1. T EAM STEPPS 05.2 Mod 1 05.2 Page 1 ValleyCare Mod 1 06.2 Page 1 ™ 1 The Impact of Medical Errors

2. T EAM STEPPS 05.2 Mod 1 05.2 Page 2 ValleyCare Mod 1 06.2 Page 2 ™ 2 Two Boeing 747s, operated by KLM and Pan Am, collide due to breakdowns in communication and safety checks. Number of people killed: 583 Diane Brack

3. T EAM STEPPS 05.2 Mod 1 05.2 Page 3 ValleyCare Mod 1 06.2 Page 3 ™ 3 This plane flew in a holding pattern for 77 minutes while awaiting landing clearance at JFK and crashed due to a failure to communicate the urgency of fuel situation. Number of people killed: 73

4. T EAM STEPPS 05.2 Mod 1 05.2 Page 4 ValleyCare Mod 1 06.2 Page 4 ™ 4 As many as 98,000 deaths occur as a result of medical errors each year

5. T EAM STEPPS 05.2 Mod 1 05.2 Page 5 ValleyCare Mod 1 06.2 Page 5 ™ 5 That’s the same as a 747 jet falling out of the sky EVERYDAY for a YEAR!!!

6. T EAM STEPPS 05.2 Mod 1 05.2 Page 6 ValleyCare Mod 1 06.2 Page 6 ™ 6 More Americans die from medical errors than from breast cancer, AIDS, or car accidents combined

7. T EAM STEPPS 05.2 Mod 1 05.2 Page 7 ValleyCare Mod 1 06.2 Page 7 ™ 7 22,980 Obstetrical adverse events every year are caused by medical error

8. T EAM STEPPS 05.2 Mod 1 05.2 Page 8 ValleyCare Mod 1 06.2 Page 8 ™ 8 Cost associated with medical errors is $8–29 billion annually

9. T EAM STEPPS 05.2 Mod 1 05.2 Page 9 ValleyCare Mod 1 06.2 Page 9 ™ 9 Failures in Communication are the leading contributor to sentinel events. ~The Joint Commision

10. T EAM STEPPS 05.2 Mod 1 05.2 Page 10 ValleyCare Mod 1 06.2 Page 10 ™ 10 Communication Failures contribute to 72% of Root Cause Analysis of sentinel events in perinatal units

11. T EAM STEPPS 05.2 Mod 1 05.2 Page 11 ValleyCare Mod 1 06.2 Page 11 ™ 11 The solution?

12. T EAM STEPPS 05.2 Mod 1 05.2 Page 12 ValleyCare Mod 1 06.2 Page 12 ™ 12 Strategies and Tools to Enhance Performance and Patient Safety ™

13. T EAM STEPPS 05.2 Mod 1 05.2 Page 13 ValleyCare Mod 1 06.2 Page 13 ™ 13 CHAIN EXERCISE

14. T EAM STEPPS 05.2 Mod 1 05.2 Page 14 ValleyCare Mod 1 06.2 Page 14 ™ 14 Using the materials in front of you, create a paper chain with the most links. You may only use your non-dominant hand. You have 2 minutes to create this chain.

15. T EAM STEPPS 05.2 Mod 1 05.2 Page 15 ValleyCare Mod 1 06.2 Page 15 ™ 15 Objectives Road To TeamSTEPPS TeamSTEPPS Concepts and Tools Impact on Culture of Safety The Journey Continues…

16. T EAM STEPPS 05.2 Mod 1 05.2 Page 16 ValleyCare Mod 1 06.2 Page 16 ™ 16 The Road to TeamSTEPPS…

17. T EAM STEPPS 05.2 Mod 1 05.2 Page 17 ValleyCare Mod 1 06.2 Page 17 ™ 17 The Components of a Patient Safety Program

18. T EAM STEPPS 05.2 Mod 1 05.2 Page 18 ValleyCare Mod 1 06.2 Page 18 ™ 18 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)

19. T EAM STEPPS 05.2 Mod 1 05.2 Page 19 ValleyCare Mod 1 06.2 Page 19 ™ 19 Institute of Medicine Report “To Err is Human” (1999) Impact of Error: 44,000–98,000 annual deaths occur as a result of errors Medical errors are the leading cause, followed by surgical mistakes and complications More Americans die from medical errors than from breast cancer, AIDS, or car accidents 7% of hospital patients experience a serious medication error Cost associated with medical errors is $8–29 billion annually.

