Evidence As a Seed for Collaboration: Separating the Wheat from the Chaff

by Lorri Zipperer, MA

I have been monitoring the patient safety literature for more than two decades now, first as the information project manager at the National Patient Safety Foundation, and for more than a decade as the development editor for AHRQ Patient Safety Network. As those in patient safety might attest and applaud, the evidence base has gotten more robust over the years, spurred by increased funding for research and public interest in the topic.

This expanding wealth of literature creates a challenge for organizations and individual practitioners. The unintended consequence of this explosion is that there is more wheat to sift through. The growing set of materials makes tracking useful evidence more cumbersome while in turn increasing the messiness of translating existing research results into actions that make sense and conclusions that are credible. We know that just because it’s science doesn’t necessarily mean it’s good science.

We know that just because it’s published, identified, and shared within an organization, community, or team that evidence derived from science is not necessarily applied or able to be translated for use on the front line. (Zipperer 2016)

While somewhat editorial in nature, Dr. Shojania’s presentation brought nuance to seeing how the evidence exploring these areas can play a part in our understanding of them.

There are tools out there to help with creating awareness of materials, such as AHRQ Patient Safety Network and the NPSF Current Awareness subscription service. However, not only should organizations have individuals trained to monitor these resources, also the search for particular evidence needs to address local gaps in understanding and effectively disseminate the literature to decision makers. Someone in the organization should navigate this output in order to help their clinicians and executives apply it if it is going to enrich the design of interventions and implementation of programs and contribute to enhancing the reliability of their patient safety work.

We could all use someone like Dr. Kaveh Shojania to help translate what is written to help create actionable knowledge in health care.

Dr. Shojania—with whom I work in my role at AHRQ Patient Safety Network, as he is on the editorial team—has for three consecutive NPSF Congresses provided a thoughtful and provocative analysis of key articles and the trends they indicate for conference attendees. This year’s session, entitled “Hot Topics in Patient Safety: Selected Papers Advancing the Field in the Past Year,” did not disappoint. Dr. Shojania covered literature on 6 important topics:

• Diagnostic errors
• Rudeness’ impact on team performance
• Trends in adverse events over time
• Incident reporting
• Fall prevention
• Reducing high-risk prescribing in primary care, with a focus on the current opioid abuse/misuse epidemic in the US

These themes should be no surprise to those in the patient safety community. While somewhat editorial in nature, Dr. Shojania’s presentation brought nuance to seeing how the evidence exploring these areas can play a part in our understanding of them. While some analysis of research design was applied, and the value of results was discussed, Dr. Shojania’s insights should enhance our ability to be more critical of what is published and by whom.

Imagine the opportunity that the sort of dialogue generated by this type of expert assessment could provide in an organization. The exercise could be brought to our care environments as more than a social or intellectually opportunity. If positioned as a patient safety improvement tactic, it could serve a more impactful role.

Dr. Shojania was challenged by an attendee, and his response provided thoughtful seeds for all of us who seek to partner to “plant” evidence-based solutions in the patient safety community garden. Imagine the learning and collaboration that could be generated in organizations if teams had these types of conversations on a regular basis, with accountability assigned to do something with the issues raised. Could the dialogues support increasing the transparency around sharing of ideas, forming of shared mental models, leveling of hierarchy, and engaging of individuals to form multidisciplinary teams to do research to reflect the frontline needs of improvers? Could be.

What tools, techniques, and team members do you use to identify, analyze, and infuse the most relevant literature to innovate and anchor patient safety efforts throughout your organization? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Reference:

Zipperer L. Jones BB, Esparza JM, Wahr J. Evidence, information, and knowledge as elements of safe surgical care. In: Stahel P, ed. Surgical Patient Safety. New York: McGraw-Hill Education; in press.

Reused with permission.
This content was originally written for and published by the National Patient Safety Foundation’s P.S. Blog.

Teamwork Grows Up.

True teams work together and share what they know and what they learn to achieve safety.
by Lorri Zipperer, MA

"Teamwork -- Teamwork -- that’s what counts!”

I was a cheerleader in junior high school. While it was fun at the time, that was enough of that.

