Disclosure

Jim Rost and Jennifer Ustianov provide teamwork training solutions to healthcare

organizations nationally through

TeamSTEPPS Elite, LLC.

The Evolution of Patient and Family-Centered Teamwork Training:

Cracking the Code for Our Most Important Team Members

Jim Rost, MD

Jennifer Ustianov, RN, MS

#WeAreAllPatients

Consultant

Nursing

Discharge Planning/ Follow-up

Social Work

Provider

Questions

• Is patient-oriented team training program feasible?

– If so, for which units? Conditions?

• Do patients understand, value and use teamwork tools and strategies?

• Are hospital staff receptive to more engaged and assertive patients?

• Can we measure the impact of the intervention?

• Considerations for YOU and your organization?

__

TBP

1. Autonomy- The ability to speak up

2. Freedom to Act3. Vigilance4. Awareness of Safety Issues

Requirements for Patient Participation

• Knowledge of how to participate (health literacy)

• Confidence and Ability

• Willingness

• Empowerment

• Existing culture of teamwork and safety

Hibbard JH. Can patients be part of the solution? Views on their role in preventing medical errors. Med Care Res Rev 2005 Oct;62(5):601-16

Longtin Y, Sax H, Leape L, Sheridan S, et al. Patient Participation: Current Knowledge and Applicability to Patient Safety. Mayo Clin Proc. 2010 Jan; 85(1):53-62

TeamSTEPPS for Patients

Research Aims

1. Identify Obstetrical events that vary in terms of risk and liability and require teamwork

2. Identify the root causes of each event3. Conduct patient/family focus groups –team

member responsibilities and useful TeamSTEPPS tools

4.Develop and test a module for teaching TeamSTEPPS tools to patients/family members

Focus Group - TeamSTEPPS

• Presented information on SBAR, Check-Back, Two-Challenge Rule, CUS, and Briefs, Huddles and Debriefs

• For each tool, participants were asked:– Do you think the tool is clear and would be easy to use?

– Would you feel comfortable using the tool with doctors and nurses providing you care?

– Do you think it would be a good idea to provide training to patient/family members on the tool?

Training Objectives

• Describe:

– how the patient and family fits into the clinical team

– how the patient and family responsibilities as team members

– the clinical team member roles and responsibilities

– the core components of team leadership, assertion, and communication

– TeamSTEPPS tools that can be used by patients:• Briefs, Huddles, and Debriefs

• Assertive Statement and Two-Challenge Rule

• SBAR and Check-Back

Training Modules

Introduction

Team Structure

Leadership

Advocacy and Assertion

Communication

Measurement: Reactions

– Assessed participant “reactions” to training at two levels:

– Did participants like the training (i.e., affective reactions)?

– Did the participants find the training useful

(i.e., instrumentality)?

Participant Learning

– Learning is defined as changes in knowledge, skills, or attitudes

– Assessed participant learning in terms of:

– Participant attitudes toward teamwork

• TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ)

– Knowledge of teamwork

• TeamSTEPPS Learning Benchmarks

– Both measures administered pre- and post-training

Results: Reactions

• Overall mean rating was 4.18 on a 5-point scale– “This training would be appropriate for patients in all care settings”

– “This training should be offered by …. in the future”

• Highest Rated Items– This training would be appropriate for patients in all care settings

– This training should be offered by ….. in the future

• Lowest Rated Item– The tools appear easy to use

Results: Learning

• Attitudes (T-TAQ)– Pre-training Mean (4.51)

– Post-training Mean (4.55)

• Learning (Learning Benchmarks)– Pre-training Mean (10.86 items correct)

– Post-training Mean (12.28 items correct)

Conclusion

• The results found that participants:– Thought the training was useful

– Had very positive reactions to the curriculum and its potential future implementation and use

• Teaching patients/family members some core TeamSTEPPS tools has promise– Labor and Delivery

– Could be embedded in prenatal education

• Future research should consider:– Larger demonstration and implementation of the training

– Measuring transfer of trained skills (Level III)

– Measuring impact on quality of care and safety outcomes (Level IV)

Teamwork Training for Ambulatory Patients

• One-hour training sessions on communication techniques

• Campaign rather than education or research

• Empowerment without obligation– “You CAN…..check, ask, notify”

• Focus on hazards rather than skills– Wrong chemo, last-minute change, hand

hygiene

Weingart, S., et. al. (2009) The you CAN campaign: teamwork training for patients and families in ambulatory oncology. The Joint Commission Journal on Quality and Patient Safety. 35: 2, 63-71.

