1. Team Training and Patient Safety: What is the Evidence? January 8, 2014

2. T EAM STEPPS 05.2 Mod 1 05.2 Page 2 TeamSTEPPS Team Training & Patient Safety Slide 2 Acknowledgements Project Sponsors Jim Battles, PhD (AHRQ) Heidi King, MS (DoD) Project Team Health Research & Educational Trust (HRET) Barb Edson (Project Director) Chris Hund (Project Manager) IMPAQ International David Baker (Team Lead)

3. T EAM STEPPS 05.2 Mod 1 05.2 Page 3 TeamSTEPPS Team Training & Patient Safety Slide 3 TeamSTEPPS Master Training Two-day training course Train-the-trainer approach Prepares you to serve as a TeamSTEPPS Master Trainer by Providing instruction on TeamSTEPPS tools and strategies Providing an opportunity to develop and plan your TeamSTEPPS implementation Prepares you to serve as a leader for implementing TeamSTEPPS within your organization

4. T EAM STEPPS 05.2 Mod 1 05.2 Page 4 TeamSTEPPS Team Training & Patient Safety Slide 4 Help Line (312) 422-2609 Or email: AHRQTeamSTEPPS@aha.orgAHRQTeamSTEPPS@aha.org

5. T EAM STEPPS 05.2 Mod 1 05.2 Page 5 TeamSTEPPS Team Training & Patient Safety Slide 5 Upcoming TeamSTEPPS Events Monthly Teleconferences Scheduled through September 2014 Topics, speakers, and registration information will be posted on the portal Annual Conference June 11-12, 2014 Minneapolis, Minnesota at the Minneapolis Marriott City Center

6. T EAM STEPPS 05.2 Mod 1 05.2 Page 6 TeamSTEPPS Team Training & Patient Safety Slide 6 Rules of Engagement A Q&A session will be held at the end of the presentation Written questions are encouraged throughout the presentation and will be answered during the Q&A session To submit a written question, send your question via email to AHRQTeamSTEPPS@aha.org at any time during the presentationAHRQTeamSTEPPS@aha.org The lines may open for call-in questions during the Q&A session

7. T EAM STEPPS 05.2 Mod 1 05.2 Page 7 TeamSTEPPS Team Training & Patient Safety Slide 7 Today’s Presenter David P. Baker, PhD Chief Program Officer, IMPAQ International, LLC TeamSTEPPS Master Trainer

8. T EAM STEPPS 05.2 Mod 1 05.2 Page 8 TeamSTEPPS Team Training & Patient Safety Slide 8 Objectives Understand the key components of teamwork Review the core components of TeamSTEPPS ® Review the evidence on team training effectiveness Examine the effectiveness of TeamSTEPPS

9. T EAM STEPPS 05.2 Mod 1 05.2 Page 9 TeamSTEPPS Team Training & Patient Safety Slide 9 Take Away Messages Team Training WORKS! TeamSTEPPS Public domain resource based on the evidence Customizable and adaptable Producing positive results Emerging, growing evidence in health care Importance of care coordination Link between care coordination and clinical outcomes

10. T EAM STEPPS 05.2 Mod 1 05.2 Page 10 TeamSTEPPS Team Training & Patient Safety Slide 10 Teamwork Basics

11. T EAM STEPPS 05.2 Mod 1 05.2 Page 11 TeamSTEPPS Team Training & Patient Safety Slide 11 What is a Team? There is substantial agreement on what constitutes a team A minimum of two or more individuals Assigned specific roles and tasks Share a common goal Perform tasks that are interdependent

12. T EAM STEPPS 05.2 Mod 1 05.2 Page 12 TeamSTEPPS Team Training & Patient Safety Slide 12 What is Teamwork? INPUTS Task Characteristics Team Member Characteristics OUTPUTS Products of Teamwork PROCESS Interaction Coordination

13. T EAM STEPPS 05.2 Mod 1 05.2 Page 13 TeamSTEPPS Team Training & Patient Safety Slide 13 Team Process Team Members Cognitions Knowledge “Think” Behaviors Skills “Do” Attitudes Affect “Feel”

14. T EAM STEPPS 05.2 Mod 1 05.2 Page 14 TeamSTEPPS Team Training & Patient Safety Slide 14 Salas Model of Team Process Mutual Trust Shared Mental Models Team Orientation Team Leadership Close Loop Comm. Back-Up Behavior MPM Adaptability THE CORE

15. T EAM STEPPS 05.2 Mod 1 05.2 Page 15 TeamSTEPPS Team Training & Patient Safety Slide 15 Levels of Competencies Individual - Task-Level Held by an individual The KSAs necessary to perform specific tasks Individual - Team-Level Team KSAs that are held by an individual The team competencies an individual brings to a team Transferable across teams Team - Team-Level Team KSAs held by a team Unique KSAs that develop within the team/not transfer

