Pulling It All Together Summary Pulling It All Together “The truth of the matter is that you always know the right thing to do. The hard part is doing it.” –Norman Schwarzkopf

Objective Recall the multiple versions of TeamSTEPPS curricula available and choose appropriate slides and videos to facilitate training. Practice applying team strategies and tools using active learning, case studies, and Team Performance Observation Tool Teach back a tool or strategy Know the plan, share the plan, review the risks Achieve awareness using data AND stories Effective root cause analysis reveals the stories…how organizational systems are or are not designed to mitigate risks that exist when human beings interact in complex systems to care for patients with complex problems. People who work in teams make fewer errors. –IOM (2000). To Err is Human: Building a Safer Health System

Tools & Strategies Summary BARRIERS Inconsistency in Team Membership Lack of Time Lack of Information Sharing Hierarchy Defensiveness Conventional Thinking Complacency Varying Communication Styles Conflict Lack of Coordination and Followup With Coworkers Distractions Fatigue Workload Misinterpretation of Cues Lack of Role Clarity TOOLS and STRATEGIES Communication SBAR Call-Out Check-Back Handoff Leading Teams Brief Huddle Debrief Situation Monitoring STEP I’M SAFE Mutual Support Task Assistance Feedback Assertive Statement Two-Challenge Rule CUS DESC Script OUTCOMES Shared Mental Model Adaptability Team Orientation Mutual Trust Team Performance Patient Safety!!

Summary Each teamwork skill: Facilitates teamwork Leadership Orientation Mutual Performance Monitoring Back-up Behavior Adaptability Shared Mental Models Trust Effectiveness Closed Loop Communication Salas, Sims, Burke. Is there a “Big Five” in teamwork? Small Group Research. 2005; 36:555-599. Big 5 Coord. Mechanism Summary Each teamwork skill: Facilitates teamwork Is dependent upon or moderated by the other skills Contributes to team performance, quality of care, and patient safety

TeamSTEPPS Outcomes Improved team performance (e.g., Weaver, et al., 2010) Improved team processes (e.g., Capella, et al., 2010) Improved patient safety culture (e.g., Thomas & Galla, 2013; Jones KJ, Skinner AM, High R, Reiter-Palmon R. A theory-driven longitudinal evaluation of the impact of team training on safety culture in 24 hospitals. BMJ Quality & Safety; 2013;22:394-404

Constraints Complexity of patients and systems Competing Values & Expectations Limited resources Complexity of patients and systems Behavioral Choices of Fallible Human Beings Desired Outcomes Fundamentally TeamSTEPPS provides healthcare professionals with a range of behavioral choices to achieve desired outcomes in the context of competing values, complex patients, complex systems, and limited resources.

Online Master Trainer Resources Curricula https://www.ahrq.gov/teamstepps/curriculum-materials.html Course Management Guide Video Training Tools Measurement Tools Printable Components Specialty Scenarios TeamSTEPPS 2.0 Basic Curriculum Rapid Response Systems Simulation in TeamSTEPPS Training Patients with Limited English Proficiency Dental TeamSTEPPS for Long Term Care Office Based Care The AHRQ website provides a wide variety of curriculum materials to meet the needs of Master Trainers in various settings. These Curriculum Materials include: TeamSTEPPS 2.0 and Additional Materials Course Management Guide (PDF Version [357.04 KB]) Video Training Tools…click here Measurement Tools Acknowledgments (PDF Version [36.39 KB]) Printable Components Specialty Scenarios

Identifying Opportunities to Use TeamSTEPPS Tools and Strategies 3:26 To review what we’ve learned across the modules, we will watch a video scenario that demonstrates breakdowns in teamwork. Let’s see if you can identify the breakdowns and apply a TeamSTEPPS tool or strategy from the Team Performance Observation tool to remedy them. As you watch the video, make note of any barriers presented and the tools and strategies that could be used to address the barriers. Assign groups to observe for specific behaviors using Team Performance Observation tool. DISCUSSION: What were the barriers presented in this video scenario?  – Lack of information-sharing; lack of coordination; lack of followup; lack of shared mental model  Which of the TeamSTEPPS tools and strategies could have been used, and how would the outcome have been different?  – Debrief after the surgery or a huddle after Mrs. Peters was in the recovery room to ensure the entire care team knew of Dr. Daniel’s concerns.  – Better handoff from recovery to floor nurse  – Followup by the nurse who noticed something in the charts but did not follow up with the doctor to confirm or clarify  – Sharing of test results came back with important information that was not shared with the care team  – Sharing of information by Mrs. Peters to make the care team aware of her changing symptoms Inpatient Surgical Opportunity to apply TeamSTEPPS technique to improve outcome

