1. FRIDAY PLENARY SESSION

2. DAY 2 of TeamSTEPPS National Conference 2012

3. T EAM STEPPS 05.2 Mod 1 05.2 Page 3 TeamSTEPPS How This Conference Fits What is needed for successful TeamSTEPPS implementations? Passion for safety and quality care Understanding of teamwork tools & how to equip people to use them Support to overcome challenges and make rapid progress Resources to support implementation efforts and knowledge about how to use them most efficiently How AHRQ is addressing each of these needs

4. T EAM STEPPS 05.2 Mod 1 05.2 Page 4 TeamSTEPPS Passion National Meeting: Next year: same general time, probable location: San Antonio Meeting sponsors Larger venue Call for papers/panels to share your TeamSTEPPS successes Adjustments made based on feedback from this year

5. T EAM STEPPS 05.2 Mod 1 05.2 Page 5 TeamSTEPPS Understanding TeamSTEPPS trainings Expanded number of seats in trainings and locations they’re offered Planning some advance topic trainings Large backlog of interested participants Addressing by: Reallocating resources to offer more trainings Opening up new set of trainings to enroll in by late summer Increased efforts to ensure participants can succeed Coordinate with hospitals, systems, HENS, etc. to pair groups wanting trainings with strong training teams

6. T EAM STEPPS 05.2 Mod 1 05.2 Page 6 TeamSTEPPS Support User Support Network Webinars ListServ/Discussion forum Library of resources http://teamsteppsportal.com/ Resources: TeamSTEPPS materials: http://www.ahrq.gov/teamsteppstools/ http://www.ahrq.gov/teamsteppstools/ TeamSTEPPS mailbox: AHRQTeamSTEPPS@aha.org

7. T EAM STEPPS 05.2 Mod 1 05.2 Page 7 TeamSTEPPS Resources

8. T EAM STEPPS 05.2 Mod 1 05.2 Page 8 TeamSTEPPS Acknowledgments

9. T EAM STEPPS 05.2 Mod 1 05.2 Page 9 TeamSTEPPS Our Organizations

10. T EAM STEPPS 05.2 Mod 1 05.2 Page 10 TeamSTEPPS TeamSTEPPS National Training Centers

11. T EAM STEPPS 05.2 Mod 1 05.2 Page 11 TeamSTEPPS Key People HRET: Chris Hund Ashka Dave Jessica Blake IMPAQ: Andrea Amodeo Booz Allen Hamilton: Melanie Sellers ZeAmma Brathwaite TN Hospital Association

12. The State of TeamSTEPPS: New Modules and Other Available TeamSTEPPS Resources

13. T EAM STEPPS 05.2 Mod 1 05.2 Page 13 TeamSTEPPS Today’s Presenters James Battles, PhD (Social Science Analyst for Patient Safety, AHRQ) Heidi King, Heidi King, MS, FACHE (Deputy Director of the Department of Defense Patient Safety Program Barb Edson, RN, MBA, MHA (Vice President, HRET) Deborah Milne, RN, MPA (Senior Research Scientist American Institutes for Research) Michelle Pandolfi, MSW, LNHA (Director of Counsulting Services, Qualidigm) Melanie Wasserman, PhD (Senior Associate/ Scientist Abt Associates)

14. T EAM STEPPS 05.2 Mod 1 05.2 Page 14 TeamSTEPPS Top 10 for Creating a TeamSTEPPS ® Module 1. It takes a team! 2. Literature review and course design plan 3. Story boards; draft curriculum 4. Identify gaps in content 5. Develop supplemental exercises/activities 6. Field test draft curriculum 7. Develop video vignettes 8. AHRQ review 9. Pilot test with end users 10. Finalize all components 14

15. T EAM STEPPS 05.2 Mod 1 05.2 Page 15 TeamSTEPPS For Release in Fall 2012 New TeamSTEPPS ® Modules Long Term Care Module Primary Care Medical Office Module Limited English Proficiency Module New Toolkit, with TeamSTEPPS integrated Comprehensive Unit-Based Program (CUSP) Toolkit

