Thoughts from a Time Out observer

Aaron Oswald, a premedical student from Cornell University and student in the Urban Semester program during Summer 2012, wrote the following narrative about his observations of Time Outs at Woodhull:

Regardless of official policies and guidelines, the tacit culture in the hospital remains the strongest force in determining whether Time Outs will be conducted. These understandings exist within a strong hierarchy, and thus are determined primarily by physicians. With or without an attending physician, team members often don’t feel comfortable acting contrary to the status quo, even if that means following official policies.

The Time Out Project provides premedical and medical students the opportunity to educate staff about Time Outs in a non-threatening way. By pitching a research study that promises not to judge individuals, I was able to persuade staff to think about their success with safety measures. Regardless, a student observer advocating for Time Outs is put in an awkward position, where he or she must play both bureaucratic and scholarly roles. Premedical and medical students generally take only scholarly roles, discussing but never openly challenging providers. Therefore, an instant baseline of tension develops when providers realize their student is observing and advocating for Time Outs. Yet, when the study is appropriately communicated to staff, they often respond positively, and are willing to work with students to incorporate Time Outs into their practice.

Aaron makes a couple very good points, about Time Out and what really determines whether these checklists are done. Last year, the Washington Post reported that despite the evidence base on the efficacy of Time Out, e.g. surgical safety checklists, to prevent error, there has been virtually no improvement in wrong-site surgeries, and the Joint Commission states that based on state data, the rate of wrong-site surgeries is 40 a week (June 2011). Mark Chassin, a former New York state health commissioner and since 2008 president of the Joint Commission, said he thinks such errors are growing in part because of increased time pressures, and involves changing the culture of hospitals and getting doctors to follow standardized procedures and work in teams. Doctors typically prize their autonomy, resist checklists and underestimate their propensity for error.

Aaron also addresses the unique role of students in this project. I believe that students are an underutilized resource in hospitals, and in the Time Out project we place them in a challenging situation; yet these students, future leaders in quality, have performed beautifully in spite of the challenges! As a result, we have about 80 observations of Time Out, and an ongoing dialogue that has been created and will expand, beginning with these observations in the clinical setting.

The Time Out project aims to create culture change, which includes learning how to implement Time Out effectively. This includes an acknowledgement of how things are done now – through observations of Time Out in the current environment – and then testing out strategies. Thus, we are rolling out two types of Time Out trainings – video and simulation – in the clinical setting. These trainings are designed to be quick and on-the-spot. We have just trained a new class of Cornell Urban Semester students this week to be observers.

And we look forward to training our next class of awesome St. George’s University medical students in this work as well! These medical students are veterans, since they — and their previous classes of peers — have been observing Time Out at Woodhull, one class after another, since February 2010.

Looking forward to seeing what this year’s observations and training will bring.

Healthcare: Shifting the Culture to Prevent Medical Error. The Time Out Project at Woodhull Hospital

Can researchers be part of culture change?
Researchers can – by just observing. (Hawthorne effect, yes, may as well work with it…)

Researchers don’t focus enough on how to put things into practice.
-Caroline Clancy, opening remarks at AHRQ Conference 2012.

We need disruptive innovation in tools – they should drive quality up, take cost down. -Reed Tuckson, closing remarks at AHRQ Conference 2012

Time Outs, e.g., safety checklists, are a simple, free tool to ensure safety, an innovation supported by Atul Gawande and Haynes’ WHO research study that reduces deaths due to error by 50%, complications by 30% (NEJM 2009).

The Time Out Project at Woodhull Hospital in Brooklyn, NY,, which I developed and initiated with Woodhull Medical Director Dr. Edward Fishkin, with the support of Dr. David Nash at Jefferson School of Population Health, AMSA, and the Patient Safety and Quality Leadership Institute led by Marina Zeltser, Boris Rosenfeld and myself, is about how to put safety checklists into practice, effectively.

