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July 12, 2011

Operator: Thank you for your patience in holding. We now have our speakers in conference. Please be aware that each of your lines is in a listen-only mode. At the completion of the presentation, we will open the floor for questions. At that time, instructions will be given if you would like to ask a question. I will now turn the conference over to Dr. David Thompson. Sir, you may begin.

Dr. David Thompson: Great. Hi. Welcome, everybody. I'm glad you could all make the call today. I am a member of the Quality and Safety Research Group faculty, soon to become The Armstrong Institute at John Hopkins. My specialty is quality improvement and safety. I'm Director of Patient Safety Curriculum here at John Hopkins. And the two tools we're going to talk about today, including situational awareness and conducting morning briefings, I developed here and piloted and there are publications on those. I also work very closely with The School of Medicine. I developed their patient safety curriculum that we've been using for the last 7 years now, and I also teach in the School of Nursing for Adult Physical Medicine as well as many other research projects. So I have a little bit of experience in lots of things. And I think what we're going to do is go over these so that we have plenty of time for questions. These tools not only as I said that I worked on them but I worked on a lot of the CUSP tools, and these two are near and dear to my heart. And I think that is because the one tool we use now, the improving situational awareness or the shadowing tool, we have all our medical students shadow the nurses, and Peter Pronovost and I thought it was very important that physicians see doctors and nurses teaching together so that they realize that nurses – which is my background, I was an ICU nurse for probably 17 years – that they actually could learn and be taught by nursing and not just physicians. So it was sort of exciting. We set it up so that all of our medical students followed our ICU nurses for 4 hours, that’s 125 medical students. And we do that every year as part of their curriculum, and every year they identify more and more defects. And if you're working in the CUSP program, you know that part of the goal is to identify your own defects. So it's been amazingly successful here.

And the other one, the morning briefing, is a way to organize your ICU care and patient flow, which has also been very helpful. We're able to get our patients out in time, leaving nobody left in the OR waiting for the bed because we've managed to address some of the issues that we saw, like through Lean Sigma and our own clinical experience, that weren't working well for us. So a briefing defined for all of you that aren't doing them yet, it’s really just a conversation between two or more people to discuss an event or a project or a procedure prior to it occurring. Briefings help us better to prepare. It maps out a plan of care. It allows the team to learn names, assignments, and responsibilities. It also allows us to raise red flags and identify contingency plans. It really allows us to heighten our situational awareness, and situational awareness is really our ability to be aware of what's going on around us or to be situationally aware is something that we say. And we're taking this, I'm actually borrowing from other patient safety industries: Department of Defense, aviation, nuclear power, offshore drilling. Lots of other people are way ahead of us, and we here in health care, we've been working on patient safety for probably 10 years so we're at least 20 to 30 years behind some of the other teams that have been working on this. So we take a lot of what we know from those other industries, and there's a lot that we could glean from them that we could include.

Situational awareness really has to do with our understanding of what's going on, and it's informed by our clinical prowess and what we know about our patient care. So we're able to determine based on a clinical situation what's going to happen next or what we can anticipate, and our situational awareness improves, actually, as we have more clinical experience. Teams are alert to developing situations, and the best teams are able to talk out loud and be appropriately assertive and let everybody else know what's going on so that you have talked about that contingency plan, you’ve talked about what's going to be going on with your patient and you're able to plan accordingly. For instance, if your patient's blood pressure drops, is it because they're hemorrhaging? Is it because they haven't had enough crystalloid? You, as a clinician, based on your clinical findings, are going to make recommendations for care, whether they need a transfusion or just they need a fluid bolus or whether or not they're getting septic and you need to start a vasospressor. So that's what being situationally aware is about. And when you add that to a briefing, a briefing really heightens our awareness of situations. In the end, we anticipate briefings will help us have a shared mental model, develop contingency plans, and use our clinical knowledge to plan very good care. This is something that we've done previously in a very disorganized manner. We kind of all work in our silos, and it's only been within this last decade that physicians have been asking nurses their opinion even though since the mid to early 1990s they've shown that interdisciplinary teams have better patient outcomes. But we haven't always included everybody. That's something that we really need to work on.

Moving on to slide four, and I think the important things about an effective briefing are really that it does set the tone for the day because what you've done is you've allowed for a hand-off to occur. You’ve talked about procedure. You've talked about unexpected changes in the care process. You prevent really a chaotic day from happening because you have let all of your staff know what they can expect for the rest of the day. It allows for participation by all team members. In fact, the best briefings are the ones where everyone is encouraged to speak up, and everybody has ownership, and the briefing is really owned by the whole team. Even in an OR setting when it's led by a surgeon or a nurse, depending on what type of facility you work for, it allows everybody to ask questions and to make sure that you've identified those people that have the appropriate skills for the case, who performs what, and what does the circulating nurse do compared to the scrub nurse? Who's going to cover during lunch? Who's going to cover for the anesthesiologist? Has somebody addressed all their comorbid conditions and those kinds of things?

