Strategies and Tools
to Enhance Performance
and Patient Safety
Introduction
Objectives
 Describe the TeamSTEPPS training initiative
 Explain your organization’s patient safety program
 Describe the impact of errors and why they occur
 Describe the TeamSTEPPS framework
 State the outcomes of the TeamSTEPPS framework
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Introduction
Joint Commission Sentinel
Events
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Introduction
OR Teamwork Climate and Postoperative Sepsis Rates
Length of ICU Stay After Team Training
(per 1000 discharges)
18
2.4
Avg. Length of Stay (days)
16
2.2
14
50
2
1.8
%
Group Mean
12
Re
du
cti
on
AHRQ National Average
10
Low Teamwork
Climate
8
1.6
Mid Teamwork
Climate
6
1.4
4
High Teamwork
Climate
1.2
2
1
June
July
August
Sept
Oct
Nov
Dec
Jan
Feb
March
April
0
May
Teamwork Climate Based on Safety Attitudes Questionnaire
(Sexton, 2006)
Johns Hopkins
(Pronovost, 2003)
Johns Hopkins
Journal of Critical Care Medicine
Adverse Outcomes
Low

High
Indemnity Experience
Pre-Teamwork Training
Post-Teamwork Training
25
20
50%
Reduction
20
50%
Reduction
15
11
10
5
0
(Mann, 2006)
Beth Israel Deaconess Medical Center
Contemporary OB/GYN
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Malpractice Claims, Suits, and Observations
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Introduction
Team
Strategies & Tools to Enhance Performance & Patient Safety
“Initiative based on evidence derived
from team performance…leveraging
more than 25 years of research in military,
aviation, nuclear power, business and
industry…to acquire team competencies”
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Introduction
The Components of a
Patient Safety Program
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Introduction
What Comprises Team Performance?
Knowledge
Cognitions
“Think”
Attitudes
Affect
“Feel”
Skills
Behaviors
“Do”
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…team performance is a
science…consequences
of errors are great…
7
Team Structure
NEXT:
The ratio of We’s to I’s is the best
indicator of the development of a
team.
–Lewis B. Ergen
Introduction
What Defines a Team?
Two or more people who
interact dynamically,
interdependently, and
adaptively toward a
common and valued goal,
have specific roles or
functions, and have a
time-limited membership
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Introduction
High-Performing Teams
Teams 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)
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Introduction
Multi-Team System (MTS) for Patient Care
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Leadership
Introduction
Effective Team Leaders
 Organize the team
 Articulate clear goals
 Make decisions through collective input of
members
 Empower members to speak up and
challenge, when appropriate
 Actively promote and facilitate good teamwork
 Skillful at conflict resolution
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Introduction
Resource Management
Core Team Leader
Coordinating Team Leader
• Information
• Information
– Patient &
Family
– Plan of care
– Facilities
Administrative
– Facilities
• Time
• Equipment
• Time
• Equipment
• Patient flow
HUMAN
CAPITAL
FOCUS
Team & Your Unit
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• Other
departments
FOCUS
Support Units
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Introduction
Delegation
 Method of re-distributing
tasks or assignments
 Process includes 4 steps:

Decide what to delegate

Decide to whom to
delegate

Communicate clear
expectations

Request feedback
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Introduction
Promoting & Modeling Teamwork
Effective leaders cultivate desired team
behaviors and skills through:
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
Open sharing of information

Role modeling and effectively cueing team
members to employ prescribed teamwork
behaviors and skills

Constructive and timely feedback

Facilitation of briefs, huddles, debriefs, and
conflict resolution
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Introduction
Team Events
 Briefs – planning
 Huddles – problem solving
 Debriefs – process improvement
Leaders are responsible to assemble the team
and facilitate team events
But remember…
Anyone can request a brief, huddle, or debrief
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Introduction
Teamwork Actions
 Empower team members to speak freely
and ask questions
 Utilize resources efficiently to maximize
team performance
 Balance workload within the team
 Delegate tasks or assignments, as appropriate
 Conduct briefs, huddles, and debriefs
 Utilize conflict resolution techniques
(i.e., Two-Challenge rule and DESC script)
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Situation Monitoring
“Attention to detail is one of the most important details ...”
–Author Unknown
Introduction
A Continuous Process
Situation
Monitoring
(Individual Skill)
Situation
Awareness
(Individual
Outcome)
Shared
Mental Model
(Team Outcome)
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Introduction
Components of
Situation Monitoring:
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Introduction
Situation Awareness is…
The state of knowing the current conditions affecting
the team’s work




