TeamSTEPPS and Reducing Patient
Falls
Prepared for the RHQN
December, 2013
Introduction
 Jefferson Healthcare
 25 beds
 CAH
 Port Townsend, WA
Background
 The Oregon Experience
 ORHQN
 Strategy for training
 Implementation
 Hard-wiring
 Results?
What is TeamSTEPPS?
Team Strategies and
Tools to Enhance
Performance and
Patient Safety
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
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
Team Events
TOPIC
 Brief - planning
Who is on core team?
 Huddle – problem solving
All members understand
and agree upon goals?
 Debrief – process
improvement
Roles and responsibilities
understood?
Plan of care?
Staff availability?
Workload?
Available resources?
Leadership Skills
Resource Management
 A strategy for balancing
workload
 People, knowledge or
information to complete a
given task
 Goal is to prevent overload
situations that compromise
situation awareness
Delegation
 Re-Distributing tasks or
assignments
 Four steps:
 What to delegate
 To whom to delegate
 Communicate clear
expectations
 Request feedback
Develop a Shared Mental Model
Situation
Monitoring
(Individual Skill)
Shared
Mental Model
(Team Outcome)
Situation
Awareness
(Individual
Outcome)
Situation Monitoring
(Individual Skill)
 Staff need to:
 Be aware of what is going
on
 Prioritize and focus on
different elements
 Share this information with
others
“Teams that perform well hold
shared mental models.”
(Rouse, Cannon-Bowers,
and Salas 1992)
Situation Awareness
(Individual Outcome)

The state of knowing the current
conditions affecting the team’s work
 Knowing the status of a
particular event/patient
 Knowing the status of the
team’s patients
 Understanding the operational
issues affecting the team
 Maintaining mindfulness
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
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
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)
Questions?
Brandie Manuel,
Director of Patient Safety & Quality
Jefferson Healthcare
Port Townsend, WA 98368
(360) 385-2200 ext. 2076
bmanuel@jeffersonhealthcare.org