And really, we get a lot of what we know about conducting a brief clinically from crew resource management or cockpit resource management, which is directly from aviation and Department of Defense. It allows, by asking all those questions – who has what skills, etc. – for us to determine technical and social competence, competence of skill, what staff has what skills, what they're best at doing at. Do you have any areas that you're missing and are you going to have to call for backup? What patients will go where -- so planning and preparation are all part of situational awareness. Do you have a bed available? Very important questions. I'm still working with teams now that still don't include all the members of their team, or the OR doesn't check to make sure that there's a bed in the ICU. So a really effective briefing really is going to include everybody that is going to touch that patient, and you're going to talk about every aspect of that patient care. And as I've said, they've been used very effectively by other high-risk, high-reliability organizations. And we really think that this allows us to reduce the risk of unplanned consequences and effects if we build our team. We did a small pilot study here, and just by adding briefings, we reduced the number of delays in care by 37 percent within 2 weeks, so really a great way to improve not only your patient outcomes but improving patient flow, which is one of the things that’s very important to how we deliver care.

So when do you want to conduct a briefing on slide 5? The beginning of the day, which is what we're talking about today, morning briefing, but they can really be used in any setting before a procedure or before any type of situation that requires more than one or two staff members to participate in care. Situational changes, those changes I talked about with the blood pressure. Sometimes it's nice to call a team huddle, to have people come over and reassess the patient to make sure that you know what you're doing for your patient and what's your backup plan if your primary plan doesn't work. So there are lots of times that we can start, and we're focusing on the morning briefing for lots of reasons. It's the beginning of the day. You're starting a new day. We want you to be organized. For those of you that are familiar with TeamSTEPPS, you might have noted that they've taken the briefing process – which is what this is – and given it names for specific times. For instance, for a situational change, you might call a team huddle, as I mentioned. It's still a briefing, and it's designed to make sure what was unclear is clear, and that comes to us from the way of nuclear naval submarines. So once again, we're borrowing in health care from other risk-averse industries. It's also brought us to understand the situational briefing that we use through SBAR, where a nuclear enabled – they would approach somebody by talking about the situation that was at hand, the background of the situation, what their assessment was, and what their recommendation is. So there are all kinds of ways.

I think what's important is not to be confused by the different terminology. Consistently use what terminology that's clear to you, but they're really all the same thing. And I think once you have something down that works well with your clinical team, that you maintain it. For instance, at Hopkins we call our morning briefing just that in ICU. But because there's a different program of care management in the OR, we call that a morning huddle because we're not only talking to the nurse and one physician, we're talking about the surgeons, the anesthesiologist, the scheduler, the nurse that directs care for the day. So not only do they have to check what's going on in that one unit, but they have to check for multiple ORs. So it's the same process. We just gave it a different name so that people wouldn't be confused by it.

Optimally, who you want to participate – you definitely want the physician doing the rounds and is responsible for patients that day. This will vary depending on the type of unit because the physician can be an intensivist, a hospitalist, pulmonologist, a general practitioner, and even an anesthesiologist actually can direct care. I've even been in some units where there is nobody who has direct responsibility for all patients and that rounds are done by the individual practitioner that's coming in to see their patient. It's always optimal to include both the nurses from night shift and day shift, so that nobody has to be a mediator to pass on information. If you get rid of that one extra step, you're going to reduce the number of communication errors, and we know that communication errors are the number one cause for adverse events in the hospital. We like to do ours first thing in the morning, about 7 o'clock, when the nurses are coming off shift and the other nurses going on shift. Other units start even earlier at 6 a.m. The night nurse begins to prepare the sheet, and she discusses it with the physician coming on, and then they just update the nurse. There are lots of ways to do this, and with all the tools that we developed here at Hopkins and piloted, none of them are done in that you have to follow them directly. As you probably heard Peter say, if we give you a tool and we expect you to implement it, it wouldn't be successful. You have to change it, tweak it to meet the needs of your own unit so that you will have something that will work for your hospital. For people who don't have intensivists or physicians leading the daily rounds, we found that nurses are often responsible for starting the morning briefing process and do it just as effectively as a physician handling the morning briefing process.

So, what are the questions? Very simple; we kept it simple. Three questions: What happened overnight that I need to know about? Where should I begin rounds? Do you anticipate any potential defects in your day, any glitches that could slow patient flow or delay a patient being transferred, those kinds of things? The answers are very important and potentially impact each member of your team. It used to be before we did this we wouldn't find out until after rounds where our patients were going, if they were going off the floor for any testing, and/or if we needed to contact an intern or resident to help us transport the patient off the floor for an MRI. There were a lot of delays. So things that could have been done quickly were delayed because we didn't have all the information. And this really did help us.

So what happened overnight? A little bit more detail on slide eight. These are the things that you should be thinking about. And what we've done is we've added prompts so that there are things that can help you decide where you need to start and what you need to address from last night. You should be thinking about: Was there adequate coverage? And some of the things that we often find, especially when culture is poor, is that people feel that they need more staffing. So beginning to address some of those issues – was there adequate staffing? Did you have the adequate equipment that you needed? And there are lots of times we do equipment counts at the beginning of a shift, and it's still not enough. And so our contingency plan then is what unit has like an extra AV pacer or something that we need to borrow? Were new cases posted to the ICU? So that way everybody knows about anything that is going to impact the number of patients, the census, and does it change, how quickly we have to get our first patient out to get the first patient in from the OR. Unexpected changes in patient acuity --  this has to do with the patients in the ICU because certainly a change in acuity where they're decompensating means that they may spend another day, but we also want to hear from our nursing supervisor who lets us know about what's going on on the floor. So if there's a patient that's decompensating, we can begin to anticipate are we going to need to trade this patient from the floor into the ICU? And were there any adverse events that we need to know of? And you know with the Learning From Defects tool, we really like to walk through the adverse events as quickly as possible so that we can really see what happened and make sure that we are able to mitigate any harm and we're also able to prevent it in the future. The goal is to keep each other informed, to be on the same page. Again, that same shared mental model is what we want. If nothing happened overnight, which is awfully rare in an ICU, that means we're going to have a good day, unlike a briefing where we ask how did things go? We just begin to move on and discuss what's going to happen next, which is where the rounds should begin, which is on slide nine.

