Strategies and Tools
to Enhance Performance
and Patient Safety
Introduction
Module 1 Introduction
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Exercise Instructions
Introduction
Goal: You have 1 minute to build the tallest tower.
Roles: Runners and Builders
Rules:
 Blocks are located at the front and back of the room.
 Runners retrieve blocks from bins but may only take 5 blocks at a
time.
 Builders build the tower using the pattern of 1 large, 3 small
blocks, repeat.
 No two blocks of the same color may touch.
 Runners are not allowed to build/ builders are not allowed to run.
 Any unused blocks that are not replaced in the storage bins before
time is called will result in subtraction from the tower height; one
block subtracted for each unused block.
Report Out: Height of tower in blocks (minus unused blocks).
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Exercise Instructions
Introduction
Debrief:
• What went well?
• What didn’t go well?
• What will you do differently?
• Same pattern we will follow in simulation
−
Plan (Brief), Do, Study (Debrief), Repeat
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Introduction
Objectives
• Describe the impact of errors and why they
occur
• Describe the TeamSTEPPS framework
• Describe the TeamSTEPPS training
initiative
• State the outcomes of the TeamSTEPPS
framework
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Introduction
Sue Sheridan Video
Videos must be saved in the same file as your
power point before you can insert them.
• Click on insert tab in power point
• Click on Video
• Click on Video from file
• Click on Sue SheridanLg001
• Click on Insert
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Video Discussion
Introduction
• Patients are harmed as a result of
poor communication and teamwork that results in
medical errors
−
How often do medical errors occur?
−
Why do medical errors occur?
−
How can we prevent medical errors?
• Applies to non-clinical situations…goals are not
achieved
…Improved teamwork and communications…
Ultimately, a culture of safety
Are you ready to be part of the transformation of
health care?
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Introduction
How Often do Medical Errors Occur?
• 44,000 – 98,000
deaths per year in
hospitals due to
medical errors
IOM (2000). To Err is Human:
Building a Safer Health System
(Photo: Ezra Shaw, Getty Images)
• Equal to one jumbo
jet crashing EVERY
DAY!
• Where is CNN?
www.foxnews.com
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Introduction
Impact of Medical Errors
• From a 2010 analysis of a claims database
−
1.8% of hospital admissions experience a medical error
(a preventable adverse outcome of medical care)
−
Medical errors cost the US at least $19.5 billion/year
• From a random sample of 780 Medicare beneficiaries
discharged Oct. 2008
−
13.5% of hospitalized Medicare beneficiaries experience
an adverse event (44% were preventable)
−
1.5% experienced an event that contributed to their
deaths (projects to 15,000 total patients/month)
http://www.soa.org/files/pdf/research-econ-measurement.pdf
http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf
9
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Human Factors
Introduction
• Study of the interaction between
humans and elements of the
system in which they live/work
•
–
Physical environment
–
Tasks
–
Tools/technology
–
Organizational conditions
Goal: achieve optimal
interaction between social,
technical, and physical
elements of a system.
https://www.hfes.org//Web/AboutHFES/about.html
10
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Introduction
Why Do Errors Occur—Some Human Factors
• Workload fluctuations
• Excessive professional
courtesy
• Interruptions
• Fatigue
• Halo effect
• Multi-tasking
• Passenger syndrome
• Failure to follow up
• Rigid Hierarchies
• Poor handoffs
• High-risk phase
• Ineffective communication • Strength of an idea
• Task fixation (lack of
• Not following protocol
situational awareness)
• Complacency
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Introduction
Task Fixation and Situation Awareness
Your
Environment
Your Team
Your
Equipment
You
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Human Factors
Introduction
Turn to your neighbor…
1. Describe a human
error that you made.
2. Describe a recent error
made at your hospital.
CNA had pt use IV pole to
walk to bathroom; pt’s legs
buckled and she fell. Walker
& gait belt were in room.
I ran a stop light.
Which human factors
contribute to this error?
Which human factors
contributed to this error?
13
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Introduction
Joint Commission Sentinel Events
http://www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_2004_2Q2012.pdf
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The Problem…
Introduction
“The problem is not bad
people; the problem is that
the system needs to be
made safer . . .”
“People make fewer errors
when they who work in
teams.”
IOM (2000). To Err is Human: Building a
Safer Health System
15
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Introduction
Teamwork Is All Around Us
Common purpose
Performance goals
Mutual accountability
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Clear role expectations
Complementary skills
Interdependent tasks
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Introduction
Team
Strategies & Tools to Enhance Performance & Patient Safety
“Initiative based on evidence derived
from team performance…leveraging
more than 30 years of research in military,
aviation, nuclear power, business and
industry…to acquire team competencies”
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Introduction
Evolution of TeamSTEPPS
Curriculum Contributors
• Department of Defense
• Agency for Healthcare
Research and Quality
• Research Organizations
• Hospitals—Military and
Civilian, Teaching and
Community-Based
• Private Companies
• Subject Matter Experts in
Teamwork, Human Factors,
and Crew Resource
Management (CRM)
• Universities
• Medical and Business
Schools
• Healthcare Foundations
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Introduction
Evolution of TeamSTEPPS:
US Army Aviation
• Army aviation crew coordination failures in mid-80s
contributed to 147 aviation fatalities and cost more than
$290 million
• The vast majority involved
highly experienced aviators
• Failures were largely attributed
to crew communication,
workload management, and
task prioritization
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Introduction
Evolution of TeamSTEPPS:
US Air Force CRM History
• Mid to Late 80s AF bombers
and heavy aircraft started
CRM training
• 1992 Air Combat Command
developed Aircrew Attention
Management /CRM Training
• By 1998, CRM deployed
uniformly across the AF
• Steady decline in human
factors based mishaps since
CRM training deployed
• AF Medical Service adapted
training, rolled out in 2000
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The Theory
Introduction
Mutual
Performance
Monitoring
Team
Leadership
Team
Orientation
Back-up
Behavior
Shared Mental
Models
Mutual
Trust
Adaptability
Big 5
Coord.