16. T EAM STEPPS 05.2 Mod 1 05.2 Page 16 TeamSTEPPS TeamSTEPPS ® Sweet 16

17. T EAM STEPPS 05.2 Mod 1 05.2 Page 17 TeamSTEPPS Contact Information Jim Battles James.Battles@ahrq.hhs.gov Heidi King Heidi.King@tma.osd.mil http://teamstepps.ahrq.gov/ http://health.mil/dodpatientsafety/

18. LEP module

19. T EAM STEPPS 05.2 Mod 1 05.2 Page 19 TeamSTEPPS Module on patients with limited English proficiency – why? Large and growing population – 8.6% of U.S. Greater length of stay  greater risks line infections, falls, surgical infection, and more More readmissions So many horror stories One misunderstood word, “intoxicado” -> quadriplegic teen, $71 million settlement

20. T EAM STEPPS 05.2 Mod 1 05.2 Page 20 TeamSTEPPS The evidence  Patient safety events more severe and more often due to communication errors for LEP patients (Divi et al. 2006, Flores 2005)  Ad hoc interpreters (family members, house staff) make serious medical interpretation errors (Flores et al. 2003)  LEP patient safety events cost hospitals millions (Price- Wise 2008; Quan 2010; Carbone et al. 2003)

21. T EAM STEPPS 05.2 Mod 1 05.2 Page 21 TeamSTEPPS More evidence  Professional interpreters reduce length of stay and readmissions for LEP (Linholm et al. 2012)  Despite evidence that LEP patients are safer with professional interpreters, health care providers often try to “get by” without (Diamond et al. 2009; Ring et al. 2010)  Even when interpreters are present, they often can’t speak up when they see a patient safety risk (Betancourt et al. 2012)

22. T EAM STEPPS 05.2 Mod 1 05.2 Page 22 TeamSTEPPS Other reasons for LEP focus  Joint Commission patient-centered communication standards come into effect July 1, 2012 Identify the patient’s oral and written communication needs; and Meet those needs Including the need for qualified interpreters

23. T EAM STEPPS 05.2 Mod 1 05.2 Page 23 TeamSTEPPS How the LEP module can help 1-hour staff training module and 4-hour train-the- trainer program so unit staff and interpreters can: Understand the risks to LEP patients Assemble the right team (call an interpreter!) Identify and raise patient communication issues Also includes a guide for hospital leaders To identify/ implement needed system changes ahead of training

24. T EAM STEPPS 05.2 Mod 1 05.2 Page 24 TeamSTEPPS Module Development Process Environmental Scan Adverse Events Database Interpreter Pilot Results Qualitative Interviews with Frontline Staff & Leaders Town Meeting Original Research TeamSTEPPS Module Hospital Guide Tool Development Field test, Validate Revisions 508 compliance production dissemination We are here!

25. T EAM STEPPS 05.2 Mod 1 05.2 Page 25 TeamSTEPPS Module preview: process map

26. T EAM STEPPS 05.2 Mod 1 05.2 Page 26 TeamSTEPPS Field-test results Module can be implemented various ways in various settings TeamSTEPPS/non-TeamSTEPPS hospital (MO, DE, NC) Stand-alone or part of overall TeamSTEPPS Hospital units (ED, L&D, OB), or primary care Catalyst for institutional changes

27. T EAM STEPPS 05.2 Mod 1 05.2 Page 27 TeamSTEPPS Evaluation Module includes an evaluation guide Satisfaction scores high Knowledge scores significantly increased Qualitative results: Clinicians more aware of need for interpreter Interpreters more empowered to raise/address communication issues Problems with language data  challenges evaluating provider behavior and patient outcomes

28. T EAM STEPPS 05.2 Mod 1 05.2 Page 28 TeamSTEPPS Next steps Module available late summer/early fall Want a copy? Sign up with me today!

