1. Teamwork in Medicine Elizabeth Harlow, MD Division of Geriatrics The University of Nebraska Medical Center

2. T EAM STEPPS 05.2 Mod 1 05.2 Page 4 Page 4 Primary Care Team ® “Initiative based on evidence derived from team performance…leveraging more than 25 years of research in military, aviation, nuclear power, business and industry…to acquire team competencies” Team Strategies & Tools to Enhance Performance & Patient Safety ®

3. T EAM STEPPS 05.2 Mod 1 05.2 Page 5 Page 5 Primary Care Team ® TeamSTEPPS Skills

4. T EAM STEPPS 05.2 Mod 1 05.2 Page 6 Page 6 Primary Care Team ® Does TeamSTEPPS Work? Clinical Outcomes 50% reduction in the Weighted Adverse Outcome Score (WAOS), which describes the adverse event score per delivery 50% decrease in the Severity Index, which measures the average severity of each delivery with an adverse event* Reduced rate of adverse drug events Improved medication reconciliation at patient admission † * Mann S, Marcus R, Sachs B. Grand Rounds: Lessons from the cockpit: how team training can reduce errors on L&D. Contemp OB/Gyn 2006 Jan;51:34-45. † Haig K, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf 2006 Mar;32(3):167-75.

5. T EAM STEPPS 05.2 Mod 1 05.2 Page 7 Page 7 Primary Care Team ® Does TeamSTEPPS Work? Teamwork Outcomes Significant improvement in communication and supportive behavior Significant posttraining increases in perceptions of teamwork* Reductions in turnover rate Increases in employee satisfaction † * Weaver, SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf 2010 Mar;36(3):133-42. † Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13 Suppl 1:85-90.

6. T EAM STEPPS 05.2 Mod 1 05.2 Page 8 Page 8 Primary Care Team ® Objectives Understand benefits of leadership activities: brief, huddle, debrief Understand how situation monitoring aids in the function of a team Learn how to mutually support team members through feedback and conflict resolution techniques Learn methods of communication for higher functioning, efficient teamwork

7. T EAM STEPPS 05.2 Mod 1 05.2 Page 9 Page 9 Primary Care Team ® Primary Care Office Environment

8. T EAM STEPPS 05.2 Mod 1 05.2 Page 10 Page 10 Primary Care Team ® Primary Care Office Environment Duck-like Chaos – calm appearing above the water while chaos churns below Primary Care Medical Office Does not conform to a pattern of work Has many components working together on multiple tasks simultaneously Treats numerous patients simultaneously

9. T EAM STEPPS 05.2 Mod 1 05.2 Page 11 Page 11 Primary Care Team ® Why Does Teamwork Matter in Primary Care Offices? Better continuity of care, access to care, and patient satisfaction* Higher patient-perceived quality of care † Superior care for diabetes patients ‡ * Stevenson K, Baker R, Farooqi A, et al. Features of primary health care teams associated with successful quality improvement of diabetes care. Fam Pract 2001;18:21-26. † Campbell SM, Hann M, Hacker J, et al. Identifying predictors of high-quality care in English general practice: observational study. BMJ 2001;323:1-6. ‡ Bower P, Campbell S, Bojke C, et al. Team structure, team climate, and the quality of care in primary care: an observational study. Qual Saf Health Care 2003;12:273-9.

10. T EAM STEPPS 05.2 Mod 1 05.2 Page 12 Page 12 Primary Care Team ® Primary Care Team Structure

11. T EAM STEPPS 05.2 Mod 1 05.2 Page 13 Page 13 Primary Care Team ® Teamwork & the Primary Care Team The Primary Care Team has all these obstacles to effective care:

12. T EAM STEPPS 05.2 Mod 1 05.2 Page 14 Page 14 Primary Care Team ® Case Example You are the resident in a multi-provider, one-staff run clinic. Your schedule today is fully booked, and a walk-in has been added. Your 2 nd patient of the day is Mr. B, an 83 yo male with HF, COPD, DM presenting with acute SOB. He has a low grade temp of 99.9, tachypnea (RR of 22), and oxygen saturation of 88% at rest, 82% while walking to the exam room (also visibly SOB). He has had a productive cough x2 weeks. You want lab and CXR to make further decisions regarding possible admission. Staff is unavailable for opinion (in another patient room), 2 patients are waiting. Your pager goes off for an inpatient issue.