There are three trigger questions, and this is pretty simple. Is there a patient who requires my immediate attention secondary to acuity? You might decide to start with the patient who's most ill and proceed based on patient acuity. Was there a patient who had a significant change, a new need for vasorpressors, a new GI bleed? This might be the patient that arrested and went into septic shock. That might be where you want to start. If those things didn't happen, which patients will be transferring out? We found that we started – we had an 18-bed unit – and we’d start at bed one, and we would stick to bed order -- bed one, bed two, bed three -- and really that was an ineffective way to make use of our time. We really needed to go based on the patients that would be transferring out because if we got a patient out because they already had orders, we had an open bed. We also had to look at acuity because if we had acuity, we looked at the sickest patients that needed to see the whole team to make their plan for the day so the daily goal form could be filled out. And then we also added in there: Who's already been seen by their primary care physician because we have some open units and some closed units. In our open units, we always look to see who's been seen by their primary care physician and have they left transfer orders? If they have transfer orders, then they might rise up in our hierarchy about who should be seen on our rounds first because we know, like I said, we can get them out the door and open up a bed. But all of these questions are based on your clinical and medical expertise. You might decide that two things are equally important to you so you might send a fellow to check on a patient who may need to transfer out, but you also might say this patient is really sick, they arrested, they've had a GI bleed, we have to put them on drip, and you might want to start there. So you begin to use your resources better so that means deciding where your physicians are going to go and who they need to see from a more informed perspective, because you have not only information from the night nurse and shared from the day nurse, but you also have the rest of staff who've been giving you input throughout the evening and also from your admission, discharge, and transfer sheet.

As you continue planning your rounds, how many admissions are planned today? What time is the first admission and how many open beds do we have? Again, going back to who do we need to get out of the unit, and we can begin to see how our day is evolving and what we need to plan for, who we need to inform of changes. So after we did this, we had a quick huddle with each on of our nurses, let them know if their patient was staying, if there was any outside road trips, and who would need a physician escort downstairs. So it really did improve not only the flow of our care, but it really changed how we worked as a unit and that we all anticipated it. Everybody had information that was important to share, and it was actually going to be shared.

Lastly, do you anticipate any potential defects in the day? If you've ever been the bedside nurse or the resident or the charge nurse, you know that there are lots of things that can throw a wrench into the best-made plans, and those are patient scheduling errors that you see. Defects can be failing to let somebody know that an MRI or a CAT scan was scheduled or the patient's going to need to go to VQ scan. What do you need to prepare for that test? Equipment issues are definitely not uncommon. Calling clinical engineering or borrowing and then making sure that you know where everything is. Who has those extra pacemakers, and who has those extra pieces of equipment? There was one day I was working, we had three arrests and I had both of my defibrillators. I was the charge nurse that day, and we had two defibrillators, and they were both in front of rooms because the patients kept going in and out of tachyarrhythmias, and they needed to be defibrillated. Then we had another patient that didn't do well, and we had to borrow one and luckily clinical engineering, we knew they had one. We called them and they said, “Oh, it's being used by the cardiac SICU.” Cardiac SICU wasn't actually using it. But these are things that we could have planned for a little bit better had we been more successful in our approach to how we addressed this. Outside patient testing, as I said off the unit, really triggers a lot of things. We mandated a few years ago that all of our patients going off the floor would be accompanied by a physician, so making that phone call early so that the resident could be up here in a timely fashion and that the patient was always covered by a doctor and a nurse when we transported them down. And then staffing and sick calls and did we have a backup plan? And did we have anybody on call? And then skill mix: You may have a very different day with an inexperienced charge nurse working with a majority of new staff compared to an inexperienced charge nurse working with their most experienced staff. So we try to take those things into account to make sure that we have somebody that can cover everything. Even with the best of circumstances, there are going to be times when you can't cover everything, but it's so much nicer when you have a busy day that you have somebody that can address the needs. I worked weekends for years after I finished my doctoral degree, and I'd come into a CVVHD patient, doubled with a patient on vasopressors, and I said, “How did I get this assignment?” They say, “David, you have the most experience.” Well, I may have had the most experience, but I worked less frequently than anybody else so was I probably the best choice? Probably not. I would have given it to somebody that had taken care of those things every day.

I think the last thing to talk about when we talk about this CUSP tool is Appendix E from the CUSP toolkits, and this is the Status of Safety Issues, which is on the Web site. And I think it's important to hold people accountable, and that's where this form is coming from. The tool itself actually says who reported the issue and to report follow-ups, so what's going to happen. So new and ongoing – so we just pass this off from shift to shift until something is completed and, then it goes down to the bottom section in blue to make sure that we really are not only addressing the issues that we've identified but that we've actually resolved them as well. And I think that's very important to good integrity for your patient flow and for making sure that everybody on board really has a good understanding instead of, “Oh, I assigned that to Nurse Nancy, but I don't know what happened after that.” So we keep that form around. It's left in the charge nurse’s office, and it's used during rounds so that we always know what's going on.

