1. TeamSTEPPS Team Strategies & Tools to Enhance Performance & Patient Safety

2. T EAM STEPPS 05.2 Mod 1 05.2 Page 2 TeamSTEPPS “TieredSTEPPS”: A Commitment to Address Behaviors that Undermine a Culture of Safety Gerald B. Hickson, MD Assistant Vice Chancellor for Health Affairs Associate Dean for Faculty Affairs Joseph C. Ross Chair in Medical Education & Administration Chair, Board of Governors, National Patient Safety Foundation Center for Patient & Professional Advocacy, Vanderbilt University School of Medicine

3. T EAM STEPPS 05.2 Mod 1 05.2 Page 3 TeamSTEPPS Pursuit of Reliability Safety Culture Willingness to report or act…  Psychological safety  Trust “Behaviors that undermine a culture of safety” threaten trust, therefore must be addressed fairly, quickly, and in a measured way Hickson, Moore, Pichert, Benegas Jr. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Jt Comm Resources;2012:1-36.

4. T EAM STEPPS 05.2 Mod 1 05.2 Page 4 TeamSTEPPS Case: “Looks a Little Red” 56 yo homeless man with frostbite to feet Initial care in burn unit...to Psych unit. Nurse and Psych Resident (Dr. PR) concerned... redness, mild fever, tachycardia? Burn Unit resident, Dr. SurgRes, examines... "on right abx...wounds OK, vitals stable...see 1 st thing in A.M....call with any concern.”

5. T EAM STEPPS 05.2 Mod 1 05.2 Page 5 TeamSTEPPS Case: “Looks a Little Red” 2nd call to Dr. SR, 2 hours later… Psych Chief Resident to Dr. SR: "please have the Burn Fellow come now and examine this patient." Shortly thereafter the phone rings in the Psych unit…“Let me speak with Dr. PR”

6. T EAM STEPPS 05.2 Mod 1 05.2 Page 6 TeamSTEPPS Case: “Looks a Little Red” Dr. BurnFellow: "is this Dr. PR or whoever the #%&! is questioning my #%&! resident’s judgment...” Dr. BF continues, “You guys in psych get so worked up....I bet you consult critical care every time a patient sneezes..." Dr. BF then hangs up...

7. T EAM STEPPS 05.2 Mod 1 05.2 Page 7 TeamSTEPPS Consider the microsystem where you work… What % of the time would the professionals report Dr. BF’s conduct to either a supervisor or through an event reporting system? 1. 0 – 20% 2. 20 – 40 % 3. 40 – 60% 4. 60 – 80% 5. 80 – 100% Countdown 10

8. T EAM STEPPS 05.2 Mod 1 05.2 Page 8 TeamSTEPPS If reported, what % of the time would a medical leader have a conversation with Dr. BF? 1. 0%-20% 2. 20%-40% 3. 40%-60% 4. 60%-80% 5. 80%-100% 10

9. T EAM STEPPS 05.2 Mod 1 05.2 Page 9 TeamSTEPPS A Few Questions From Reason’s “Unsafe Acts” algorithm (1997): Is the team member intending to cause harm? Is the team member impaired? Is the team member knowingly and unreasonably increasing risk? Is another team member in the same situation likely to act in a similar manner? Reason J.T.: Managing the Risks of Organizational Accidents. Aldershot, UK: Ashgate Publishing, 1997.

10. T EAM STEPPS 05.2 Mod 1 05.2 Page 10 TeamSTEPPS Definition of Behaviors That Undermine A Culture of Safety Include but are not limited to, words or actions that:  Prevent or interfere w/an individual’s or group’s work, academic performance, or ability to achieve intended outcomes (e.g. intentionally ignoring questions or not returning phone calls or pages related to matters involving patient care, or publicly criticizing other members of the team or the institution);  Create, or have the potential to create, an intimidating, hostile, offensive, or potentially unsafe work or academic environment (e.g. verbal abuse, sexual or other harassment, threatening or intimidating words, or words reasonably interpreted as threatening or intimidating);  Threaten personal or group safety, aggressive or violent physical actions; Violate VUMC policies, including conflicts of interest and compliance. It’s About Safety Vanderbilt University and Medical Center Policy #HR-027, 2010

11. T EAM STEPPS 05.2 Mod 1 05.2 Page 11 TeamSTEPPS The Balance Beam Do nothingDo something Staff satisfaction and retention Reputation Patient safety, clinical outcomes Liability, risk mgmt costs Fear of antagonizing Leaders “blink” Not sure how lack tools, training Competing priorities “Can’t change…” June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Center for Patient and Professional Advocacy; Hickson GB, Pichert JW. Disclosure and Apology. National Patient Safety Foundation Stand Up for Patient Safety Resource Guide, 2008; Pichert JW, Hickson GB, Vincent C: “Communicating About Unexpected Outcomes and Errors.” In Carayon P (Ed.). Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety, 2007

12. T EAM STEPPS 05.2 Mod 1 05.2 Page 12 TeamSTEPPS Professionalism and Self-Regulation Professionals commit to: Technical and cognitive competence Professionals also commit to: Clear and effective communication Modeling respect Being available “Self awareness” Professionalism promotes teamwork Professionalism demands self and group regulation You have a critical role Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

13. T EAM STEPPS 05.2 Mod 1 05.2 Page 13 TeamSTEPPS Infrastructure for Promoting Reliability & Professional Accountability (PA) 1. Leadership commitment (will not blink) 2. Goals, a credo, and supportive policies 3. Surveillance tools to capture observations/ data 4. Process to guide graduated interventions 5. Processes for reviewing observations/data 6. Multi-level professional/leader training 7. Resources to address unnecessary variation 8. Resources to help affected staff and patients Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring and addressing unprofessional behaviors. Academic Medicine. 2007; Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

