1. Teamwork and Transparency
Jill Marsteller, PhD, MPP
David Thompson, DNSc, MS, RN
On the CUSP: Stop BSI
Tuesday, February 9, 2010

2. Learning Objectives You should be able to
Explain transparency and the need for it in this project
Describe importance of strong teamwork on CUSP/CLABSI team and in unit generally
Provide examples of teamwork-enhancing tools 2

3. Transparency Make harm visible Need to share data with Share stories
Discuss BSI rates
Link to patients
Need to share data with
The unit
Executive partner
Board
Transparency-- Making project and progress visible to everyone; being open about mistakes/ errors/ BSI rates
Stories can be of things identified and resolved from asking how the next patient will be harmed. This is great to continue to keep everyone engaged informed of the units progress. Share your data where staff can see their progress. 3

4. Transparency Track progress visibly
Bulletin boards that show improvements
Memos
Announcements at meetings
Milestone celebrations
Recognition of people’s efforts
Frequent reminders, keep in the front of caregivers’ minds
Transparency Making project and progress visible to everyone—try run charts with a goal line (NC suggests labelling with team name); perhaps use data from Team Checkup Tool (e.g., staff use with markers for different interventions tried); for DG sheet, try tracking pages 4

5. Percent Understanding Patient Care Goals
This is just an example of the kind of chart you could make to keep progress visible 5

6. Transparency’s Link to Teamwork
Be open about issues and problems, challenges
Confront the elephant in the room
Be explicit about sharing a common goal
Admit we all need each other
Starting conversations as "safety is our top priority and to keep the patients safe we have designed a daily goals sheet where we look at safety concerns each shift. If you have a safety concern for your patient we want you to speak up." 6

7. Available Tools to Enhance Transparency
Executive Senior Leader Checklist
Infection Preventionist Checklist
Weeks with CLABSI Banner
Staff Safety Assessment
Team Check Up Tool
Central Line Audit Forms

8. Teamwork Effective communication Situational awareness
Closed loop communication/active listening
Responsiveness of team members
Communication skill set
Situational awareness
Shared mental model
Mutual support
Teamwork and communication tools
Responsiveness is a member that answers your request, phone calls and s. If you never get a response or it is extremely late- you are not dealing with a team player. Don’t let conflict about care be personal. It is not who is right or wrong but what is best for the patient.
Your communication skill set should include conflict management, assertion and the ability to listen until the other team member is finished speaking. Interruptions do not provide for closed loop communication. Effective communication usually requires that you have someone’s attention and you are making eye contact. If you are walking away while still talking you have not been the most effective. CUSP teamwork tools are a big start but there are smaller things that we should be doing everyday that I will discuss. 8

9. Communication Breakdowns are frequently the root cause of…
undesirable outcomes
Communication is a big component of Teamwork. As you can see poor communication is responsible for many undesirable outcomes. When we talk about teamwork we need a place to start. In most of our past nursing and medical education--- teamwork, communication and it components such as assertion were not include in the curriculum Where do we start. Next slide. 9

10. Teamwork Climate Across Michigan ICUs
% of respondents within an ICU reporting good teamwork climate
These were participants in the Michigan collaborative. a lot of variability and only 4 units at the 80% mark. You have seen other slides that showed at the start 80 percent needed improvement at year one but by year 3 only 20 % needed improvement.

11. Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence:
caregivers feel comfortable speaking up if they perceive a problem with patient care
% of respondents within an ICU reporting good teamwork climate
You can then see that one of the biggest predictors of CLABSI was an effective teamwork function. “The ability to speak up when there was a patient issue”
No BSI 21%
No BSI 44%
No BSI 31%
No BSI = 5 months or more w/ zero

12. Impact on Healthcare ‘Caregiver interaction’ aka effective teamwork
Reduced length of stay
Lower nurse turnover
Higher quality of care
Greater ability to meet family member needs
(Shortell et al, Med Care;1994: )
Stephen Shortell and colleagues looked at ‘caregiver interaction’ --culture, leadership, coordination, communication and conflict management abilities and found that good interaction was strongly associated with
Reduced LOS
Lower nurse turnover
Higher quality of care
And greater family satisfaction 12

