aha/hret hen improvement leader fellowship, wave … wave 2... · aha/hret hen improvement leader...
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AHA/HRET HENImprovement Leader Fellowship, Wave 2:
San Francisco
The Use of TeamSTEPPS to Prevent High Priority HarmsThursday, August 2, 2012
Welcome and Introductions
• Bruce Spurlock, MD– Physician Advisor, Cynosure Health
• Ross Ehrmantraut, RN, CCRN– Chief Safety Officer, Harborview Medical Center
• Ken Plitt, CRNA, MBA– Institute for Simulation and Interprofessional Studies (ISIS), University of Washington
• Jessica Blake, LSW, MA– Senior Program Manager, HRET
• Cheryl Ruble, RN, MS, CNS– Improvement Advisor, Cynosure Health
• Kim Werkmeister, RN, BA– Improvement Advisor, Cynosure Health 2
3
Agenda
• Team exercise• Recap of the Preconference webinar (July 26)• Review TeamSTEPPS, as an application for PFP goals
– Discuss why teamwork matters– Highlight TeamSTEPPS, and how TeamSTEPPS’ concepts and tools can help:• Increase team improvement capacity• Reduce harm
• Connect the dots . . . between project PDSA cycles and TeamSTEPPS, for sustainability and spread (Wave 3)
Team Exercise
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Key Elements of the Preconference Webinar
• During the Preconference webinar, we: – Recapped the Partnership for Patients (PfP) goals
– Reviewed the Fellowship timeline (where Fellows lie in their Improvement Capacity journey)
– Previewed Wave 2– Previewed TeamSTEPPS, as an application for PFP goals
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Polling Results
• During the Preconference webinar, we also polled attendees per the following two questions: 1) Our current (quality improvement) teamwork is:A. Very good – 20%B. Good – 53.3%C. Fair – 24%D. Poor – 2.7%E. Very poor – 0%
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Polling Results
2) What is your experience‐level with TeamSTEPPS? A. Experienced (Master Trainer) – 6.9%B. Knowledgeable (not a Master Trainer,
but familiar with modules, tools, etc.) – 19.5%
C. New to TeamSTEPPS (not familiar with modules, tools, etc.) – 73.6%
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TeamSTEPPS Tools:Worksheet Results
In addition, we assigned you a task: to think about the tool(s) that you wanted to discuss / use per your (1) general teamwork and communication issues; and (2) for your focused areas(s) of harm.
1. Brief
2. Huddle
3. Debrief
4. STEP
5. Cross Monitoring
6. Feedback
7. Advocacy and
Assertion
8. Two‐challenge Rule
9. CUS
10. DESC Script
11. Collaboration
12. SBAR
13. Call‐Out
14. Check‐Back
15. Handoff
Why Does Teamwork Matter
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• Teamwork matters, as highlighted below, and we want to ensure that we equip Fellows with effective tools to allow your teams to function at their highest level. Key reasons why teamwork matters, include: – Poor communication and teamwork is the most common root cause of patient harms
– Poor teamwork is source of job dissatisfaction, burnout and employee turnover
– Teamwork is not the focus of most clinical education efforts, so few staff are well equipped to work as teams
– Teamwork is linked to outcomes that hospitals focus on most, such as lower:• HCAHPS scores• Safety culture scores
Institute of Medicine(IOM) Report
This report lays out a comprehensive strategy by which government, health care providers, the industry and consumers can reduce preventable medical errors. The reports goes on to say that there should be a minimum goal a 50 percent reduction in errors over the next five years, concluding that the know‐how already exists to prevent many of these mistakes.
November, 1999
“…approximately 100,000 patients die inthe hospital each year from medicalErrors, and 72 % resulted fromcommunication errors…”
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… and all of us in this room are keenly aware of the IOM Report in relation to communication errors:
Where is the Evidence?