So the next tool I wanted to talk about is Shadowing Another Provider and, again, this is one that we have used as part of our training for our medical students. We also use this in the ICU and on the floor, especially when we see that there's a big cultural difference between two provider types. Like I've had sterile processing shadow my neurological OR nurses, and I've had them shadow sterile processing because no matter what we did I couldn't get people to put the kits back together to send to sterile processing, and there were delays in our neurosurgical cases. When they finally showed each other what they were actually doing, then they finally had a complete understanding on why it was important not just to put equipment in the drawer to go down, but they had to put the complete kit and leave them together. It saved the sterile processing time from having to put the kits together. And we've used it as part of our training in the ICU. So I send all of our nurses. I have them shadow the residents. They shadow respiratory therapy but, as I said, most often it's when people really don't understand other people's jobs.

And so why do we shadow? It's to gain perspective. I think in your CUSP toolkit this is Appendix K. Gain perspective of alternative providers that we work with. We developed this tool after we realized that many of our providers had no knowledge of practice limitations or practice responsibilities. We had residents asking nurses to push medications that they weren't allowed to push. We had residents being asked to manipulate the smart pump, and they had no training on them at all, so we had some medication errors. So we really had to say to the nursing staff that, “Residents don't have the same type of orientation or in service education that you have. If you're going to ask them to do something, make sure you've given them an adequate orientation.” The shadowing tool really helped with that.

Slide 16, who should have this experience? We believe that this should be open to many and we found it to be beneficial. You've heard Sean Berenholtz and Brad and some of our other physicians that are on the faculty. They've all shadowed nurses. And we have nurses shadow the residents and attendings, so they really get a feel for what it's like. Why is that doctor not returning my page? Because you have no idea what it's like to be a resident on a Monday when clinic is going on and have responsibility for the ICU as well. We involve pretty much everybody and, using the HSOPS, we look at, as I said, we look at culture scores. So if we see a big divergent thinking on as far as what teamwork is or what good communication is between two disciplines, and their scores are less than 60 percent -- I think the cutoff with HSOPS is 75, but we dropped it to 60 percent -- we say, “You know what, you're a good candidate.” Also when there's a difference of 20 percent between cultures of provider types -- those questions where we're looking at collaboration and where nurses feel that physicians are poor collaborators but physicians feel a nurse is a good collaborator and their scores are different by 20 to 40 percent -- we'll say, “You know what, you guys would really benefit from spending time with each other on the unit.” It's been effective. It really has shown that there's a huge dichotomy, and then after they shadow each other, they're able to come back to unit and we ask them what they learned. It's amazing the things that we've done. In fact, some of it is so interesting we've had them present to our Patient Safety Committee on an annual basis. Some of the things they identified to improve clinical practice are recommended as standard points of care after the shadowing process has happened. As I said, we use this a lot for new orientation and, as I said, also for our medical students. It was our medical students that first identified the number of adverse events or defects that they identified. I'm going to talk about those in a little bit.

So is it really hard to shadow somebody? Well, no, but there are some things that we ask you to do. How do you do it on slide 17. Review the tool. I mean, there's nothing that unnerves people more than having somebody continue to read something and follow-up so that they know you're watching their every step. In high-reliability organizations, we have a shared mental model and we're also able to give some negative feedback, but you know what? If you have no experience in doing it, you're probably not very good at it. So it's better to know what you're looking for before you go in and not take notes as you're going so the people don't think that you're writing down everything that you believe they're doing wrong. Save that for afterward. So we recommend that after you've reviewed your tool, you follow the health care provider through their activities. We recommend 4 hours, but we understand that time is very limited. We've had people identify things in as little as 2 hours. So for orientation, some providers will split 12-hour shifts between three providers, such as the nurse who shadows the respiratory therapist, the pharmacist, and a physician. And they spend 4 hours with each of them so it's a whole-day total. Review your list of teamwork and communication issues at the end of the shadowing experience, things that you see definitively as being an obstacle to providing good patient care that related to collaboration or teamwork and communication issues that have been noticed amongst team members observed. It's okay that when you're shadowing to ask other members of the staff about how do you deal with communication issues and how do you deal with teamwork issues? There are lots of things that are very eye opening when you ask the frontline staff about how is communication in this unit? Discuss with your provider that you shadowed what you found, ask questions, gain insight into their scope of practice and the unit characteristics. There are a lot of things that once you understand, we kind of take that judgment away as somebody being a poor provider or poorly responsive because we actually have walked in their shoes, which I think is really important.

As you review the tool, when you get a chance to look at it, you'll see that we developed it to be really easy to use. We set up the questions with prompts to help the person shadowing be more observant, a very easily edited tool, again, so you can make this very specific to your unit. We've left it very broad, so this can easily be used by doctors, nurses, pharmacists, anybody. If you have a specific need, again, take out the questions or the prompts that you find not to be helpful and, again, make it unit specific. If you're already aware of an issue, make it specific to your needs and update the tool as you see fit. If you continue to see, however, things like nurses are not notified of new orders after a CPOE or computerized physician order entry is initiated, that may be one of your questions or prompts for the person shadowing because in almost all the circumstances after CPOE is being implemented, I have a complaint to me from the physician that the nurses aren't following up quick enough and that from the nurses that the physician is not alerting me to stat medication orders. When you look at policies and procedures, you definitely see the two very divergent methods of thinking, and by adding the CPOE, I've heard from everybody that we've lost that one special thing and that was that the physician used to notify the nurse of any change or any stat medication order. So those were things that people added really quickly once CPOE implementation was very popular. But there may be other things as well, like electronic medical records and those kinds of things. We want you to feel that making it unique to your unit or your setting will give you the most opportunities for positive change.

