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Contents

1. What Are Problem Solving and Escalation?
2. What Is a Problem and What Is a Solution?
3. Where Are Problems Identified?
4. Problem Triage: More on Different Types of Problems
5. Applying the Model for Improvement To Advance Problem Solving
6. What About Immediate Problems That May Compromise Patient Safety?
7. Plan-Do-Study-Act “Ramp”: Learn To Use an Escalation Procedure for Urgent Issues
Example: CUS Contact Person On-Call Response to an Escalated Urgent Concern
8. Learn More About CUS
9. Additional Reference Tools To Support Problem Solving and Escalation

1. What Are Problem Solving and Escalation?

Effective systems to support safety standard work depend on the existence of well-understood and widely used problem solving and escalation protocols. Staff must know how to solve problems noted in daily huddles and other venues (problem solving), and they must be able to distinguish the severity of a given problem and respond appropriately (escalation). Without these key capabilities in place, other practices—from huddles to visual management to observation—fail to have much of an impact.

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2. What Is a Problem and What Is a Solution?

A problem is an undesirable gap between an expected state and the actual state of a system. A solution closes the gap between the undesirable state and the expected state (Table 1).

Consider two broad types of solutions you might encounter in your daily work. Type 1 solutions close the immediate gap. Type 2 solutions prevent the problem from recurring in the future. Type 2 solutions often require dedicated time for in-depth study of the problem, hypothesis testing, and data collection. Table 1 includes additional discussion of the difference between Type 1 and Type 2 solutions.

Table 1. Distinguishing Problems and Solutions, and Types of Solutions

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3. Where Are Problems Identified?

Daily huddles serve as a major forum to identify problems. As part of the standard huddle agenda, staff raise safety concerns from the previous day, anticipate issues for patients on the current day, and also raise any other issues. Supervisors have an opportunity to consider whether issues raised count as type 1 or type 2 problems and take action accordingly.

Observation of safety standard work, such as during observation of the surgical safety checklist use using the checklist observation tool provided by the ������ƵSafety Program for Ambulatory Surgery, also offers an opportunity to identify problems, such as inconsistent use of timeouts.

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4. Problem Triage: More on Different Types of Problems

The frontline manager and frontline staff must be able to distinguish between type 1 and type 2 problems. The following flow diagram (Figure 1) and description can help.

Figure 1. Problem Triage

Imagine that a staff member identifies a problem. Some problems will require immediate management attention, such as problems that compromise the safety of patients. Staff can use tools such as SBAR (Situation, Background, Assessment, Recommendation)¹ to describe the problem to the next-level manager and recommend a course of action.

Many problems will not require immediate management attention. Staff and frontline leaders will have to then consider how best to address the problem. The flowchart distinguishes four types of such problems:

• Compliance with existing protocol: These problems represent relatively simple departures from clear, well-understood clinical protocols and workflows. They can be addressed through reminders of protocol and often do not require complex problem-solving methods.
• “Just do it”:  These problems do not represent clear departures from protocol, but have simple solutions. For example, a staff member might need to restock a supply or adjust the schedule. Protocols do not exist because the workflow here is fairly straightforward.
• Issue symptomatic of a larger problem: In some cases, it will be clear that the problem is symptomatic of a larger issue. For example, staff may point out that a particular medication is chronically understocked. Such a problem will require deeper analysis to understand the root problems and the problem may require several solutions.
• Problem requiring larger cross-department initiatives: Some problems will require cross-unit collaboration. For example, some problems with patient satisfaction will touch every department in the center. Such issues will often require dedicated, cross-functional quality improvement initiatives.

“Compliance” and “just do it” problems typically represent type 1 problems. The second two types described above are type 2 problems.

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5. Applying the Model for Improvement To Advance Problem Solving

You can introduce Plan-Do-Study-Act (PDSA) cycles, described in Module 1, to improve problem solving in your facility. Your goal will be to reduce recurring problems and coach staff in how to distinguish between different problems. For example, you may structure a PDSA to review all problems identified in a given week and to categorize each problem as type 1 or type 2, as well as in one of the four categories explained above if the problem did not require immediate escalation to higher level managers. 

This categorization will help you surface additional gaps in how you understand, chronicle and solve problems, surfacing additional areas for PDSA cycles and improvement.

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6. What About Immediate Problems That May Compromise Patient Safety?

The ������ƵSafety Program for Ambulatory Surgery has provided tools to help frontline staff address issues that arise in the course of clinical work that may compromise patient safety.

In particular, the CUS (“Concern-Uncomfortable-Safety Issue”) method serves as a communication framework to flag problems that arise (Figure 2). If your organization has adopted the surgical safety checklist advanced by the ������ƵSafety Program for Ambulatory Surgery and has tested and adapted the surgical safety checklist, and if you teach staff and physicians to speak up using the CUS language, you have a powerful combination that can reduce patient harm.² Figure 3 demonstrates what it means to apply CUS in clinical care.

Figure 2. ������ƵCUS Pocket Card

Figure 3. CUS in Action

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7. Plan-Do-Study-Act “Ramp”: Learn To Use an Escalation Procedure for Urgent Issues

You can also apply PDSA thinking to improve the integration of CUS thinking into your work. The PDSA cycles below (Table 2) will help you think about how you can hardwire CUS and also structure improved followup to any CUS events. Figure 4 reminds you that many improvement projects involve a series of PDSA cycles.

Figure 4. PDSA Ramp

Table 2. PDSA Cycles To Try

Table 3: Example CUS Contact Person On-Call Response to an Escalated Urgent Concern

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8. Learn More About CUS

Speaking Up Training Kit

CUS Pocket Card: This card should be customized and distributed to staff and physicians as a reference for how to use structured language. We recommend laminating the card.

CUS Scenarios for Role Playing: This sheet contains multiple scripts using the TeamSTEPPS® concept called CUS for individuals to use. We recommend that each breakout group practice role-playing the CUS scenarios multiple times.

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9. Additional Reference Tools To Support Problem Solving and Escalation

Reporting Your Concern:  SBAR Structure

Adapted by clinicians at Kaiser Permanente from a U.S. Navy method, SBAR (Situation, Background, Assessment, and Recommendation) is an effective and efficient way to communicate important information. SBAR offers a simple way to help standardize communication and allows parties to have common expectations related to what is to be communicated and how the communication is structured:

S=Situation (a concise statement of the problem)
B=Background (pertinent and brief information related to the situation)
A=Assessment (analysis and considerations of options — what you found/think)
R=Recommendation (action requested/recommended — what you want)

AHRQ’s TeamSTEPPS educational materials include coverage of SBAR in greater detail. See, for example: http:/ /www.ahrq.gov/ teamstepps/instructor/fundamentals/module3/slcommunication.html.

Analogy to Clinical Escalation

Escalation for safety issues is like the challenge of escalating clinical care for a patient who needs clinical “rescue.” The barriers to escalation in clinical rescue are the same as the barriers you face in escalating a safety concern:

• Missing or unclear escalation protocols.
• Inability to identify the appropriate point of escalation.
• Availability of senior staff to address the issues
• Fear of negative response
• Insufficient tools and methods for communication

¹ Kaiser Permanente. . Institute for Healthcare Improvement. Accessed February 28, 2016.
² AHRQ. CUS pocket card. In Pocket Guide: TeamSTEPPS. Accessed August 30, 2016.