Prepared for the RHQN December, 2013 TeamSTEPPS and Reducing
Patient Falls
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Introduction Jefferson Healthcare 25 beds CAH Port Townsend,
WA
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Background The Oregon Experience ORHQN Strategy for training
Implementation Hard-wiring Results?
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What is TeamSTEPPS? Team Strategies and Tools to Enhance
Performance and Patient Safety
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Why use TeamSTEPPS? Goal: Produce highly effective medical
teams that optimize the use of information, people and resources to
achieve the best clinical outcomes Teams of individuals who
communicate effectively and back each other up dramatically reduce
the consequences of human error Team skills are not innate; they
must be trained AHRQ, 2012
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Patient Falls Falls account for nearly 40% of accidents in
hospitals Leading cause of injury and death among older adults Root
causes of falls in rural facilities Not identifying patients at
high risk for falls Failure to implement safety strategies Failure
to routinely complete fall risk assessments Failure to complete
post fall assessment Ruddick, Hannah, & Schade, 2008
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Team Events Brief - planning Huddle problem solving Debrief
process improvement TOPIC Who is on core team? All members
understand and agree upon goals? Roles and responsibilities
understood? Plan of care? Staff availability? Workload? Available
resources?
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Leadership Skills Resource ManagementDelegation A strategy for
balancing workload People, knowledge or information to complete a
given task Goal is to prevent overload situations that compromise
situation awareness Re-Distributing tasks or assignments Four
steps: What to delegate To whom to delegate Communicate clear
expectations Request feedback
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Develop a Shared Mental Model Situation Monitoring (Individual
Skill) Situation Awareness (Individual Outcome) Shared Mental Model
(Team Outcome)
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Situation Monitoring (Individual Skill) Situation Awareness
(Individual Outcome) Staff need to: Be aware of what is going on
Prioritize and focus on different elements Share this information
with others The state of knowing the current conditions affecting
the teams work Knowing the status of a particular event/patient
Knowing the status of the teams patients Understanding the
operational issues affecting the team Maintaining mindfulness Teams
that perform well hold shared mental models. (Rouse, Cannon-Bowers,
and Salas 1992)
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Strategies to Increase Situation Awareness Visual Cues Posey
System Arm bands Colored socks Magnets on doors Engage patients and
family members White boards in rooms Patient Journals Education
Hourly Rounding
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Post Fall Huddle Debrief Implement a post fall huddle or rapid
response team Interdisciplinary Stabilize the patient Process
improvement Debrief: Designed to improve outcomes Use post fall
assessment tool An accurate reconstruction of key events Analysis
of why the event occurred What should be done differently next
time
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Feedback Implement a process for feedback RCA Debriefing
Incident reports Quarterly newsletters Staff Meetings Leadership
Briefings Safety Rounds Feedback is the giving, seeking, and
receiving of performance-related information among the members of a
team. (Dickinson and McIntyre 1997)
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Questions? Brandie Manuel, Director of Patient Safety &
Quality Jefferson Healthcare Port Townsend, WA 98368 (360) 385-2200
ext. 2076 [email protected]
