Clarifying
Key
Concepts
Strategies and Tools
to Enhance Performance
and Patient Safety
Introduction
Objective
• To clarify key concepts that a majority did not
know the answer for on the knowledge test taken
at the end of the training
−
The components of an effective team structure
−
Designated and situational leaders
−
The role of a structured framework in information
exchange
−
What makes handoffs different from other
communication?
−
What is a shared mental model?
−
What is mutual support?
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Introduction
• TeamSTEPPS is
composed of four
teachable/learnable skills
−
Leadership
−
Situation Monitoring
−
Mutual Support
−
Communication
• Skills are supported by
team structure
…team performance is a
science…consequences
of errors are great…
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Introduction
Components of Effective Team Structure
• A team is composed of two or more people who…
−
Interact interdependently and adaptively
−
Have complementary skills
−
Have effective leadership
−
Work toward a common goal… this is the MOST important
component of team structure…knowledge of the common goal
accounted for 14% of the difference in team function
−
Have clear roles and responsibilities…second most important
component of team structure…accounted for 12% of the difference
in team function
−
Hold them selves mutually accountable for achieving the goal
Salas et al. Does team training work? Principles for health care. Acad Emerg
Med. 2008. 15:1-8.
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Introduction
Designated and Situational Leaders
• Leadership is one of the four key teachable/learnable
TeamSTEPPS strategies
• There are two type of leaders
1.
2.
Designated leader is assigned to lead and organize a
designated core team by

Establishing clear goals

Facilitating open communication, information, and mutual
support sharing through briefs, huddles, debriefs

Resolving conflict
Situational leader is any team member who steps forward
because they have the skills/knowledge to manage the
situation-at-hand; situational leader may step forward during
a brief or debrief or they may call a huddle
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Introduction
Information Exchange
Communication contributes to nearly 2/3 of sentinel events because
effective communication does not come naturally
http://www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_04_4Q2012.pdf
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Introduction
Information Exchange
• Effective communication is the exchange of information
between a sender and a receiver…and it is
−
Complete
−
Brief
−
Clear
−
Timely
−
Closed loop by asking for confirmation and providing
time for follow up questions
• Structured communication strategies such as SBAR, CallOut, Check-Back, and Handoffs decrease errors by setting
expectation for what will be communicated
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Introduction
What makes Handoffs Different?
• A handoff involves the transfer of information—along with
authority and responsibility—during transitions in care
across the continuum;
• Because authority and responsibility are being transferred,
the handoff must include opportunity to address
−
Safety concerns
−
Background…what are the co-morbidities, medications, history
−
Actions…what has already been done?
−
Timing…how urgent, what should be done first:
−
Ownership…who is responsible for what?
−
Next…what will happen next?
• Which is why SBAR may not be the best tool for a handoff
across shifts or levels of care unless it is modified
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Introduction
“I PASS THE BATON”
Introduction: Introduce yourself and your role/job (include patient)
Patient:
Identifiers, age, sex, location
Assessment: Present chief complaint, vital signs, symptoms, and
diagnosis
Situation:
Current status/circumstances, including code status,
level of uncertainty, recent changes, and response to treatment
Safety:
Critical lab values/reports, socio-economic factors, allergies, and alerts
(falls, isolation, etc.)
THE
Background: Co-morbidities, previous episodes, current medications, and family
history
Actions:
What actions were taken or are required? Provide brief rationale
Timing:
Level of urgency and explicit timing and prioritization of actions
Ownership: Who is responsible (nurse/doctor/team)?
Include patient/family responsibilities
Next:
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What will happen next? Anticipated changes?
What is the plan? Are there contingency plans?
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Introduction
What is a Shared Mental Model?
• A shared mental model is
the perception of,
understanding of, or
knowledge about a
situation or process that is
shared among team
members through
communication
Situation
Monitoring
(Individual Skill)
• Shared mental models
require individuals to
monitor what is going on
around them and share that
information during briefs,
huddles, and debriefs
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Situation
Awareness
(Individual
Outcome)
Shared
Mental Model
(Team Outcome)
10
Introduction
What is a Mutual Support?
• Mutual support is one of the four key skills or team strategies
taught in TeamSTEPPS; the other three are leadership,
situation monitoring and communication
• Mutual support is “back up behavior” in which team members
provide a safety net for each other to prevent errors
Task Assistance
can prevent
work overload
Patient Safety
I’m Concerned,
I’m Uncomfortable,
this is a Safety
issue!
I must advocate
for my patient;
others may not
have the same
information
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Feedback focuses
on behaviors and
is needed to
improve team
performance
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Introduction
What is a Mutual Support?
• Mutual support has the most tools of the four key strategies
−
Task assistance
−
Feedback
−
Advocacy and Assertion
−
Two Challenge Rule
Information
Conflict
−
CUS (resolve information conflict)
−
DESC Script (resolve personal conflict)
Personal
Conflict
• Advocating for patients may lead to conflict when decision
makers don’t have the same information (shared mental
model) or there is a personality conflict
• Assertion is NOT aggressive; it does not undermine
authority, attack the decision maker, or question a decision
without reason
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Summary
Introduction
Teams provide organizations with a greater ability to adapt and learn than do
individuals. However, just because groups of people call themselves a team
doesn’t mean that they are truly a team. Based on an extensive review of the
literature, Eduardo Salas and colleagues published the theoretical model on
the next slide in 2005. This framework is called the big 5 of teamwork. The
purpose of the model is to identify the core concepts that enable groups of
people to work together, to collaborate, to adapt to changing circumstances,
and effectively work toward a common goal. The diagram illustrates that
when team leaders direct and coordinate the activities of other team
members by clarifying roles, establishing goals & expectations, and
organizing meetings for planning and feedback, they provide the opportunity
for team members to communicate, collaborate, and cooperate. It is during
these meetings—briefs, huddles, and debrief—that team members
communicate what they have learned by monitoring others, a new shared
mental model of how to reach a goal emerges, and team members offer
back up or mutual support to achieve that goal. When team members trust
each other, value team goals above individual goals, and use closed loop
communication, they have the ability to be adapt, manage complex systems
and complex patients and learn from experience.
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The Theory
Mutual
Performance
Monitoring
Team
Leadership
Team
Orientation
Back-up
Behavior
Shared Mental
Models
Mutual
Trust
Adaptability
Big 5
Coord.
Mechanism
Team
Effectiveness
Closed Loop
Communication
Salas, Sims, Burke. Is there
a “Big Five” in teamwork?
Small Group Research.
2005; 36:555-599.
14
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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