30. T EAM STEPPS 05.2 Mod 1 05.2 Page 30 TeamSTEPPS Outline Why LTC version What changes were made and why Video creation TEP recommendations Field testing Findings – potential future work Availability

31. T EAM STEPPS 05.2 Mod 1 05.2 Page 31 TeamSTEPPS Why Long-Term Care? Long-term care environment is unique Long-term/chronic and short term/sub-acute Patients are called “residents” Multi-disciplinary teams, including non-clinical staff Long-term care: custodial care through IV therapy Approximately 16,000 nursing homes and 1.6M nursing home residents across the country

32. T EAM STEPPS 05.2 Mod 1 05.2 Page 32 TeamSTEPPS Changes Targeted The work of this project was to modify the text and associated training materials to be relevant to the long-term care environment Changed language throughout to be meaningful to long-term care Exercises, scenarios, tests and videos were changed and centered around chronic medical or rehabilitation circumstances Graphics and pictures were changed to reflect nursing home staff, care and environment

33. T EAM STEPPS 05.2 Mod 1 05.2 Page 33 TeamSTEPPS Long-Term Care Team

34. T EAM STEPPS 05.2 Mod 1 05.2 Page 34 TeamSTEPPS Long Term Care Team Nurse Assistant Chef Rosie the Housekeeper Social Worker Therapeutic Recreation/Activity Staff Nurse Administrator

35. T EAM STEPPS 05.2 Mod 1 05.2 Page 35 TeamSTEPPS Videos Two videos created Long-term care – subtle decline in a resident over a 24 hour period Sub-acute care –possible MI/PE in a resident receiving physical therapy 14 of 15 TeamSTEPPS skills were highlighted Time-Out is not a skill deemed necessary for most nursing homes

36. T EAM STEPPS 05.2 Mod 1 05.2 Page 36 TeamSTEPPS Long Term Care Video Filmed in a Connecticut nursing home 2 days of filming Over 40 hours of footage 3 nursing home staff served as “extras”

37. T EAM STEPPS 05.2 Mod 1 05.2 Page 37 TeamSTEPPS Sub-Acute Video Filmed in a Massachusetts nursing home’s rehabilitation gym 1 day of filming 15 hours of footage

38. T EAM STEPPS 05.2 Mod 1 05.2 Page 38 TeamSTEPPS Technical Expert Panel National Experts in: Long-term care TeamSTEPPS (Master Trainers) Nursing Workforce Development Culture Change Quality of Care/Life Outcomes Individual calls with each TEP Member were conducted Materials were sent prior to each call: description, agenda, questions

39. T EAM STEPPS 05.2 Mod 1 05.2 Page 39 TeamSTEPPS TEP Recommendations Joint Commission Accreditation of nursing homes is very low nationally Language/terms not commonly used in nursing homes Culture Change and Patient Safety Clear language on the two “concepts” Sample Exercise Illustrate benefit of including all members of the healthcare team in care planning

40. T EAM STEPPS 05.2 Mod 1 05.2 Page 40 TeamSTEPPS TEP Recommendations 2 Other Content should be delivered at literacy levels appropriate for the audience Deliver training in interactive sessions: role play and “teach back” Advanced skills introduced after basic concepts mastered

41. T EAM STEPPS 05.2 Mod 1 05.2 Page 41 TeamSTEPPS Field Testing 120-bed nursing home, part of a continuing care retirement community (CCRC) 1 day (8 hour) training Held on the campus of the nursing home Various departments and staffing levels attended Nursing Staff Development/Education Therapeutic Recreation Social Work Dietary/Food Service Housekeeping Maintenance/Physi cal Plant Administrator/COO

42. T EAM STEPPS 05.2 Mod 1 05.2 Page 42 TeamSTEPPS Field Test Findings Participants pleased with training 86-98% gave the training session a positive grade Communication module had widest appeal Appreciated the interactive exercises; wanted more Videos complemented material, though “too clinical” Add more examples and exercises that included non-clinical staff/departments

43. T EAM STEPPS 05.2 Mod 1 05.2 Page 43 TeamSTEPPS Field Test Findings 2 Recommended including: resident abuse prevention exercises and examples interactions and role plays of communicating with families (staff to family) intergenerational communication among staff removing the multi-team system exercise

