Title of Presentation Here Presenter Name Here Month Day, 2012 WELCOME Uteam Leadership Education Forum Be Safe Leadership Basics June 10, 2014

Title of Presentation HerePresenter Name Here

Month Day, 2012

WELCOMEUteam Leadership Education Forum

Be Safe Leadership Basics

June 10, 2014

In case of an emergency… AED located on wall directly across from

restrooms Who is certified in BLS? Emergency site location if we have to evacuate

Pavilion

For your safety… Police will direct traffic as you exit

Our patients are at the center of all we do

We want to eliminate anything and everything that harms or could harm our patients and/or team members

We want to decrease activities that keep us from being effective and efficient

Most of us only need the right tools and support

Be Safe gives us a process and tools that allow us to tackle problems in a thoughtful and organized way

Be Safe learning is continuous

Teaching and Coaching Teaching and Coaching

KAIZEN

Continuous improvement

Eliminate harm and waste

Make it better nowMake it perfect later

Be Safe learning materials On the Mend: Revolutionizing Healthcare to Save Lives and

Transform the Industry Focus on patients, value and time using continuous

improvement and respect for people as the foundation

A3 Problem Solving for Healthcare: A Practical Method for Eliminating Waste Practical workbook, case studies and “how to” instructions for

each A3 section

Website

HR Homepage Leadership Tools Be Safe

Forum objectives Understand Be Safe initiative - philosophy and terminology

Increase awareness of problem solving principles and tools

Experience problems & activity observation and debrief

Understand purpose and function of a Unit-Based Team (UBT) and Unit-Based Leadership (UBL)

Learn how to teach Be Safe Team Member Essentials to your unit/department

Explore how Be Safe changes the way we work, lead and coach Necessary leadership behaviors Culture change process

Our Journey toBecome the Safest Place

to Work and Receive Care

Be Safe is the roadmap

Opening remarks

Rick Shannon, MDEVP, Health Affairs

Our goals for UVA Health System

To become the safest place to receive care

To be the healthiest work environment

To provide the highest level of clinical care

To generate biomedical discovery that betters the human condition

To train the health care workforce of the future in teams

Ideal state for healthcare

Exactly what the patient needs, defect free

One by one, customized to each individual patient

On demand, exactly as requested

Immediate responses to problems or changes

No waste

Safe for patients, team members and clinicians: physically, emotionally & professionally

How we will get there Prevent problems/harm in our environment

through observation and standardization of work processes

Address problems/harm in real-time using help chains and the A3 Scientific Method Problem-Solving Tool

Transform problem-solving and work processes throughout UVAHS

Our Be Safe initiative is

advancing our status as a high performing organization

by systematically applying the scientific method to improve the safety of our patients and workforce

through real time problem solving

Culture trilogy of Be Safe

Team members are treated with dignity and respect by everyone they interact with

Team members have the tools to do their job, including training, supplies, and encouragement

Team members are recognized for the contribution they make by someone they care about

Engagement

UBL Capacity Development

T. Hoke, L. Facteau, C. Ghaemmaghami

Leads

UBL Capacity Development

T. Hoke, L. Facteau, C. Ghaemmaghami

Leads

Be Safe Steering Committee

T. Hoke, L. Facteau, R. Cofield,

C. Ghaemmaghami

Be Safe Steering Committee

T. Hoke, L. Facteau, R. Cofield,

C. Ghaemmaghami

Be Safe Coordinator

S. Lewis

Be Safe Coordinator

S. Lewis

Be Safe Senior Leaders

Be Safe Senior Leaders

Marketing & Communications

T. Cluff, Lead

Marketing & Communications

T. Cluff, Lead

Technical Tools

R. Skinner, T. Hoke, Co-Leads

Technical Tools

R. Skinner, T. Hoke, Co-Leads

Be Safe SponsorR. Shannon

Be Safe SponsorR. Shannon

J. AmatoB. BellJ. BoswellT. CluffD. FontaineS. KirkM. RosnerR. SchmaleR. SkinnerK. White

Structure

Team Member Safety

J. Amato, Lead

Team Member Safety

J. Amato, Lead

Training & Education

R. Schmale, Lead

Training & Education

R. Schmale, Lead

Situation Room

• McKim 1116

• Every weekday morning at 7:00 am

• Contains problem solving tool displays and Health system event data

• Daily leadership huddles review patient deaths, CAUTI, CLABSI, falls, pressure ulcers, team member injuries

