Patient Safety through Team Training in Healthcare

Stephen A. Knych, MD, MBADivision Chief, Patient Safety

and QualityOffice: 407-303-4607

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

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**

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

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

Patient Safety: CMS Actions

• Serious preventable event—object left in place during surgery

• Serious preventable event—air embolism• Serious preventable event—blood incompatibility• Catheter-associated urinary tract infections• Pressure ulcers (decubitus ulcers)• Vascular catheter–associated infection• Surgical site infection—mediastinitis after

coronary artery bypass graft surgery• Hospital-acquired injuries – fractures,

dislocations, intracranial injuries, burn

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 placeput 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 Children’s Hospital **

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).

• Webster’s Dictionary online

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

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)

11

Indemnity Experience

20

11

0

5

10

15

20

25

Malpractice Claims, Suits, and Observations

Pre-Teamwork Training Post-Teamwork Training

Adverse 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 M arch April M ay

Avg

. L

eng

th o

f S

tay

(day

s)

Length of ICU Stay After Team Training

50% Reduction

OR Teamw ork Climate and Postoperative Seps is 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

A HRQ National A verage

Teamwork Climate Based on Safety Attitudes Questionnaire

Low High(Sexton, 2006)Johns Hopkins

(Pronovost, 2003)Johns HopkinsJournal of Critical Care Medicine

RESULTS OF TEAMWORK IN THE HEALTHCARE ENVIRONMENT

Believe that decisions of the “leader” should not be

questioned

0%

10%

20%

30%

40%

50%

SurgeonsPilots

Sexton, BMJ, 2000

Surgeons

Pilots

TEAM FUNCTION & SAFETY

BEST TEAMBEST TEAM• Least Experience

Surgeon• Cohesive Team• Simulation• Pre case planning• Debriefing• Results tracked• Removed

hierarchy

WORST TEAMWORST TEAM• Most experienced

surgeon• Team members

changed• No (de)briefing• No tracking of results• No preplanning• Hierarchical Bohmer, R. Harvard Bus.School

14

High-Performing TeamsTeams 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)

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

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

Outcomes of Team Performance

• Knowledge– Shared Mental Model

• Attitudes– Mutual Trust– Team Orientation

• Performance– Adaptability– Accuracy– Productivity– Efficiency– Safety

Barriers to Team Effectiveness TOOLS and STRATEGIES

BriefHuddle DebriefSTEP

Cross MonitoringFeedback

Advocacy and Assertion

Two-Challenge RuleCUS

DESC ScriptCollaboration

SBARCall-Out

Check-BackHandoff

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

Sustainable Excellence

(Effectiveness)

CULTUREPERFORMANCEIMPROVEMENT

Process

Continuous Improvement

Cycle

Education, Training &

Competencies

Just & Fair Culture

Executive Patient Safety WalkRounds

BEHAVIORS (Based on

Mission & Values)

Mutual Support

Situational Awareness

Structured Communication

Leadership

Reliable Design

Accelerating ResultsMonday, July 14, 2008 Sustainable

Excellence(Effectiveness)

CULTUREPERFORMANCEIMPROVEMENT

Process

Continuous Improvement

Cycle

Education, Training &

Competencies

Rapid Response

Team

Executive Patient Safety WalkRounds

BEHAVIORS (Based on

Mission & Values)

Mutual Support

Situational Awareness

Structured Communication

Leadership

Reliable Design

Accelerating ResultsMonday, July 14, 2008

Impact Evaluation

Level 1 – ReactionDid the participants like the training? What do they plan to do with what they learned?

Level 2 – LearningWhat skills, knowledge, or attitudes changed after training? By how much?

Level 3 – Behavior / Training TransferDid the participants change their behavior on-the-job based on what they learned?

Level 4 – Results Did the change in behavior positively affect the organization?

Level 5 – Return on InvestmentWas the training worth the cost? Kirkpatrick’s Model

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

TeamSTEPPS Pilot/Research Project at

Celebration Health

Current Status – report from the work of the FH

(system, CH, WP) and UCF Research Teams

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

Phased Implementation• Phase 1 (April – June)

OR – wheels in to wheels outMon – Fri, 7:30 – 3:30 start timesGeneral Surgery, Orthopedic, Bariatric Surgical

Teams• Phase 2 (July – August)

Disseminate to all surgeons24/7 includes all cases, emergent, weekend, holiday

• Phase 3 (handoffs & transitions) (Aug – Dec)Pre-op to OROR to PACU

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

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)

TeamSTEPPS Current Status – TeamSTEPPS training completed - General

reactions were positive

TeamSTEPPS Reactions to Training Survey

7 6

29

13 10 1019 19

94 94

52

81 83 81 8171

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1. The trainingwas well

organized.

2. The trainingcontent (materials,

videos,demonstrations,

etc.) wasappropriate.

3. As a result ofthe training, I feel

confident that I amprepared to train

others to useTeamSTEPPS.

4. I believe thatthis training will

help myorganization

immprove patientsafety.

5. I am confidentthat I can use theknowledge that I

learned on the job.

6. As a result oftraining, I feel

more confidentabout my ability

towk effectively in ateam.

7. I am likely toapply the toolsprovided in this

training to a varietyof situations on

the job.

8. I wouldrecommend this

training to theothers at work.

Question

Per

cen

tag

e

Strongly/Agree/Agree/Somewhat Agree

Neither

StronglyDisagree/Disagree/SomewhatDisagree

TeamSTEPPS Current StatusTrainee 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.”

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.

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

Patient Safety

“Knowing is not enough; we must apply. Willing is not enough; we

must do”

Goethe

QUESTIONS?

THANK YOU FOR THE INVITATION TO SPEAK TO YOU

TODAY!