20. T EAM STEPPS 05.2 Mod 1 05.2 Page 20 ValleyCare Mod 1 06.2 Page 20 ™ 20 JCAHO Sentinel Events

21. T EAM STEPPS 05.2 Mod 1 05.2 Page 21 ValleyCare Mod 1 06.2 Page 21 ™ 21 (Mann, 2006) Beth Israel Deaconess Medical Center Contemporary OB/GYN (Sexton, 2006) Johns Hopkins (Pronovost, 2003) Johns Hopkins Journal of Critical Care Medicine

22. T EAM STEPPS 05.2 Mod 1 05.2 Page 22 ValleyCare Mod 1 06.2 Page 22 ™ 22 TeamSTEPPS Key Principles Team Structure Leadership Situation Monitoring Mutual Support Communication

23. T EAM STEPPS 05.2 Mod 1 05.2 Page 23 ValleyCare Mod 1 06.2 Page 23 ™ 23 Paradigm Shift to Team System Approach Dual focus (clinical and team skills) Team performance Informed decision-making Clear understanding of teamwork Managed workload Sharing information Mutual support Team improvement Team efficiency Single focus (clinical skills) Individual performance Under-informed decision-making Loose concept of teamwork Unbalanced workload Having information Self-advocacy Self-improvement Individual efficiency

24. T EAM STEPPS 05.2 Mod 1 05.2 Page 24 ValleyCare Mod 1 06.2 Page 24 ™ 24 High-Performing Teams Teams that perform well: Hold shared mental models Have clear, valued, and shared vision Have strong team leadership Engage in a regular discipline of feedback Develop a strong sense of collective trust and confidence Optimize resources Have clear roles and responsibilities Create mechanisms to cooperate and coordinate Manage and optimize performance outcomes (Salas et al. 2004)

25. T EAM STEPPS 05.2 Mod 1 05.2 Page 25 ValleyCare Mod 1 06.2 Page 25 ™ 25 Why Teamwork? “High-performance teams create a safety net for your healthcare organization as you promote a culture of safety."

26. T EAM STEPPS 05.2 Mod 1 05.2 Page 26 ValleyCare Mod 1 06.2 Page 26 ™ 26 Organize the team Articulate clear goals Make decisions through collective input of members Empower members to speak up and challenge, when appropriate Actively promote and facilitate good teamwork Skillful at conflict resolution Effective Team Leaders

27. T EAM STEPPS 05.2 Mod 1 05.2 Page 27 ValleyCare Mod 1 06.2 Page 27 ™ 27 A Continuous Process Situation Monitoring (Individual Skill) Situation Awareness (Individual Outcome) Shared Mental Model (Team Outcome)

28. T EAM STEPPS 05.2 Mod 1 05.2 Page 28 ValleyCare Mod 1 06.2 Page 28 ™ 28 Cross Monitoring

29. T EAM STEPPS 05.2 Mod 1 05.2 Page 29 ValleyCare Mod 1 06.2 Page 29 ™ 29 Shared Mental Model?

30. T EAM STEPPS 05.2 Mod 1 05.2 Page 30 ValleyCare Mod 1 06.2 Page 30 ™ 30 What Do You See?

31. T EAM STEPPS 05.2 Mod 1 05.2 Page 31 ValleyCare Mod 1 06.2 Page 31 ™ 31 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!” Task Assistance

32. T EAM STEPPS 05.2 Mod 1 05.2 Page 32 ValleyCare Mod 1 06.2 Page 32 ™ 32 Characteristics of Effective Feedback Good Feedback is— TIMELY RESPECTFUL SPECIFIC DIRECTED toward improvement Helps prevent the same problem from occurring in the future CONSIDERATE FIRST HAND encouraged “Feedback is where the learning occurs.”

33. T EAM STEPPS 05.2 Mod 1 05.2 Page 33 ValleyCare Mod 1 06.2 Page 33 ™ 33 CHAIN EXERCISE

34. T EAM STEPPS 05.2 Mod 1 05.2 Page 34 ValleyCare Mod 1 06.2 Page 34 ™ 34 Using the materials in front of you, create a paper chain with the most links. You may only use your non-dominant hand AND you cannot speak. You have 2 minutes to create this chain.

35. Strategies and Tools to Enhance Performance and Patient Safety ™ TOOLS

36. T EAM STEPPS 05.2 Mod 1 05.2 Page 36 ValleyCare Mod 1 06.2 Page 36 ™ 36 Leadership Tools ™

37. T EAM STEPPS 05.2 Mod 1 05.2 Page 37 ValleyCare Mod 1 06.2 Page 37 ™ 37 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

38. T EAM STEPPS 05.2 Mod 1 05.2 Page 38 ValleyCare Mod 1 06.2 Page 38 ™ 38 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

39. MUTUAL SUPPORT Conflict Resolution Tools ™

40. T EAM STEPPS 05.2 Mod 1 05.2 Page 40 ValleyCare Mod 1 06.2 Page 40 ™ 40 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 “Empower any member of the team to “stop the line” if he or she senses or discovers an essential safety breach.” If the outcome is still not acceptable: Take a stronger course of action Use supervisor or chain of command

41. T EAM STEPPS 05.2 Mod 1 05.2 Page 41 ValleyCare Mod 1 06.2 Page 41 ™ 41 Please Use CUS Words but only when appropriate!