Uninspired to take the same path in high school, I participated in both live theater and a variety of musical group activities (pep band, marching band, jazz band, symphonic band) that provided me with the chance to work with others toward shared goals. I thought I understood what teamwork was – until I grew up.

My first introduction to teamwork as a component of safety was as a staff member at the National Patient Safety Foundation. It was then that I was presented with the idea that teamwork was much more complicated than staying in line during marching practice. Granted, to be in a marching squad you had to commit to knowing your role, pay attention to what others were doing, achieve some level of reliable proficiency, give up your personal preferences as warranted for the greater good (is standing on a wind-swept football field in January in Chicago what any teenager wants to do?) and be aware that if you failed, the group could do poorly.

But, despite some similarities, teams and their role in safety go beyond that. In the safety sense of the word, teams rely on communication, mindfulness, and culture to enable their processes to be as highly reliable as possible during times of crisis. The focus on the flattening of hierarchy to encourage and support performance that is sensitive to, while capitalizing on, the humanness of people working together contributes to the reliability of collective action that expands beyond band practice in the 1970s. Trust and understanding create an environment that facilitates individual, group, and organizational learning from failures through a team’s commitment to feedback and open discussion.

It is no news to readers of this blog that team training models have been adopted from other high-risk industries to help health care evolve in the right direction. Commercial aviation and the military are the obvious examples. Given health care’s experiences with crew resource management and the Agency for Healthcare Research and Quality’s TeamSTEPPS initiative, the idea of building teamwork skills and the expectation that clinicians develop professional competencies in this area serves the logical foundation to infusing team practice and improvement into the frontline of care delivery. People are taught to do this well because poor teamwork can be catastrophic.

Explicit attention to the team roles of health care executives came later. And patient safety leaders—as they have done in other instances—looked outside health care for successful models. The business world certainly has had C-suite members that walk-the-talk of teamness. With credibility and integrity, those who model team behaviors and enable a culture at their company that support teamness provide examples to emulate its value. They demonstrate for health care executives the importance of purposely training and engaging a wide range of staff as team members.

Business schools and executive books champion teamwork skills as a foundational competency. The language and ideas of how to recognize and practice those skills from the business literature always resonated with me, a non-clinician. From that field, one author of particular interest is Harvard Professor Amy Edmondson. Edmondson’s writings caught my eye early on in my safety career. Her discussions about how organizational, unit, and peer culture and leadership affect staff willingness to report errors was inspiring to see—at a time when the value of that approach wasn’t as universally accepted as it is now (Edmondson 1996).

I distinctly remember working hard to get copies of her early articles (read pre-World Wide Web as we know it today). I still have the hard copies of those reports. Once a librarian, always a librarian.

Professor Edmondson’s publishing output since then covers a range of topics that touch on patient safety. Her articles on organizational and individual learning from failure are core resources in my readings list (Edmondson 2008, 2011). They provide foundation to my belief that knowledge management is a key driver of that learning. Edmondson’s 2012 Teaming is an excellent resource for considering how a culture of sharing what is known amongst people working closely together on a collective goal—no matter what box on the organizational chart represents them—is imperative to both team success and continuous learning (Edmondson 2012). She emphasizes that process, commitment, and leadership—both informal and at the executive level—must be present to translate learning into sustainable change in iterative constant fashion.

The sustained commitment to a culture of teams and teaming at variety of levels across a health care system can make that happen. True teams work together and share what they know and what they learn to achieve safety. Training and facilitating all health care workers—outside of rank and role—to participate in the cross-functional activity of teaming is vital to safety achievement. It offers health care yet another opportunity for synergy that presents clinicians, the organizations they work for and the patients they care for—with a chance to really make teamwork count.

Reused with permission. 

This content was originally written for and

 published by the National Patient Safety Foundation’s P.S. Blog.

At the 2016  NPSF Patient Safety Congress, the Lucian Leape Institute will present a Keynote Session, Teaming at the Heart of Safety. The presentation and panel discussion between Robert Wachter MD, Gary Kaplan MD and Susan Edgman-Levitan will be will be led by Prof. Amy Edmondson.

