IPED 15, IPED 14, IPED 13, IPED 12, IPED Set 11, IPED Set 10

Know the role of students as advocates, the process to assert themselves including DESC , CUS and the two-challenge rule.

(Describe behavior, Express concerns, Suggest alternatives, Consequences for goal) (I am Concerned, I am Uncomfortable, This is a Safety issue)

Recall the seven most crucial concerns, and the modes for handling conflict

...Broken rules, mistakes, lack of support, incompetance, poor teamwork, disrespect, and micromanagement

Examples of COI

1) A practice that sells supplements "on the side", or has a line of health care products that are offered separately to patients who are able to pay out of pocket and co-workers (other professionals) are asked to offer products to patients, too. 2) Herbal supplements offered in a pharmacy 3) Fabricating orthotics in the name of prevention with little evidence - stock in company supplying the materials or receive a percentage from orthotics fabricated 4) Gifts from patients or patient's families 5) Gifts for preceptors 6) Researcher is also provider and asks patients to enroll in study 7) Study sponsor "owns" research results and controls dissemination of research results

What are strategies for managing?

1) Self-awareness / mindfulness 2) Consultation with peers 3) Guidance from codes of ethics 4) Institutional policies and procedures 5) Disclosure 6) Institutional oversight

8 step process of analysis

1. Identify the ethical question 2. Describes the gut reactions 3. Identify relevant facts and the ones that need to be gathered 4. List the stakeholders how values apply in the case 5. Describe the options 6. Describe what you should do, the process and outcome choice 7. Justify your choice Anticipate objections 8. Describe preventions for the ethical issue

Arguments against supporting a right to health care?

1. collective social protection argument- focuses on similarities between health needs and other needs the government protects if government has an obligation to provide one type of essential service, then it must have an obligation to provide another 2. Fair opportunity rule- social institutions are judged according to their tendency to counteract the lack of opportunity caused by unpredicted misfortune

Set an aim

A general statement that is time specific and measurable

According to Paul Levy, which of the following were factors that led to the wrong-site surgery at Beth Israel Deaconess Medical Center in June 2008?

According to Levy, multiple factors led to the wrong-site surgery (which occurred even though the surgical team marked the correct site), one of which was that the team did not conduct a "time out" safety check, another of which was a broader systems issue

Implement changes

After you get a change that results in and improvement you need to make the change standard for what you do.

Identify the key elements of an effective aim statement.

An aim statement is the answer to the first question in the model for improvement: what are we trying to accomplish? A good aim looks at how good, by when, and for whom or what system is it for.

ARCC

Ask Request Concern Chain of command

According to the World Health Organization (WHO), how could at least half a million deaths due to surgical error be prevented every year?

By implementing systemic changes in operating rooms

Key components of the AMC policy

Can't receive personal gifts from industry, can't accept or distribute materials, meals should not be provided, even off campus not allowed. Can't get free drug samples, medical devices, or supplies from industry. Don't accept gifts, monetary stipends, etc just for attending a lecture. Can't accept "no strings attached" gifts Have to submit COI , lectures have to disclose don't shield students from marketing but educate them about drugs and development

Which of the following opinions did Dr. Robert Wachter express in his response to Paul Levy's blog about the wrong-site surgery of June 2008?

Circumstances could exist where the providers were to blame for the error

CUS

Concerned, uncomfortable, unsafe/safety issue

Plaintiffs had four main reasons for suing

Concerns about standards of care- both patient and relatives wanted to prevent similar incidents in the future

CSTE

Curiosity, status, time, education (students as advocates)

DESC

Describe the behaviors Express how it made you feel Suggest alternative Consequences for team goals

The radiology department you work in has had an unusual number of errors in the past year. Specifically, several patients have undergone procedures entirely different from the ones ordered. Unfortunately, the department does not have a culture of safety, and open discussion of mistakes is almost unheard of. Despite the current culture, you decide to try and form an improvement team to address these errors. In order to help foster a culture of safety, which of the following is an action you should consider taking?

Develop a plan to ensure that everyone in the department is clear about the problem.

