1. Strategies and Tools to Enhance Performance and Patient Safety

2. T EAM STEPPS 05.2 Mod 1 05.2 Page 2 Introduction Mod 1 06.2 Page 2 ® 2 Objectives Describe the importance of communication Recognize the connection between communication and medical error Discuss The Joint Commission national patient safety goals Define communication and discuss the standards of effective communication Describe strategies for information exchange Identify barriers, tools, strategies, and outcomes to communication

3. T EAM STEPPS 05.2 Mod 1 05.2 Page 3 Introduction Mod 1 06.2 Page 3 ® 3 Teamwork Is All Around Us

4. T EAM STEPPS 05.2 Mod 1 05.2 Page 4 Introduction Mod 1 06.2 Page 4 ® 4 (Mann, 2006) Beth Israel Deaconess Medical Center Contemporary OB/GYN (Sexton, 2006) Johns Hopkins (Pronovost, 2003) Johns Hopkins Journal of Critical Care Medicine

5. T EAM STEPPS 05.2 Mod 1 05.2 Page 5 Introduction Mod 1 06.2 Page 5 ® 5 Introduction Evolution of TeamSTEPPS Curriculum Contributors Department of Defense Agency for Healthcare Research and Quality Research Organizations Universities Medical and Business Schools Hospitals—Military and Civilian, Teaching and Community-Based Healthcare Foundations Private Companies Subject Matter Experts in Teamwork, Human Factors, and Crew Resource Management (CRM)

6. T EAM STEPPS 05.2 Mod 1 05.2 Page 6 Introduction Mod 1 06.2 Page 6 ® 6 “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

7. T EAM STEPPS 05.2 Mod 1 05.2 Page 7 Introduction Mod 1 06.2 Page 7 ® 7 2006 Patient Safety and Quality Improvement Act of 2005 Patient Safety Movement Executive Memo from President DoD MedTeams® ED Study Institute for Healthcare Improvement 100K lives Campaign “To Err is Human” IOM Report T eam STEPPS 199519992001200320042005 JCAHO National Patient Safety Goals Medical Team Training

8. T EAM STEPPS 05.2 Mod 1 05.2 Page 8 Introduction Mod 1 06.2 Page 8 ® 8 The Components of a Patient Safety Program

9. T EAM STEPPS 05.2 Mod 1 05.2 Page 9 Introduction Mod 1 06.2 Page 9 ® 9 Why Do Errors Occur—Some Obstacles Workload fluctuations Interruptions Fatigue Multi-tasking Failure to follow up Poor handoffs Ineffective communication Not following protocol Excessive professional courtesy Halo effect Passenger syndrome Hidden agenda Complacency High-risk phase Strength of an idea Task (target) fixation

10. T EAM STEPPS 05.2 Mod 1 05.2 Page 10 Introduction Mod 1 06.2 Page 10 ® 10 What Comprises Team Performance? Knowledge Cognitions “Think” …team performance is a science…consequences of errors are great… Attitudes Affect “Feel” Skills Behaviors “Do”

11. T EAM STEPPS 05.2 Mod 1 05.2 Page 11 Introduction Mod 1 06.2 Page 11 ® 11 Outcomes of Team Competencies Knowledge Shared Mental Model Attitudes Mutual Trust Team Orientation Performance Adaptability Accuracy Productivity Efficiency Safety

12. T EAM STEPPS 05.2 Mod 1 05.2 Page 12 Introduction Mod 1 06.2 Page 12 ® 12 Teamwork Actions Recognize opportunities to improve patient safety Assess your current organizational culture and existing Patient Safety Program components Identify teamwork improvement action plan by analyzing data and survey results Design and implement initiative to improve team- related competencies among your staff Integrate TeamSTEPPS into daily practice. “High-performance teams create a safety net for your healthcare organization as you promote a culture of safety."

13. T EAM STEPPS 05.2 Mod 1 05.2 Page 13 Introduction Mod 1 06.2 Page 13 ® 13 Teamwork Encompasses CRM DoD has led the way in team research and innovations Non-Healthcare Combat Information Centers Joint Forces Operations Emergency Management Communities Army Special Forces Tank, Submarine, and Air Crews Healthcare ED, OR, L&D, ICU, Dental Whole Hospital Combat Casualty Care CRM Team Training … striving to be a high reliability healthcare system…

14. T EAM STEPPS 05.2 Mod 1 05.2 Page 14 Introduction Mod 1 06.2 Page 14 ® 14 Background: US Army Aviation Army aviation crew coordination failures in mid-80s contributed to 147 aviation fatalities and cost more than $290 million The vast majority involved highly experienced aviators Failures were attributed largely to crew communication, workload management, and task prioritization

15. T EAM STEPPS 05.2 Mod 1 05.2 Page 15 Introduction Mod 1 06.2 Page 15 ® 15 US Navy Breakthroughs: Tactical Decisionmaking Under Stress (TADMUS) Cross-Training Stress Exposure Training Team Coordination Training (CRM) Scenario-Based Training and Simulation Team Leader Training Team Dimensional Training Team Assessment