References

Edmondson AC. 1996. Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. J Appl Behav Sci. 32:5-28.

Edmondson AC. 2008. The competitive imperative of learning. Harv Bus Rev. 86:60-67, 160.

Edmondson AC. 2011. Strategies of learning from failure. Harv Bus Rev. 89(4):48-55, 137.

Edmondson AC, Schein EH. 2012. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Franscisco, CA: Jossey-Bass.

Intros to KM concepts from the NHS. Bravo and let's keep going!

Anne Gray, Knowledge Officer at the NHS shared this set of videos recently that I'd like to share here: In her words: the goal was to "encourage people to consider the importance of KM improve quality of care, outcomes and patient experience." They are worth a look:

http://www.nhsiq.nhs.uk/capacity-capability/knowledge-and-intelligence/better-knowledge-better-care/bkbc-animations.aspx

Of course I see things that could be tweaked...but I embrace these as nice tools to introduce the concepts associated with KM to a wide range of individuals. There are many professions/services that can contribute to effective knowledge sharing in healthcare--none of which are explicitly called out--so I don't think librarians, clinicians, informaticians or patients should feel left out here. We all have knowledge to share, so let's not quibble and get defensive if our roles or professions aren't called out.

I have a challenge for the NHS thou. I am interested in how they are going to use these to help healthcare understand how to:

1) measure the impact of true KM in the healthcare environment.

2) support and implement a knowledge sharing culture and how it concretely contributes to safe care

3) truly articulate the costs involved in changing culture to support true knowledge sharing

4) implement strategies to create accountability for both organizations and individuals that work in healthcare to share what they know

5) identify KM barriers and work through them in the same fashion that healthcare approaches patient safety improvement barriers. If we can present lack of knowledge sharing as a contributor to unsafe care--can support for improvements be articulated in a way that generates support and interest in sustainable change?

To those who might feel they already do this so why do we need to focus energy on KM -- respectfully, it doesn't move innovation forward for any of us to say--we already do this, we do it well -- even thou we might. If we can't articulate it, measure it and improve it the case hasn't been effectively made.

What stories are out there that translate what is being done concretely to manage and share knowledge (not data, not info and not evidence) as a component of safe, highly reliable care? Do tell, please, DO TELL! Don't keep that knowledge under a bushel! 

Expert Insights for Info Pros to "Ratchet it up" for Patient Safety

The following commentary was originally published earlier this year as a part of the "Whoo Says" article series on the NNLM/MidContinental Region web site

While the comments are closed on the original, they are open here. Please share your thoughts!

Lorri

Dear Whooo,

I am a hospital librarian who is very interested in keeping my library active and relevant to the needs of my hospital. Lately, I have been considering the issue of patient safety; my thoughts were triggered by hospital activities during this year’s Patient Safety Awareness Week, and Barb Jones’ call for feedback from librarians involved in patient safety initiatives. I thought about the work I do with various units and professions within my hospital, and how the overall goal is the safety and good health of our patients. I wonder if there is something I am overlooking, or missing in the patient safety discussion. I do lots of searches for quality improvement, protocols, and individual treatment. Is there more?  Wondering

Dear Wondering,

Thank you so much for writing, Wondering. I am glad to see that you are involved with a variety of units within your hospital and are considering the issue of patient safety as well as addressing specific inquiries that involve patient safety problems.

Since you have been observing the priorities of your hospital, you are probably aware of the emphasis on high reliability. Weick and Sutcliffe have written about how high reliability organizations function and stay safe. Their description of a HRO (high-reliability organization) is “an environment of ‘collective mindfulness’ in which all workers look for, and report, small problems or unsafe conditions before they pose a substantial risk to the organization and when they are easy to fix.”1 This description generally does not describe the conditions found in healthcare. “…in health care, uncoordinated and poorly designed and maintained mechanical systems (like medical device alarms) are tolerated, even though they are not safe. Intimidating behaviors suppress reporting and lead to additional unsafe behaviors as caregivers create workarounds to avoid repetitive exposure to intimidators. Errors are not seen as valuable information, essential to a hospital’s ability to improve patient safety.”2 Thus, I think you will agree that the current emphasis on high reliability is justified, and time spent on high reliability is time well spent.

