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Maureen Paul, MD, MPH

Elizabeth Poitras, NP

Jennifer Yocum, MSN, RNC, CPPS, CPHQ

Joseph Montella, MD, MS, CPE

TeamSTEPPS for the Ambulatory Setting

Stepping Up for Safety: A National Project to Improve Teamwork in 

Ambulatory Reproductive Healthcare

Maureen Paul, MD, MPHPhysician Director of Patient Safety and Quality

Affiliates Risk Management Services, Inc.Director, Family Planning Division

Beth Israel Deaconess Medical Center

Disclosures

Provide services to Affiliates Risk Management Services, Inc. (ARMS) on behalf of my employer, Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center (BIDMC)

Serve as Principal Investigator for this project’s  research evaluation component, which is funded by a grant from ARMS to BIDMC

Paid part‐time employee at Planned Parenthood League of Massachusetts

BACKGROUND

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64 independently‐incorporated affiliates that operate 700 ambulatory health centers nationwide

Accredited by PPFA

Vary in:

Size and geographic scope

Client base

Staffing patterns

Regulatory and security challenges

All engaged in other important initiatives

Characteristics: 2013-14 Affiliate Medical Services

STD testing and Rx42%

Contraception34%

Other services12%

Cancer screening

9%

Abortion3%

Goals Improve the culture of safety

Adapt TeamSTEPPS processes and resources for      use  in ambulatory reproductive healthcare settings

Evaluate impact 

Partnership: ARMS, Planned Parenthood affiliates, TeamSTEPPS master trainer, BIDMC/HMS

Pilot before longer‐term investment

Project Overview

Cohort 1 Cohort 2 TOTAL

# States 17 17 29

# Health Centers 160 113 261

# Clients (2013) 575,958 536,934 1,048,215

# Visits (2013) 909,348 950,206 1,759,918

Participating Affiliates – Cohorts 1 and 2

Participating affiliates represent 38% of all health centers in the federation and serve more than 1 million clients annually, which is nearly 40% of all patients served by Planned Parenthood affiliates.

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Evaluation Component  Impact on Organizational Culture

Teamwork Perception Questionnaire (TPQ)

Team Communication Assessment

Key informant interviews

Impact on Patient Outcomes

Patients’ Insights and Views Observing Teamwork (PIVOT) 

Incidents and claims trends (AIMS)

Impact on Staff Retention

Staff retention rates 

LESSONS LEARNED

LESSON 1The Importance   

of Buy‐In 

Who are your stakeholders?

How are the interests of each stakeholder served by your project?

Recruitment Tactics

Leadership buy‐in Direct communications to CEO with copy to others

Appeal to stakeholder interests 

Spreading the word Webinar

Presentations at conferences

ARMS resources: newsletter, portal, e‐learning 

Invitation

Individual phone calls with affiliates

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LESSON 2 Preparation is Paramount

How will you prepare people to participate in your project without overwhelming them?

How will you know what was helpful?

Tips: Pre‐Master Training Preparation

Provide helpful resources Toolkit, webinar, designated contact  

Prioritize change team formation

Articulate clear objectives for planning process Develop shared mental model

Don’t cast ideas in stone

Consider small steps with early “wins”

Evaluate!

LESSON 3: Relevance is the 

Real Deal

What are the characteristics of your ambulatory health care setting? 

How can you  adapt TeamSTEPPSresources to your environment?

Clinic Emergency Scenario

Demonstrates:

• Attempts to maintain leadership and procedural responsibilities simultaneously

• Non‐directed requests/orders

• Lack of closed loop communication

• Lack of assertiveness by team members

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Non‐Directed Requests Team Concerns Not Communicated

Degrading Teamwork and Leadership Clinic Emergency Scenario – Take 2

Demonstrates:

• Huddle

• Handoff of situational leadership 

• Directed requests/orders

• Closed loop communication

• Mutual support / CUS

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Huddle and Handoff of Leadership Mutual Support through CUS

LESSON 4: Implementation is 

not linear

How does training translate into real and lasting change? 

How do you help people “get there”?