13. T EAM STEPPS 05.2 Mod 1 05.2 Page 15 Page 15 Primary Care Team ® Part 1: Leadership Leadership is a process of motivating people to work together collaboratively to accomplish tasks Shared leadership Characteristics of effective leadership: Role modeling and shaping teamwork through open sharing of information Constructive and timely feedback Facilitation of briefs, huddles, debriefs, and conflict resolution

14. T EAM STEPPS 05.2 Mod 1 05.2 Page 16 Page 16 Primary Care Team ® Leadership Strategies 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

15. T EAM STEPPS 05.2 Mod 1 05.2 Page 17 Page 17 Primary Care Team ® Briefs Planning Form the team Designate team roles and responsibilities Establish climate and goals Engage team in short- and long-term planning

16. T EAM STEPPS 05.2 Mod 1 05.2 Page 18 Page 18 Primary Care Team ® Briefing Checklist TOPIC Who is on your team today? All members understand and agree upon goals? Roles and responsibilities understood? Staff availability? Workload? Available resources? Review of the day’s patients?

17. T EAM STEPPS 05.2 Mod 1 05.2 Page 19 Page 19 Primary Care Team ® Sample Brief: review of patients by physician 1:00 – Ms. A - f/u for DM, will need lab 1:30 – Mr. B – acute visit for SOB, complicated med hx, may need lab, CXR, possible admission 2:00 – Mr. C – hosp f/u after CHF exacerbation 2:30 – Ms. D – annual exam, will need lab, prep for pelvic 3:30 – Mr. E – f/u depression 4:00 – Ms. F – f/u for lab and imaging results And just so the team is aware, I am juggling a very sick pt at the hospital, so will likely be paged

18. T EAM STEPPS 05.2 Mod 1 05.2 Page 20 Page 20 Primary Care Team ® Huddle Problem Solving Hold ad hoc, “touch-base” meetings to regain situation awareness Discuss critical issues and emerging events Anticipate outcomes and likely contingencies Assign resources Express concerns

19. T EAM STEPPS 05.2 Mod 1 05.2 Page 21 Page 21 Primary Care Team ® Sample Huddle After seeing Mr. B you gather with your nursing staff to discuss what is going on. I need a chest X-ray to further evaluate if this patient needs to be admitted. If it shows an infiltrate, I will call the admitting team but I need help to call the beds desk and arrange for his transfer

20. T EAM STEPPS 05.2 Mod 1 05.2 Page 22 Page 22 Primary Care Team ® Debrief Process Improvement Very quick, informal information exchange and feedback sessions Occur after an event or shift Designed to improve teamwork skills Designed to improve outcomes An accurate reconstruction of key events Analysis of what worked or did not work and why What should be done differently next time Recognize good team contributions or catches

21. T EAM STEPPS 05.2 Mod 1 05.2 Page 23 Page 23 Primary Care Team ® Debrief Checklist TOPIC Communication clear? Situation awareness maintained? Workload distribution? Did we ask for or offer assistance? Were errors made or avoided? What went well, what should change, what can improve?

22. T EAM STEPPS 05.2 Mod 1 05.2 Page 24 Page 24 Primary Care Team ® Debrief Sample Discussion between resident, staff physician, and nursing staff working as a team in the days clinic How did the schedule get so far behind? Anything that could be done differently in the future to help share the workload? Recognition and appreciation of the work that was done to help

23. T EAM STEPPS 05.2 Mod 1 05.2 Page 25Page 25 RRS Part 1 Questions What could the attending in the scenario have done as clinic was starting, to improve your predicament?: brief, huddle debrief? What could you have done as you were falling behind: brief, huddle, debrief? What strategy would be helpful to avoid this situation in the future? Brief, huddle, debrief?

24. T EAM STEPPS 05.2 Mod 1 05.2 Page 26Page 26 RRS Part 1 Questions What could the attending in the scenario have done as clinic was starting, to improve your predicament?: brief, huddle debrief? What could you have done as you were falling behind: brief, huddle, debrief? What strategy would be helpful to avoid this situation in the future? Brief, huddle, debrief?

