Download Creating Collaborative Care

Creating Collaborative
Care
Root Cause Analysis of Case:
“A Tooth Gone Bad”
Performed by
Heather Jensen, Spencer Lovelace,
Justin Lowe, Margaret Maclin, and
Poppy Markwell
Observed by
Donna Kern, M.D.
Our Team
College of Dental
Medicine
Margaret Maclin
College of Medicine
Spencer Lovelace
Justin Lowe
Poppy Markwell
College of Nursing
Heather Jensen
Interacting
With Others
The Site:
Medical University Hospital
Charleston, SC
Vision: to become a leading academic health center
MUH is a fully accredited not for profit quaternary care center
- level 1 trauma service
- inpatient 24hr pharmacy
- 16 staff interpreters
providing round the
clock coverage
Task: Train 600 residents and host 51 Graduate Medical
Education training programs and two American Dental
Association training programs
The Case:
Juanita Dorantes
30 year old Hispanic female
Day one:
Presents to the MUSC dental clinic with a toothache
A 4th year surgery student removes the tooth and prescribes antibiotic
Day six:
Presents to ER febrile with chills and edema @ extraction site and is admitted
Day seven:
Dr. Smith notes antibiotic allergy (w/o interpreter)
Lab results show evidence of bacterial infection and antibiotic is ordered
Due to the noted allergy the antibiotic is not administered
Day eight
Dr. Smith examines patient, noting the patient appears pale and is unresponsive w/ a BP of 78/40
Medical emergency response team is called
Day nine and on:
Juanita is unconscious for 7 days and shows signs of cognitive deficit on awakening
She is transferred to the MUSC Transitional Care unit
Lack of Interdisciplinary
Role Awareness &
Communication
Care Availability
on the Weekends
Juanita arrives in ER at 8 am on a Saturday and must
wait 2 hours before being seen
Failure of various health
care professionals to take
responsibility for direct
patient care
Patient is passed from ER to oral surgeon
Antibiotic administration delayed
Lack of quality care and overall inability to treat
Juanita after being in ER for several hours
Central line attempt without
appropriate guidance results in
perforated lung.
Sub-Standard Care
The dental student believed “yes” was
enough of a response to assume that Juanita
clearly understood how and why to take the
antibiotic.
Dr. Smith interviewed
Juanita without a
translator and falsely
recorded that she had an
antibiotic allergy. He did
not clarify the allergy
with the translator.
Student had never placed a
central line and was therefore
not confident in his ability to do
so.
The student did not speak
up for fear of a negative
impact on his grade.
Oscar was not allowed to contact the
doctor directly and the doctor did not
respond to the page.
Patient-Provider
Communication
The resident left the student unattended to
place the central line assuming he was capable
of placing it.
The mentality of “See
One, Do One, Teach One”
found in healthcare
Recommendations: Care Availability on the Weekends
•
Rotating weekend schedule for health care workers to increase the rate of patient
admittance
•
Design a networking system for constant stream of communication between medical facilities
•
Establishing a required health care staff to patient ratio to promote a high quality of patient
care
Recommendation: Shift Away From the “See one, Do One, Teach One” Philosophy.
•The residents should not negate the students apprehension by instilling a possible false sense of
security assuming that everyone is capable of performing a procedure if it has previously been
watched.
• A grading system should be in place that does not penalize students who are unsure of their
skills. Especially regarding never before performed, dangerous procedures. But rather it should
be one that encourages learning and expanding the student’s skills rather than punishing them
for being hesitant or cautious.
• An attending should never leave a student unattended to perform any procedure until the
student has proven that they can perform the task with satisfaction and confidence. This should
be documented for the resident to double check if necessary.
Recommendations: Interdisciplinary Role Awareness and Communication
•
Role Visibility: College coursework regarding knowledge/training of other disciplines to foster
respect and to promote utilization of other’s expertise as a resource.
•
Awareness of the Professional Culture: Exploration of harmful misconceptions of the professional
culture. We can’t change what we don’t acknowledge.
•
Critical Thinking: Quarterly hospital seminars for case study discussions. Example of job well done
to recognize positive clinical decision-making and successful interprofessional collaboration. If the
patient were your loved one, where would you stop?
•
Support System: Written information regarding the institution-specific hierarchy in place. Mentor
programs for new employees.
Problem: Patient-provider communication
Part I. Translator
•
Development of telephone interpretation “on call” services for all languages (Reduces
wait time)
•
Certification of medical interpreters (Quality)
•
Patient activated translator system
•
Patient satisfaction survey
Problem: Patient-provider communication
Part II. Patient education/ response to patient questions
•
•
•
•
•
Teaching communication skills in medical school
– open ended questions
– 5 A’s-- assess, advise, agree, assist, arrange
– Cultural sensitivity
Require physicians to keep record of patient’s understanding of his or her illness and questions
asked/answered
Reimburse physicians for preventative care
Provide relevant patient educational pamphlets and always include medication directions with
prescriptions (not just “take as directed”)
– In patient primary language
– Ex: CDC, UpToDate, etc.
Patient satisfaction survey
1) Appreciation of the value of
team decisions and a positive
regard for teamwork
2) Respect for all
team members
Teamwork
4) Openness to feedback
and improving team
effectiveness
3) Mutual trust
5) Importance of a
shared vision
The Value of an Interprofessional Approach
• Using colleagues as resources
• Creates a relational and caring environment
• More patient advocates with specialized
expertise
• Diverse perspectives for problem solving
• Facilitates critical thinking to maximize
patient care