42. Communication Tools Assumptions Fatigue Distractions HIPAA ™

43. T EAM STEPPS 05.2 Mod 1 05.2 Page 43 ValleyCare Mod 1 06.2 Page 43 ™ 43 R-SBAR “I am concerned about………” “I need you to come in now because….” 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…

44. T EAM STEPPS 05.2 Mod 1 05.2 Page 44 ValleyCare Mod 1 06.2 Page 44 ™ 44 Check-Back is…

45. T EAM STEPPS 05.2 Mod 1 05.2 Page 45 ValleyCare Mod 1 06.2 Page 45 ™ 45 Team Effectiveness TOOLS and STRATEGIES Brief Huddle Debrief STEP Cross Monitoring Feedback Advocacy and Assertion Two-Challenge Rule CUS 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

46. T EAM STEPPS 05.2 Mod 1 05.2 Page 46 ValleyCare Mod 1 06.2 Page 46 ™ 46 Perinatal Safety Program ■ Mandatory Team STEPPS Training ■ Mandatory Simulation Training ■ Implementation of Laborist Program ■ Leadership Rounds ■ Quality Initiatives ● Intradepartmental Performance Improvement ● Peer Review ● Case Conferences ■ Mandatory Debriefing

47. T EAM STEPPS 05.2 Mod 1 05.2 Page 47 ValleyCare Mod 1 06.2 Page 47 ™ 47 Team STEPPS Team Assessment Questionnaire “The team is a safety net for patients.” Pre Team STEPPS training Post Team STEPPS training

48. T EAM STEPPS 05.2 Mod 1 05.2 Page 48 ValleyCare Mod 1 06.2 Page 48 ™ 48 Hospital Survey on Patient Safety Culture 2011 Composite Report - MCH Patient Safety Culture Composites Average % Positive 2009 AHRQ n=196,462 2011 AHRQ n=472,397 2009 ValleyCare n=600 2011 ValleyCare n=593 2009 MC n=68 2011 MC N=41 1. Teamwork Within Units79%80%85%82%90%92% 2. Supervisor/Manager Expectations & Actions Promoting Patient Safety75% 76% 85%89% 3. Organizational Learning—Continuous Improvement71%72%76%78%90%86% 4. Management Support for Patient Safety70%72%74%78% 89% 5. Overall Perceptions of Patient Safety64%66%62%69%71%73% 6. Feedback & Communication About Error63%64%62%67%72%76% 7. Communication Openness62% 59%62%66% 8. Frequency of Events Reported60%63%57%60% 72% 9. Teamwork Across Units57%58%60%64%69%71% 10. Staffing55%57%49%57%64%57% 11. Handoffs & Transitions44%45%42%45%54%56% 12. Nonpunitive Response to Error44% 35%39%41%50%

49. T EAM STEPPS 05.2 Mod 1 05.2 Page 49 ValleyCare Mod 1 06.2 Page 49 ™ 49

50. T EAM STEPPS 05.2 Mod 1 05.2 Page 50 ValleyCare Mod 1 06.2 Page 50 ™ 50 Hospital Survey on Patient Safety Culture 2011 Item Level Report - MCH 2009 AHRQ Averag e Percent Positiv e (n=196, 462) 2011 AHRQ Averag e Percent Positiv e (n=472, 397) 2009 ValleyC are Averag e Percent Positiv e (n=600) 2011 ValleyC are Averag e Percent Positiv e (n=593) 2009 MCH Averag e Percent Positiv e (n=68) 2011 MCH Averag e Percent Positiv e (n=41) TEAMWORK WITHIN UNITS 1. People support one another in this unit. (A1)85%86%93%89%97%100% 2. When a lot of work needs to be done quickly, we work together as a team to get the work done. (A3)86% 90%88%96%98% 3. In this unit, people treat each other with respect. (A4)78% 86%81%93%90% 4. When one area in this unit gets really busy, others help out. (A11)68%69%72%73%76%80%

51. T EAM STEPPS 05.2 Mod 1 05.2 Page 51 ValleyCare Mod 1 06.2 Page 51 ™ 51 COMMUNICATION OPENNESS 1. Staff will freely speak up if they see something that may negatively affect patient care. (C2)76% 80%84%83% 2. Staff feel free to question the decisions or actions of those with more authority. (C4)47% 43%44%52%53% 3. Staff are NOT afraid to ask questions when something does not seem right. (C6)63% 59%61%62%61%

52. T EAM STEPPS 05.2 Mod 1 05.2 Page 52 ValleyCare Mod 1 06.2 Page 52 ™ 52 TEAMWORK ACROSS UNITS 1. Hospital units coordinate well with each other. (F2)45%46%44%51%49%59% 2. There is good cooperation among hospital units that need to work together. (F4)58%59%63%67%78%71% 3. It is often pleasant to work with staff from other hospital units. (F6)58%59%63%62%69%76% 4. Hospital units work well together to provide the best care for patients. (F10)67%68%69%77%78%80%

53. T EAM STEPPS 05.2 Mod 1 05.2 Page 53 ValleyCare Mod 1 06.2 Page 53 ™ 53 ValleyCare’s Key Success Factors Strong Need for Team Approach Identified Support From Senior Administration Support From Department Leadership Support From Physician Champions Support From Ancillary Department Leadership Support From Staff Staff Buy In Strength in Numbers-Multidisciplinary Core Team

54. T EAM STEPPS 05.2 Mod 1 05.2 Page 54 ValleyCare Mod 1 06.2 Page 54 ™ 54 The Journey Continues…