Tips: Implementation

Provide strong follow‐up and support 

Discourage post‐training lag time

Solidify the change teams

Develop sharing mechanisms

Continually learn and adapt

Build capacity from the “get‐go”

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THANK YOU and STAY TUNED! TeamSTEPPS at Planned Parenthood League of Massachusetts

June 16, 2015

Elizabeth Poitras, NP, Quality Assurance Manager

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TeamSTEPPS Implementation Guide

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Early Challenges/Successes• Challenges:

– Determining a shared mental model among the Change Team

– Metrics– Competing projects, initiatives, and “change

fatigue” • Successes:

– Support from our Medical Director, Executive Team Members, and Managers

– Support from ARMS/PPFA and the TeamSTEPPS Master Trainer.

– Resources and Trainings

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TeamSTEPPS at PPLM

• Improve Communication

• Improve Flow

• Improve Morale

• Create a “Just Culture”

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TeamSTEPPS Timeline

• November 2013: PPLM applied to participate in ARMS’s TeamSTEPPS Pilot Project.

• Approved April 2014

• April 2014: Change Team selected and TeamSTEPPS Change Team Meetings held.

• June 2014: TeamSTEPPS Master Training.

• August 2014: Implemented “Briefs, Huddles, Debriefs” in our Boston GYN clinic.

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TeamSTEPPS Timeline

• November 2014: Master Trainer visited PPLM to meet with the Change Team.

• December 2014: Implemented “CUS” in Boston/Somerville health centers.

• February 2015: Implemented “Briefs, Huddles, Debriefs” at all 7 health centers.

• April 2015: Implemented “CUS” at all 7 health centers.

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Resources and Trainings

• Resources Provided by ARMS• Confluence Page• Internal Training• Trainings at All Health Center Meetings• Binders/Checklists• Posters• Bulletin Board

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Early ResultsAverage Appointment

Length (Boston)3/1/14‐7/31/14 12/1/14‐4/30/15

First Trimester Abortion 3 hours 17 minutes 3 hours 5 minutes

Non‐exam GYN visits 1 hour 18 minutes 1 hour 4 minutes

GYN exam visits 1 hour 23 minutes 1 hour 12 minutes

Medication Abortion 2 hours 30 minutes 2 hours 6 minutes

Same Day/Walk‐in visits 1 hour 30 minutes 1 hour 13 minutes

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Feedback from Staff

• “I like attending the briefs and hearing what the day ahead looks like, as well as how the previous day went.” (from an Advanced Practice Clinician)

• “I feel like we work more like a team in providing care to our patients.” (from a GYN Health Care Assistant)

• “My favorite part is announcing the on-call MD, which can be a huge time-saver. It is also helpful to be told what is going on in Reception as it affects our flow.” (from an Advanced Practice Clinician)

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Recommendations

• Gather support from your Medical Director and Executive Team Members.

• Use the resources provided by AHRQ.

• Celebrate small successes and implement TeamSTEPPS at your organization’s own pace.

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Thank you!

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TeamSTEPPS  for the Ambulatory Setting:Successfully Using TeamSTEPPS Principles and Tools to 

Improve Care Transitions

Jennifer Yocum, MSN, RNC, CPPS, CPHQ Women’s Health Safety SpecialistTeamSTEPPS Master Trainer

Joseph M. Montella, MD, MS, CPEDirector of Quality and Safety, Dept. of Ob‐Gyn

Team STEPPS Master Trainer

Thomas Jefferson University, Philadelphia, PA

Financial Disclosures

None

Who We Are

• Established in 1825

• 951 licensed acute care beds

• 2000+ deliveries per year

• Admissions: 45,131

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Primary Aim

Using TeamSTEPPS tools and methods to increase the number of cesarean sections that occur within 30 

minutes of the scheduled start time.

Current State # 1The current state represents what you are actually seeing with 

your own eyes.

Only 56% of the time, our cesarean sections started within 30 minutes of their scheduled start 

time.

Secondary Aim

Using TeamSTEPPS tools and methods, to increase the number of patients who had the appropriate dating, laboratory studies or consultations when they arrived 

for their scheduled cesarean section.