Patient and Family Engagementfor Safety and Quality

Nicholas

Meghan

Homer and Doris

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Patient Safety

Patient Family Engagement (PFE)in Focus

“Understanding role of patients in patient safety, as well as barriers to engaging patients, can help reduce adverse events and improve quality of care”

Scobie and Persaud. Patient Engagement in Patient Safety. PSQH March/April 2010

“Rules of Engagement”Duke University Health System

• Patients and families will be engaged, educated and empowered to easily access information and participate in care and decision-making opportunities at their level of comfort

• Challenge ourselves to think differently about “partnering with patients”

• Encourage patients to take an active role • Facilitate opportunities for patients to “speak up” and

share their ideas about reducing harm, improving care

• Sometimes it’s humbling, but patients are helping us with this

TeamSTEPPS and PFEPatients and Family As Team Members

• Briefs/Huddles/Debriefs• Situation Monitoring• Task Assistance

Team Events for PFEBriefs/Huddles/Debriefs

Situational MonitoringPFE for Better Outcomes

Situation monitoring requires patient activation

• Patient activation is a behavioral concept… Defined as 'an individual's knowledge, skill, and confidence for managing their health and health care' (Hibbard et al 2005)

• Four measures in a patient activation model (PAM):

believing the patient role is important

having the confidence and knowledge to take action

actually taking action to maintain and improve one's health

staying the course even under stress

Task Assistance for PFE Partnering for Mutual Support

• Asking patients and families to be involved in care: Increases competency in home care Reduces patient and family stress Strengthens team dynamics among providers, family and

patients• Making this work for providers, patients and families involves

finding out everyone’s comfort level relative to assisting with medical tasks

• Example: Johns Hopkins checklist entitled “Family Involvement Menu.”

http://armstronginstitute.blogs.hopkinsmedicine.org/2015/05/19/getting-patients-loved-ones-off-the-sidelines-the-family-involvement-menu/

Advocacy and AssertionThe Hallmark of PFE

• What does “speak up” really mean?

• What is the fine line between being an

effective advocate and an offensive

advocate?

• How can TeamSTEPPS tools help

empower patients and families to

advocate and assert?

TeamSTEPPS Tools Patient Family Engagement (PFE)

The “most accessible” are:

• Handoff

• Patient Safety Call Out

• CUS

• Two-Challenge Rule

PFE in Handoffs

Handoffs are safer and of higher quality when patients and families are included- define and share the

patient and family role

- use a standardizedtool

- minimize distractions and interruptions

- make it interactive

• Taught to patients and families at admission• Used by patients and families to ensure information shared is

accurate and complete

Example from Madigan Hospital in Tacoma, Washington:

Admitting Team Member(s): “At any time during this admission, if you have a safety concern, have a crucial question, or if you hear us mention that doesn’t sound quite right, let us know so we can discuss your concerns as a team. This is called a safety Call Out.

To make it easier to do this, we ask all of our patients and families to make the “time out” symbol with their hands to alert us that you have a safety call out.

Let’s try it.”

CALL OUT for PFEPartnering for Safety

A strategy to empower patients and families to communicate important or critical information “in the moment”

CALL OUT for PFEPartnering for Safety

A strategy to empower patients and families to communicate important or critical information “in the moment”

• Taught to patients and families at admission

• Used by patients and families to ensure information shared is accurate and complete

Example from Madigan Hospital in Tacoma, Washington:

• Admitting Team Member(s): “At any time during this admission, if you have a safety concern or a crucial question, please let us know so we can discuss your concerns as a team. This is called a safety Call Out.

• To make it easier to do this, we ask all of our patients and families to make the “time out” symbol with their hands to alert us that you have a safety call out.

• Let’s try it.”

CUS for PFEPartnering for Safety

Concerned

Uncomfortable

Scared…Safety

Assertive Statement:

Two-Challenge Rule for PFE Communication of Concerns

Mr. Jones: “I am glad you’re here, Doctor. I was not happy with

my nurse last night. She was rude and did not give my

medications to me on time.”

Doctor: “I want to make sure your concerns are addressed. I

like to tell my patients to use the ‘Two Challenge Rule.’ If you

feel someone is not being kind or not giving you proper medical

care, we encourage you to speak up and share your concern. If

they don’t acknowledge your concern and/or change what they

are doing, we encourage you to challenge them again.”

Mr. Jones: “That’s fine, I guess. I don’t think she’s here today

since she worked last night.”

Doctor: “Yes, normally, I would suggest you talk with the nurse

directly to see if you can work it out that way but, since she’s

not here, I would like to bring in the charge nurse so you can

share your experiences. If the charge nurse can’t help, you can

talk with the Nurse Manger for this unit. You can also ask for a

patient advocate if you feel your concerns have not be

addressed to your satisfaction.”