Effective Use of TeamSTEPPS Tools and Strategies 6:59 Now that we have analyzed the scenario and identified opportunities to use TeamSTEPPS strategies and tools to improve the outcome, let’s watch an example of the same scenario when effective teamwork is displayed. Assign groups to observe for specific behaviors using Team Performance Observation tool. DISCUSSION:  Which TeamSTEPPS strategies and tools were used in this scenario? – Several TeamSTEPPS strategies and tools were used, including:  – SBAR between the physician and the recovery room nurse  – Structured handoff from recovery nurse to floor nurse  – Brief at start of new nursing shift  – Check-back by Mrs. Peters and her daughter of signs and symptoms to monitor  – Check-back to confirm understanding of medication orders and dosing between the physician and pharmacist  How did the use of these TeamSTEPPS tools and strategies affect the course and outcome of the scenario?  – Information was continually shared with the care team, resulting in a shared mental model of Mrs. Peters’ status and plan of care  – Team members appeared aware of their role and responsibilities and ensured that the team leader (the physician) was informed of changes in Mrs. Peters’ status so that she could modify the plan of care  – Mrs. Peters was discharged because the team’s performance ensured patient safety Inpatient Surgical Successful outcome using TeamSTEPPS techniques

Active Learning Goal: You have 3 minutes to build the tallest tower. Roles: Rules: Blocks are located at the front and back of the room. Runners retrieve blocks from bins but may only take 5 blocks at a time. Builders build the tower using the pattern of 1 large, 3 small blocks, repeat. No two blocks of the same color may touch. Runners are not allowed to build/ builders are not allowed to run. Any unused blocks that are not replaced in the storage bins before time is called will be subtracted from the tower height; one block subtracted for each unused block.   Report Out: Height of tower in blocks (minus unused blocks). Create teams of about 6 people. Complete the first iteration of the exercise. The situation has changed as compared to the first experience during the team structure module. Specifically, goals, rules, and resources have changed. Goal: Build the tallest tower you can in 3 minutes. Rules: runners can only take blocks from their assigned bin. Resources: bins contain only one or two colors of blocks. Teams will have to adapt in real time by huddling to develop a plan (e.g. runners must huddle and communicate with runners from other teams to exchange blocks for the colors that each team needs to follow the rules).

Learn from Experience Debrief What went well? What didn’t go well? Each Department/Unit is a Team Your Organization is a Team of Teams Traditional Org. Structure Debrief What went well? What didn’t go well? What will you do differently? Debrief. How quickly did teams establish situational awareness including the fact that assigned bins only had one or two colors? How did runners coordinate to distribute blocks to each team and still follow the rule that you can only take blocks from your assigned bin? Monitoring progress toward the MTS goal requires situation monitoring and mutual support tools as well as closed loop communication within and across teams. Summarize the key points to the larger group. Teams will have the pre-conceived idea that they have already done this activity. They will have to apply what they have learned about huddles to overcome their complacency and re-establish situational awareness, which includes recognizing that assigned bins have limited colors of blocks and that the builders cannot follow the rules unless runners obtain different colored blocks from different teams. When the situation changes, situational leaders can call a huddle to re-establish situational awareness. Roles may need to change to achieve the agreed upon goal (e.g. runners must now coordinate with runners from other teams to share resources).

Applying TeamSTEPPS Exercise 2:30 – 3:15 Discuss your assigned scenario in your team and use your pocket guide, course handouts, or the online instructor guide to identify the barriers to teamwork and the tools that can address the barriers 3:15 – 4:45 Teach Back (5 minutes): State the barriers to team performance/patient safety Identify one tool or strategy chosen to address some aspect of the problem/need and why Teach the tool or strategy using role play or lecture Receive Feedback/Answer Questions (3-4 minutes)

Case Study Assignments Overworked Clinic Employee ANM, API/APR, Fairbanks Implementation Strategy Gone Wrong SEARHC/Mt Edgecumbe1 CAUTI that Didn’t Need to Happen Bartlett Regional1 Concerning Conversation Bristol Bay, ASHNHA Close Call in the ER Cordova, Sitka, Norton Sound Overloaded Behavioral Health Unit SEARHC/Mt Edgecumbe2 Fallen Clinic Patient Bartlett Regional2 Concerned New Hire SEARHC/Mt Edgecumbe3 Mini-Case #1 Peace Health/Wrangell

Summary In the preceding section, we learned that teamwork strategies and tools: Are available to both team members and leaders Can be used to address barriers to team effectiveness in a given situation Are a system of interacting behaviors that improves the ability or individuals and organizations to adapt to complexity and learn from experience

Practice Teaching Session

Summary of Training One shot didactic lectures can not change people’s behavior…we need a plan to transfer learning to behavior Organizations and human beings adopt new behaviors in stages Rogers EM. Diffusion of Innovations. 5th ed. New York: Free Press; 2003.