Mechanism
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Team
Effectiveness
Closed Loop
Communication
TEAMSTEPPS 05.2
Salas, Sims, Burke. Is there
a “Big Five” in teamwork?
Small Group Research.
2005; 36:555-599.
21
Introduction
The Framework:
What Comprises Team Effectiveness?
Knowledge
Cognitions
“Think”
Attitudes
Affect
“Feel”
Skills
Behaviors
“Do”
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…team performance is a
science…consequences
of errors are great…
22
More Evidence
Introduction
• Exploding Literature
−
Patient Care Team + Evidence-Based Practice = 1,128
−
Patient Care Team + Evaluation Studies = 843
• Studies in diverse patient populations demonstrate
relationship between teamwork and
−
Improved clinical processes
−
Reduction in medical errors
−
Improved surgical team performance
−
Increased adherence to guidelines
−
Decreased length of stay
−
Increased functional status
−
Decreased mortality
Salas et al. What are the critical success factors for team training in
health care? Jt Comm Jrnl Qual Safe. 2009;35:398-405.
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Introduction
Your Contribution to the Evidence
• Team training can result in transformational change in safety
culture when the work environment supports the transfer of
learning to new behavior.
• Hospital Survey on Patient Safety Culture conducted in 24
hospitals before training one year after training
• To successfully implement and sustain new behaviors
−
Stay connected to the community via monthly calls
−
Train supervisors/managers first so they can role model behaviors
−
Provide multiple follow-up learning opportunities
−
Job descriptions/performance evaluations include use of team skills
Jones KJ, Skinner AM, High R, Reiter-Palmon R. A theory-driven longitudinal evaluation of the
impact of team training on safety culture in 24 hospitals. BMJ Qual Saf. 2013;22:394-404.
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Introduction
Supported by AHRQ
Washington -TRC
Minnesota -TRC
North Shore Long I. TRC
10
18
UNMC
58
5
Duke TRC
1
1
Tulane TRC
http://teamstepps.ahrq.gov/aboutnationalIP.htm
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Introduction
HOW DOES TEAMSTEPPS WORK?
SHIFT TOWARDS A CULTURE OF SAFETY
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Introduction
HSOPS Teamwork
Teamwork Within Departments
Positive
1. People support one another in this department.
(A1)
(Belief/Attitude)
Neutral
58%
2. When a lot of work needs to be done quickly,
we work together as a team to get the work done.
(A3)
a
74%
74%
3. In this department, people treat each other
with respect. (A4)
63%
4. When one area in this department gets really
busy, others help out. (A11)
(Behavior)
26%
Negative
11%
32%
a
a
Practices/skills that bridge the gap
 Identify team leaders
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
Set team goals

Use briefs, huddles, debriefs

Cross monitor (“watch each others’ back”)
TEAMSTEPPS 05.2
11%
11%
a
a
32%
16%
16%
16%
21%
42%
32%
GAP
27
Introduction
Agenda
DAY 1
DAY 2
•
Module 1—Introduction
•
Coaching Workshop
•
Module 2—Team Structure
•
High Fidelity Simulation
•
Module 3—Leadership
−
Practice team skills
•
Module 4—Situation
Monitoring
−
Coach team skills
−
Identify team skills
•
Module 5—Mutual Support
•
Module 6—Communication
•
Module 7—Summary—
Putting It All Together
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Webinars to Complete
Requirements for Master
Trainer Certification
•
Wed. Oct. 16 10 - 11 a.m.
•
Thurs. Nov. 21 2 – 3 p.m.
28
Training
BARRIERS to Team
Performance
• 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
• ModLack
Clarity
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TOOLS and
STRATEGIES
Brief
Huddle
Debrief
Situational Monitoring
Situational Awareness
STEP
Cross Monitoring
Feedback
Advocacy and Assertion
Two-Challenge Rule
CUS
DESC Script
Collaboration
SBAR
Call-Out
Check-Back
Handoff
TEAMSTEPPS
05.2
Introduction
OUTCOMES
 Shared Mental
Model
 Adaptability
 Team
Orientation
 Mutual Trust
 Team
Performance
 Patient Safety!!
29
Summary
Introduction
• Impact of errors…patients are harmed, non-clinical teams
do not achieve goals
• TeamSTEPPS Framework
−
Safety net for fallible human beings
• TeamSTEPPS training meets a need
−
Diffuse evidence-based training program nationally and
internationally http://teamstepps.ahrq.gov/
• Outcomes of TeamSTEPPS
Shared Mental Model
Mutual Trust
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Adaptability
Team Orientation
Team Performance
Patient Safety!!
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