Mr. Jones: “I am glad you’re here. I was not happy with my nurse last night. She was rude and did not give my medications to me on time.”

Doctor: “I’m sorry to hear that. I’m not sure who your nurse was last night but I will do my best to let her know.”

Mr. Jones: “Ok good. I don’t want that happening to another patient”

Barriers Impacting PFE

• Awareness

• Traditional roles

• Self efficacy

• Healthcare Setting and Illness

• Demographic

• Legality

Facilitators of PFE

• Provider Modelling

• Perception of Risk and Preventability

• Willingness to Participate

• Organizational Culture

PFEAssess Readiness and Skills

Patient/Family Participation • Step at a Time Patient and Family

- One simple “job” at a time

• Eager Patient and Family- Track their data and medications

• Expert Patient and Family- Trained in SBAR for more concise and effective conversations at clinic, in the hospital or the ER

One Step for PFE“One Minute for Patient Safety”

• Align with existing Quality Patient Safety Initiatives

• Seek out champions

• Start small to create wins

• Start with one tool for enhance PFE (new or existing)

• Educate all team members including patient/family

• Start with one test: one patient/family, one team

When and How to Test

• On admission

• Small instructional card

• Reinforced: reminders, invited and modeling

Implementation and Sustainability

• Keep educating across the team

• Collect & share data (qualitative and quantitative)

• Share lessons learned

• Spread

• Hardwire

• Publish

MeghanNic

Doris

Questions and Answers

Jim Rost, MDMedical Director, Quality, Patient Safety and NICUShady Grove Medical Center

Jennifer Ustianov, MS, RNSenior Director, National Institute for Children’s Health Quality (NICHQ)Quality Improvement Expert

8. Institute of Medicine. To err is human: building a safer health care system. Washington, DC: National Academies Press; 1999.9. Institute of Medicine. Crossing the quality chasm: a new health care system for the 21st century. Washington, DC: NationalAcademies Press; 2001.15. Vincent CA, Coulter A. Patient safety: what about the patient? Qual Saf Health Care 2002 Mar; 11(1):76-80.16. Friedman SM, Provan D, Moore S, et al. Errors, near misses and adverse events in the emergency department: what can patients tell us? Can J Emerg Med 2008 Sep; 10(5):421-7.18. Kuzel AJ, Woolf SH, Gilchrist VJ, et al. Patient reports of preventable problems and harms in primary health care. Ann Fam Med 2004 Jul; 2(4):333-40.19. Weingart SN, Price J, Duncombe D, et al. Patient-reported safety and quality of care in outpatient oncology. Jt Comm J QualPatient Saf 2007 Feb; 33(2):83-94.20. Attree M. Patients' and relatives' experiences and perspectives of 'Good' and 'Not so Good' quality care. J Adv Nurs 2001 Feb; 33(4):456-66.47. Waterman AD, Gallagher TH, Garbutt J, et al. Brief report: hospitalized patients' attitudes about and participation in errorprevention. J Gen Intern Med 2006 Apr; 21(4):367-70.48. Coulter A, Ellins J. Effectiveness of strategies for informing, educating, and involving patients. Br Med J 2007 Jul 7; 335(7609):24-7.49. Unruh KT, Pratt W. Patients as actors: the patient's role in detecting, preventing, and recovering from medical errors. Int J Med Inform 2007 Jun; 76 [Suppl 1]:S236-S44.• Johnstone, M. J., & Kanitsaki, O. (2009). Engaging patients as safety partners: some considerations for ensuring a culturally and

linguistically appropriate approach. Health policy, 90(1), 1-7.• Fleurence, R., Selby, J. V., Odom-Walker, K., Hunt, G., Meltzer, D., Slutsky, J. R., & Yancy, C. How the Patient-Centered Outcomes

Research Institute is engaging patients and others in shaping its research agenda. Health Affairs (2013) 32(2):393-400.• Hibbard, J. H., & Greene, J. What the evidence shows about patient activation: better health outcomes and care experiences;

fewer data on costs. Health affairs (2013); 32(2):207-214.• Kohn L., Corrigan J.M., Donaldson M.S. To err is human: Building a safer health system. Washington, DC: National Academies

Press (1999). • Starmer AJ, Spector ND, Srivastava R, et al; I-PASS Study Group. N Engl J Med. 2014;371:1803-1812.

doi:10.1056/NEJMsa1405556• Coulter A, & Ellins, J. Effectiveness of strategies for informing, educating, and involving patients. BMJ. 2007 Jul 7; 335(7609):

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