Section one, were there any health care providers difficult to approach? This was one of the first things identified by an interdisciplinary group of providers when we were piloting this. It was identified because there was not a specific method of addressing problems that allowed for people to speak up after they'd been yelled at and that whole issue of being appropriately assertive. We found that if somebody was difficult to work with, they developed a workaround so that one provider, instead of being approached at all, they'd go to a second provider who was more amenable to discussion about plans of care, who was more affable and they would go to that person, so that one member of our surgical team was being used a lot less than his counterpart. We also found that there was a lot of conflict, and after we found this issue and the workarounds that resulted, we taught three different methods of conflict resolution – a two-attempt rule, a DES Script and a Lean, which is some of the methods that are also taught in TeamSTEPPS, and it was really a positive outcome after we did this because we found out not only was the conflict related just to these two professions, but everybody really needed help with appropriate assertion and conflict resolution.

In section two of the form, did one provider get approached more often, as I said, for patient issues? That definitely did occur, and it was all based on how somebody was perceived.

Sections three to five, did you observe an error in transcription by the provider you followed? Did you observe an error in the interpretation? So you can do these in several ways. Unit clerks taking orders written by providers or the attending or fellow giving orders while another physician is training or a nurse practitioner who is transcribing. We have seen something as simple as Lasix and potassium being transcribed differently, so instead of 20 milligrams of Lasix with 40 milligrams of potassium because they were talking about both of them, they had the doses reversed. So one got 40 of Lasix. So we did recognize that there were a lot of medication errors that were occurring. So we also found that this was also helpful to include every member of the staff, so we added unit clerks and our unit secretaries to do this as well. Again, this is going away with CPOE, but we found that a lot of times, people didn't write things down quickly so not only did we have medications given without anything being signed off, we had the wrong medications being given. Were patient problems identified quickly? It's always important to identify when a nurse is having trouble getting the doctor’s attention. When they assess significant change or vice versa, a physician assesses change and the nurse is too busy with the other patient. So this definitely led us to identifying backup plans and the buddy system so that there was somebody always there to cover for a nurse that might not be there.

If you were following a nurse. So this was for our physicians and our pharmacists, we put this in specifically for them because it's important when observing the 12 to 14 nurses on any unit on a given day here at Hopkins and for the other units I worked with, how often a nurse's page was not returned. And there was one nurse that had a really sick patient, and I was there with her and I counted that she paged the resident three times before she had a callback from the intern who wasn't able to help her. He didn't know the patient. It's very interesting, some of the things that we learned. And then, of course, there are other CUSP tools like the daily goals that actually reduced the number of pages because you really do have a good plan of care. And if you do the briefing part first and you have a contingency plan, there's also going to be hopefully even further need to page the resident for a plan of care because you've already discussed that. And I just have to say it again, communication problems and delays are the number one cause cited reason for adverse events. And I think one of the things we found and we were able to identify the communication issues in this tool very readily.

And if you are following a physician, so this was for our pharmacist and for our nurse, what were the obstacles that a physician faced in returning the calls and pages? We found lots of things. This is often routine activities such as already seeing other patients, being in the operating room or clinic, or assessing a new patient in the emergency room. All of these things take time, and if you don't have a good backup plan for who's going to cover and take your calls or a system in which the nurse can return calls for you while you're assessing a patient, there are going to be a lot of delays and sometimes tragic delays. So how do you deal with physician coverage while making them more available to patient care when they're pulled from every angle? How do we address this? We may be focusing on on-call schedules. Are they adequate? M&M rounds – should everybody be in M&M rounds at the same time? Should somebody be available to actually see the patients so that there's not a 2-hour period when you have no access to a physician? And we finally came up with, well, they turn their pagers off. So we got text pagers and that was one way of doing it, but we still needed clinical coverage so we changed who was going to M&M rounds and that was sort of rotating. Work with them to provide better coverage. For instance, we know on Thursdays here, there are rounds so, as I said, we get them to write transfer orders before they go to M&M rounds, before 7 a.m., so we know who's going out and who we can have an open bed for. We save multiple steps and many unreturned phone calls by doing it this way. We also set up a system on the inpatient unit where doctors were text paged pertinent information for serious issues were given to them so they actually could get up and respond to the issues that nurse and the other staff have identified.

And then, lastly, as you're shadowing, how would you assess handoffs, communications during a crisis? We already know that handoffs are a great opportunity to not provide all the information that you should, communication during a crisis. A physician who says, “I'm the only one who should be talking,” is that advantageous or does that limit your situational awareness? I would say that limits your situational awareness because what if you're there and the patient's not doing well and they just dumped a liter of blood into their pleuravac that was just placed? Somebody needs to know about that. To hear anybody say, “I'm the only one who should be talking” is definitely a communication issue, and it has detrimental effects to not only the teamwork and collaboration that you have but to your patient as well. Provider skill, not just technical skill, but communication skill and bedside manners, we found that we had to do a lot of work with teamwork and communication. As I said, we did appropriate assertion, conflict resolution, cockpit resource management a lot of time. In fact, we closed ORs down, ICUs down to make sure that everybody went through a basic 4-hour training and then a continued training after that. Did they have adequate supervision when you're looking at provider skills? In a teaching hospital, this is really important because when I read adverse advents, and there was one study where I read over 3,000 adverse events, and what I noticed was that not only did the resident not seek supervision when they should have, but unless they did the physician was less likely, especially if they had done a procedure before -- you know that watch one, do one, teach one. Maybe it's a medical model, but it's often not effective in making sure that we have safe implementation of different medical treatments, dressing changes, or procedures. And I couldn't get that across to the physicians enough until residents started coming out and saying, “You know what, after doing this I have to say I’m jealous that nurses have in-service education, where I'm just allowed to flounder with what I'm doing.” It changed how we trained our residents here. We also make our policies and procedures, which used to be in a book behind the monitor, they're all on our Intranet so that everybody before they do a procedure, they can pull up the policy, read it, and make sure that they're comfortable with it before they actually attempt it. Huge, huge improvements with that. Staffing at all levels, adequate nurses and physicians staffing, could you have used a mid-level provider like nurse practitioners? Ultimately with the changes to the physician work week and with the acuity, we did end up hiring a lot more mid-level providers because we just didn't have adequate coverage.