5 questions to help assess accountability for error

Did the individuals intend to cause harm? Did they come to work drunk or impaired? Did they do something they knew was unsafe? Could 2 or 3 peers have made the same mistkae in similar circumstances? Do these individuals have a history of involvement in similar events?

Which of the following is an example of transparency?

Discussing a time when you made an error similar to one that just occurred, and explaining what you learned

One hospital CEO insists on including performance data in the hospital's annual report. "We do very well on most measures, except for one or two, but we put those in anyway," she says. "We want to hold ourselves accountable." Does this practice demonstrate effective or ineffective leadership?

Effective leadership: Being transparent, even about poor results, is a mark of a good leader.

Recognize change concepts as they relate to potential strategies for change.

Eliminate waste Improve workflow Optimize inventory Enhance producer-customer relationship Change the work environment Manage time Manage variation Design systems to prevent errors Focus on the design of the products and services

Good team leaders promote safety by:

Engaging all team members Using first names Involving team members in two way conversations Encouraging feedback Responding to suggestions Respecting and valuing every team member and his or her input

Recommendations for handling conflict

Establish a baseline and a target for improvement Conduct focus group interviews Focus on problem areas Implement training- i.e. leaders teach, qualitiy materials, spaced learning,sustained attention, and relevant

A medical unit in a hospital is in the midst of hiring some new physicians. During an orientation for new employees, a senior leader stands up and says, "We expect that the same rules apply to everyone on the unit, regardless of position." Which aspect of a culture of safety does this unit seem to value?

Fairness

At the large multi-specialty clinic in which you work, there have been two near misses and one medical error because various clinicians did not follow up on patient results. Different caregivers were involved each time. After the second near miss, the physician involved was asked to leave the clinic. This outcome is an example of a failure of which aspect of a culture of safety?

Fairness

Establish measures

Feedback helps so that you know if a change lead to improvement. Quantitative measures are typically the best feedback

Compensation

For actual losses, pain, and suffereing or to provide care in the future for an injured person

Team leaders who promote a culture of safety focus on (according to Dr. Guttman)

Global awareness Shared mental models Open sharing of information

Gathering and reviewing data during an improvement project—that is, measuring—helps you answer which of the three questions of the Model for Improvement?

How will we know that a change is an improvement?

Identify changes

How will you achieve it and where do new ideas come from? This can spark creativity to think in various ways.

During the course of the improvement project in the radiology department, it becomes clear that certain radiology technicians suspected that patients were about to undergo the wrong procedures, but they did not speak up. Which of the following changes is likely to be low-cost, quick to implement, AND effective?

Implement standardized procedures to help enable workers to speak up.

Describe barriers to access

Income, education, race, ethnicity, transportation, literacy, language access, affordability, complex health needs

Applying the Model for Improvement to the clinic's improvement goal, which of the following is the most reasonable aim statement?

Increase the number of patients reporting they are "very satisfied" with the clinic's scheduling by 50 percent within six months.

Why is psychological safety a crucial component of a culture of safety?

It allows people to learn from mistakes and near-misses, reducing the chances of further errors.

What does the PDSA do?

It gives us a way to quickly test changes on a small scale, observe what happens, tweak the changes as necessary, and then test again, with a large or broader group. It allows to learn and practice things quickly, testing quickly too, and not taking weeks or months to create change.

Questioning attitude

Its about patient safety, quality of care, professional education

Obstacles to direct communication

Lack of ability "Not their job" Low confidence it will do any good

Active leadership

Leaders actively create an environment where all staff are comfortable expressing their concerns.

The orthopedic clinic plans the change to improve scheduling, and then it carries out a small test of change with three patients on Tuesday morning. What's the next thing the clinic's improvement team should do?

Measure to see if the change led to improvement

Authority gradient

Needed to facilitate decision making in a timely fashion Recall the seven most crucial concerns, and the modes for handling conflict

What are two ways to talk about justice?

Non-discrimination and distributive justice

An aim statement should include

Numeric goals, specific time frame, patient population, or system affected

Test changes

PDSA comes into play here, the model for improvement specifically. Planning a test change, trying it out, then observing the results and acting on what you learn you can move towards your aim.