Current State  # 2

Only 54% of the time, patients arrived on labor and delivery for scheduled cesarean sections with

adequate dating, laboratory studies or consultations. 

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12 12

3

4567

8

9

1011

Impact on Patient Care

Patient dissatisfaction due to:

Delay or cancellation of procedure

Additional blood work required

Delay in OR case secondary to abnormal lab testing results

Unanticipated changes in plan of care due to interdepartmental communication barriers

Interruption of family plans for scheduled C‐sections

Impact on Patient Care

Concerns for patient safety:

• Deliver patient before 38 weeks

• Pertinent lab work not completed or resulted

• Appropriate consults not completed

What Did We Do?

Using the TeamSTEPPS tool of Team Structure and Leadership, we created an 

interdepartmental/interdisciplinary team to identify opportunities for improvement

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Creating a Team

Communication:

Do the team members communicate and listen well?

Learning:

Is the team open to learning?

Receptive:

Is the team open to hearing feedback?

This is What We Heard

Our Team

Physicians

Nurses

Unit ClerksRisk Management

Inpatient and

Outpatient Staff

Implementation

Constructed a process map to visualize current and future state.

Developed a scheduling tool to standardized medical information needed for scheduling cesarean sections.

Partnered with Admissions and Laboratory Services to implement a seamless pre‐admission process for scheduled c‐section patients

Redefined and streamlined the workflow to eliminate non‐value added process in the transmission of information from the outpatient office to the inpatient unit. 

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Initial Step –Identified Current State

Initial Meeting

Follow-Up

Meeting

Parking Lot & Action Items

Agenda

Process Map – used to explain each part of the process

Future State

Implementation:Scheduling Tool

Dating

Labs 

Patient Name: ______________________________________ DOB: _____________________ Tool Completed By: __________________________________Date: _____________ Time: _______ Care Provider: _______________________________________________________________________ Procedure:

C / Section

Induction (oxytocin)

Version

PUBS _____________

□ Cervical Ripening

□ TOLAC Location: Labor and Delivery Other (See Complicated Procedure Checklist)

Indications: __________________________________________________________________________ Cervical Exam: _______________________________________________________________________ OB History: G P Term Pre-Term Abortion Living

Final EDD: _______________ Dates By:

LMP LMP + 1st trimester U/S LMP + 2nd trimester U/S

LMP + 3rd trimester U/S U/S only ___wks at U/S Other (IUI, embryo transfer, etc.)

High Risk Concerns: □None

HTN disorder

Prev C/S x ___

Multiples Diabetic Prev myomectomy Fetal anomaly Infectious disease Prev classical C/S IUGR Morbid obesity (BMI >40) Abnormal placenta Other ___________ Blood disorder/coagulopathy Abnormal presentation

Inpatient delivery plan / postpartum care: ________________________________________________ Abnormal/relevant labs: See Labs Other ________________ Antibodies identified Anesthesia consult: Needed Done Date: ________ N/A Neonatology consult: Needed Done Date: ________ N/A Surgery consult: Needed Done Date: ________ N/A

- -- - -- - -- - - -- - -- - -- - - -- - -- - -- - - -- - -- - -- - -- - --- Desired EGA at Delivery (range): __wk __/7 days to __wk __/7 days Desired Date: ___________ Acceptable Window: ___________ _____________ Comments: _________________________________________________________________________ Best Patient Contact #: __________________ Date/Time of Procedure: _________________ Provider: ___________________ Patient to Arrive at: _________________

Consults

Effective Team Structure and Collaboration

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Barriers and Strategies

Barriers

• Lack of Time

• Lack of Information Sharing

• Varying Communication Styles

• Lack of Coordination and Follow‐up with Co‐Workers

• Heavy Workload

TeamSTEPPS Tools

TeamSTEPPS Tools  

• Team Structure

• Leadership

• Collaboration

• Check‐back

• Cross‐monitoring

• Task Assistance/Mutual Support

Using TeamSTEPPS Tools  Mutual Support and Task Assistance

Assuring that each team member “watches the backs” of the other team members

• The completed Scheduling Tool was given to the surgery scheduler to call labor and delivery with the necessary information to relieve the provider of this duty. 