Indemnity Experience
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11
0
5
10
15
20
25
Malpractice Claims, Suits, and Observations
Pre-Teamwork Training Post-Teamwork TrainingAdverse Outcomes
50%Reduction
50%Reduction
(Mann, 2006) Beth Israel Deaconess Medical CenterContemporary OB/GYN
1
1.2
1.4
1.6
1.8
2
2.2
2.4
June July August Sept Oct Nov Dec Jan Feb March April May
Avg
. Len
gth
of S
tay
(day
s)
Length of ICU Stay After Team Training
50% Reduction
OR Teamwork Climate and Postoperative Sepsis Rates (per 1000 discharges)
Group Mean
Low Teamwork Climate
Mid Teamwork Climate
High Teamwork Climate
0
2
4
6
8
10
12
14
16
18
AHRQ National Average
Teamwork Climate Based on Safety Attitudes Questionnaire
Low High
(Sexton, 2006)Johns Hopkins
(Pronovost, 2003)Johns HopkinsJournal of Critical Care Medicine
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TeamSTEPPS
Strategies and Tools to Enhance Performance and Patient Safety
What is TeamSTEPPS, and How Can it be Applied to HEN?
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• Free, public use application of principles of crew resource management optimized for health care teams
– Developed by Department of Defense’s (DoD’s) Patient Safety Program, in collaboration with Agency for Healthcare Research & Quality (AHRQ)
– Supported by 20 years of research on the impact of teamwork on broad range of quality and safety outcomes, including safety culture, staff and patient satisfaction
• Modular materials that include:– Resources for a variety of care settings and faculty – Tools to address teamwork challenges relevant to ten clinical topics HENs are targeting
TeamSTEPPS Resources
• http://teamstepps.ahrq.gov/abouttoolsmaterials.htm– Complete user guides– Downloadable video vignettes– Newly developed modules
• HRET, and partners Booz Allen Hamilton and IMPAQ providing implementation support:– TeamSTEPPS 2.0– Master Training: http://register.rcsreg.com/r2/hret2012/ga/top.html
– TeamSTEPPS User Portal:http://teamsteppsportal.com/
– User Support Network 14
TeamSTEPPS Resources: User Support Network
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What are the Components of TeamSTEPPS?
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… But more important – how can the concepts help
improve our work in HEN?
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Components of Team Performance
KnowledgeCognitions“Think”
…team performance is a science…consequences of errors are great…
AttitudesAffect“Feel”
SkillsBehaviors“Do”
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
TOOLS & 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!!
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Core Competencies of Highly Performing Teams
Leadership
Mutual Support
CommunicationSituationMonitoring
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Leadership
Mutual Support
Communication SituationMonitoring
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Leadership
Mutual Support
Communication SituationMonitoring
SHAREDMENTALMODEL
Shared Mental Model
A shared knowledge and understanding, e.g. a shared mental model about a patient or patient plan amongst a healthcare team.
• Provides common understanding of the situation, task responsibilities and information requirements
• Allows team members to anticipate one another’s needs so they can work synchronously
. . . for the benefit of the patient!! 22
What is a Shared Mental Model?
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CommunicationProcess by which information is clearly and
accurately exchanged among the team members.
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Shared Mental Model???
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Good Clinical Care Requires Team Work
Otherwise Patient Care and Patient Safety Will Be De‐Railed
Good Communication is the Skill
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INTRA-TEAMCOMMUNICATIONINTRA-TEAMCOMMUNICATION
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INTER-TEAMCOMMUNICATIONINTER-TEAMCOMMUNICATION
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Effective Communication
Must be:• Complete: relevant information avoiding unnecessarydetail
• Clear: standard terminology, minimize an acronyms• Brief: be concise• Timely: avoid delays, verify, validate or acknowledge
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Information Exchange Strategies
• SBAR
• Call‐Out
• Cross‐Check
• Check‐Back
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SBAR provides…
A standardized 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/context)
• Assessment (what is the problem)
• Recommendation (what is the recommendation)
Remember to introduce yourself… 31
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Call‐Out
Tactic used to communicate or share information with the whole team; may be directed at a specific individual (often the team leader).
Two common situations:
1. Team member offering unrequested data/information– RN: “Latest BP is 80/50.”– Anesthesia provider arrival on scene: “Anesthesia is here.”
2. Data/information provided in response to a request:– Leader: “Airway status?” – Team member: “Airway clear.”– Leader: “Breath sounds?”– Team member: “Breath sounds decreased on right.” 33
Cross‐Check
Closed‐loop communication strategy used to verify a request is received. Sender initiates request or message, receiver confirms he/she has received the request.