And then lastly, in section three there's a chart that we use. What will you do differently in your clinical practice? What would you recommend to improve teamwork and communication, such as on-call schedules, hierarchy for each service so that nurses have access? Actions taken: It may be a quick fix. It may take a while but, again, this is something that we also put back on that list that I talked about earlier with the yellow and blue. So we talk about things that are active, and then we talk about things that are resolved, and then we make recommendations from changes in policies and procedures, all the way down to how we manage patient flow. We've been doing this probably since 2004. We've had some really interesting findings. Handoffs for 4-hour shifts, you know, there's a nursing crisis. We were very happy to take moms that had kids at home, and they were able to work 7 to 11 or 11 to 3, and what we identified was the more handoffs that we had, the more opportunity we had to forget key details. Did we stop allowing 4-hour shifts? Not during the nursing shortage, but what we did do was mandate that there was a report sheet that people used so the information was consistently passed on. Physician consults usually obtained but not always read. In fact, we found in just observing, it could take up to 2 days before the team that ordered the physician consult actually read it. And this was identified by our medical students during the shadowing, and this was pretty consistent for 2 years in a row, so that we had to put a mechanism in place to make sure that not only did they realize that the consult was obtained but they got the information, so that with the electronic system there was a little checkmark or a little light that came on so they knew to check that the results were there and recommendations for care. Not unusual, nurses are often the most informed about the patient but not always able to speak up a lot of times because they've been reproached or their work schedule was too busy. So we had to go out of our way, and you may have heard Peter say that he's asked the nurse, “Do you have anything to add?” but he would keep moving. What was really important to do was to ask the nurse if they had anything to add but to actually stop and listen as well. So really improve how interdisciplinary rounds were, but knowing that, making sure that they didn't always have to be the mediator between two different people of disagreeing opinions about what should be done, so they could pass on the information and let the two other providers decide.

So our findings also – not good to function in silos. Nurse is the provider most often left with the patient information, and we saw few conversations between physician and physician and the nurse, again, was playing the mediator to give that information. And sometimes there wouldn’t even be a note to say that it was recognized except for what the nurse wrote, that the nurse was informing the GI team about what the GU team said about managing their care. Pharmacists that don't realize how critical supplying Pyxis was and stock drugs were. One of the things they did was they took some of the things that were stocked, and they took them out of our stock and during an emergency, when we were used to having our drug diluted, it wasn't there, and the first time that they did it they put a little tag on it, a little red tag that just said this must be diluted. It wasn't recognized by the nurse. She was pulling it out – a new nurse – out of the Pyxis machine. She gave it over to the resident, he gave it, so he gave a full dose instead of a diluted dose and what do you think happened? The patient overdosed, arrested, resuscitated luckily. So pharmacists had to then talk about all the changes that they were going to make to how they supplied medications to the unit with the staff and the medical director before they made any changes. As I said, some providers avoided -- EMR was not always accessed. We addressed that again with communication.

In slide 28, nurses didn't realize how complicated sterile processing was. I think I told you about that with the neuro nurses. So they really did make it a significant part of their day to make sure when they put together the kits to go back to sterile processing, that they were sending complete kits. POE removed an important step. Communication to an RN for a stat order was definitely important. Otherwise the policy was POE had to be checked every 2 hours -- not really great if you're looking for the stat communication. Anything else? Some nursing practices identified by our physicians in some of our ICUs weren't being used in other units, and they were so good in presenting them to the Patient Safety Committee that they were made mandatory hospital wide. Of course to any nurse sitting out there who has watched isolation policies not adhered to primarily by the physicians and people doing the consults, it required the RNs to speak up and, again, required us to jump back into action and do the appropriate assertion and hold people accountable. Very difficult, very long process. As I said, we closed ICUs for 4 hours. I shouldn't say closed. We found alternative providers so everybody got to go through the training, and we continue with that.

In closing, I'd say that the shadowing tool has been used by over probably 800 medical students here, 250 or more of our physicians and nurses in our ICUs here. As I said, we branched out to the emergency room, the OR, the sterile processing. And we've only had positive feedback when they return from their experience. I should caution this tool works best when the person shadowing has the lenses that you see system space error, so if they haven't seen the science and safety talk, I would recommend they see the science and safety talk before you send them out on their shadowing excursion. It really does open up their mind to system space error rather than looking at the person that's responsible or the person that's there that is being held accountable when really it's a system space error. I'm happy to open up the lines to take any questions if anybody has any.