44. T EAM STEPPS 05.2 Mod 1 05.2 Page 44 TeamSTEPPS TeamSTEPPS for Long Term Care Available: ???

45. T EAM STEPPS 05.2 Mod 1 05.2 Page 45 TeamSTEPPS Contact Information Abt Associates: Donna Hurd donna_hurd@abtassoc.comdonna_hurd@abtassoc.com Qualidigm: Michelle Pandolfi mpandolfi@qualidigm.orgmpandolfi@qualidigm.org Ann Spenard aspenard@qualidigm.orgaspenard@qualidigm.org TeamSTEPPS ® Primary Care Medical Office Module Deborah A. Milne, RN MPA American Institutes for Research June 22, 2012

47. T EAM STEPPS 05.2 Mod 1 05.2 Page 47 TeamSTEPPS First Step Convened Technical Expert Panel (TEP) December 2010 Representatives from AHRQ and DoD Experts in primary care and quality improvement Interprofessional primary health care providers

48. T EAM STEPPS 05.2 Mod 1 05.2 Page 48 TeamSTEPPS Laying the Groundwork Defined the “team” Identified the “system” Evaluated the challenges Decided areas of focus

49. T EAM STEPPS 05.2 Mod 1 05.2 Page 49 TeamSTEPPS Primary Care Office (PCO) Team TEP defined the scope of “team” for purpose of this project Focus of the project was intended to be on optimizing teamwork within the medical office Caveat - it was noted that external care coordination is of extreme importance for future work

50. T EAM STEPPS 05.2 Mod 1 05.2 Page 50 TeamSTEPPS Primary Care Team Structure

51. T EAM STEPPS 05.2 Mod 1 05.2 Page 51 TeamSTEPPS How is the PCO Different? Complex Adaptive System Non – linear, non – episodic The agents in the system are all the components of that system Agents interact and connect with each other in unpredictable and unplanned ways Interactions cause regularities to emerge Start to form a pattern which feeds back on the system and informs the interactions of the agents

52. T EAM STEPPS 05.2 Mod 1 05.2 Page 52 TeamSTEPPS Model of a Complex Adaptive System

53. T EAM STEPPS 05.2 Mod 1 05.2 Page 53 TeamSTEPPS Primary Care Office Environment

54. T EAM STEPPS 05.2 Mod 1 05.2 Page 54 TeamSTEPPS Some of the “Agents” Patient phone calls/emails Scheduling Medication refills Interruption of patient flow Walk-ins, lab results Formulary questions Missed appointments Population data management Information from insurers Urgent appointments Calls from consultants/external providers

55. T EAM STEPPS 05.2 Mod 1 05.2 Page 55 TeamSTEPPS Challenges to Teamwork in Primary Care Offices Delayed Manifestation of Mistakes Role Ambiguity Non – linear work flow

56. T EAM STEPPS 05.2 Mod 1 05.2 Page 56 TeamSTEPPS Curriculum Training Structure When training teams to implement TeamSTEPPS: developed to be taught in conjunction with TeamSTEPPS Essentials OR When training Master Trainers: To be taught as an addition to TeamSTEPPS Fundamentals

57. T EAM STEPPS 05.2 Mod 1 05.2 Page 57 TeamSTEPPS Next Steps Literature review Curriculum design guide development Developed draft curriculum slides and instructor guide Begin preliminary scripts for video vignettes We asked all TEP members to send us brief “stories” that represented actual scenarios they had experienced

58. T EAM STEPPS 05.2 Mod 1 05.2 Page 58 TeamSTEPPS Field Testing Two sites TeamSTEPPS essentials followed by Primary Care Office Module Data collection

59. T EAM STEPPS 05.2 Mod 1 05.2 Page 59 TeamSTEPPS Highlights of Field Testing Focus Groups “What parts of the module are most relevant to primary care?” Patient advocacy and communication Conflict resolution Situation monitoring Debriefing

60. T EAM STEPPS 05.2 Mod 1 05.2 Page 60 TeamSTEPPS Highlights of Field Testing Focus Groups “What improvements could be made to the module?” More emphasis on roles of non-clinical staff in the care team More case-based scenarios, especially across team roles Non clinical staff felt that they often had important information to communicate but no process to do so Quote: “Little bits that you don’t automatically put into the records as a formal thing are so important.” Resulting module change: Included 4 scenarios in module that emphasize non-clinical staff

61. T EAM STEPPS 05.2 Mod 1 05.2 Page 61 TeamSTEPPS Highlights, cont… “What parts of the module do not make sense?” Definitions of “Huddles” and “Briefs” conflicts with NCQA Primary Care Medical Home (PCMH) language Quote: “PCMH designates the TeamSTEPPS Brief as a Huddle. We all need to know what we mean in terms of what we’re doing.” Resulting module change: More emphasis on flexibility/customizability throughout the curriculum, as long as each team member has the same mental model.