The project includes the following work that addresses individual, systemic, and education issues so we can shift the culture of safety:

1. An NYU IRB-approved research study designed to understand the successes and failures of the hospital’s implementation and training of Time Outs. We are studying not only how well Time Outs are conducted in the OR, ICU, GI Clinic and ED, but also ways to more effectively train staff (beyond a one-time video viewed at the beginning of the year). We observe staff conducting Time Out using videotaped and written observations. We now have about 60 observations, and plan to gather another 60+ this coming year, incorporating “on-the-spot” video or simulation training.

2. Advocacy projects, such as:

  • The development of a housestaff safety council for residents to communicate with senior management around safety issues. See the below post about the Housestaff Safety Council I worked with Dr Fishkin, Chermain Cross, Senior Associate Director, and Dr. Rafael Hernandez, then PGY-3 / CIR-SEIU-Woodhull president, to launch.
  • Training the Time Out medical and pre-medical student observers to become “quality consultants.” The Time Out Project provides premedical and medical students the opportunity to serve as a resource to staff who request info about how to conduct Time Outs. For the past year, the Time Out observations provide a way to regularly communicate with staff to think about their success with safety measures. While tension may develop when providers realize they are being observed, observers found staff often respond positively when the study is appropriately communicated to staff; and they are willing to work with students to incorporate Time Outs into their practice.

3. Video projects. We are developing a series of training videos that can be viewed before procedures requiring Time Out, for the operating room and the medicine departments, to improve safety and how staff communicate through the Time Out. Here is our first one, for training at grand rounds.

4. Writing projects. Not only will we contribute to the research base on best practices for checklist implementation, but we will also regularly document our journey to positively shift the culture of safety at Woodhull so others can learn from our experience.

This project is all about communication.
We’ve found, so far, that there is a growing awareness of Time Out and how to best conduct them, at Woodhull. Stay tuned, as we will continue to report our learnings.

(above post includes writing from Aaron Oswald, Cornell University Urban Semester Program, Summer 2012 Time Out observer)

The Importance of Culture

The importance of culture in medicine, and education (e.g., School Climate) — Speakers at the 2012 AMSA Patient Safety Symposium* acknowledged that when “reforming the system,” the community, such as an organization seeking to become more excellent in the area of patient safety, for instance, must make substantive shifts in a culture, or even create a new culture. That is, how things get done, and how people think on a day to day basis.

It’s so fundamental, that policy and strategy fade under the power of culture.

Culture eats strategy for breakfast. -Tim McDonald of University of Illinois at Chicago

How is this change accomplished?

Create a culture of safety: Educate the young. Regulate the old.- David Mayer of MedStar Health educatetheyoung.wordpress.com

One way to “educate the young” is through the nurturing and development of leadership at the frontline staff level – the people who really see the issues happening on the ground.

Here is an article about Housestaff Safety Councils, featuring the one I helped start with Chermain Cross and Rafael Hernandez MD at Woodhull Hospital. This began because I had heard about a Housestaff Quality Council started by Peter Fleischut MD at NY Presbyterian, while at AMSA’s Patient Safety and Quality Leadership Institute in 2010. Dr. Fleischut walked us through the first steps. And now, it is really beautiful to see this take off throughout NYC HHC with CIR’s support. http://lnkd.in/xaeEnT

The key thing is incorporating the perspectives of those who see the issues directly, like house staff, e.g. residents, at a hospital so that they have a direct line of communication with senior management. It also gives the committee members multiple opportunities to learn how to communicate with management effectively. Would it not be useful to have committees like this for teachers, for students, for patients, in every health and school system?

Diane Ravitch’s recent post about teacher evaluation system, What If Teacher Evaluation Is Not Broken?, is another manifestation of this tension between individual and systemic failure. It is crucial to provide frontline providers the power and space to provide feedback that effectively advocates for themselves and those they serve, and directly impacts decisions of senior management.

See the sidebar to the right of the article, below, to learn how to start a resident-led Housestaff Safety Council at your institution.

From CIR-SEIU Vitals newsletter, Summer 2012.

*2012 AMSA (American Medical Student Association) Patient Safety Symposium, 9/7/12 to 9/8/12organized with David Nash at Jefferson School of Population Health, and funded by AHRQ.