25. T EAM STEPPS 05.2 Mod 1 05.2 Page 27 Page 27 Primary Care Team ® Leadership BARRIERS Hierarchical Culture Lack of Resources or Information Ineffective Communication Conflict 27 OUTCOMES Shared Mental Model Adaptability Team Orientation Mutual Trust TOOLS and STRATEGIES Brief Huddle Debrief

26. T EAM STEPPS 05.2 Mod 1 05.2 Page 28 Page 28 Primary Care Team ® Case Part 2 After seeing Mr. B and returning your page you now have 3 patients waiting. You see your hospital f/u who is fortunately doing quite well. You reconcile his medications, ensure he has the needed HHC services, remind him to weigh daily and send him home. When you come out of the room, you learn that the X-ray tech called in sick this am so no X-ray has been done. You decide to go ahead an admit Mr. B given his hypoxia. As you are on the phone with the admitting team, one of your co-residents waves good-bye as (s)he heads home (his/her schedule was light and the last patient no-showed). You overhear someone discussing a med order for a patient that you know from the hospital. You are pretty sure that the dose being described is way too high, but you wonder if you should take time to say anything given you are so far behind. When you finally get to your walk-in patient you note that they have been waiting for 2 hours for a “cold” but he is actually having shaking chills and appears septic. No temperature was checked.

27. T EAM STEPPS 05.2 Mod 1 05.2 Page 29 Page 29 Primary Care Team ® Situation Monitoring Process of actively scanning behaviors and actions to assess elements of the situation or environment Fosters mutual respect and team accountability Provides safety net for team and patient Includes cross-monitoring …Remember, engage the patient whenever possible.

28. T EAM STEPPS 05.2 Mod 1 05.2 Page 30 Page 30 Primary Care Team ® Situation Monitoring Examples Nursing triage assessment of the walk-in patient‘s condition (acute respiratory illness) Temperature taken upon arrival Noting and reporting malfunctioning equipment

29. T EAM STEPPS 05.2 Mod 1 05.2 Page 31 Page 31 Primary Care Team ® Cross-Monitoring is… A process of monitoring unfolding actions against the established plan of care to avoid errors Helps maintain accurate situation awareness Way of “watching each other’s back” Gives team members a way to monitor patient care and give constructive feedback Mutual performance monitoring has been shown to be an important team competency. (McIntyre and Salas, 1995)

30. T EAM STEPPS 05.2 Mod 1 05.2 Page 32 Page 32 Primary Care Team ® Cross Monitoring Awareness of workload spikes and stress levels among team members Willingness of the resident who was done early to help when needed Freedom to speak up when concerned for errors/unsafe behaviors MA mentioning her concern for ill-appearing patient not being seen in the exam room. Your willingness to take time to stop a possible med error overheard in clinic.

31. T EAM STEPPS 05.2 Mod 1 05.2 Page 33 Page 33 Primary Care Team ® Components of Situation Monitoring:

32. T EAM STEPPS 05.2 Mod 1 05.2 Page 34 Page 34 Primary Care Team ® Situation Monitoring BARRIERS Hierarchical Culture Lack of Resources or Information Ineffective Communication Conflict Time Distractions Workload Fatigue Misinterpretation of Data Failure To Share Information 34 TOOLS and STRATEGIES Brief Huddle Debrief STEP Cross- Monitoring OUTCOMES Situation Awareness Shared Mental Model Adaptability Team Orientation Mutual Trust

33. T EAM STEPPS 05.2 Mod 1 05.2 Page 35 Page 35 Primary Care Team ® Mutual Support Mutual support is the essence of teamwork: It includes the ability to anticipate the needs of other team members through knowledge of their tasks and responsibilities It protects team members from work overload situations that may reduce effectiveness and increase the risk of error

34. T EAM STEPPS 05.2 Mod 1 05.2 Page 36 Page 36 Primary Care Team ® Task Assistance Team members foster a climate in which it is expected that assistance will be actively sought and offered as a method for reducing the occurrence of error. “In support of patient safety, it’s expected!”

35. T EAM STEPPS 05.2 Mod 1 05.2 Page 37 Page 37 Primary Care Team ® What Is Feedback? “Feedback is the giving, seeking, and receiving of performance- related information among the members of a team.” (Dickinson and McIntyre, 1997)

36. T EAM STEPPS 05.2 Mod 1 05.2 Page 38 Page 38 Primary Care Team ® Types of Feedback Can be formal or informal Constructive feedback Is considerate and task specific and focuses attention on performance and away from the individual* Is provided by all team members Evaluative feedback Helps the individual by comparing behavior to standards or to the individual’s own past performance † Most often used by an individual in a coaching or mentoring role * Baron RA. Negative effects of destructive criticism: impact on conflict, self-efficacy, and task performance. J Appl Psychol 1988 May;73(2):199-207. † London M, Larson H, Thisted L. Relationships between feedback and self-development. Group Org Manage 1999;24(1):5-27.