Bob, the Team Leader says: “Joe, get me a blood gas.”
Joe, the Team Member cross‐checks: “Bob, I will get the blood gas.”
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A communication loop involving a sender initiating the message, and a receiver accepting the message and providing feedback that the task has been completed.
Check‐Back
• Resident to nurse: “ Bill, Call anesthesia.”
• Nurse confirms by saying:“Calling for Anesthesia.”
• Nurse checks back:“I have contacted Anesthesia” or“I have not been able to reach Anesthesia”
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Sender notified of task completion
Call‐Out
Check‐BackCross‐Check
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LeadershipAbility to coordinate the activities of team
members by ensuring team actions are understood,changes in information are shared and that team
members have the necessary resources.
Team Leader
Three types of leaders:
• Designated: The person assigned to lead and organize a designated core team, establish cleargoals and facilitate open communication andteamwork among team members
• Situational: Any team member who has theskills to manage the situation‐at‐hand
• Default: Tag – You’re it!!38
Team Leader Expectations
Organize & Prioritize
Articulate Clear Goals
Make Decisions
Empower Members to Speak Up
and Challenge
LEADERS ARE NOT DOERS
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TeamSTEPPS Leadership Skills
• Briefs – planning
• Huddles – problem solving
• Handoffs – transfer of care
• Debriefs – process improvement
Leaders are responsible to assemble the team and facilitate team events but . . .
anyone can request a brief, huddle or debrief
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FRAMEAssumptionsFeelingsKnowledge BaseSituation AwarenessContext
ACTIONSVerbalPhysical
RESULTS
Debriefing 101
Individual‐level Team‐level
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FRAMEAssumptionsFeelingsKnowledge BaseSituation AwarenessContext
ACTIONSVerbalPhysical
RESULTS
Debriefing 101
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Debriefing 101
Goals:
1. All participants make sense of, learn from and apply experience to change frames and actions
2. Everyone feels empowered to provide accurate evaluative feedback
3. Atmosphere of psychological safety maintained throughout 43
1. Reactions phase• Encourage initial “reactions spill”• Don’t have to process immediately
2. Understanding Phase• Exploring (advocacy + Inquiry)• Leading/Coaching
3. Summary Phase• Takeaways (what worked/what didn’t)• Action items
Debriefing 101
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Situation MonitoringProcess of actively scanning and assessing situational elements to gain awareness to
support functioning of the team.
Situation Monitoring/Awareness
The benefits of Situation Monitoring/Awareness include:
• Fosters mutual respect and team accountability
• Provides safety net for team and patient
• Includes cross monitoring46
A Continuous Process
SituationMonitoring
(Individual Skill)SituationAwareness
(Individual Outcome)
Shared Mental Model(Team Outcome)
Situation Awareness/Monitoring
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Mutual SupportAbility to anticipate and support other team members’ needs
through accurate knowledge about their responsibilities and workload.
‘Team of Experts’
‘Expert Team’
‘Team of Experts’ ≠ ‘Expert Team’
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Mutual Support
The team is only as strong as its weakest link
• Willingness and preparedness to assist other team members during patient care
• Modeled by good leadership• Derived from situational monitoring• Moderated by communication
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Mutual Support – Task Assistance
Task Assistance:• Assures success• Assures appropriate task assignment• Prevents task overload• Fosters a ‘team culture’
Climate in which assistance will be actively sought and offered as a method for reducing the occurrence of error.
“In support of patient safety, it’s expected!” 51
Managing Conflict
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Common Approaches to Conflict Resolution
• Compromise—Both parties settle for less
• Avoidance—Issues are ignored or sidestepped
• Accommodation—Focus is on preserving relationships
• Dominance—Conflicts are managed through directives for change
Typically do not result in the best outcome
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Conflict Resolution Options
Information Conflict(We have different information!)
Personal Conflict(Hostile and harassing behavior)
CUSTwo‐Challenge rule
DESC script54
Please Use CUS Wordsbut onlywhen appropriate!
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CUS
Objective “Stop the Line!”