Operator: At this time if you'd like to ask a question please press the star key followed by the one key on your touchtone phone now. Again, that's star, one on your telephone keypad if you would like to ask a question. Again, please press star, one on your telephone keypad if you would like to ask a question. Our first question comes from John Sundheimer with Memorial Medical Center.

John Sundheimer: Hello, I know you have residents and you've been talking about some of them a lot. We don't have residents really in the same capacity, and I was really interested in really your ability to communicate with physicians in multiple different aspects. One of them, what you said even about physicians and residents going with patients while they're transported to a different unit or something like that. Can you tell me more about that, but also more about do you have physicians that are in charge of the ICU or the medical director for the ICU, too, and something like that and how did that come to be?

Dr. David Thompson: Okay, so we've always had a medical director. We've had different rules, and policies and procedures have changed over the years. When I first got here many years ago, an intern was capable of taking a patient on transport, but after using the CUSP program and working, focusing specifically on patient safety, we found that people with more experience so eventually you had to be at least a second-year resident to be in the ICU and to be responsible for a patient off floor. For the shadowing tool and the morning briefing, that can be used by any physician. In fact, as I said, two of our faculty members that are on the National Stop BSI Project have done the shadowing program – Brad and Sean – so we have attendings all the way down to our residents and medical students. Their findings are often the same. It's amazing what they don't really know about practice limitations or what their responsibilities are. It's been eye opening all the way. And with each new thing that we learn -- like an intern doesn't have the adequate experience to take care of a patient on vasopressors while waiting for a CAT scan -- everything that we learn really feeds into improvements that we do, not only in patient flow, but in policy. That's how we come about with the new policies. And I think that once you begin to shadow and you begin to treat everybody more the same so that everybody feels comfortable in speaking up, you begin to identify things more readily that can be improved. And that's really our process. Now it's not unusual, as I said, we even have residents that will correct attendings. Ten years ago, we would never have seen that happen.

We have many models here at Hopkins. We have an intensivist model, where it's an open unit with intensivist staffing, and we've done shadowing with them and they did the morning briefing so that they're touching base with their night and daytime nurse. In our medical ICU we have, it's pulmonologist led, and it is a closed unit so we have a pulmonologist managing the patients. If you're a physician that has primary care and responsibility for the patient, you can come in and offer your opinion but it's really up to the pulmonologist. So we've practically had every model here imaginable, although it is a teaching hospital so even our hospitalists run units. We do have some residents. But we also have some units like our step-down cardiac unit, which we found we had much better and more consistent care when our step-down unit was run by all nurse practitioners and the residents really played a secondary role. So it was that other mid-level provider that was consistent, the same nurse practitioners every day, and we saw that we had better care delivery that way rather than having residents rotate through one at a time. I hope that was helpful.

John Sundheimer: Yes, thank you very much.

Operator: Thank you for your question. The next question comes from Mary Mahella with Holy Cross Hospital.

Mary Mahella: Hi, I have a couple of questions. You were talking about an 18-bed unit. How long did it take you to do rounds for that unit?

Dr. David Thompson: Usually, if they start about 7, they were done with daily goals and everything by 10 o'clock, sometimes earlier, sometimes 9, 9:30.

Mary Mahella: These were multidisciplinary rounds?

Dr. David Thompson: They were. So for us that was the physician, residents, fellows, nurses, pharmacists, point-of-care pharmacists, dietician, social worker, clergy, practically everybody.

Mary Mahella: Okay. And one other question: Did you actually go into patient rooms and do the rounds in the patient rooms or did you do them outside at a desk?

Dr. David Thompson: So that has also evolved. We do rounds in front of the patient's room. Now that has changed. We used to close the door so the patient didn't hear what we were saying or family members because we never made them leave. Now we are inclusive of including the family in the rounds. They can also listen and ask questions as well, which is a big change, and that's just been over the last couple of years. When I was still at the bedside, they were not allowed to participate in rounds, but now they do.

Mary Mahella: Okay, thank you.

Operator: Thank you. Our next question comes from Sandra Diaz from Hospital Auxilio.

Dr. David Thompson: Hi, Sandra.

Sandra Diaz: Hi, we had a question here related to the open ICUs. With all the physicians coming in and out and patients having different attending physicians, how do you do the briefing in the morning?

Dr. David Thompson: The morning briefing, so what we do is we have the nighttime nurse start with the census of who she knows is going to be coming to the unit, who's in the unit, identify who has transfer orders and that kind of thing. So she kind of preps before anybody gets there and then as the individual provider comes in she's able to update the daytime charge nurse. If the physician comes in later then that's left for the daytime charge nurse. So the form is still completed, and they still do rounds with each individual physician, a lot like we do the daily goals form when we don't have one physician doing rounds on all the patients. We have the night nurse start it and we have the daytime nurse finish up, and usually they're finished by mid-morning, after the physicians have done their rounds.

Sandra Diaz: Thank you.

Dr. David Thompson: You're welcome.

Operator: Thank you. Our next question comes from Craig Pennington with Ochsner.

Craig Pennington: Good afternoon. The question I have is how do you coordinate the actual testing time with transporting that patient down so there's not a backup of patients waiting to get a CT?