• The surgery scheduler calls patient with date and time to arrive removing this responsibility from the provider.

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Using TeamSTEPPS Tools  Check‐Back

Using closed‐loop communication to ensure that information conveyed by the sender is understood by 

the receiver as intended.

• The unit clerk read back the information on the form to assure that all information was correct

Using TeamSTEPPS Tools  Cross‐Monitoring

If all information was not completed, it was given back to the provider to redo 

The unit clerk followed an identical template to assure that all the information was  received

Patient Name: ______________________________________ DOB: _____________________ Tool Completed By: __________________________________Date: _____________ Time: _______ Care Provider: _______________________________________________________________________ Procedure:

C / Section

Induction (oxytocin)

Version

PUBS _____________

□ Cervical Ripening

□ TOLAC Location: Labor and Delivery Other (See Complicated Procedure Checklist)

Indications: __________________________________________________________________________ Cervical Exam: _______________________________________________________________________ OB History: G P Term Pre-Term Abortion Living

Final EDD: _______________ Dates By:

LMP LMP + 1st trimester U/S LMP + 2nd trimester U/S

LMP + 3rd trimester U/S U/S only ___wks at U/S Other (IUI, embryo transfer, etc.)

High Risk Concerns: □None

HTN disorder

Prev C/S x ___

Multiples Diabetic Prev myomectomy Fetal anomaly Infectious disease Prev classical C/S IUGR Morbid obesity (BMI >40) Abnormal placenta Other ___________ Blood disorder/coagulopathy Abnormal presentation

Inpatient delivery plan / postpartum care: ________________________________________________ Abnormal/relevant labs: See Labs Other ________________ Antibodies identified Anesthesia consult: Needed Done Date: ________ N/A Neonatology consult: Needed Done Date: ________ N/A Surgery consult: Needed Done Date: ________ N/A

- -- - -- - -- - - -- - -- - -- - - -- - -- - -- - - -- - -- - -- - -- - --- Desired EGA at Delivery (range): __wk __/7 days to __wk __/7 days Desired Date: ___________ Acceptable Window: ___________ _____________ Comments: _________________________________________________________________________ Best Patient Contact #: __________________ Date/Time of Procedure: _________________ Provider: ___________________ Patient to Arrive at: _________________

There is missing information regarding the 

reason for her c‐section

Results

To increase the number of cesarean sections that occur within 30 minutes of the scheduled start time.

56%

72%, a 29% improvementTo increase the number of patients who had the appropriate dating, laboratory studies or consultations when they arrived for their scheduled cesarean section

54% 

94%, a 74% improvement

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Barriers and Strategies

Barriers

• Lack of Time

• Lack of Information Sharing

• Varying Communication Styles

• Lack of Coordination and Follow‐up with Co‐Workers

• Heavy Workload

TeamSTEPPS Tools

• Collaboration (LEADERSHIP)

• Cross‐Monitoring (MUTUAL SUPPORT)

• Check‐Back (COMMUNICATION)

• Handoff (COMMUNICATION)

• Task Assistance (SITUATION MONITORING)

Process Integration

TeamSTEPPS Tools and Strategies

• Cross‐Monitoring (SITUATION MONITORING)

• Check‐Back (COMMUNICATION)

• Handoff (COMMUNICATION)

• Task Assistance (MUTUAL SUPPORT)

Process steps

• Assuring that form was complete prior to scheduling

• Scheduler and unit clerk assuring that all information was complete; reminder task to provider

• Provider giving completed form to scheduler

• Scheduler informing patient of date and time instead of provider

Five Keys to Success1. Involve physicians from the very beginning of the project 

and provide a tangible benefit to them to improve acceptance and sustainability

2. Allow professionals to practice to the fullest extent of their experience

3. Pilot with a small group first before introducing the project on a wide scale

4. Review the project within 2‐4 weeks to determine what changes need to be made based on user feedback

5. Do not delay project implementation in order to solve every “kink” in the plan—”paralysis by analysis”