13. Impact on Healthcare
Effective teamwork in ICU reduced risk of readmission or death--16% to 5% (Baggs, Heart Lung 1992;21:18-24.)
Ineffective collaboration & communication in OR = retained sponges, mismatched blood transfusion & wrong extremity nerve blocks (Gawande, NEJM 2003;348: Edmonds, Reg Anesth Pain Med 2005;30: Gibbs, AHRQ report 2001;2557.)
Good and bad collaboration has a tremendous impact on patient and staff outcomes.
1. Prospective study of nurse and resident teamwork while deciding whether to transfer patients out of the MICU. Effective teamwork was associated with a decreased risk from 16% to 5% for death or MICU readmission
3 recent studies found that poor collaboration and communication resulted in retained sponges after surgery, mismatched blood transfusions and wrong extremity nerve blocks
Data from a current collaborative in 108 Michigan ICUs shows that good teamwork—especially the ability to speak up with concerns—strongly correlates with reduced blood stream infection rates 13

14. Percent Understanding Patient Care Goals
Here you can see the our house officers and nurses were never on the same page as far as goals for the patient. The simple teamwork tool of Daily goals had a tremendous impact on both knowledge and outcomes (next slide) 14

15. Impact on ICU Length of Stay
Daily Goals
Reduce 1 day form length of stay, allowing more admission and more revenue. So there are effective ways to manage teamwork issues.
654 New Admissions: 7 Million Additional Revenue 15

16. What Are the Required Teamwork Competencies?
Skill requirements in teams:
Mutual performance monitoring and adaptability
Supporting/back-up behavior
Team leadership
Task-related assertiveness
Conflict resolution
Closed-loop communication
Knowledge of how to get knowledge is vital to our success- policies and procedures, the local intranet,
Staff not to take it personally when another members identifies something is incorrect with orders etc. We should appreciate that we have prevented errors. We are all watching each others’ backs.
This includes task related assertiveness. Which includes nurse empowerment to stop a procedure and support for any team member that has to speak. Story of Dr. Ed Miller and Line placement. 16

17. Strategies to achieve a
“shared mental model”
What we can do to stay on the same page…
Individual Strategies
Situation Monitoring
Group Strategies
Environmental
support
Brief
Debrief
Huddle
Meetings
Documentation
Hand-offs
Call Out
Know the patient care plan
Active listening
Read back
Verify
Cross monitoring
Self monitoring
Visual management tools
Checklists
Distraction control
Technology aids
These are examples of techniques to Improve Situational Awareness and Our Ability to Communicate as an effective team member. This slide is taken from team stepps and modified to identify activities or methods that we have been using here at JH for several years. We are all situation monitors in the clinical area. Our ability to use these techniques allows us to be both transparent in our actions while improving overall team situational awareness.
From NC--individual team member take responsibility for his/her ability to perform the job responsibilities safely. E.g., when they are fatigued should communicate to coworkers to keep them in a safe place. 17

18. Situational Awareness
Members of the team have an understanding of “what’s going on” and “what is likely to happen next.”
Teams are alert to developing situations, sensitive to cues and aware of their implications.
Interpreting cues- change in patient, problem that exists that may require an intervention or decision.- YOU must appreciate the cues significance
Based on knowledge and experience from similar situations We will call these yellow or red flags because they indicate caution or something is out of order 18

19. Situational Awareness
Focus is
Preparation/planning and vigilance
Workload distribution
Distraction avoidance
In Healthcare this is traditional planning of care, vigilance in the monitoring of our patient-systems. The goal is to have a shared mental model. All members of the team informed equally. When you are all informed and everyone is allowed to speak up to keep everyone situationally aware-you are being transparent.
Distraction avoidance in acute situation- but general personal conversation when there is time builds the team. Examples 19

20. Elements That Affect Situational Awareness
Interruptions
Task absorption
Verbal abuse
Fatigue
Not following plan of care
Ambiguous orders/directions
Change in team member
Work load
Skill level 20

21. Improving Situational Awareness
Know the game plan – through briefings and team management (e.g., workload & workflow management, task coordination)
Anticipate next steps and possible events
Follow known policies and procedures
Cross-check and verify
Provide ongoing updates – call-outs, cross-talk, and briefings
Implement team huddles
Not cook book medicine- Most policies and procedures are evidence based, although some are preferences and or standards set within the hospital. 21