16. T EAM STEPPS 05.2 Mod 1 05.2 Page 16 TeamSTEPPS Team Training & Patient Safety Slide 16 TeamSTEPPS ® AHRQ and DoD public domain curriculum for teaching teamwork to healthcare professionals Developed by AHRQ and DoD Released in Fall 2006 National standard for team training in healthcare Initiative based on evidence derived from team performance…leveraging more than 25 years of research in military, aviation, nuclear power, business and industry (Baker et al. 2006) Designed to be customizable to the institution

17. T EAM STEPPS 05.2 Mod 1 05.2 Page 17 TeamSTEPPS Team Training & Patient Safety Slide 17 Tools and Strategies TOOLS and STRATEGIES Brief Huddle Debrief STEP Cross Monitoring Feedback Advocacy and Assertion Two-Challenge Rule CUS DESC Script Collaboration SBAR Call-Out 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 Follow-Up with Co-Workers Distractions Fatigue Workload Misinterpretation of Cues Lack of Role Clarity

18. T EAM STEPPS 05.2 Mod 1 05.2 Page 18 TeamSTEPPS Team Training & Patient Safety Slide 18 Day 2: Coaching, Planning, and Implementation

19. T EAM STEPPS 05.2 Mod 1 05.2 Page 19 TeamSTEPPS Team Training & Patient Safety Slide 19 Does Team Training Work? YES

20. T EAM STEPPS 05.2 Mod 1 05.2 Page 20 TeamSTEPPS Team Training & Patient Safety Slide 20 Comprehensive Search (1955 – 2007) Over 300 empirical articles 245 journal articles 33 conference presentations 20 theses/dissertations 13 book chapters 13 technical reports 3 unpublished works Meta-Analyses (Salas)

21. T EAM STEPPS 05.2 Mod 1 05.2 Page 21 TeamSTEPPS Team Training & Patient Safety Slide 21 Database Over 10,000 teams represented Aviation teams - 6,962 Lab teams - 1,845 Organizational teams - 1,527 Military teams - 464 Medical teams - 181 Education teams - 26 Sports teams - 12

22. T EAM STEPPS 05.2 Mod 1 05.2 Page 22 TeamSTEPPS Team Training & Patient Safety Slide 22 41 studies; 84 effect sizes Examined factors influencing the relationship between team training and outcomes: Training Content Team Member Stability Team Size TTMA (Salas et al., 2008)

23. T EAM STEPPS 05.2 Mod 1 05.2 Page 23 TeamSTEPPS Team Training & Patient Safety Slide 23 Results Overall, team training was shown to have a moderate, positive effect on team outcomes (ρ =.38) Accounted for 14.4% of variance Effect of team training was moderated by outcome type Cognitive (ρ =.41) – accounted for 16.8% of variance Affective (ρ =.35) – 12.3% of variance Process (ρ =.44) –19.4% of variance Performance (ρ =.37) –13.7% of variance Meta-Analysis Results

24. T EAM STEPPS 05.2 Mod 1 05.2 Page 24 TeamSTEPPS Team Training & Patient Safety Slide 24 Trauma Study Purpose To improve teamwork in the trauma bay To test the effects of TeamSTEPPS Field Study – MESSY! Background Team training improves team process by 20% (Salas et al., 2008) Few studies on impact of TeamSTEPPS Hard to link team training to clinical outcomes (i.e., mortality, complications, HAIs, etc.)

25. T EAM STEPPS 05.2 Mod 1 05.2 Page 25 TeamSTEPPS Team Training & Patient Safety Slide 25 Design Quasi-experiment Pre-test/Post-test, no control group design Interventions Training – Didactic and Simulation 2-hour TeamSTEPPS Essentials; 2 hours simulation (skills practice and feedback) Nurses and Doctors separately trained Trauma Room Roles and Responsibilities Policy Briefing, STEP, CUS, Call-Outs and Check- Backs One-day Nursing Crash Course

26. T EAM STEPPS 05.2 Mod 1 05.2 Page 26 TeamSTEPPS Team Training & Patient Safety Slide 26 Measures (Kirkpatrick) Level I Reactions End of Training Level II Learning – Pre/Post Test Knowledge, Attitudes, Skills Level III Transfer – Observed Teamwork (TPOT) 3 months pre and post-training Level IV Outcomes Clinical Outcomes (ICU LOS, Hospital LOS, Complication Rate, Mortality) Clinical Process (Time to CT SCAN, Surgery, Intubation)

27. T EAM STEPPS 05.2 Mod 1 05.2 Page 27 TeamSTEPPS Team Training & Patient Safety Slide 27 Measures Knowledge Test TeamSTEPPS Learning Benchmarks Trauma Roles and Responsibilities T-TAQ – (Baker, Amodeo et al., 2010) 30-Items Reliability (Alphas ranged.70 -.83) TPOT – (Baker, Capella et al., 2010) 21-items plus an overall rating Inter-rater Agreement (ICC ranged.44 -.64 and agreement ranged 65% - 86%) Observations performed by 4 trained raters (clinicians)