14. T EAM STEPPS 05.2 Mod 1 05.2 Page 14 TeamSTEPPS “So, is this TeamSTEPPS stuff required?” What about: – Hand hygiene – Handoffs/documentation – Time outs – Arriving on time – Answering pages – Refraining from jousting – Practicing EBM

15. T EAM STEPPS 05.2 Mod 1 05.2 Page 15 TeamSTEPPS Our organization has Leadership Commitment to address behaviors that undermine TeamSTEPPS… 1. Strongly agree 2. Agree 3. Uncertain 4. Disagree 5. Strongly disagree 10

16. T EAM STEPPS 05.2 Mod 1 05.2 Page 16 TeamSTEPPS I am committed (act, report) to address behaviors that undermine safety… 1. Strongly agree 2. Agree 3. Uncertain 4. Disagree 5. Strongly disagree 10

17. T EAM STEPPS 05.2 Mod 1 05.2 Page 17 TeamSTEPPS Policies and programs will not work if behaviors that undermine a culture of safety go unobserved, unreported and unaddressed

18. T EAM STEPPS 05.2 Mod 1 05.2 Page 18 TeamSTEPPS What Are “Surveillance Tools”? Risk Event Reporting System “Dr. __ entered the room without foaming in… proceeded to touch area with purulent drainage…I offered gloves…took and dropped them into trash.” Patient Relations Department Record pt/family concerns: Father: “Son had surgery so I asked Dr. XX to explain plan. Dr. XX said, ‘I drew a picture. If you don't get it, you just don't get it.’“ Compliance hotline; Equal Opportunity, Affirmative Action, and Disability Services (EAD) Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

19. Promoting Professionalism Pyramid Adapted from Hickson GB, Pichert JW, Webb LE, Gabbe SG. Acad Med. Nov 2007. © 2011 Vanderbilt University Apparent pattern Single “unprofessional" incidents (merit?) "Informal" Cup of Coffee Intervention Level 1 "Awareness" Intervention Level 2 “Guided" Intervention by Authority Level 3 "Disciplinary" Intervention Pattern persists No ∆ Vast majority of professionals - no issues - provide feedback on progress Mandated Reviews Egregious Mandated

20. T EAM STEPPS 05.2 Mod 1 05.2 Page 20 TeamSTEPPS 3 Conversations for Professionals and Leadership to address unnecessary variation Authority: EDICTS Conversation Awareness: An Awareness Intervention Informal: Cup of Coffee Conversation and Espresso Conversation

21. T EAM STEPPS 05.2 Mod 1 05.2 Page 21 TeamSTEPPS But are “awareness” interventions effective?

22. a. Reliably coded* b. Data aggregated & analyzed** c. PARS Risk Score*** d. Local & nat’l comparisons**** * Hickson et al, 2002; ** Hickson et al, 2002; 2006; ***Mukherjee et al, 2010; ****Stimson et al, 2010 a. Promote complaint collection and Service Recovery best practices* b. Unsolicited pt/family complaints collected/recorded by Pt Relations c. Transmitted to CPPA *Hayden et al, 2010; Moore et al, 2006; Pichert et al, 2004 22

23. T EAM STEPPS 05.2 Mod 1 05.2 Page 23 TeamSTEPPS Does it work? PARS ® Progress Report Total # high complaint physicians810 Departed after initial intervention59 First follow-up in 2012 - 2013149 Total with follow-up results602 Results for those with follow-up data: Good – Intervention Visits suspended302(50%) Good – Anticipate suspension in 2012 - 2013 93(16%) Some Improvement—still needs tracking43(7%) Subtotal438(73%) Unimproved/worse127(21%) Departed Unimproved37(6%) Total with follow-up results602 Pichert JW, Moore IN, Hickson GB. Professionals promoting professionalism. Jt Comm J Qual Patient Safe. 2011; 37(10):446. This document is confidential and privileged pursuant to the provisions of State Statutes

24. Malpractice Claims (per 100 MDs) FY1992 – 2011 * * Data used with permission, State Volunteer Mutual Insurance Company, a mutual insurer of 10,500 TN non-VUMC physicians of all specialties, 29% to 33% who practiced in Middle TN during the target date. **TN Certificate of Merit ** 24

25. T EAM STEPPS 05.2 Mod 1 05.2 Page 25 TeamSTEPPS Infrastructure for Promoting Reliability & Professional Accountability (PA) 1. Leadership commitment 2. Goals, a credo, and supportive policies 3. Surveillance tools to capture observations/data 4. Processes for reviewing observations/data 5. Model to guide graduated interventions 6. Multi-level professional/leader training 7. Resources to help address unnecessary variation 8. Resources to help those affected Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring and addressing unprofessional behaviors. Academic Medicine. 2007. Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

26. T EAM STEPPS 05.2 Mod 1 05.2 Page 26 TeamSTEPPS CPPA Conferences Promoting Professional Accountability: Addressing Behaviors That Undermine A Culture of Safety The How and When of Communicating Adverse Outcomes and Errors For details, please visit our website: http://www.mc.vanderbilt.edu/centers/cppa/courses.htm http://www.mc.vanderbilt.edu/centers/cppa/courses.htm

27. T EAM STEPPS 05.2 Mod 1 05.2 Page 27 TeamSTEPPS Let Us Hear Your Comments, Questions Now or Later www.mc.vanderbilt.edu/cppa www.mc.vanderbilt.edu/cppa