62. T EAM STEPPS 05.2 Mod 1 05.2 Page 62 TeamSTEPPS Video Production Scenario video production – 4 paired scenarios (right way and wrong way) Script changes influenced by field testing results Each based on an actual event Leadership, Communication, Mutual Support, Situation Monitoring

63. Comprehensive Unit-based Safety Program Barbara Edson, RN, MBA, MHA VP, Clinical Quality Health Research and Educational Trust American Hospital Association

64. T EAM STEPPS 05.2 Mod 1 05.2 Page 64 TeamSTEPPS What is CUSP? The Comprehensive Unit-Based Safety Program A safety culture program that is designed to; Educate & improve awareness about patient safety and quality of care Empower staff to take charge and improve safety in their workplace Create partnerships between units & hospital executives Provide resources and tools for unit improvement Provide tools to investigate and learn from defects Used in combination with technical intervention

65. T EAM STEPPS 05.2 Mod 1 05.2 Page 65 TeamSTEPPS Adaptive + Technical CUSPCAUTI 1. Science of safety1. Appropriate reason for insertion (HICPAC Guidelines) 2. Identify defects2. Prompt removal catheters when no longer indicated (HICPAC Guidelines) 3. Sr. exec. partnership3. Proper care for appropriate catheters 4. Learning from defects4. Insertion intervention –sterile placement 5. Teamwork and communication

66. T EAM STEPPS 05.2 Mod 1 05.2 Page 66 TeamSTEPPS CUSP Toolkit Funded by AHRQ Content –CUSP and other safety content Modular PowerPoint presentations with facilitator notes Exercises Short video vignettes illustrating key messages Vignettes demonstrate CUSP used with various healthcare acquired conditions

67. T EAM STEPPS 05.2 Mod 1 05.2 Page 67 TeamSTEPPS CUSP Modules Module stepsModule Description Learn about CUSPDescribes the CUSP Toolkit and its modules Assemble the TeamDevelop team, characteristics of high performing teams, define roles and responsibilities Engage the Senior Executive Role, assist with alignment within organization resources, remove depart barriers, accountability Understand the Science of Safety Context of safety in healthcare, system design, common system breakdowns Identifying Defects Through Sensemaking Identify potential harms, contributing factors and potential solutions, organizational learning Implement Teamwork & Communication Importance of communication and safety, TeamSTEPPS tools Apply CUSPImplementation steps, accountability

68. T EAM STEPPS 05.2 Mod 1 05.2 Page 68 TeamSTEPPS How do you use CUSP? Educate teams on CUSP components using PowerPoints with facilitator notes Share videos, lead discussions with staff Train on use of teamwork and communication tools Provide templates and discussion guides to project leaders

69. T EAM STEPPS 05.2 Mod 1 05.2 Page 69 TeamSTEPPS Briefing A briefing is a discussion between two or more people, often a team, using succinct information pertinent to an event. A briefing immediately: Maps out the care plan Identifies each team member’s roles and responsibilities Heightens awareness of the situation Allows the team to plan for the unexpected Allows team members’ needs and expectations to be met Sets the tone for the day Encourages team members’ participation As seen in TeamSTEPPS ® 69

70. T EAM STEPPS 05.2 Mod 1 05.2 Page 70 TeamSTEPPS

71. T EAM STEPPS 05.2 Mod 1 05.2 Page 71 TeamSTEPPS

72. T EAM STEPPS 05.2 Mod 1 05.2 Page 72 TeamSTEPPS DISCUSSION AND Q&A