Technique for conflict resolution and mutual support using signal words that catch the teams attention.
1. State your concern“I don’t think this is second degree AV block.”
2. State why you are uncomfortable“I think this is third degree block.”
3. If not resolved, state there is a safety issue“This is serious, I think we need a pacer immediately.”
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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
• The member being challenged must acknowledge
• If the outcome is still not acceptable– Take a stronger course of action
– Use supervisor or chain of command
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Leadership
‘Teamanship’vs
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Leadership:• SBAR• Requests• Call‐Outs• Cross‐Checks• “Shake the Yoke”• Task Prioritization• Situational Awareness• Mutual Support• Briefs/Huddle/Debriefs• Hand‐Offs• Expect and monitor Teammanship
Teammanship:• SBAR• Call‐Outs• Check‐Backs• Cross‐Monitoring• Cus’ ing• Two Challenge Rule• Mutual Support• Requests Help
Expected Team Behaviors
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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
To recapTOOLS & 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!! 60
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Linking TeamSTEPPS to general teamwork issues and
HEN HAC Challenges
Process for Selecting Tools for Team and Topic Interventions
• What are the underlying causes for the teamwork and communication problems – Within your teams?– Related to the HAC improvement?
• Which tools can directly address one or more of these causes?
• How can relevant tools be embedded into your Quality Improvement strategies and resources?
• What process measures should be monitored to see whether tools are helping?
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Teamwork Challenges Staff hierarchy and fear of “speaking up” Overload Resource constraints Burnout Flavor of the month Lacking leadership, culture, innovation, education, etc. Existing beliefs Dysfunctional communication patterns Unclear role expectations / accountability
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General Teamwork Challenges
Teamwork Challenges
Knowing when ADE’s occur and talking about them
Making “the right thing to do” feasible Reporting barriers because of time constraints Self‐reports may be biased Promoting cross‐monitoring
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Clinical Topic Team Challenges: ADE
Clinical Topic Team Challenges: CAUTI
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Teamwork Challenges Avoiding unnecessary catheter insertion in the ED Failing to discuss or have plans for catheter removal or assessment of appropriateness
Concerns about being able to toilet patients due to high work load
Failure to clarify who owns responsibility for continuing to leave catheters in patients
Perception that CAUTIs are not important due to ease of treatment
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Teamwork Challenges
Failure to establish plans for removing central lines Belief CLABSIs are inevitable in some patients Safeguards not consistently followed because of lacking mutual accountability
Materials required to maintain sterile environment are not easily accessible
Clinical Topic Team Challenges: CLABSI
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Teamwork Challenges Miscommunication between nurses and physicians related to terminology
Hospital leadership and hospital’s unwillingness to speak up when a delivery should/should not be happening
Lack of community knowledge regarding the concerns with earlier pregnancy
Empowering nurses to confront physicians about early elective pregnancy
Clinical Topic Team Challenges: EED/OB
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Teamwork Challenges Lack of information sharing across the continuum of care; it is important
to get the history of falls. Lack of sensitive measures – some put everyone on fall risk Challenge of convincing staff that they can make changes that matter Tailoring and communicating a care plan that may evolve over time Geographical layout of units – nurses are further and further from patient Accountability – do all team members understand that the patient is at
risk for a fall Lack of understanding regarding the role of medication in fall risk cases
Clinical Topic Team Challenges: Falls
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Teamwork Challenges
Staff recognizing that it is everyone’s responsibility to move the patient Coordinating care between multiple care settings Creating an integrated HAPU care plan that is standardized and ensures
supplies are available in a common location Ensuring care plan is triggered when someone senses a problem Ensuring wound care nurses have backup Identifying the possibility of a HAPU when it is present on admission
and assuring follow‐up Accurately staging he PU and coordinating communication among
nurses
Clinical Topic Team Challenges: HAPU
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Teamwork Challenges Transforming discharge process to accommodate transitions to other
care settings Engaging the patient Re‐defining discharge planning process and where it starts Tracking patient education throughout their stay and ensuring a
consistent message is delivered Tailoring discharge process to ensure it meets patients’ needs;