Transparent sharing of safety events and solutions

Expectations of Real Time Problem Solving

Every patient and team member safety event investigated within 24 hours and solved to root cause and the learning shared within 48 hours

In order to accomplish this, front line workers need a help chain

Expectations of a Help Chain Member Respond to safety events from your reports and go to the

place where the event occurred and help to solve the problem to root cause

If you cannot solve the problem or it exceeds your span of control, you call your supervisor for help

Share with all the learnings and disseminate to others through the Be Safe Sharing Network

Responding to pull from the front line is now a fundamental component of your work as a manager

To make time, we will eliminate meetings and events that add no value to patients

What is a Help Chain?

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&docid=ZDos4Jj56xY6NM&tbnid=MtowygQN5zHgLM:&ved=0CAUQjRw&url=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FJust_Say_No&ei=qaGVU6HKDNWnsQS3-IC4Cg&bvm=bv.68445247,d.cWc&psig=AFQjCNH1MzV0JiEraEIxyNPcYEGRURfRxA&ust=1402401522067409

Context setting

Rebecca Schmale, PhDLearning Officer

New LogoNew Logo

Team member safetyTeam member safety – – the safest place to workthe safest place to work

We are taking care of ourselves as well as our patients

What is Be Safe?

The systematic application of the scientific method to improve the safety of our patients and team members through real time problem solving

Solving a problem at the place where the problem occurs by the people who encounter the problem so the problem never happens again

Building a community of problem solvers for the good of our patients and team members

The way we become a high performing organization by actively seeking out ways to improve work processes every day in every area

Be Safe reinforces our RISE values

Be Safe is NOT:•An “A3”•5S•Dr. Shannon’s project•Clinical only•Dr. Hoke’s job•Value Capture•Quality & Performance Improvement department initiative•Magical way to fix everything•A new way to cut costs•Flavor of the month•Medical Center only•More work added to already busy days•A program•Optional

Terminology

• Help chain• A3 • Waste• Standard work• Unit-Based Team (UBT)

and Unit-Based Leadership Team (UBL)

• Root cause analysis• Current condition• Problem

TABLE ACTIVITYTABLE

ACTIVITY

Do you remember?

Methodologies•TQM• Six Sigma• LEAN• PDCA

Tools•Kanban• A3• Scientific Method• 5S• Root Cause Analysis• Statistical Process Control Are you on this bus?

Root cause problem-solving

Direct observation

Asking people

Help chains

Quick resolution

Leaders: enablers of an empowered workforce

Countermeasures: progressive steps toward ideal state

Work-around solutions

Retrospective data

Assumptions

Chains of command

Delayed response

Bosses

Permanent solutions

How Be Safe works

VS

VS

VS

VS

VS

VS

VS

Transforming problem-solving and work processes throughout UVAHS Transforming problem-solving and work processes throughout UVAHS

SAFETY

Everyone can be taught to “see” problems by learning the technique of direct observation

Any process has at least 3 versions:What you think it isWhat it actually isWhat it should be

Observation

Problems & activity observation

Jody Reyes, RN, OCNAdministrator, Cancer Services

Observation is the starting point of problem solving

•Everyone can be taught to “see” by learning the technique of direct observation

•Observation helps us understand how work is performed and to identify where variances and problems occur

•Pilot teaching units are training and deploying observation teams to watch co-workers in action and gain insight to the problems they encounter in doing their jobs

Direct observation

Additional information on observation:A3 Problem Solving for Healthcare: A Practical Method for Eliminating Waste Pages 30-33

Problems and activity observation

• We will simulate the experience using a video

• Put on Be Safe Observer button

• Read Guidelines • Get Observation Sheet ready to

record what you see

Observation sheetKey things to observe:•What is the need that the team member is trying to meet for the patient/customer?

• Record how the need is being met:• Time• Location• Steps they are doing• People with whom they are interacting

•When team members encounter a problem or are not able to do the work, what happens?

Time Location Doing/Saying What(To Whom)

Problems? Resolved?

10:35

Pyxis TS

RN moves from Pyxis to tube station looking for a med Can’t find med-looked in multiple places

Found med in PT basket

Video

See “Simulated Problems & Activity Observation” video on

the Be Safe website

Observation debrief 1. What are your general impressions of the experience you

observed?2. Use the Problems & Activity Observation Debrief sheet to

record the following:

Barrier/Obstacle/Problem What team member did Solved?