I think all of us who work in hospitals can point out the validity of these statements. We see issues on nursing units, in the emergency department, in the hierarchy that occurs among the healthcare personnel, and in many other places. The question for us, Wondering, is whether we see any of these issues in the library or in library services provided. Every health sciences librarian I know truly believes that services provided by librarians lead to a higher quality of care. These librarians are conscientious, well-educated, and highly skilled professionals. However, they are all people and are subject to the same errors and lapses in judgment as members of any other profession.3

So, the answer to your question is yes, there is more. As conscientious professionals, librarians need to be sure to examine their own practices for small mistakes, workarounds, and potential for error. We need to be unafraid to find and admit our errors, and be willing to use those errors to learn how to perform in a highly reliable way. We need to examine our systems within the context of the larger hospital system to identify where the evidence/information we provide intersects with others, and ensure that intersection is fully functional. This is a continual effort; it cannot be addressed once and then put aside with the conviction that all is well.

All of this is pretty theoretical and abstract. To bring it down to the practical level, here are some examples of areas that librarians should address in the daily practice of their profession.

Peer review of searches: Do you ever have another librarian or information seeker review your search strategy and evaluate its effectiveness? Obviously, this is not practical for every search, and is difficult if you are a solo librarian. Maybe you can find someone in another hospital and ask your colleague to review your strategy for a difficult search or at a predetermined interval. You can offer to reciprocate which will ensure that both of you will benefit.

Complete the communication loop: When you perform a search for a user and deliver the results, do you attempt to close the communication loop and find out if your search was useful, and if so, why? All of the librarians I know have drawers full of compliments from users stating how wonderful the librarian’s service was. Few of those compliments state why the service was so useful. It is impossible to learn and improve without the knowledge of what is expected and what works.

Clarity in reference interview: Once you have received a search request, and you find when searching that you are not really clear about the specific need of the user, are you able to contact that person for clarification? Often complex topics require some dialogue to identify the precise need.

Completeness of database selection: When you are conducting a search, are you open to searching in multiple databases? What about the gray literature? What about in other disciplines? Medicine and healthcare are highly complex fields, and often the required “answer” is found in sources other than traditional medical sources. For instance, information on the reliability of medical equipment may be found in the engineering literature.

These are only a few of the ways librarians need to examine their processes and work to uncover error. For a more complete discussion of this topic, you may want to read the chapter “Analyzing Breakdowns in the EIK Pathway”4 in the recent text Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer edited by Lorri Zipperer in 2014.

Thank you again for your question, Wondering. This is an issue that I care about very deeply, and I think that our profession should consider it seriously. I hope this has been helpful. Please write again if you have further questions.

Sincerely,

Whooo
_____________________

Jones B. Patient Safety: Librarians have nothing to do with that, right? April 2015. Plaines to Peaks Post. http://nnlm.gov/mcr/p2pp/2015/04/patient-safety-librarians-have-nothing-to-do-with-that-right/

Weick K, Sutcliffe K. 2007. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. San Francisco, CA: Jossey Bass.

Chassin MR, Loeb JM. High-reliability health care: getting there from here.
Milbank Q. 2013;91:459-490.
http://www.jointcommission.org/assets/1/6/Chassin_and_Loeb_0913_final.pdf p. 462-3.

Tavris, Carol. Mistakes Were Made (But Not by Me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts. Harcourt, Inc. 2008.

Jones BB, Graber M and Alligood, E. “Analyzing Breakdowns in the EIK Pathway” in Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer. L. Zipperer, ed. Gower. 2014.

This story was originally published in the Vol 13 No 4 - April 2015 issue of the Plains to Peaks Post. It is used here with permission by the author. The Plains to Peaks Post is published quarterly by the National Network of Libraries of Medicine NNLM/MidContinental Region.

What are the top three skills needed to drive knowledge sharing in healthcare today?