16. T EAM STEPPS 05.2 Mod 1 05.2 Page 16 Introduction Mod 1 06.2 Page 16 ® 16 US Air Force CRM History Mid to Late 80s AF bombers and heavy aircraft started CRM training 1992 Air Combat Command developed Aircrew Attention Management /CRM Training By 1998, CRM deployed uniformly across the AF Steady decline in human factors based mishaps since CRM training deployed AF Medical Service adapted training, rolled out in 2000

17. T EAM STEPPS 05.2 Mod 1 05.2 Page 17 Introduction Mod 1 06.2 Page 17 ® 17 John Kotter Eight Steps of Change

18. T EAM STEPPS 05.2 Mod 1 05.2 Page 18 Introduction Mod 1 06.2 Page 18 ® 18 Catalytic event drives need for change Build team, strategy, buy-in, establish goals Implement Action Plan, Train, Empower Others TeamSTEPPS Change Coaching I’m staying right here. Yeah they’ll be back. What are they doing? Why do we need change ? Jt. Comm. Status QUO FUTURE Errorville Celebrate wins! Staying the course Sustaining Develop Action Plan Test Intervention (Outcomes) Monitor, Integrate, Continuous Process Improvement Prepare the Climate Roadmap to a Culture of Safety

19. T EAM STEPPS 05.2 Mod 1 05.2 Page 19 Introduction Mod 1 06.2 Page 19 ® 19 Are better able to predict the needs of other team members Provide quality information and feedback Engage in higher level decision-making Manage conflict skillfully Understand their roles and responsibilities Reduce stress on the team as a whole through better performance “Achieve a mutual goal through interdependent and adaptive actions” Effective Team Members

20. T EAM STEPPS 05.2 Mod 1 05.2 Page 20 Introduction Mod 1 06.2 Page 20 ® 20

21. T EAM STEPPS 05.2 Mod 1 05.2 Page 21 Introduction Mod 1 06.2 Page 21 ® 21 Team Events 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

22. T EAM STEPPS 05.2 Mod 1 05.2 Page 22 Introduction Mod 1 06.2 Page 22 ® 22 Briefs Planning Form the team Designate team roles and responsibilities Establish climate and goals Engage team in short and long-term planning

23. T EAM STEPPS 05.2 Mod 1 05.2 Page 23 Introduction Mod 1 06.2 Page 23 ® 23 Planning Essentials for Teams Leader usually initiates the planning process Team members are included in the planning process Team members have a common understanding of the problem and their roles

24. T EAM STEPPS 05.2 Mod 1 05.2 Page 24 Introduction Mod 1 06.2 Page 24 ® 24 TOPIC Who is on core team? All members understand and agree upon goals? Roles and responsibilities understood? Plan of care? Staff availability? Workload? Available resources? Briefing Checklist

25. T EAM STEPPS 05.2 Mod 1 05.2 Page 25 Introduction Mod 1 06.2 Page 25 ® 25 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

26. T EAM STEPPS 05.2 Mod 1 05.2 Page 26 Introduction Mod 1 06.2 Page 26 ® 26 Debrief Process Improvement Brief, 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 why the event occurred What should be done differently next time

27. T EAM STEPPS 05.2 Mod 1 05.2 Page 27 Introduction Mod 1 06.2 Page 27 ® 27 TOPIC Communication clear? Roles and responsibilities understood? 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? Debrief Checklist

28. T EAM STEPPS 05.2 Mod 1 05.2 Page 28 Introduction Mod 1 06.2 Page 28 ® 28 Facilitating Conflict Resolution Effective leaders facilitate conflict resolution techniques through invoking: Two-Challenge rule DESC script Effective leaders also assist by: Helping team members master conflict resolution techniques Serving as a mediator

29. T EAM STEPPS 05.2 Mod 1 05.2 Page 29 Introduction Mod 1 06.2 Page 29 ® 29 Leadership OUTCOMES Shared Mental Model Adaptability Team Orientation Mutual Trust BARRIERS Hierarchical Culture Lack of Resources or Information Ineffective Communication Conflict TOOLS and STRATEGIES Brief Huddle Debrief

30. T EAM STEPPS 05.2 Mod 1 05.2 Page 30 Introduction Mod 1 06.2 Page 30 ® 30 Teamwork Actions Empower team members to speak freely and ask questions Utilize resources efficiently to maximize team performance Balance workload within the team Delegate tasks or assignments, as appropriate Conduct briefs, huddles, and debriefs Utilize conflict resolution techniques (i.e., Two-Challenge rule and DESC script)

31. Communication Assumptions Fatigue Distractions HIPAA ®

32. T EAM STEPPS 05.2 Mod 1 05.2 Page 32 Introduction Mod 1 06.2 Page 32 ® 32

33. T EAM STEPPS 05.2 Mod 1 05.2 Page 33 Introduction Mod 1 06.2 Page 33 ® 33 The Joint Commission: Importance of Communication Ineffective communication is a root cause for nearly 66 percent of all sentinel events reported* * (The Joint Commission Root Causes and Percentages for Sentinel Events (All Categories) January 1995−December 2005)