What problems did you observe?

Resist giving solutions!

What did the team member do in response to the barrier/obstacle/ problem encountered?

Did the team member’s actions solve the problem?

TableActivityTable

Activity

Debrief3. Will the team member’s action to solve the problem prevent it

from happening to the team member again tomorrow?

4. Will that action prevent the incident from happening to someone else?

5. How many problems did you see in this very short video? Great organizations put in place a system for stabilizing the

work and solving problems so they do not recur

Types of Work

INCREASE MINIMIZE ELIMINATE

Turn to page 138 in your A3 Problem Solving for Healthcare: A Practical Method for Eliminating Waste workbook

•Confusion•Motion•Waiting•Processing•Inventory•Defects•Over-production

Waste

Table Activity•Go around table and assign each team member a type of waste

•Take 2-3 minutes to read the definition, examples, causes, and countermeasures for the type you were assigned

•Each person then shares with the table

Additional information:On the Mend Pages 48-60

Give examples of the 3 types of work from the video:

Estimate how much time was spent doing each type

Shocking yet trueIn healthcare, typically 30% of the time is spent doing value-added work while the remaining 70% is non-value added or wasteful

This is not because people are doing a bad job; it is because of how the system was designed

Great organizations focus their energy helping their team members (experts in their own work) to see, call out, and eliminate waste so that all of their time and energy can be directed toward meeting the customer’s need

Great organizations create a system where problems never repeat themselves

Activity observation drawing

• A simple sketch of how the work is done now (current condition)

• Drawing allows the movement of patients, team members, products, and information to become transparent

• Go to page 9 in your A3 Problem Solving for Healthcare: A Practical Method for Eliminating Waste workbook for an example

• Highlights when there are differences in processes and waste

Standard work

Variation in process occurs when work activities are not well defined and can result in variation in outcome

Standard work is the one best way known today to complete an activity and should evolve over time as we learn better ways to do the work

Every activity should be specific to:•Content•Sequence•Timing•Location•Expected outcome

UVA Current Condition of Variation- Pericare (5C & MICU)

Wipes Gel Gloves Assess ptChange Linens Explain Move pt

Get absorb pad Gloves

Turn/Position patient Open legs

Wipe Male pt

Wipe Foley and drainage tube

Dipose of w ipes Gel

Wipes Gloves Gow n Privacy Open WipesTurn/Position patient Explain Step 7? Wipe r Arm

Dipose of w ipes Wipe L arm Gow n

Problem- Help w ith IV

Wipe Male pt


Unhook r SCD Wipe r leg Hook R SCD

Unhook L SCD Wipe l leg Hook L SCD

Turn/Position patient

Problem- o2 86%

Elevate patient

Gel Gloves Drain tube Get urinaldump urine in urinal reclip clamp

Put top on urinal

place on cath measure

dump in toilet f lush Privacy Gel Gloves

Assess/ Gets supplies

pull back underw ear

w ashcloth under

syringe to balloon

empties syringe

Disconnects syringe Explain

puts in red bin Gel

Get linens Wipes Gow n GlovesPosition/Bring up bed Open Wipes Untie gow n Wipe r Arm Wipe Chest Wipe L arm

Problem- trip on shoe Open legs Wipe r leg

Wipe Male pt


patient request gow n set w ipe back

Dipose of w ipes Gow n off

Wash hands

Wipes Get linens Gloves Gow n Explain PrivacyTurn/Position patient Wipe neck Wipe Chest Wipe Arm

Dipose of w ipes

Change Pt Gow n


Pt Request- go slow er

Wipe female (around folds)


