Patient Safety through Team Training in Healthcare

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Patient Safety through Team Training in Healthcare

• Stephen A. Knych, MD, MBA
• Division Chief, Patient Safety and Quality
• Office 407-303-4607

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On 9/11/01 The World Changed

• We Cannot
• Wait for perfect information
• Stay in your stovepipes
• Be complacent again
• Forget about lessons learned
• Debate and delay the issues
• Marginalize solutions
• Dwell on constraints or concerns

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Patient Safety Scope of Problem

• Human Costs
• Estimated as many as 44,000 to 98,000 deaths each
  year
• More than motor vehicle accidents, breast cancer
  and AIDS combined annually
• The total number of deaths that would occur if a
  747 airplane crashed killing all aboard every
  other day for one year!
• Source To Err is Human, Institute of Medicine,
  1999
• Source Newhouse et.al., Measuring Patient
  Safety, 2005

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Patient Safety

• Financial Cost of Medical Errors 29 billion
  each year in the United States alone
• Doctors, patients, insurers and hospital systems
  play a role in eradicating errors

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Patient Safety Scope of the Problem

• 1 out of every 5 people says that they or a
  family member experienced a medical mistake
• 51 reported the error as serious
• 28-35 of admissions experience an event that
  causes HARM ( IHI, Dec 2007, Global Trigger
  Tool, Roger, Resar, MD)
• Source Commonwealth Fund 2001 Health Care
  Quality Survey

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Patient Safety CMS Actions

• Serious preventable eventobject left in place
  during surgery
• Serious preventable eventair embolism
• Serious preventable eventblood incompatibility
• Catheter-associated urinary tract infections
• Pressure ulcers (decubitus ulcers)
• Vascular catheterassociated infection
• Surgical site infectionmediastinitis after
  coronary artery bypass graft surgery
• Hospital-acquired injuries fractures,
  dislocations, intracranial injuries, burn

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Patient Safety Leadership Role

• Our systems are too complex to expect merely
  extraordinary people to perform perfectly 100
  percent of the time. We as leaders have a
  responsibility to put in place systems to support
  safe practice.
• .90 X .90 X .90 X .90 .65 or 65
• Law of Composite Reliability
• Leadership Guide to Patient Safety, Institute for
  Healthcare Improvement, 2005
• James Conway, former VP and COO of the
  Dana-Farber Cancer Institute
• Frederick Ryckman, MD, Cincinnati Childrens
  Hospital

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Patient Safety Culture

• System of shared values (what is important) and
  beliefs (how things work) that interact with a
  company's people, organizational structures, and
  control systems to produce behavioral norms (the
  way we do things around here).
• Websters Dictionary online

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Team Training - Why Now?

• Significant performance gaps
• Sentinel Events
• Baldrige requires aligned, systematic and fully
  deployed approach
• Growing regulatory national expectations
• Patient Experience on Public Web
• Joint Commission Leadership Std 2009
• NQF Safe Practice 1.3 Requirement
• IHI 5 million Lives Campaign
• CMS New Scope of Work
• ACGME and Professional Organizations

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What is the Evidence?

• Teamwork is a key initiative within patient
  safety that can transform the culture within
  health care
• 27 reduction in nurse turnover (Dimeglio, 2005)
• 31 to 4 decrease in clinical error (Morey,
  2002)
• Communication other teamwork skills are
  essential to prevent mitigate medical errors
  and harm
• 50 Less Adverse Outcomes (Mann 2006)
• 50 Less Post-Op sepsis (Sexton 2006)

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RESULTS OF TEAMWORK IN THE HEALTHCARE ENVIRONMENT
(Sexton, 2006) Johns Hopkins
(Pronovost, 2003) Johns Hopkins Journal of
Critical Care Medicine
(Mann, 2006) Beth Israel Deaconess Medical
Center Contemporary OB/GYN
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Believe that decisions of the leader should not
be questioned
Surgeons
Pilots
Sexton, BMJ, 2000
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TEAM FUNCTION SAFETY

• WORST TEAM
• Most experienced surgeon
• Team members changed
• No (de)briefing
• No tracking of results
• No preplanning
• Hierarchical
• Bohmer, R. Harvard Bus.School

• BEST TEAM
• Least Experience Surgeon
• Cohesive Team
• Simulation
• Pre case planning
• Debriefing
• Results tracked
• Removed hierarchy

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High-Performing Teams

• Teams that perform well
• Hold shared mental models
• Have clear roles and responsibilities
• Have clear, valued, and shared vision
• Optimize resources
• Have strong team leadership
• Engage in a regular discipline of feedback
• Develop a strong sense of collective trust and
  confidence
• Create mechanisms to cooperate and coordinate
• Manage and optimize performance outcomes
• (Salas et al. 2004)

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Definition of a Team

• Two (2) or more individuals with specific tasks
  that are interdependent who cooperate and
  coordinate their activities, able to adapt and
  have a shared end goal