37. T EAM STEPPS 05.2 Mod 1 05.2 Page 39 Page 39 Primary Care Team ® Advocacy and Assertion Advocate for the patient Invoked when team members’ viewpoints don’t coincide with that of a decision maker Assert a corrective action in a firm and respectful manner

38. T EAM STEPPS 05.2 Mod 1 05.2 Page 40 Page 40 Primary Care Team ® Characteristics of Effective Feedback Good Feedback is— TIMELY RESPECTFUL SPECIFIC DIRECTED toward improvement Helps prevent the same problem from occurring in the future CONSIDERATE “Feedback is where the learning occurs.”

39. T EAM STEPPS 05.2 Mod 1 05.2 Page 41 Page 41 Primary Care Team ® The Assertive Statement Respect and support authority Clearly assert concerns and suggestions Use an assertive statement (nonthreatening and ensures that critical information is addressed) Make an opening State your concern Explain the problem Offer a solution Reach an agreement

40. T EAM STEPPS 05.2 Mod 1 05.2 Page 42 Page 42 Primary Care Team ® Conflict Resolution Options Information Conflict (We have different information!) Two-Challenge rule Personal Conflict (Hostile and harassing behavior) DESC script

41. T EAM STEPPS 05.2 Mod 1 05.2 Page 43 Page 43 Primary Care Team ® Two-Challenge Rule 1 2

42. T EAM STEPPS 05.2 Mod 1 05.2 Page 44 Page 44 Primary Care Team ® Two-Challenge Rule Invoked when an initial assertion is ignored… It is your responsibility to assertively voice your concern at least two times to ensure that it has been heard The member being challenged must acknowledge If the outcome is still not acceptable Take a stronger course of action Use chain of command

43. T EAM STEPPS 05.2 Mod 1 05.2 Page 45 Page 45 Primary Care Team ® Please Use CUS Words but only when appropriate!

44. T EAM STEPPS 05.2 Mod 1 05.2 Page 46 Page 46 Primary Care Team ® Conflict Resolution DESC Script A constructive approach for managing and resolving conflict D —Describe the specific situation E —Express your concerns about the action S —Suggest other alternatives C —Consequences should be stated Ultimately, consensus will be reached.

45. T EAM STEPPS 05.2 Mod 1 05.2 Page 47 Page 47 Primary Care Team ® DESC-It Have timely discussion Frame problem in terms of your own experience Use “I” statements to minimize defensiveness Avoid blaming statements Remember: Critique is not criticism Focus on what is right, not who is right Let’s “DESC-It!”

46. T EAM STEPPS 05.2 Mod 1 05.2 Page 48 Page 48 Primary Care Team ® Ineffective Approaches to Conflict Resolution Often used to manage conflict; however, typically do not result in the best outcome— Compromise—Both parties settle for less Avoidance—Issues are ignored or sidestepped Accommodation—Focus is on preserving relationships Dominance—Conflicts are managed through directives for change

47. T EAM STEPPS 05.2 Mod 1 05.2 Page 49 Page 49 Primary Care Team ® Collaboration Achieves a mutually satisfying solution resulting in the best outcome All Win!: Patient Care Team (team members, the team, and the patient) Includes commitment to a common mission Meets goals without compromising relationships “True collaboration is a process, not an event.”

48. T EAM STEPPS 05.2 Mod 1 05.2 Page 50 Page 50 Primary Care Team ® Front Office Scenario Your clinic has a rule that patients will still be seen if they arrive within a 30-minute window of their appointment. Mr. E arrives 5 minutes past the window and sincerely apologizes for being late. The administrative assistant tells Mr. E that he will simply have to reschedule the appointment for a later time. You overhear this and pull the administrative assistant aside. You agree that Mr.E should be rescheduled according to the clinic’s rules, but you explain that he lives far away and does not drive so he relies on friends and family to transport him to doctor’s visits and that all efforts should be made to see him today. The administrative assistant appreciates this information and the fact that you pulled him aside to tell him. The administrative assistant ensures that Mr. E will be seen today.