Dr. David Thompson: Right, so we've tried lots of different things. One of the things that, you know, a patient can be bumped, a high-acuity patient can be bumped by a higher acuity patient. Before we come down they call. We have the CT or MRI call and tell us, “We'll be ready for you in 10 minutes,” and we'll ask them first thing in the morning what time they think they'll be able to have the patient down. So we'll then call the resident or whoever's going to be transporting the patient with us, to give them a heads up. And then we have them call us within the 10 minutes that they think they're going to be able to take the patient. Immediately they call us and they called a resident so that we're down there on time, so that we're not sitting there waiting. Unfortunately I've waited for 2 hours with a patient on pressors trying to get in the CT. So that's been very effective, having direct communications with the technicians from the CAT scanners or the radiologists. So based on their diagnosis, they decide who should be seen first and keep in contact with us. Usually, like I said, within 10 minutes of being able to take the patient, we get a phone call. As soon as we know the patient is going to go downstairs, we begin prepping. So the oxygen tank goes in the holder, the medication cart, the transfer form goes under the bed. We're ready to go as soon as they're going to make their phone call.

Craig Pennington: Thank you.

Operator: Thank you for your question. Again, if you would like to ask a question press star, one on your telephone keypad now. Our next question comes from Margie Willis with OHSU.

Margie Willis: Hi, I have a quick question in regards to the CT scan that you were just speaking about. We've had a few bad outcomes or outcomes that could have been prevented by taking a patient down and then they code on the CT table. And we've been discussing about doing a fit for CT kind of thing prior to them going where we lay them flat if they need to lay flat for a certain amount of time or put them on whatever oxygen that they're going to be allowed to be on, depending on what the restraints are for the amount of time they'll be there. Do you guys have anything, some standard, that you have implemented there?

Dr. David Thompson: Well, as I said I've been away from the bedside every day for a while. I can check for you. I do know that if our patients are unstable and we do a lot of the testing that you're talking about. If they're too unstable to get through the procedure that they don't go. So let me look to see if there's a policy that I can find you. My email address is DTHOMPS1@JHMI.edu. If you could send me your email address, and I'll tell you what I find out for you.

Margie Willis: Thank you.

Dr. David Thompson: You're welcome.

Operator: Our next question comes from Eileen Watkins with Community Memorial Health.

Dr. David Thompson: Hi, Eileen.

Eileen Watkins: Hi, David. I have three questions. I know we're crunched for time. My first question is when is the shadowing done for the nurses? We are actually staffed for average patients so there's not a lot of wiggle room for free time. Do nurses come in on their day off to be assigned to shadow a particular provider?

Dr. David Thompson: So we've done a couple of different things. Some of our nurses are given administrative time. They allow for the administrative time so they can do it on the administrative time, which is 4 hours a month. We give them that time. If not we might schedule them for a 8-hour shift and do the last 4 hours or the first 4 hours, especially if we get -- even with surgical units we get a lot of our admissions after 11 o'clock -- so from 7 to 11 they shadow and then be back in the unit in time to take an admission. But we do have nurses that volunteer to come in on their day off and do it that way. But we try not to do it that way because they're already required to keep up with their committee work so it's just one less thing that we try to work around their schedule. We also look at census. The times when our census is low, rather than giving nurses vacation days we give them the option of doing a shadowing experience if it was identified as a need, rather than having them use vacation days or mandatory time off, paid time off day.

Eileen Watkins: My other question is our ICU is a combined adult, pediatric, basically a general ICU. We come from a small community hospital. Our setup for the doctors, the providers that come in here, we have the regular internal medicine doctors for the hospital and plus we have the hospitalists from the Eagle Group, and they have a separate load of patients. How can we go about with morning briefings with these two groups of doctors? They come at different times. The hospitalists will come in around 8, 8:30 and the regular internal medicine is already there by 7 a.m. I don't know how to go about doing morning briefings with two different groups and trying to get the night charge nurse to stay as long.

Dr. David Thompson: Right, so again we found a lot of success in giving the night nurse the form and he or she starts to fill it out and then address with each one of the physicians. We also don't have them stay. So usually the report is finished sometime between 7:30 and 8 a.m. and the night nurse is gone. So to make sure that all that information is passed to the day nurse, as I said earlier, they continue where the night nurse left off. So if you have two different teams that are following, meet with one team, as you said, at 7 a.m. and the next team at 8 a.m. Then you can go through the unit and alert the nurses to transport off the unit who's going to be transferred out and that kind of thing. It really is an interdisciplinary effort, and I have to say that it's the night nurses that often get things started. I'm very dependent on the night nurses to do that in a lot of hospitals I've worked with.

Eileen Watkins: Great, thank you.

Dr. David Thompson: You're welcome.

Operator: Thank you. Our next question will come from Don Zonelo with Presbyterian Health Care.

Don Zonelo: Hello, I have a question. Early on in your comments on briefings, you did a study on the impacts of briefings. Can you give a little more detail how to access that study?

Dr. David Thompson: I can see if we have that published. If not, did you catch my email address?

Don Zonelo: I did.

Dr. David Thompson: Okay, so if you send me your email I can send you some slides from that study, and that was done here at John Hopkins Bayview Medical Center, and I'm happy to send those to you.

Don Zonelo: I will do that.

Operator: Thank you. Again, if you would like to ask a question hit star, one on your telephone keypad. Our final question is from Bonnie Coalt with Miami Valley Hospital.

Dr. David Thompson: Hi, Bonnie.

Bonnie Coalt: Hello, I just wanted to know if this lecture's archived on the Web site.

Dr. David Thompson: It is or, yes, actually it's divided into two different lectures, but it is on the Web site.

Bonnie Coalt: Okay, thanks.

Dr. David Thompson: Okay everybody, thank you very much. You guys have a great week.

Operator: This concludes our teleconference. You may now disconnect your lines.