What are two levels of justice concern that conflict with each other? (But these are not always in conflict)

Patient advocacy and social systems of allocation (seek the best uses of shared resources for the population of all patients together)

What did Paul Levy do after handling the immediate fallout from the wrong-site surgery?

Paul Levy employed a multi-pronged approach to spread awareness of the error and the hospital's response to it, as well as collect feedback from the public. It's critical to communicate effectively after a preventable mistake, as patients often want to know what steps are being taken to prevent similar mistakes from occurring again. Further, being transparent about errors allows the entire organization — and even other organizations — to learn from them.

a distinction is made between errors that result from poor decision making and those that result from system flaws. What are they?

Peolpe know that certain kinds of behavior are not acceptable They know they won't be punished for admitting to errors that happen when they are trying to do the right thing.

Psychological safety

People know their concerns will be openly received and treated with respect. People believe that if they make a mistake others will not penalize or think less of them for it. They also believe that others will not resent or penalize them for asking for help, information, or feedback. This belief fosters the confidence to...gain from the associated benefits of learning.

Fairness

People know they will not be punish or blamed for system based errors

Model for improvement

Plan, do, study, act

Recognize characteristics of a culture of safety

Psychological safety Active leadership Transparency Fairness

Procedural matters

Publicity Condition: Decisions regarding coverage for new technologies (and other limit-setting decisions) and their rationales must be publically accessible. Relevance Condition: The rationales for coverage decisions should aim to provide a reasonable construal of how the organization (or society) should provide "value for money" in meeting the varied health needs of a defined population under reasonable resource constraints. Appeals Condition: There is a mechanism for challenge and dispute resolution regarding limit-setting decisions, including the opportunity for revising decisions in light of further evidence or arguments. Enforcement Condition: There is either voluntary or public regulation of the process to ensure that conditions 1-3 are met.

Assertion statements

Respect and support authority ,assert concerns and suggestions, use a nonthreatening statement.

Identify the processes that make up the Plan-Do-Study-Act (PDSA) cycle.

Set an aim Establish measures Identify changes Test changes Implement changes

Accountability

Staff or organization should be accountable for their actions

Transparency

Team members feel comfortable speaking up about safety concerns and have a high degree of confidence that the organization will learn from problems and use them to improve the system

On a particularly busy night in the emergency department, a patient comes in with chest pain. The triage nurse, who's been on the job only two days, takes the patient's information, fills out the form, and puts the patient's chart on the rack so he'll be seen in the order in which he arrived. She mentions to a passing nurse, "There's a patient here who has pain — he's waiting to be seen." Thirty minutes later, still waiting to be seen, the patient collapses in the waiting room.

The lack of a shared plan for patients with chest pain resulted in a failure to act quickly.

Ben, a 36-year-old patient with Type I diabetes mellitus and kidney failure, comes to the hospital to have a special arteriovenous fistula placed in his arm to allow him to begin dialysis in a few weeks. The fistula was supposed to be placed on the left arm, but the surgical team accidentally operates on the opposite arm, not realizing until the procedure is finished. When Ben wakes up from anesthesia, he sees a bandage on his right arm and is confused. What should happen right away?

The mistake should be communicated to Ben and the hospital's administrators.

During a debriefing, it becomes clear that a nursing assistant was concerned about a patient's breathing just after a drug was administered, but he did not feel comfortable telling the physician. What conclusion can you draw about the unit where this adverse event occurred?

The unit's culture doesn't effectively promote psychological safety.

Need for an explanation

They wanted to know how the injury happened and why

Why would you collect balancing measures?

To make sure you didn't unintentionally damage other aspects of the unit's work.

What are values at stake?

Trust, personal and professional integrity, relationship between patient and physician fidelity, justice

Two challenge rule

Voice two concerns at least two times, acknolwedgement, outcome poor? use stronger course of action and chian of command

Building a culture of safety process

We start with a culture that is pathological, where we are not interested in improving. As long as nothing bad happens and we are not caught, we continue as we are. As the culture evolves, it becomes reactionary. That is, safety is important, and whenever we have an issue, we respond. The next step is when we become calculative. That is, we spend time putting systems in place that prevent harm to patients from happening. We then become proactive. We work to anticipate harm before it happens and prevent problems. In the final step, we become generative. That is, our focus on safety is how we do business. It is not a project. A culture of safety is how we do our work.

