Introduction
On November 18, 2009, Pediatric ED staff (all attendings, 2 RNs) held a retreat to
become trained in TeamSTEPPS and discuss innovations to improve patient care and
safety in the Pediatric ED. Cheryl Jackson, Director of the Pediatric ED, invited Celeste
Mayer, Patient Safety Officer, and the RTI TeamSTEPPS evaluation team to participate,
and during this time, the group targeted areas for quality improvement and collaborated
to develop a TeamSTEPPS Action Plan to address care and safety concerns. This report
elaborates on each of the Action Planning steps.
The change team selected improving staff situation monitoring and communication for
their first project. Using the Strengths, Weaknesses, Opportunities, and Threats (SWOT)
analysis conducted by an external consultant in 2007, they pinpointed the following
threat: “inadequate system or practice for accurate cuing of patient status (especially on
unit admission) or progress towards goal that allows entire ED team to maintain vigilance
and situation awareness.” To ameliorate this concern, they opted to incorporate two
specific activities into their regular activities:
1) conducting three scheduled huddles/briefings throughout the day (9AM, 6PM,
and midnight) and
2) developing a white board system that tracks lab status (ordered, obtained,
pending, completed) for each room.
The change team intends to begin implementing these innovations on December 8, 2008
after speaking with the ED Nurse Manager, briefing incoming residents and other
Pediatric ED staff, and discussing the changes at an upcoming ED nurse staff meeting.
The RTI evaluation team and Celeste Mayer will document the implementation process
and monitor program success using the metrics identified during the retreat. The
performance measures and evaluation plan are outlined in more detail below, and staff
hopes to see changes within a six month time frame.
To make these interventions possible, Pediatric ED staff left the retreat with several tasks,
listed in the table below.
Change Team
Next Steps
Member
Cheryl Jackson
 Meet with Sandy Pabers, ED Nurse Manager
 Brief incoming residents and HUCs
Dan Macklin &
 Create checklist for huddles/briefings
Jessica Katz-Nelson
Robin Davis
 Make calendar with checkboxes for 9AM, 6PM, and
midnight briefings
Becky Wheeler &
 Develop white board/lab status system
Paula Toney
Celeste Mayer
 Contact Sergio Rabinovitz for Pediatric ED data
 Collect ongoing data (calendar, white board status, and
clinical outcome measures)
The following sections detail the Pediatric ED’s Action Plan.
Step 1. Create a Change Team
In developing the action plan, Pediatric ED staff identified the hospital, physician,
nursing and frontline leaders (enumerated below). Of these team members, several have
process improvement experience. Celeste Mayer has IHI Process for Improvement
experience, and Alan Stiles, Jessica Katznelson, and Cheryl Jackson are Six-Sigma
yellow belts.
Change Team
Member
Senior Leader -“Executive Sponsor”
Clinical or Technical
Expert – “The
Champion”
Front-Line Leader
Other Change Team
Members
Name (Staff Position)
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

Brian Goldstein, MD (Chief of Staff, UNC
Hospitals)
Alan Stiles, MD (Chair of Pediatrics)
Mary Tonges, RN (Vice-President, Nursing)
Cheryl Jackson, MD (Director of Pediatric ED)
Jeff Strickler, RN (Clinical Nursing Director)
Celeste Mayer, RN PhD (Patient Safety Officer)
Kelly Revels, RN
Al Bonifacio, RN
Jennifer Haynes, RN
Becky Wheeler, RN
Jessica Katznelson, MD
Pediatric ED faculty
Paula Toney, RN
Step 2. Define the Problem, Challenge or Opportunity for Improvement
An analysis of strengths, weaknesses, opportunities, and threats (SWOT analysis)
revealed several processes that would benefit from improved teamwork and
communication. During the November 2008 faculty retreat, the Pediatric ED staff
selected one area for process improvement from the “Threats” section of the SWOT
analysis: inadequate system or practice for accurate cuing of patient status (especially on
unit admission) or progress towards goal that allows entire ED team to maintain
vigilance and situation awareness.