Always interesting to hear from colleagues on these types of questions. Is knowledge management in healthcare "old news" for hospitals? I heard that indirectly from a librarian at a recent conference. Maybe -- but I guess it depends on how you define KM. If we look at knowledge as what the "knower knows" (Prusak and Davenport, 1999) and place its management in the sphere of safety science, high reliability and systems thinking -- I am not so convinced it is old news. Either way, what would you say are the primary skills to help make knowledge (not evidence, not info, not data) more usable, accessible and reliable as a resource to support high quality safe patient care?

Evidence seeking and checklists: does it make sense?

Atul Gawande's The Checklist Manefesto placed the use of checklists as failure prevention mechanisms in the laps of health care professionals and management worldwide, Since the book came out in 2009, checklists have now been planted in the minds of many in healthcare as tools to improve patient safety that typically wouldn't have considered them. 

Take librarians, for example. "My work is too messy", they say, "to use a checklist."

I would submit that most of the functions that librarians deliver in the course of their work in hospitals are NOT complex -- but the world they function in is. (I would love to have that discussion with my peers in this forum -- if they are game. But I digress ... ). This isn't and shouldn't be taken as a insult--and I apologize up front if its received in that light. The notion of when a tool like a checklist is needed and **should** be used is an important question--and determining the type of process its being applied to is important. It certainly isn't useful to pile more paperwork and process into the daily work of anyone - especially if it doesn't really improve anything--or to do so for a process that is complex vs complicated. or even simple, for that matter.

For sake of discussion, I do think there may be applicability of a checklist in some areas of the clinical librarian / Informationist domain, such as in the reference review process. For instance, gaps that happen due to communication failures, cognitive biases and production pressures should cause us to think about ways to make the reference interview process more reliable via structured communication tools and/or a checklist. Especially in an emergent situation.

I do also wonder if the checklist idea would be useful in an organizational.system sense. Let's face it: librarians aren't the only ones doing lit reviews in hospitals and, as demonstrated by the gaps in the lit review process at Hopkins that contributed to the research volunteer death some years back that are discussed here, we know it can result in failure if not completed effectively. Perhaps a tool that would enable more reliable searching no matter **who** does the work, would have multidisciplinary impact.

One example of a review tool that may serve as the model for a checklist to help examine the robustness and reliability of the search activities at the sharp end is the CADTH Peer Review Checklist for Search Strategies.

I would say IRB activity, systematic review support and similar "project and task flow" examples of evidence and information seeking may be "complicated" (ie "building the space shuttle") rather than "complex" (ie performing surgery, raising children) If we consider complexity theory in all of this, the CADTH tool (complicated task review) would probably benefit from the application of "local context" to help us all understand how to apply it in real time to shore up the effectiveness of search that frontline info seekers--librarians or others--undertake to inform info seeking actions that take place in a more complex context--in the midst of clinical decision making. 

Its important for librarians, and the clinicians that require the best evidence/information to do their work in complex situations, to explore how such a checklist could be enabled to affect patient safety in this intersection of professions. Can we draw from existing safety tools and processes in other high-risk domains such as aviation and nuclear power plants-- to help enlighten a discussion around how the information/evidence identification, acquisition and dissemination process in hospitals can be made more "highly reliable" through the use of checklists?

Some food for thought:http://www.springerlink.com/content/6x37w435wp32203t/fulltext.pdf

The value of sharing stories ... a request to hear some!

What Flavor Lifesaver are you?
Barb Jones
(used with permission: http://nnlm.gov/mcr/p2pp/2015/02/what-flavor-lifesaver-are-you/ )

As a health sciences librarian, your work buoys the diagnosis and treatment of many people in many different ways. What activities do you do that contribute to the safety of the patients treated in your hospital? Which of the following lifesavers apply to you?

Orange – You are on the team that develops protocols for the various units in your hospital.

Lime – You have worked with your nursing staff and your hospital has achieved Magnet status.

Pineapple – You often work with the Quality Improvement team.

Cherry – You attend the M & M meetings.

Grape – You are a clinical librarian.

There are several other lifesaver flavors, and many other library-related activities that contribute to the safety of hospital patients. Can you think of others that you are involved with? What flavor are YOU?

Share your contributions with your colleagues! Contact Barb Jones (jonesbarb @health.missouri.edu or @BarbJones17) to tell your story. Or comment right here on this blog!