49. T EAM STEPPS 05.2 Mod 1 05.2 Page 51 Page 51 Primary Care Team ® Part 2 Questions What strategy would you be using if you stopped to point out the possible med error? situation monitoring, cross monitoring? The fact that a patient went unnoticed while becoming sicker in the exam room is an example that which of the following behaviors was lacking? situation monitoring, cross monitoring? When you point out the concerning behavior you say “I am concerned regarding the dose you recommended for that patient. I am uncomfortable that at that dose, the patient may have an adverse event.” This is an example of : DESC, CUS words, or the two challenge rule?

50. T EAM STEPPS 05.2 Mod 1 05.2 Page 52 Page 52 Primary Care Team ® Part 2 Questions What strategy would you be using if you stopped to point out the possible med error? situation monitoring, cross monitoring? The fact that a patient went unnoticed while becoming sicker in the exam room is an example that which of the following behaviors was lacking? situation monitoring, cross monitoring? When you point out the concerning behavior you say “I am concerned regarding the dose you recommended for that patient. I am uncomfortable that at that dose, the patient may have an adverse event.” This is an example of : DESC, CUS words, or the two challenge rule?

51. T EAM STEPPS 05.2 Mod 1 05.2 Page 53 Page 53 Primary Care Team ® Mutual Support BARRIERS Hierarchical Culture Lack of Resources or Information Ineffective Communication Conflict Time Distractions Workload Fatigue Misinterpretation of Data Failure To Share Information Defensiveness Conventional Thinking 53 TOOLS and STRATEGIES Brief Huddle Debrief STEP Cross-Monitoring Feedback Advocacy and Assertion Two-Challenge Rule CUS DESC Script Collaboration OUTCOMES Shared Mental Model Adaptability Team Orientation Mutual Trust Team Performance Patient Safety!

52. T EAM STEPPS 05.2 Mod 1 05.2 Page 54 Page 54 Primary Care Team ® Part 3: Communication “The process by which information is clearly and accurately exchanged between two or more team members in the prescribed manner and with proper terminology and the ability to clarify or acknowledge the receipt of information.” Cannon-Bowers JA, Tannenbaum SI, Salas E, et al. Defining competencies and establishing team training requirements. In Guzzo RA, Salas E, and associates, eds. Team effectiveness and decision-making in organizations. San Francisco: Jossey-Bass; 1995. p. 333.

53. T EAM STEPPS 05.2 Mod 1 05.2 Page 55Page 55 RRS Communication is… The process by which information is exchanged between individuals, departments, or organizations The lifeline between the patient and any member of the team Effective when it permeates every aspect of an organization Includes: SBAR, patient handoffs, check back, and patient centered communication Assumptions Fatigue Distractions HIPAA Primary Care Team ®

54. T EAM STEPPS 05.2 Mod 1 05.2 Page 56 Page 56 Primary Care Team ® SBAR provides… A framework for team members to effectively communicate information to one another: Situation―What is going on with the patient? Background―What is the clinical background or context? Assessment―What do I think the problem is? Recommendation/Request ―What would I recommend? What do I need from you? SBAR’s adaptability is encouraged – make this work for your team! Remember to introduce yourself…

55. T EAM STEPPS 05.2 Mod 1 05.2 Page 57 Page 57 Primary Care Team ® SBAR for the walk-in, Ms. G Discussion with attending staff: S: Ms. G is having shaking chills and I am concerned for sepsis. B: She is an 88 y o female with recent URI now presenting with cough, fatigue, and shaking chills. Her VS 2 hours ago showed tachypnea (RR 24), tachycardia (HR 100), and hypotension (BP 102/68) A: I am concerned that she may be in the early stages of sepsis. R: I asked for repeat vitals now with a temperature, it is highly likely this patient will need admission.