34. T EAM STEPPS 05.2 Mod 1 05.2 Page 34 Introduction Mod 1 06.2 Page 34 ® 34 Joint Commission Goals That Relate To Communication National Patient Safety Goals (NPSGs) related to communication: Improve the effectiveness of communication among caregivers Read-Back Handoff Accurately and completely reconcile medications and other treatments across the continuum of care Address specifically during handoff Encourage the active involvement of patients and their families in the patient’s care, as a patient safety strategy

35. T EAM STEPPS 05.2 Mod 1 05.2 Page 35 Introduction Mod 1 06.2 Page 35 ® 35 The process by which information is exchanged between individuals, departments, or organizations The lifeline of the Core Team Effective when it permeates every aspect of an organization Communication is… Assumptions Fatigue Distractions HIPAA

36. T EAM STEPPS 05.2 Mod 1 05.2 Page 36 Introduction Mod 1 06.2 Page 36 ® 36 Standards of Effective Communication Complete Communicate all relevant information Clear Convey information that is plainly understood Brief Communicate the information in a concise manner Timely Offer and request information in an appropriate timeframe Verify authenticity Validate or acknowledge information

37. T EAM STEPPS 05.2 Mod 1 05.2 Page 37 Introduction Mod 1 06.2 Page 37 ® 37 Brief Clear Timely

38. T EAM STEPPS 05.2 Mod 1 05.2 Page 38 Introduction Mod 1 06.2 Page 38 ® 38 Information Exchange Strategies Situation–Background– Assessment– Recommendation (SBAR) Call-Out Check-Back Handoff

39. T EAM STEPPS 05.2 Mod 1 05.2 Page 39 Introduction Mod 1 06.2 Page 39 ® 39 SBAR provides… A framework for team members to effectively communicate information to one another Communicate the following information: 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―What would I recommend? Remember to introduce yourself…

40. T EAM STEPPS 05.2 Mod 1 05.2 Page 40 Introduction Mod 1 06.2 Page 40 ® 40 SBAR Example

41. T EAM STEPPS 05.2 Mod 1 05.2 Page 41 Introduction Mod 1 06.2 Page 41 ® 41 Call-Out is… A strategy used to communicate important or critical information It informs all team members simultaneously during emergency situations It helps team members anticipate next steps …On your unit, what information would you want called out?

42. T EAM STEPPS 05.2 Mod 1 05.2 Page 42 Introduction Mod 1 06.2 Page 42 ® 42 Check-Back is…

43. T EAM STEPPS 05.2 Mod 1 05.2 Page 43 Introduction Mod 1 06.2 Page 43 ® 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

44. T EAM STEPPS 05.2 Mod 1 05.2 Page 44 Introduction Mod 1 06.2 Page 44 ® Reporting Tools:Handoff Optimized Information Responsibility– Accountability Uncertainty Verbal Structure Checklists IT Support Acknowledgement Great opportunity for quality and safety

45. T EAM STEPPS 05.2 Mod 1 05.2 Page 45 Introduction Mod 1 06.2 Page 45 ® 45 “I PASS THE BATON” I I ntroduction:Introduce yourself and your role/job (include patient) P P atient:Identifiers, age, sex, location A A ssessment:Present chief complaint, vital signs, symptoms, and diagnosis S S ituation:Current status/circumstances, including code status, level of uncertainty, recent changes, and response to treatment S S afety:Critical lab values/reports, socio-economic factors, allergies, and alerts (falls, isolation, etc.) THE B B ackground:Co-morbidities, previous episodes, current medications, and family history A A ctions:What actions were taken or are required? Provide brief rationale T T iming:Level of urgency and explicit timing and prioritization of actions O O wnership:Who is responsible (nurse/doctor/team)? Include patient/family responsibilities N N ext:What will happen next? Anticipated changes? What is the plan? Are there contingency plans?

46. T EAM STEPPS 05.2 Mod 1 05.2 Page 46 Introduction Mod 1 06.2 Page 46 ® ISHAPED – Another Report Tool I: Introduction S:Story H:History A:Assessment P:Plan E:Error-Prevention D:Dialogue * From Inova/Picker Institute available at: http://alwaysevents.pickerinstitute.org/?p=1251http://alwaysevents.pickerinstitute.org/?p=1251 46

47. T EAM STEPPS 05.2 Mod 1 05.2 Page 47 Introduction Mod 1 06.2 Page 47 ® 47 Communication Challenges Language barrier Distractions Physical proximity Personalities Workload Varying communication styles Conflict Lack of information verification Shift change Great Opportunity for Quality and Safety

48. T EAM STEPPS 05.2 Mod 1 05.2 Page 48 Introduction Mod 1 06.2 Page 48 ® 48 Barriers to Team Effectiveness 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

49. T EAM STEPPS 05.2 Mod 1 05.2 Page 49 Introduction Mod 1 06.2 Page 49 ® 49 Teamwork Actions Communicate with team members in a brief, clear, and timely format Seek information from all available sources Verify and share information Practice communication tools and strategies daily (SBAR, call-out, check-back, handoff)