22. Team Huddle
Pulling together members of the team to review patient data and decide on the course of action
Can be prearranged like evening rounds or as needed when a patient’s condition requires a change in course of action
May involve strategies to plan oversight, physician availability
ANYONE CAN ASK FOR A TEAM HUDDLE, ANYTIME 22

23. Active Listening Focused on the speaker
“Actively” listening and processing the information being presented
Used to retain information and gain knowledge
Goal: The ability to repeat the sender’s message-“read back” 23

24. Cross Monitoring
Process of monitoring the actions of other team members for the purpose of sharing the workload and reducing or avoiding errors
Mechanism to help maintain accurate situation awareness
Way of “watching each other’s back”
Ability of team members to monitor each other’s task execution and give feedback during task execution
Mutual performance monitoring has been shown to be an important team competency.
(McIntyre and Salas 1995) 24

25. Call Out
Statements of action or description of what you are seeing to keep people informed:
“The patient is experiencing runs of v-tach despite the medication…”
Can be used for routine care such as checking an alarm
Can be used during a procedure or arrest situation to let members of the team know what has been completed 25

26. Briefing Defined
A briefing is a discussion between two or more people, often a team, using succinct information pertinent to an upcoming event.
What the briefing does is Map out the plan of care.
Identify Roles and Responsibilities for each team member .
Heightens awareness of the situation.
Allows the team to plan for the unexpected.
5. Team members needs, and expectations are met. 26

27. SITUATION driven-Structure based
The SBAR Briefing
SITUATION driven-Structure based
Situation - Current situation that needs reporting
Background - Pertinent history and treatment
Assessment - Diagnosis of categorization of the current situation
Recommendation - Proposed plan of care
This comes to us from the DOD, navy, adopted by aviation in CRM- then Kaiser Permanente
This is very short and succinct. A standard format to be used over and over.
Focused on one situation. Can be used by RN’s, residents, house officers anyone needing to seek higher level direction/orders. 27

28. Conflict Resolution Tools
DESC script (Describe, Express, Specify, Consequences)
Two-challenge rule
Mediation 28

29. What makes up an effective team?
Effective Team Members
Effective Team Leaders
Healthy and productive interactive process

30. Another way of looking at it
Any team member may be called upon to be leader in a given situation/or subpart of the effort.
Designated team leaders are always team members at the same time.
Effective Team Members
Effective Team Leaders

31. Effective team member-leaders
Organize the team
Articulate clear goals
Make decisions through collective input of members
Empower members to speak up and challenge
Actively promote and facilitate good teamwork
Assist in conflict resolution
Members
Understand their role
Agree on the goals
Provide input to decisions, assert their case
Speak up and challenge
Actively promote and facilitate good teamwork
Be open to conflict resolution 31

32. Effective team member-leaders
Share information openly
Act as role models and cue team members to use teamwork skills
Offer constructive and timely feedback
Facilitate briefings, huddles, debriefs, and conflict resolution
Members
Share information openly
Use teamwork skills and cue other team members to also do so
Offer constructive and timely feedback
Participate actively in briefings, huddles, debriefs, and conflict resolution 32

33. Effective team member-leaders
Initiate planning and include team members
Delegate tasks
What, to whom
State clear expectations
Ask for feedback
Facilitate conflict resolution
Two-attempt rule
DESC script
Helping team members practice techniques
Serving as a mediator
Members
Contribute to planning process, initiate subparts of the plan
Accept delegation, be accountable, provide feedback
Practice and use conflict resolution techniques
Mediate among coworkers informally 33

34. Key Benefits of Effective Teamwork
Ability to predict the needs of other team members/fewer surprises
Decisions use better, complete information
Conflict management provides more pleasant environment/fewer hurt feelings and grudges
Better accountability for team performance
Reduced stress on the team as a whole
Better experience for patients/improved safety 34

35. Available Resources to Improve Team Communication
Science of Safety Video
CUSP Toolkit:
Staff Safety Assessment
Daily Goals Checklist
Safety Issues Worksheet
Culture Check-up Tool
Team Stepps

36. AHRQ Team Stepps