avoiding a “one size fits all” solution is adequate. Redesigning physician discharge summary Medication reconciliation in‐house and in the community Status of primary care in community
Clinical Topic Team Challenges: Readmission
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Teamwork Challenges Normalization of Deviance ‐ timeouts and checklists have become so
routine that people are desensitized Fear or failure to speak‐up in the OR Lack of handoff among surgery teams when moving from one procedure
to another during the same surgery Non‐compliant physicians Staff “going through motions” without patient and clinical knowledge Lack of communication when site markings occur outside of the timeout Lack of perception that everyone involved in a procedure is responsible
for ‘safe surgery’ Lack of handoff communication when moving patients throughout the
perioperative setting
Clinical Topic Team Challenges: Safe Surgery / SSI
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Teamwork Challenges Measuring compliance with the bundle Lacking VAP definition Difficulty understanding conflicting care goals, for example ‐ the need to have a
conversation with the family of a patient who is at the end of life prior to putting the patient on a ventilator is often overlooked
Mutual accountability related to elevation at head of bed Challenge of complacency or lack of perception of need among rural hospitals;
difficulty in maintaining a level of heightened awareness. Difficulty in understanding extubation criteria and allowing protocol to be
executed; often a communication challenge as to who can execute the criteria. Sedation vacation and ensuring everyone understands the need of it Difficulty managing delirium nutrition
Clinical Topic Team Challenges: VAP
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Teamwork Challenges Clarifying responsibility for prophylaxis Reaching consensus across various care groups regarding the right
course of action Developing a standardized risk assessment as well as protocol of
care and making sure people adhere to them Making sure the right people in the team are involved Lack of communication among providers; everyone is doing their
piece, but there is no follow‐up. Making sure people know what risk assessment is and they have
consensus on what the response should be
Clinical Topic Team Challenges: VTE
Clinical Topic TeamSTEPPS Matrix
LeadershipSituation
Awareness Mutual Support Communication
HAC-DescriptionBr
ief
Hudd
le
Debr
ief
STEP
I am
Saf
e
Task
Ass
istan
ce
Feed
back
Asse
rtion
DESC
Scr
ipt
Two-
Chall
enge
Ru
le
CUS
SBAR
Call-
Out
Chec
k-Ba
ck
I Pas
s the
Bat
on
Adverse Drug Event X X X X X X
Catheter Associated Urinary Tract Infection X X X X
Central Line Associated Blood Stream Infection X X X
Falls without Injuries X XObstetrical Harm X X X X
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Clinical Topic TeamSTEPPS Matrix
LeadershipSituation
Awareness Mutual Support Communication
HAC-DescriptionBr
ief
Hudd
le
Debr
ief
STEP
I am
Saf
e
Task
Ass
istan
ce
Feed
back
Asse
rtion
DESC
Scr
ipt
Two-
Chall
enge
Ru
le
CUS
SBAR
Call-
Out
Chec
k-Ba
ck
I Pas
s the
Bat
on
Hospital- acquired Pressure Ulcers X X
Safe Surgery X X X X
Ventilator Associated Pneumonia X X
Venous Thromboembolism X XReadmission -Preventable X X
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• Emphasize teamwork improvement as a separate, stand‐alone initiative– You will risk competing with other Improvement efforts
• Neglect linking teamwork Improvement efforts to specific outcomes– You will risk minor, tangible short‐term improvement
• Ignore conflicts• Deny the need for Quality Improvement• Reduce the number of areas you work on• Push staff to promote multiple efforts that will fail or be unsustainable
Linking TeamSTEPPS to HEN Quality Improvement: The Don’ts
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• Make all improvement efforts part of an integrated whole that includes:– Common core: leadership engagement, safety culture, teamwork, data and a Quality Improvement method
– Topic‐specific component– One organization‐wide improvement effort, with unit‐specific components
• Tailor Improvement to specific problems in each targeted area
• Recognize that teamwork impacts each Quality Improvement effort you are making
Linking TeamSTEPPS to HEN Quality Improvement: The Dos
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Implementation
TeamSTEPPS Action PlanningAt‐A‐Glance Create a Change Team1
Define the Problem/Challenge or Opportunity for Improvement2
3
Define the TeamSTEPPS Intervention4
Develop Plan for Testing the Effectiveness of Your TeamSTEPPS Intervention5
Develop Implementation Plan6
Develop a Plan for Sustained Continuous Improvement 7
Develop a Communication Plan8
Putting it All Together: Writing the TeamSTEPPS Action Plan9
Review your TeamSTEPPS Action Plan with Key Personnel
10
Define the Aim(s) of your TeamSTEPPS Intervention Identify Priority Problem/
Challenge or Opportunity from Step 2
Incorporate Feedback from Key Personnel
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TeamSTEPPS: Towards a Culture of Safety
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Evaluating Training Effects
LEVEL 1
Trainee Reactions
LEVEL 2
Trainee Learning
LEVEL 3
OTJ Behaviors
LEVEL 4
Measured Outcomes
per Kirkpatrick, 1994
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BRIEF? HUDDLE? DEBRIEF?CUS?TWO‐CHALLENGE RULE?