Dipose of w ipes Wipe l leg Hook R SCD

Dipose of w ipes

Turn/Position patient w ipe back

Change Linens

Problem Need Ultrasorb

Foley bag moved Assess pt Get help


Go to Warmer Get help Privacy

Turn/Position patient Wipe Arm Wipe Chest

Wipe Foley and drainage tube Wipe l leg

Change Pt Gow n


Foley bag moved w ipe back

Interruption: Comb Hair

Dipose of w ipes


Gel Gloves ExplainPull dow n blankets

Turn/Position patient w ipe back Wipe Face Wipe R leg Wipe r Arm Wipe l leg

Change Pt Gow n

Turn/Position patient Lotion

Wipe Male pt

Turn/Position patient w ipe back Lotion

Foley collection on bed

Resnap gow n

Change dressing on Back


Wipe Foley and drainage tube Wipe foot Wipe foot EHA cream

Put socks on Ultrasorb

Resnap gow n

Problem: cord unhooked

Put socks on

Turn/Position patient HOB Up Covered up

Return call bell

Go to Warmer Wipes Gel Gloves Explain

Wipe Male pt


Wipes Gloves Explain Gel Privacy Open legsWipe Male pt


Wipe Male pt Wipes Gloves

Wipe Stat Lock Wipe Groin

Dipose of w ipes


Privacy Gloves WipesTurn/Position patient

Wipe Male pt

Unclamp clamp

Dipose of w ipes Wipes Gloves

replace tubing

Dipose of w ipes Covered up Gel

Gel Gow n Gloves Explain Privacy

Wipe female (around folds) Open legs

CHG on w ashcloth


Washcloth in bin

Get w ashcloths

Wet w ashcloth Soap cloth

Wet w ashcloth Wipe l leg Wipe R leg

Wet w ashcloth Soap cloth Wipe L arm Wipe Chest Dries

Untie/remove gow n Wipe r Arm Dries Wipe Face

Gow n on patient

Removes monitor device

Desiton Cream legs

Problem: patient allergic aloe that comes

Explain Wipe l leg Wipe R leg Wipe L arm Wipe r ArmUntie/remove gow n Adjust abd binderWipe Chest

Gow n on patient

Turn/Position patient Open legs w ipe back

Turn/Position patient Adjust abd binderOpen legs



Dipose of w ipes



Go to Warmer Wipes Gel Gloves

Assess/ Gets supplies Explain Offer new gow n

Position/Bring up bed


Untie/remove gow n Wipe arm Open legs

Wipe Male pt

Dipose of w ipes

Untie/remove gow n Wipe arm Wipe Chest


Dipose of w ipes

Interruption: New gow n

Interruption: rn get gow n Gel

Untie/remove gow n


Untie/remove gow n

Gow n on patient (new )

Get help

Look in room for Wipes Gel Gloves Explain


Wipe w ith Ultrasorb

Wipe Male pt

Removes mepelox?

Request Instaf low Gloves Wipes

Change Linens Ultrasorb

Rolls up stuff and puts under old sheets Gloves

Opens instaf low Obtains h2o

Obtains lube

Inserts instaf low

Blow s up balloon

Turn/Position patient Gloves

Turn/Position patient Wipe Chest


Gets more w ipes


Problem: ventilator tub pops off

Reconnect tube w ipe back

Change Linens


Get help Gel Gloves PrivacyTurn/Position patient Explain

Visible stool removed w ipe back

Change Linens


Visible stool removed

Change Linens


Get w ipesGo to Warmer Gloves Gow n Gel Get help Explain Open legs Privacy



Dipose of w ipes Get linens

Unhook r SCD

Unhook L SCD

Actif lo in place

Problem- interuption- speech to do sw allow


Change Linens


Actif lo w ipe dow n

Problem- interuption- charge nurse Get help

Gow n on patient

Change Linens Get help


Get w ipes Gel Gloves ExplainTurn/Position patient


Remove bedpan from pt w ho remains in

Empty bedpan

Visible stool removed w ipe back Ultrasorb


Dipose of w ipes Gloves Explain

Wipe Male pt


Dipose of w ipes

Privacy Gloves Gow n Assess pt

Look in room for Wipes Get w ipes

Turn/Position patient Open legs Gel Gloves Gow n

Wipe Foley and drainage tube Explain


Contain visible stool Explain

Change Linens Explain

Turn/Position patient Open legs Explain


Turn/Position patient Explain

Male pt/Female Pt cleanse

Wipes Gloves Assess pt Gow n Explain Privacy

Assess/ Gets supplies

Wipe Male pt



Visible stool removed

Dipose of w ipes Gloves

Dipose of w ipes

Change Linens Reassure pt

Wipe Male pt Reassure pt



Get w ipesGo to Warmer Gloves Gow n Gel Get help Explain Open legs Privacy



Dipose of w ipes Get linens

Unhook r SCD

Unhook L SCD

BM Device:Actiflow

Interruption: speech pathology


Change Linens


Wipe BM Device

Interruption: chg RN rounds Get help

Gow n on patient

Change Linens

Turn/Position patient Get help


Wash hands Gloves

Open CHG w ipes Explain

Introduce self

pull cover lift gow n


Wipe w ith CHG front to back Ultrasorb

New pad under patient

Wipe w ith CHG front to back


roll out clean pad

Remove pad and place in trash Wipe pt

ask about diaherra Wipes Wipe pt

Wash hands Wipe Tube

throw aw ay trash

Covered up simulated Foley w ith stool

PeriCare - General

Foley with Daily Bath

Foley with Stool

Standard work

•Is different from a best practice because it is designed to be tested and changed because there will always be opportunities for improvement no matter how “good” the “best practice” may be