28. T EAM STEPPS 05.2 Mod 1 05.2 Page 28 TeamSTEPPS Team Training & Patient Safety Slide 28 Analyses Level I Reactions – Post-Training Only Level II Learning Attitudes Pre-Training only Knowledge Pre/Post; t-tests Skills T-tests Level III Transfer and Level IV Outcomes Chi Square ANCOVA Equate for trauma severity score – ISS

29. T EAM STEPPS 05.2 Mod 1 05.2 Page 29 TeamSTEPPS Team Training & Patient Safety Slide 29 Expected Findings Reactions - Positive Learning Knowledge No change – staff know what to do Attitudes Positive – Believe in teamwork or social desirability Skills Significant improvement in simulator Transfer Not sure about trauma bay – many environmental factors Outcomes Unlikely due to base rate issues

30. T EAM STEPPS 05.2 Mod 1 05.2 Page 30 TeamSTEPPS Team Training & Patient Safety Slide 30 Descriptive Data Pre-TrainingPost-Training Observed 3340 Trauma 176263 ISS M=13.97, SD=11.85 M=11.63, SD=11.04

31. T EAM STEPPS 05.2 Mod 1 05.2 Page 31 TeamSTEPPS Team Training & Patient Safety Slide 31 Level II Learning Attitudes Rating Scale Teamwork Skills Positive reactions

32. T EAM STEPPS 05.2 Mod 1 05.2 Page 32 TeamSTEPPS Team Training & Patient Safety Slide 32 Level II Learning Knowledge MeanSDMeanSDp value Learning Benchmarks 73.0712.2182.279.56.004 Trauma Team Roles 76.6215.0980.9512.50.312 Pre-TrainingPost-Training Note: Mean values are percent correct scores.

33. T EAM STEPPS 05.2 Mod 1 05.2 Page 33 TeamSTEPPS Team Training & Patient Safety Slide 33 Level II Learning Skills P=.005P=.343 Sd= 1.09 Sd=.94 Sd=.74 Note: Reflects mean performance across all 21 TPOT items

34. T EAM STEPPS 05.2 Mod 1 05.2 Page 34 TeamSTEPPS Team Training & Patient Safety Slide 34 Level III Transfer Pre-Training N=33 Post-Training N=40 p value Leadership2.873.460.003 Situation Monitoring3.303.910.009 Mutual Support3.403.960.004 Communication2.903.460.001 Total3.123.70<0.001 Note: Pre-training and post-training reflect observations in trauma bay by four trained raters.

35. T EAM STEPPS 05.2 Mod 1 05.2 Page 35 TeamSTEPPS Team Training & Patient Safety Slide 35 Pre-TrainingPost-Trainingp value NMSDNMeanSD ICU LOS (days) 735.506.37825.616.45 Ventilator days 534.495.08556.427.27 Hospital LOS (days) 1767.6313.992636.255.81 % without complications 17670.4526376.80 % alive at discharge 17686.9326391.54 Time to FAST 1238.35.72219.67.8 Time to CT 12426.414.517422.111.70.005 Time to ETT 2110.16.8226.64.20.049 Time to OR 46130.182.74794.563.80.021 Time in ED 176186.1151.0263187.4159.3 Note: Ns vary as a function of clinical condition and treatment

36. T EAM STEPPS 05.2 Mod 1 05.2 Page 36 TeamSTEPPS Team Training & Patient Safety Slide 36 Conclusions TeamSTEPPS had an impact on: Reactions (positive) Learning Increases in knowledge – surprising Increases in skill in the simulator Transfer Improved teamwork skills Outcomes Clinical process measures improved No effects on clinical outcomes

37. T EAM STEPPS 05.2 Mod 1 05.2 Page 37 TeamSTEPPS Team Training & Patient Safety Slide 37 Take Away Messages Team Training WORKS! TeamSTEPPS® Works Emerging, Growing Evidence in Health Care Importance of care coordination Link between care coordination and clinical outcomes

38. T EAM STEPPS 05.2 Mod 1 05.2 Page 38 TeamSTEPPS Team Training & Patient Safety Slide 38 Additional Materials http://teamsteppsportal.org/evidence-base Capella, J., Smith, S., Philp, A., Putnam, T., Gilbert, C., Fry, W., Harvey, E., Wright, A., Henderson, K., Baker, D., Ranson, S., & ReMine, S. (2010). Teamwork training improves clinical care of trauma patients. Journal of Surgical Education, 67, 439-443.

39. T EAM STEPPS 05.2 Mod 1 05.2 Page 39 TeamSTEPPS Team Training & Patient Safety Slide 39 Questions and Answers

40. T EAM STEPPS 05.2 Mod 1 05.2 Page 40 TeamSTEPPS Team Training & Patient Safety Slide 40 Thank You! For more information, please contact our team at: AHRQTeamSTEPPS@aha.org