Team Strategies and Tools to Enhance Performance and Patient Safety Quality Improvement Leaders January 26, 2015 Show of hands who has had TeamSTEPPS training in the past – show of hands who has heard of it or work with clinical teams that you know have had this training?

Goals of presentation Become familiar with the use teamwork fundamentals and tools of TeamSTEPPS Provide a practice environment for teamwork improvement in your core teams Provide a practice environment and strategies for improving teamwork between QI teams and departments Define what a core team is – also a contingency team – and what we mean between teams.

Survey Results Overall I’m satisfied with my knowledge of teamwork tools and strategies & when to use them WITHIN my QI workgroup/department. We work well as a team WITHIN my QI workgroup/department. We have opportunities to improve the level of teamwork WITHIN my QI workgroup/department. We have opportunities to improve the level of teamwork ACROSS QI workgroups/departments. We demonstrate good teamwork ACROSS QI workgroups/departments. What is important to you? Summarize comments good and bad Graphic rep of first question discuss

Survey Results Please share a successful teamwork example and the tools/techniques that were employed Please share an example of a time in which your team didn't work so well together and what opportunities you saw for improvement Examples of stressful times where mutual support “pulling together to support each other” Meeting quality goals and celebrating that success Examples for opportunities – themes of duplicated efforts in a team and poor communication leading to wasted time and effort Need for better teamwork between QI teams due to duplicated efforts and not sharing information

Fundamentals Leadership Situation Awareness Mutual Support Communication

Why Errors Occur Workload fluctuations Excessive professional courtesy Interruptions Fatigue Multi-tasking Failure to follow up Poor handoffs Ineffective communication Not following protocol Excessive professional courtesy Halo effect Passenger syndrome Hidden agenda Complacency High-risk phase Strength of an idea Task (target) fixation Consider how these things impact your areas and teams– distractions, a rushed Friday like you mentioned before, complacency, “going through the motions” etc.

Research in OR teamwork Research in OR teamwork. Multiple AHRQ and IOM reports have isolated Teamwork and unnecessary variations in care practices as the root for a majority of adverse events and medical errors. 2006 study Makary et al

The 74 facilities in the training program experienced an 18% reduction in annual mortality (rate ratio [RR], 0.82; 95% confidence interval [CI], 0.76-0.91; P = .01) compared with a 7% decrease among the 34 facilities that had not yet undergone training (RR, 0.93; 95% CI, 0.80-1.06; P=.59). The risk-adjusted mortality rates at baseline were 17 per 1000 procedures per year for the trained facilities and 15 per 1000 procedures per year for the nontrained facilities. At the end of the study, the rates were 14 per 1000 procedures per year for both groups. Propensity matching of the trained and nontrained groups demonstrated that the decline in the risk-adjusted surgical mortality rate was about 50% greater in the training group (RR,1.49; 95% CI, 1.10-2.07; P = .01) than in the nontraining group. A dose-response relationship for additional quarters of the training program was also demonstrated: for every quarter of the training program, a reduction of 0.5 deaths per 1000 procedures occurred (95% CI, 0.2-1.0; P=.001). JAMA, October 20, 2010—Vol 304, No. 15

"What we need to do is learn to work in the system, by which I mean that everybody, every team, every platform, every division, every component is there not for individual competitive profit or recognition, but for contribution to the system as a whole on a win-win basis." Even our leader knew the important of teamwork W. Edward Deming

5 Dysfunctions of a Team Patrick Lencioni Teamwork is studied in all areas of success and failure

Video beyond the checklist – covers Crew Resource Management in aviation and applicability to healthcare – start video at 2:51 to end

Leadership

Effective Team Leaders Organize the team Articulate clear goals Make decisions through collective input of members Empower members to speak up and challenge, when appropriate Skillful at conflict resolution

Anyone can request a brief, huddle, or debrief Team Events Briefs – planning Huddles – problem solving Debriefs – process improvement Leaders are responsible to assemble the team and facilitate team events But remember… Anyone can request a brief, huddle, or debrief 14 14