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Knowing the status
of a particular event
Knowing the status
of the team’s
patients
Understanding the
operational issues
affecting the team
Maintaining
mindfulness
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Introduction
Conditions that Undermine
Situation Awareness (SA)
Failure to—
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
Share information with the team

Request information from others

Direct information to specific team members

Include patient or family in communication

Utilize resources fully (e.g., status board,
automation)

Document
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Introduction
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.
“Teams that perform well hold
shared mental models.”
(Rouse, Cannon-Bowers,
and Salas 1992)
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Introduction
Shared Mental Model?
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Introduction
Teamwork Actions
 Conduct team exercises to increase situation monitoring skills
 Share information in a timely fashion
 Include patient and/or family in communication
 Use cross monitoring
 Apply the STEP process when monitoring the situation
 Foster communication to ensure that all members of the team
have a shared mental model
 Share information during briefs, team huddles, debriefs, and
transitions in care
“Teams do not seek consensus; they seek
the best answer.”
–Katzenbach and Smith
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Mutual Support
“A chain is only as strong as its
weakest link.”
–Author Unknown
Introduction
Mutual Support
Mutual support is the essence of teamwork

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Protects team members from work overload
situations that may reduce effectiveness and
increase the risk of error
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Introduction
Task Assistance
Team members foster a climate in which it
is expected that assistance will be actively
sought and offered as a method for reducing
the occurrence of error.
“In support of patient safety,
it’s expected!”
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Introduction
Characteristics of Effective Feedback
Good Feedback is—

TIMELY

RESPECTFUL

SPECIFIC

DIRECTED toward improvement


Helps prevent the same problem
from occurring in the future
CONSIDERATE
“Feedback is where the learning occurs.”
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Introduction
Advocacy and Assertion
 Advocate for the patient

Invoked when team members’
viewpoints don’t coincide with
that of a decision maker
 Assert a corrective action in a
firm and respectful manner
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Introduction
Conflict Resolution Options
Information Conflict
(We have different information!)
Personal Conflict
(Hostile and harassing behavior)
Two-Challenge rule
DESC script
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Introduction
Please Use CUS Words
but only when appropriate!
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Introduction
Conflict Resolution
DESC Script
A constructive approach for
managing and resolving conflict
D—Describe the specific situation
E—Express your concerns about the action
S—Suggest other alternatives
C—Consequences should be stated
Ultimately, consensus shall be reached.
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Introduction
Teamwork Actions
 Foster a climate supportive of task assistance
 Provide timely and constructive feedback
 Be assertive and advocate for the patient
 Use the Two-Challenge rule, CUS, and DESC
script to resolve conflict
 Resolve conflict through collaboration—Create a
“Win-Win-Win” situation
“Those whom we support hold us up in life.”
–Marie von Ebner-Eschenbauch
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Communication
Assumptions
Fatigue
Distractions
HIPAA
Introduction
Standards of
Effective Communication
 Complete

Communicate all relevant information
 Clear

Convey information that is plainly understood
 Brief

Communicate the information in a concise manner
 Timely



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Offer and request information in an appropriate timeframe
Verify authenticity
Validate or acknowledge information
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Introduction
Call-Out is…
A strategy used to communicate
important or critical information

It informs all team members
simultaneously during
emergency situations

It helps team members
anticipate next steps
…On your unit, what information
would you want called out?
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Introduction
Check-Back is…
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Introduction
Handoff
 Optimized Information
 Responsibility– Accountability
 Uncertainty
 Verbal Structure
 Checklists
 IT Support
 Acknowledgement
Great opportunity for
quality and safety
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Introduction
Teamwork Actions
 Communicate with team members in a brief,
clear, and timely format
 Seek information from all available sources
 Verify and share information
 Practice communication tools and strategies daily
(SBAR, call-out, check-back, handoff)
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Introduction
Pulling it All Together
 Recognize opportunities to improve patient safety
 Assess your current organizational culture and
existing Patient Safety Program components
 Identify teamwork improvement action plan by
analyzing data and survey results
 Design and implement initiative to improve team-
related competencies among your staff
 Integrate TeamSTEPPS into daily practice.
“High-performance teams create a safety net for
your healthcare organization as you promote a
culture of safety."
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