•Reduces variability, waste, and costs

•Is easier to learn and practice

•Everyone must practice the standard consistentlyTeach standard workAudit standard work

Draft of standard work developed by front line staff in MICU and 5C

Supplies Prepare at bedside

You and your team members will participate in the

Problems & Activity Observation training session

when your UBL & UBT go live

Now that we have “observed a problem”

we are ready to do problem solving

A3 thinking

Tracey Hoke, MDChief, Quality & Performance Improvement

A3 thinking

•Structured problem solving approach that uses a tool called A3

•The scientific method is the foundation for A3 thinking

A way to look with “new eyes” at a specific problem identified by direct observation or experience

The A3 scientific method problem solving tool

•Effective learning is what A3 thinking and problem solving is all about

•Rigorous use of tool prevents problem solvers from jumping directly to solutions without identifying root cause(s)

•Encourages collaboration, interaction and continual experimentation

Four Rules in UseRule 1: Clearly specify all steps

Rule 2: All steps in the request for a product or service are as simple and direct as possible

Rule 3: The pathway (or flow of steps) required to produce the request is simple and direct

Rule 4: All problems are addressed, as close in time and in person as possible, under the guidance of a coach

Assess all processes and activities against the Rules in Use

Activities

Connections

Pathways

Improvement

Turn to page 15 in A3 workbook

You will always find at least one of these in a problem

Rule 1: Work is not clearly defined

Rule 2: The way two areas connect isn’t clear or direct

Rule 3: The process isn’t clearly defined and so many paths could be traveled that they create opportunities for error

Rule 4: The method for solving problems doesn’t use the scientific method, doesn’t include the people who do the work or doesn’t involve the people who have the perspective and authority to change processes that cross more than one area

A3 Format

Additional information:A3 Problem Solving for Healthcare: A Practical Method for Eliminating Waste Pages 35-48

The way things happen now

Left Side

A better way to work

Right Side

• Read the case study and answer the questions at the end

• A debrief and an overview of the completed A3 will take place following this exercise

Case study: EKG Leads

Case study debrief

• Question 1 – Sources of Waste: Confusion, Waiting, Overprocessing, and defects

• Question 2 – Relationship to the 4 Rules in Use:• Rule 1: Work not clearly specified. (There was no process for

replacing defective labeling on the EKG machine.)

• Rule 4: The initially suggested solution for improvement (retraining staff) did not get to the root of the problem and would not have assured that the problem wouldn’t occur again

• Question 3 – Potential questions• Why did the EKG need to be repeated?• Why were there increased costs to the hospital and patient?• Why were the staff frustrated and confused?• Why were the materials not labeled correctly?• Etc.

Need/Rationale• Focus on a specific event or problem, not multiple problems,

and describe it clearly

• State the issue through the eyes of the patient or customer

• Include background information needed to understand the problem and why it is important

• Provide quantifiable data (safety, quality, financial, etc.)– Includes baseline data – Data collected during the A3 experiment is compared to the

baseline to validate the hypothesis and actions

1

Turn to Pages 134 and 135 in A3 workbook

Turn to Pages 134 and 135 in A3 workbook

Current Condition

• Describe, preferably in a drawing, how work is actually done

• Reflect actual observation (“Go and see”)

•Involve the people who do the work

• Use the Rules in Use to see the system and identify problems

• Utilize the ‘5 Whys’ as a means of determining the root cause of problems

2

•The concept of asking a series of causal questions in order to discover the root cause of a problem

•Typically the root cause is related to activities, connections pathways, and improvement (Rules in Use)

•Compare what occurred at each step with what is supposed to occur and at discrepancies, ask the 5 Whys to determine the cause of variance

•Don’t get hung up on counting the Whys; the point is to drill down into a problem in order to understand it deeply

5 Whys

Target Condition & Reasoning

• A pictorial representation of an improved state; how work will be done (how the process is expected to work) based on the changes we develop

• Moves work design toward Ideal and is more consistent with the Rules in Use than the Current Condition

• Target condition is not the same as ideal condition but gets you closer to the ideal

• Reasoning is the hypothesis for change - IF (we do these actions), THEN (we will expect these changes which will produce these results)

3, 4

Action Plan• State the activities required to implement the solutions

proposed by target condition

• Link actions to specific problems identified in current condition

• Be specific in terms of ownership, time lines and expected outcome

EXAMPLE

Root Cause #

Who What By When Test of Value

5

Key Learning

• Make explicit what each participant expects to learn from this experiment

• State what was actually learned through carrying out the experiment

– Did you achieve your expected result? Why or why not?