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Why TeamSTEPPS

• 5 to 7 years DOD world-wide experience
• Civilian Spread funded by AHRQ
• Master TeamSTEPPS Training Free
• National Network
• All Education Material provided at cost
• Based on Evidence-Based Practices
• Growing national recognition and movement toward
  TeamSTEPPS
• Florida Hospital joins Pacesetting Hospitals
• UCF-Ed Salas expert mentor and consultant

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Outcomes of Team Performance

• Knowledge
• Shared Mental Model
• Attitudes
• Mutual Trust
• Team Orientation
• Performance
• Adaptability
• Accuracy
• Productivity
• Efficiency
• Safety

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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 Hand
off

• 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

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TeamSTEPPS
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Impact Evaluation

• In FY 08-09, TeamSTEPPS will
• Continue to collect quantitative data for Level 1
  and Level 2
• evaluation
• Develop and implement standardized Level 3 4
  assessment
• tools
• Include sustainment as part of system-wide
  evaluation

Level 5 Return on Investment Was the training
worth the cost?
Kirkpatricks Model
Level 4 Results Did the change in behavior
positively affect the organization?
Level 3 Behavior / Training Transfer Did the
participants change their behavior on-the-job
based on what they learned?
Level 2 Learning What skills, knowledge, or
attitudes changed after training? By how much?

• Level 1 Reaction
• Did the participants like the training?
• What do they plan to do with what they learned?

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TeamSTEPPS Pilot/Research Project at Celebration
Health

• Current Status report from the work of the FH
  (system, CH, WP) and UCF Research Teams

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Celebration HealthOR Pilot Milestones

• Assessment/Project Charter/Metrics Feb
• Baseline Observations Mar
• Instructor Training Mar
• Coach/Mentor Training- Mar
• Start Project Apr
• On-Going Observations Apr - Dec
• Complete Pilot Project Dec 2008

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Phased Implementation

• Phase 1 (April June)
• OR wheels in to wheels out
• Mon Fri, 730 330 start times
• General Surgery, Orthopedic, Bariatric Surgical
  Teams
• Phase 2 (July August)
• Disseminate to all surgeons
• 24/7 includes all cases, emergent, weekend,
  holiday
• Phase 3 (handoffs transitions) (Aug Dec)
• Pre-op to OR
• OR to PACU

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TeamSTEPPS Current Status

• Phase 1 baseline completed
• 3 complete surgical teams trained
• Orthopaedics, Bariatric Surgery, Minimally
  Invasive General Surgery teams
• 4 hours of Fundamentals Training
• 3 surgeons, 1 PA, 1 First Assist
• 6 nurses and scrub techs
• 18 anesthesiology providers (CRNA/MD)
• 35 CH Council members 1hr Essentials
• FH sent 13 people for 2.5 day Master Trainer
  Certification

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TeamSTEPPS Current Status

• Phase 1 baseline completed
• Observations of 30 surgical cases at CH and 30
  surgical cases at WP (control group)
• Baseline surveys included
• AHRQ Patient Safety Culture Survey
• ORMAQ (assess attitudes towards teamwork and
  current perceptions of teamwork)
• Stress
• Job satisfaction
• Others

Operating Room Management Attitudes
Questionnaire (ORMAQ)
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TeamSTEPPS Current Status

• TeamSTEPPS training completed - General reactions
  were positive

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TeamSTEPPS Current Status

• Trainee comments included
• Better ways to collaborate and facilitate
  communication.
• Improving communication, decreasing barriers
  based upon hierarchy.
• Great training - needs to be given to all staff
  - mostly surgeons
• More interaction and exercise hearing about
  it, is way different than performing it.
• Did training meet your expectations, why or why
  not?
• Yes. Good information. Patient safety is our
  ultimate goal. It needs to be preserved above
  all.
• Yes, it actually exceeded my expectations since
  practical examples were used throughout.

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TeamSTEPPS Current Status

• What we Learned
• OR team members do find TeamSTEPPS training
  helpful and find the concepts viable for their
  work.
• Simulation or practice is important to training
  effectiveness and perceptions of trainees that
  they are ready to implement teamwork behaviors
  covered in training in the OR.
• It is vital the physicians champion training
  efforts with their team, their buy-in is crucial
  to success.

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TeamSTEPPS Current Status

• Next Steps
• Impact of training on culture, stress, teamwork
  perceptions and actual behavior in the OR will be
  analyzed in August
• Cost Analysis is underway for current Project
• Follow up is scheduled for Oct-Nov 2008. It will
  consist of observations and surveys
• 2009
• Spread to different location and/or service line?
• Continue evaluation at different location and/or
  service line?
• Implement simulation as part of future training
  roll-out
• Implement formalized coaching plan for future
  roll-out
• Develop a GLITCH database for system-wide use

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Patient Safety

• Knowing is not enough we must apply. Willing is
  not enough we must do
• Goethe

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QUESTIONS?

• THANK YOU FOR THE INVITATION TO SPEAK TO YOU
  TODAY!