Implementing Team Communications Initiative
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Connecting the Dots…
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… To the Improvement Leader Fellowship and your
Quality Improvement journey
Partnership for Patients
The 40/20 Goal: 10 Clinical Topics
• Keep patients from getting injured or sicker. Reduce preventable hospital‐acquired conditions by 40%.
1.8 million fewer injuries to patients, with more than 60,000 lives saved over the next three years.
• Help patients heal without complication.Reduce all hospital readmissions by 20% .
1.6 million patients will recover from illness without suffering a preventable complication requiringre‐hospitalization within 30 days of discharge.
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Institute for Healthcare ImprovementModel for Improvement
Fellowship Design: You are Here
What are we trying to
accomplish
How will we know that a change is an improvement
What change can we make that will result in
improvement85
Action Period 3:Resource sharing,
LISTSERVs®, project work, TOC, data, webinars,
etc.
Action Period 2: Resource sharing,
LISTSERVs®, project work, TOC, data, webinars,
etc.
Action Period 1: Resource sharing,
LISTSERVs®, project work, TOC, data, webinars,
etc.
Wave 1: 1.5 Days4 Sites
Wave 2:2 Days4 Sites
Wave 3: 2 Days4 Sites
Wrap Up
Plan
DoStudy
ActPlan
DoStudy
ActPlan
DoStudy
Act
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• Purpose: To build improvement / safety capacity at the hospital level
• Deliverables and Expectations– Three in‐person meetings– Virtual meetings (like today)– Pre and post homework (as applicable)– Submit Project Progress Reports– Utilize the Project Assessment Scale to assess your progress
– Submit data– Demonstrate learning through a hospital‐specific action learning project(s), focused on ten clinical topics
Improvement Leader Fellowship
Aim?: (Including your How Good and By When statement)
Why is this project important?:
Aim Statement
Changes being Tested, Implemented or Spread
Recommendations and Next Steps
Lessons LearnedRun Charts
(For each listed change, indicate whether it is being tested (T), Implemented (I) or Spread (S))
(Enter summary here)
• Enter summary here (what do you need from Executive Project Champion, Sponsor at this time to move project?)
• Recommendations
• Next steps for testing
Project Title: ______________________________ Date: _____________Hospital Name: ____________________________ State: _____________
© 2012 Institute for Healthcare Improvement
Team Members
(Name of Project Champion, Senior Leader Sponsor & all other names & roles)
(Make fonts large, title, labels, datesand notes very simple on graphs priorto shrinking graphs. Should be able to
fit 6-8 readable graphs here. If no data are available for a particular measures either create “empty” run list
the name of the measure(s) to be collected.)
Self Assessment Score, 1‐5 (see AHA/HRET Assessment Scale document) = _____
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Strategically – Pragmatically – Outcomes focused
1. What is one problem you are trying to fix ‐ that some aspect of TeamSTEPPS will help you with?
2. When you go back to your facility, how are you going to introduce that aspect of TeamSTEPPS to the people that need it?
3. When will that happen?4. How will that happen?5. How will you know whether it is working?
THINK . . .
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Your Fellowship Homework for the Next Action Period
Thank you! Questions?
Thank you for joining us!
What questions do you have for our presenter(s)?
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