– What did you learn as a result of your efforts?

• Share with others in the organization who may be able to apply the learning to their work

6

Coaching A3s

•Daily work of leaders is to coach others in problem solving and coach development of A3s

•Review chapter 7 on coaching in A3 Problem Solving for Healthcare: A Practical Method for Eliminating Waste workbook

•Effective coaches:

Go “see”

Ask “Why?”Show respect

We are just learning to use A3s -

we will get better over time We are just learning to use A3s -

we will get better over time

You’ve learned some tools, now let’s hear how Be Safe is

actually coming to life in a unit

Unit-Based Leadership (UBL) and Unit-Based Teams (UBT)

Kyle Enfield, MDMedical Director

Unit-Based Leadership (UBL)

•Formalize the problem solving process in the unit

•Solve problems encountered in the course of work in real time

•Create time to learn and improve

•Includes the nurse manager, unit clinical nurse specialist or improvement specialist (QPI), and unit medical director

Our unit ensures a UBL member or designee is available 24/7

UBL tasks•Meet Monday-Friday in am (time defined by group) to review “bumps in the night” •Address urgent safety issues•Identify safety problems that can be addressed at unit level •Elevate safety problems that can’t be addressed at the unit level up the Help Chain•Review identified problems at next daily huddle•One person from the team or a designee is available 24/7 to help stabilize problems and collect perishable knowledge after an event•Nurse manager or medical director are “interruptible” to coach problem solving

Unit-Based Team (UBT)

•All front-line staff on the unit who are trained in the fundamentals of Be Safe

•UBT members call out safety problems in real-time, ensure the patient or team member’s needs are met, then notify their immediate manager (or other UBL designee) of the incident or observation

•UBT members participate in problem solving by sharing perishable information, answering the 5 Whys, and direct observation of work

Help chain

•Activated when team members call out problems

•First link: Unit-Based Leadership that investigates situation, seeks additional assistance if needed, helps develop countermeasures

•If more help is needed, escalation occurs to higher leadership levels that can break down barriers and allocate resources beyond the unit level and that can provoke a deeper understanding of problems and solutions

•Last link: EVP

INFORMATION AND TECHNOLOGY

Patient or Team Member Safety Event

StaffProviders & Team

Unit-Based Leadership Teams (UBL)

Chiefs

CEO

Management

Directors, Administrators

and ACMOs

AVPs

Patient

• Address issues that require Board or external action

Real-Time Help Chain for Safety Problems:Standard Work for Roles

• Provoke a deeper understanding of problems and solutions

• Allocate resources and break down barriers to facilitate RT-RCPS*


• Allocate resources and break down barriers to facilitate RT-RCPS*

• Support UBL investigations and development of experiments


• Enable experiments that span departments

Be Safe Events

• Initiate RT-RCPS*• Inform/seek assistance as needed• Develop and

implement experiments

• Update investigation and learnings

• Meet immediate need• Call out problem• Assist in RT-RCPS*• Report event in “Be Safe

Events”

*RT-RCPS: Real Time - Root Cause Problem Solving

Escalate up the Help Chain until Resolution.

Communicate Risks, Root Cause Analyses, and Solutions up and across the Chain.

