the next patient? On the spot when fall occurs

14. CAUTI The Defect: CAUTI Catheter Associated Urinary Tract Infection

15. CAUTI The Defect: CAUTI

16. Front line staff Reaches all shifts Open Communication Multidisciplinary Quick Brainstorming Updates r/t LFD action plan New opportunities How are things going? Continuity Transparency Daily Shift Huddle-Everyday, Every Shift

17. Conclusion Easy, efficient & organized Supports staff engagement Multidisciplinary approach to quality care Provides transparency Staff want to know what we do. Staff want to know that we listen. Provides structure & accountability Tracks progress

18. Next Steps for CUSP 18  Conduct a culture assessment (HSOPS)  Establish an interdisciplinary CUSP team  Partner with a Senior Executive  Review the Science of Safety training  Identify defects  Download results from your culture assessment (HSOPS) and share with team  Meet regularly with your CUSP team  Use the Daily Goals tool in your ICU

19. Next Steps for Data Collection 19  Unit Lead completes Structural Assessment  Unit staff complete HSOPS  Unit Lead/Data Facilitator enters Daily Process Measures  Unit staff complete Exposure Receipt Assessment via survey link  One person from unit (we recommend the Unit Lead) complete the Implementation Assessment.  Unit Lead/Data Facilitator enters monthly VAE rates  Unit Lead/Data Facilitator enters Early Mobility Measures  Data Facilitator contemplates next steps for collecting Objective Outcomes Measures  Unit Lead/Data Facilitator pulls data reports from the data portal and share the feedback with your frontline staff