56. T EAM STEPPS 05.2 Mod 1 05.2 Page 58 Page 58 Primary Care Team ® Handoff The transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify, and confirm

57. T EAM STEPPS 05.2 Mod 1 05.2 Page 59 Page 59 Primary Care Team ® Handoff Optimized Information Responsibility– Accountability Uncertainty Verbal Structure Checklists Acknowledgment Great opportunity for quality and safety

58. T EAM STEPPS 05.2 Mod 1 05.2 Page 60 Page 60 Primary Care Team ® Handoff of Ms. G You call the admitting team while your staff calls the beds desk. After introducing yourself to the new intern, you use SBAR S: I have a sick patient n clinic that I am admitting to your service. B: Ms. G is 88 yo with a 2 week h/o URI symptoms and now has a productive cough. Vitals show fever (100.8), tachypnea, and mild hypotension 98/60. She is not hypoxic. She has mild dementia at baseline, but is accompanied by her daughter.She has a longstanding DNR/DNI. A: I am concerned she has pneumonia with sepsis. R: I recommend evaluation for pneumonia as a possible source and a low threshold for ICU transfer. Q: Any questions?

59. T EAM STEPPS 05.2 Mod 1 05.2 Page 61 Page 61 Primary Care Team ® Check-Back is…

60. T EAM STEPPS 05.2 Mod 1 05.2 Page 62 Page 62 Primary Care Team ® Closed Loop Communication You are paged by a nursing home nurse about one of your patients, who had been complaining of dysuria and increasing incontinence. The nurse reports a positive urine culture ”greater than 100,000 cfu/ml E Coli, it’s sensitive to everything and she has no allergies.” You determine the patient is not taking warfarin and that CrCl is over 50 ml/min You then say, “ Start trimethoprim sulfamethoxazole DS 1 PO BID for 5 days”. The nurse then completes closed loop communication by saying, “OK. That’s trimethoprim sulfa 1 PO BID for 5 days to treat UTI”

61. T EAM STEPPS 05.2 Mod 1 05.2 Page 63 Page 63 Primary Care Team ® Patient- and Family-Centered Care Primary care teams should: Hear the patient’s stories, be open and honest with them, and take action with them Respect the patient and family as the central hub of the care team Make sure patients share fully in decision making Speak to patients in a way they can understand and enable them to feel empowered to be in control of their care

62. T EAM STEPPS 05.2 Mod 1 05.2 Page 64 Page 64 Primary Care Team ® Equipping the Patient Improving health care quality is a team effort. Patients can improve their care and the care of their loved ones by taking an active role in the process. Encourage patients to ask questions, understand their condition, and evaluate their options. The AHRQ Web site “Questions Are the Answer” is a great resource for patients and families on what questions to ask their providers: www.ahrq.gov/questionsaretheanswer/ What is the test for? Questions Your Patients Should Ask When will I get the results? Why do I need this treatment? Are there any alternatives? What are the possible complications? Which hospital is best for my needs? How do you spell the name of that drug? Are there any side effects?

63. T EAM STEPPS 05.2 Mod 1 05.2 Page 65 Page 65 Primary Care Team ® Patient Centered Scenario Mr. C is a 74 yo male returning to clinic for hospital f/u after admission for a heart failure exacerbation. You ask him, “What is your understanding of why you ended up in the hospital?” He replies, “Well, I kind of thought I didn’t need the water pill. I was having to get up every hour at night to pee, so I stopped taking it.” At hospital discharge, he was again prescribed furosemide 40mg BID, so you wonder if he is taking his later dose, which, it turns out, he is not. You and the patient decide to change his 2 nd dose to mid-afternoon to decrease his nocturia. He agrees with this plan and promises to call if it doesn’t seem like it will work for him. He thanks you for asking why he wasn’t taking his furosemide, as no one had asked about this and he hopes he now has a solution.

64. T EAM STEPPS 05.2 Mod 1 05.2 Page 66 Page 66 Primary Care Team ® Barriers to Team Effectiveness 66 TOOLS and STRATEGIES Brief Huddle Debrief STEP Cross-Monitoring Feedback Advocacy and Assertion Two-Challenge Rule CUS DESC Script Collaboration SBAR Check-Back Handoff OUTCOMES Shared Mental Model Adaptability Team Orientation Mutual Trust Team Performance Patient Safety!! 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 Co-Workers Distractions Fatigue Workload Misinterpretation of Cues Lack of Role Clarity

65. T EAM STEPPS 05.2 Mod 1 05.2 Page 67 Page 67 Primary Care Team ® TeamSTEPPS for Primary Care Teams Process for working together in teams for the best patient outcomes Leadership: Briefs, huddles, and debriefs Situation monitoring and mutual support: cross monitoring, feedback, and conflict resolution Communication: SBAR, handoffs, check back Effective teamwork allows for patient-centered care