Role Responsibilities:



ChiefsManagement


and ACMOs

Risks & Solutions

Communicated Across

Help Chain

Risks & Solutions

Communicated Across

Help Chain

Crossover and Sharing

Higher levels of Help Chain are pulled into the problem solving as needed via Crossover

• Assist in investigation when it involves their area

• Assist in developing experiments with staff who do the work

• If experiment crosses departments inform/seek assistance from other managers

• If process breakdown did not occur in their department, work with manager of other department to advance RT-RCPS*

• Report any events and solutions in the sharing system

• Read all events from prior day and mitigate all risks that exist in your area

• Assist in investigation when it involves areas of responsibility

• Assist in developing experiment with managers and staff who do the work

• If experiment crosses departments, inform/seek assistance from peers

• Inform other s as needed to continue RT-RCPS*

• Report any events and solutions in the sharing system

• Read all events from prior day and mitigate all risks that exist in your areas

• Read all events from prior day and mitigate all risks that exist in your area

• Work with Directors and others to develop experiments as needed

• Collaborate with peers to support experiments that span areas of responsibility

• Break down barriers and allocate resources as appropriate to facilitate RT-RCPS*

• Provoke a deeper understanding of possibilities and solutions

• Inform and seek assistance of AVPs• Report any events and solutions in the

sharing system

* RT-RCPS: Real Time - Root Cause Problem Solving

Help Chain is part of a successful problem solving system

•Each team member has a designated “first responder” that helps/coaches

•If that “first responder” does not have command of the resources to meet the immediate need and investigate the root cause, the first responder goes up the chain to the next level

•Everyone has clear roles and timeframes for response

•Information is shared transparently

Everyone with information about

the Event

MICU UBL Standard Work

System

PatientEvent

Shift Managerand other team members Shift Manager UBL team

Staff Event

OR

Help Chain

Meet the Immediate needs of the patient, staff member, or visitor Shift Manager

gathers information about the event from those involved

If, Yes- page UBL team for additional assistance

Shift Manager determines if the event could happen again

PIC # 1689

UBLs share learning across the institution as applicable.

MICU UBL Standard Work

On-call system for coaching (8am-5pm), PIC # 1689

Daily Reviews:•Identify all patient Mortalities in the last 24hrs•List of patients in MICU with Foleys and Lines•Identify all Foley’s in place >2 day - Talk with the RN caring for the patient•Talk with the Shift Manager to identify Patient or Team Member Events

o Go to the area in which the event occurred and talk to the most proximal person involved - Ask “What” and “Why”

•Identify patients transferred to MICU <3 calendar days from admission- Root Cause Analysis

•There are initially too many problems to solve

•UBLs must determine and communicate guidelines to the number and type of problems they have the capacity to solve

•Use documented Be Safe Events within unit as starting point

Falls

Medication errors

Team member injuries

•Start small with 1-2 A3s on Be Safe Events

•Culture change is important

Pilot lessons learned

UBL & UBT Roll Out

Tracey Hoke, MDChief, Quality & Performance Improvement

Roll out of UBLs and UBTs

•First wave – inpatient units

•Second wave – ambulatory setting and non-unit based functions (pharmacy, therapies, etc.)

•Medical Director and Nurse Manager roles being redefined

•Leadership commitment to decrease non-value added activities (meetings, etc.)

Train the TrainerBe Safe Team Member Essentials

Rick Carpenter, RNNurse Manager, MICU

Be Safe Training

•Be Safe Team Member Essentials is awareness training delivered by the manager, assistant manager, RNAC or supervisor

•Our goal is for all team members to complete Be Safe Team Member Essentials by October 1, 2014

•Once your UBL Team is formed, the UBL Team will go through additional training on problem solving

What team members need to know:

1.What Be Safe is and why it is important

2.Professional safety and the responsibility to call out issues, problems, events as soon as they see or experience them

3.Team members’ role in problem solving

4.UBT and UBL roles

5.Terms they may hear in the course of problem solving

6.Next steps and how they can learn more

Train the Trainer

•We will go through the Be Safe Team Member Essentials training and provide several options that you can adapt to your situation or group

•You have a bag full of materials and online resources to help you train your team members:

IN BAG

1 - Team Member Essentials Facilitator’s Guide1 - Team Member Essentials Tabletop Slides 2 - Problems & Activity Observation Pads2 - Be Safe Clipboards with clocks3 - Be Safe Observer buttons2 - Terminology Activity card1 - Job aid for LMS documentation

IN BAG

1 - Team Member Essentials Facilitator’s Guide1 - Team Member Essentials Tabletop Slides 2 - Problems & Activity Observation Pads2 - Be Safe Clipboards with clocks3 - Be Safe Observer buttons2 - Terminology Activity card1 - Job aid for LMS documentation

ONLINE

Video: Cofield on Be Safe 101Slides: Be Safe 101Be Safe glossaryVideo: Bob and the UBL Today’s forumArticlesMore added weekly!

ONLINE

Video: Cofield on Be Safe 101Slides: Be Safe 101Be Safe glossaryVideo: Bob and the UBL Today’s forumArticlesMore added weekly!