Brief During the brief, the team should address the following questions: Who is on the team?  Do all members understand and agree upon goals?  Are roles and responsibilities understood?  What is our plan?  What is staff's availability?  How is workload shared among team members?  What resources are available? Go over concept Show video of a medical team brief Discuss how you (presenter) might use a brief in non-clinical area? Or at the beginning of the day – beginning of the week, etc

Huddle Problem solving Hold ad hoc, “touch-base” meetings to regain situation awareness Discuss critical issues and emerging events Concept Video Non clinical examples with audience

Debriefs Debriefs should be conducted for the following reasons: So team collectively learns from actual situations So teams can improve performance Valuable time to reinforce and recognize good teamwork behavior

What can we do better next time? Debriefs What went well? What didn’t go so well? What can we do better next time? SAY: Debriefs include: • Accurate recounting and documentation of key events • Analysis of why the event occurred, what worked, and what did not work • Discussion of lessons learned and how they will alter the plan next time • Establishment of a method to formally change the existing plan to incorporate lessons learned Debriefs are most effective when conducted in an environment where honest mistakes are viewed as learning opportunities. Debriefs also maintain effectiveness by not assigning blame or failure to an individual. Think of the last high stress situation you were in. What if the team had taken 5 minutes to use this debrief guide?

Practice in small groups THINK OF AN SCENARIO FOR QI ATTENDEES – PERHAPS A PROJECT MEETING OR SOMETHING THAT NEEDS A DEBRIEF – HAVE THEM BREAK INTO GROUPS TO PRACTICE A DEBRIEF

Situation Monitoring

Situation Monitoring Process Awareness (Individual Outcome) Shared Mental Models (Team Outcome) Monitoring (Skill) 1. 2. 3.

Situation Monitoring Cross Monitoring I’M SAFE – ask for assistance – “watch my back” Video example cross monitoring

How to Foster a Shared Mental Model Routinely update others Acknowledge deviations or changes in the situation Alert team to actual or potential problems Verbalize a course of action Request needed information when uncertain Examples for these – QI team members giving routine updates. Team member giving heads up regarding possible problems with buy-in, ask for feedback

Discuss use in our areas Case scenario

Communication importance of a common language – communicate and get it right the first time 

Check Back Loop Communication Receiver accepts the message and provides feedback confirmation Closed Sender verifies that the message was received A check-back is a closed-loop communication strategy used to verify and validate information exchanged. Example: med requested, med and dose repeated back, repeat back correct confirmed (strong aviation connection here, all air traffic control instructions to pilots are communicated this way.) Examples? Repeat back to ensure you both have the same information. Another example is on rounds – talk about doing something and come back later in the day and it was not done – it was not clear who was to do it and there were no check-backs regarding this. Sender initiates the message

Callout A strategy used to communicate important information. It informs all team members simultaneously It helps team members anticipate next steps In your work situations, what information would you want called out?

SBAR-Q Situation Background Assessment Recommendations Questions? Non-clinical examples

Critical Language (“CUS”) Concerned (I’m concerned about …) Uncomfortable (I’m uncomfortable proceeding without…) Safety (I don’t think it’s safe to…)

Mutual Support

Mutual Support Protects team members from work overload situations Help your fellow teammates by offering assistance Task Assistance Feedback Advocacy and Assertion

DESC Script D—Describe the specific situation or behavior; provide concrete data. E—Express how the situation makes you feel/what your concerns are. S—Suggest other alternatives and seek agreement. C—Consequences should be stated in terms of impact on established team goals; strive for consensus.

Two Challenge Rule When an initial assertive statement is ignored: It is your responsibility to assertively voice concern at least two times to ensure that it has been heard. The team member being challenged must acknowledge that concern has been heard. If the safety issue still hasn't been addressed: Take a stronger course of action. Utilize supervisor or chain of command.

Goals of presentation Become familiar with the use teamwork fundamentals and tools of TeamSTEPPS Provide a practice environment for teamwork improvement in your core teams Provide a practice environment and strategies for improving teamwork between QI teams and departments Break into groups to brainstorm things that can be done to improve work in and between groups – examples might be using CUS or calling a huddle for duplicated efforts and planning, agreeing to use check backs, etc. go back to large group and report out and have large group discussions. Agree to try some things out but we will not be tracking or holding them to it. Just discussing tools and agreeing to try them out and respect others efforts when the tools are used.