State the three fundamental questions that are the basis of the Model for Improvement.

What are we trying to accomplish? How will we know a change is an improvement? What change can we make that will result in an improvement?

A nurse who realized that his colleagues weren't consistently following up on patient results reported the problem to the clinic leadership right away. Which response would be most consistent with a culture of safety?

Writing a letter of commendation for his file

Culture change

a fundamental type of change involving a shift in the perspective and values of a group. Transformation ot a new way to thinking that leads to new norms

What is conflict of interest?

a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest, will be unduly influence by a secondary interest occurs when the actions of the health care professional serve not only the patient, but others as well - such as insurance companies, other health care industries, and even the health care professional himself or herself. One of the most challenging aspects of a conflict of interest is that it does not only involve actual harms to patients as a result of "divided loyalties", but also the appearance of a conflict between the professional's loyalty to patients and to others

preoccupation with failure

a strong feeling that if anyone says there is a problem, the problem is real until proven otherwise. This focus on safety is a powerful reminder of the team's common goal: providing safe, effective care for the patient

Advocacy and assertion

assert in a respectful manner and ensure information is in there that is critical

Positive deviance

based on the idea that solutions to community problems already exist in the community. Identify who is performing the best and identify the attributes of successful performance rather than focus on what not to do

The virtues of integrity represent two aspects of a person's character

coherent integration of self, that emotions aspirations, knowledge and values complement and balance one another Fidelity to moral values: that one will be faithful to moral values and will stand up in their defense when necessary. Persons can lack moral integrity in several respects such as hypocrisy, insincerity, bad faith, and self-deception.

Reckless behavior

consciously disregarding a visible, significant risk. Reckless behavior, such as driving drunk, involves choosing to put others in harm's way.

Classic COI examples

elaborate meetings, hiring providers as educators, reps bringing lunch for office when demonstrating a new device

distributive

giving each his or her due

Counterarguments

health care is a private good and forced reallocation of resources is unfair

Human error

inadvertently doing something other than what you should have done. For example, you suddenly notice while driving that you've exceeded the speed limit, without intending to do so.

Just culture definition

initially defined for health care by the lawyer and engineer David Marx, recognizes that competent professionals make mistakes and acknowledges that even competent professionals will develop unhealthy norms (e.g., workarounds, "routine rule violations"). However, it has zero tolerance for reckless behavior.

Intrinsic motivators

joy or idealism

What is a right?

justified claim by one party that commits another party to respect the claim

At-risk behavior

making an intentional behavioral choice that increases risk — without perceiving that heightened risk or believing the risk is justified. An example is consciously driving 72 miles per hour when the posted speed limit is 65 miles per hour. At-risk behavior is also known as "routine violation" or "drift."

Identify three kinds of measures:

process measures, outcome measures, and balancing measures

Extrinsic motivators

promotions or monetary rewards

integrity

soundness, reliability, wholeness, and integration of moral character.

Process measures

tells you how things are going

Balance measures

tells you if the changes are just creating problems in other places

Justice in health care

the fair treatment of people without discrimination based on race, ethnicity, language spoken, education, age or economic status OR the fair distribution of benefits (health care) and burdens (payment) among patients.

Outcome measures

the measures you want to move.

Material principles of justice

• To each person an equal share (i.e. all residents of Denver City/County can receive care at Denver Health Medical Center regardless of ability to pay) • To each person according to need (i.e. emergency trauma care given to all patients who need treatment because of a trauma) • To each person according to effort (i.e. preferred access to bariatric surgery based on efforts to adhere to specific diet instructions) • To each person according to contribution (i.e. Veterans are entitled to receive care at VA hospitals based on their service record) • To each person according to merit (i.e. access to special units at hospitals based on VIP status.) • To each person according to free-market exchanges (i.e. care provided based on which insurance plan you purchase)