Be Safe Team Member Essentials

Be Safe Team Member Essentials

•Pull out Tabletop slides and Facilitator’s Guide

•You may divide the training into smaller chunks to deliver via huddles or quick meetings

•You may use video, PowerPoint or tabletop slides


Patient or Team Member Safety Event

StaffProviders & Team


Chiefs

CEO

AVPs

Management


and ACMOs

Patient

Real-Time Help Chain for Safety Problems:Standard Work for Roles

• Initiate problem solving• Inform/seek assistance as needed• Develop and implement

experiments• Update investigation and

learnings

• Meet immediate need• Call out problem• Assist in problem

solving• Report event in “Be

Safe Events” system

Your Unit-BasedLeadership Team:

Escalate up the Help Chain until Resolution

Record completion of Be Safe Team Member Essentials in Learning Management System (LMS/ NetLearning)

•Use your LMS administrator

•Job aid in your bag

Be Safe Awareness Training Plan

May June July Aug Sept OctLeaders

Unit Based Leadership Teams

Clinical Staff

Team Members

By Oct 1, 2014, all team members will have completed Be Safe awareness training

Team Member Essentials

Don’t underestimate the change in culture required to make Be Safe a reality in your area

Culture change

Bo Cofield, DrPHAVP, Hospital and Clinic Operations

How you react when a team member comes to you with a problem or issue

Where you find time to coach and facilitate problem solving

How you approach team members who do the work to involve them in problem solving

How you communicate

Our Be Safe journey requires a culture change

A. 20%B. 40%C. 50%D. 70%

What percentage of healthcare errors or sentinel events are the result of communication failures?

The Joint Commission. Sentinel Events Statistics, 1995-2005. Accessible at http://www.jointcommission.org/SentinelEvents/Statistics

http://www.jointcommission.org/SentinelEvents/Statistics

From•All knowing•Autocratic•Impatient•Blaming•Controlling•Always in meetings•Never asking for help from above•Buck stops here mentality•Lone Ranger

To:

•Coach•Facilitator•Teacher•Student•Helper•Communicator•Respectful•Readily available

Be Safe leadership

Changing leadership habits/ behaviors

•Dismantle shame and blame with dataUse tools such as A3 and 5S•Go and “see”

•Use A3 scientific method thinking

•Provide visual management that front line staff can understand and embrace

•Encourage and follow standard work for leadership

•Focus effort on value-added workReduce meetingsCommunicate more than ever

Leadership challenges

•Reducing waste and non-value added work comes before adding technology or people

•One leader’s “silo” is another leader’s “value stream”

•Cross-boundary perspective is vital

•Asking for help is not only OK, it is encouraged

•Understanding the organizational and human response to change and managing resistance

1. Awareness5. Integration

4. Compromise

3. Resistance

2. Reality Testing

Five stages of change

Additional information:On the MendPage 175

Information

ExperienceDialogue

Whoa!Slow down!

Lock inStandardize

Typical emotional responses

EndingEnding

Denial

Shock

Acceptance

Anxiety

Adaptation

Hurt

New BeginningNew Beginning

Enthusiasm

Ambivalence

Fear

Anger

Frustration

Confusion

Stress

Hope

Testing

Understanding

Skepticism

Awareness

Chaos

Resistance and naysayers

•I don’t feel safe

•Now management wants me to do their job

•I don’t get paid enough to solve problems

•How can I get away from doing my real job to do this extra stuff?

•Where are the resources coming from to do this?

•We tried this before and it didn’t work

•This too shall pass

How will you respond?

Leader expectations

•Teach Be Safe Team Member Essentials to your team members by October 1st

•Attend additional training when scheduled and begin practicing A3 thinking

•Coach team members to observe and solve problems once the UBT and UBL are trained

•Maintain a culture of respect and ensure professional safety

•Challenge yourself and others to continuous improvement

•Inspect what you expect

•Collaborate to yes

General questions about Be Safe

Email: [email protected]

mailto:[email protected]

You have just completed

Be Safe Leadership Basics

Our Journey toBecome the Safest Place

to Work and Receive Care

Be Safe is our roadmap

Closing remarks

Rick Shannon, MDEVP, Health Affairs

Documents

Title of Presentation Here Presenter Name Here Month Day, 2012 WELCOME Uteam Leadership Education Forum Be Safe Leadership Basics June 10, 2014