The team determined that inconsistent follow-up on lab status could benefit from
situation monitoring and from creating an environment of mutual support. They will
initiate a new white board system, indicating lab status for each room (e.g., labs ordered,
obtained, pending, and completed). This should improve their ability to disposition
patients in a timelier manner. All staff will share the responsibility for updating the board
and there will be primary responsibilities based on roles (e.g., RNs who draw the blood
for a lab would indicate that the lab was obtained). The change team also discussed
involving the HUCs in this process because they can check A2K/SMS to follow lab
status, even though they cannot see the results. Becky Wheeler and Paula Toney agreed
to collaboratively create the first version of the white board.
In addition, the staff decided to institutionalize three huddles/briefings during shift
changes and prior to the Pediatric ED’s closure at night based on near misses due to
breakdowns in team skills and staff member concerns of possible adverse events. These
huddles/briefings will occur at 9AM, 6PM and at midnight. Attending physicians will
lead the huddles/briefings. Drs. Dan Macklin and Jessica Katznelson agreed to create a
checklist of important topics to cover during these concise huddles/briefings.
The change team anticipates commencing these improvements on December 8, 2008 after
Dr. Cheryl Jackson meets with the ED nurse manager and the ED nursing staff meets.
Step 3. Define the Aims of Your TeamSTEPPS Intervention
In this step, the change team outlined their process and outcome aims and identified
several clinical outcomes. The table below summarizes the team’s plan:
Planning Question
TeamSTEPPS
Process Aim
What do we want to
achieve?
Who will be involved
in the change?
When will the
improvement occur?
Outcome Aim
What do we want to
achieve?
Who will be involved
in the change?
When will the
improvement occur?
Clinical Outcome
Aims
Plan
 Scheduled huddles/briefings occur 80% of the time (based on
calendar with checkbox indicating whether huddle occurred)
 White board up-to-date 85% of the time (based on self-report
or observations made by Celeste Mayer)
 Consistent use of practices meant to improve situation
awareness, mutual support, communication and efficiency.
 All Pediatric ED staff
 The huddles and white board system will be implemented in
early December.
 Adherence to implementation goals is expected to be met by
the end of January 2009.
Improve Pediatric ED staff perceptions of teamwork, situation
awareness, mutual support, communication, and efficiency,
based on interviews within 6 months of TeamSTEPPS
Intervention implementation
 Improve staff perceptions of situation awareness, mutual
support, communication, and efficiency
 All Pediatric ED staff
 Official start date will be December 8, 2008
 Expect to see changes within 6 months
 Decrease in length of stay (as compared to same six months of
previous year)
What do we want to
achieve?
Who will be involved
in the change?
When will the
improvement occur?
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
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Decrease in time to triage
Decrease in time to see the doctor
Decrease in time to disposition
Decrease in time from disposition to discharge
Improve efficiency
Improve patient care and satisfaction
Improve staff satisfaction
All Pediatric ED staff
 Expect to see changes within 6 months
Step 4. Design a TeamSTEPPS Intervention
As a first step, all of the Pediatric ED attendings as well as several nurse leaders were
trained on TeamSTEPPS. As described above, the change team decided to emphasize
communication and situation monitoring for their intervention. Specifically, they plan to
implement three scheduled briefings during shift changes and prior to the nightly closure
of the Pediatric Emergency Department (i.e., 9AM, 6PM, and midnight). To maintain
consistency and ensure coverage of important topics (e.g., bed availability, patient status),
Drs. Katznelson and Macklin will develop a list of key topics for discussion. Both noted
that they regularly use the same mental list, but this will codify their mental lists, support
a shared mental model and promote resident professional socialization.
In addition to the scheduled huddles/briefings, they decided to implement a white board
system to update a room’s lab status (ordered, obtained, pending, and complete). Paula
Toney, RN and Becky Wheeler, RN will develop the first version of the white board and
will involve other staff in the decisions about where to hang it and exactly how it should
be updated. The change team also hopes to use this new system as an opportunity to
integrate HUCs and volunteers into the team. HUCs can look up lab status, not results, in
the A2K/SMS systems, and volunteers can report lab status to families when patients
inquire (rather than trying to search for a physician). All Pediatric ED staff are
responsible for updating this board, but the change team felt that clear responsibilities
need to be assigned based on roles (e.g., a nurse may be responsible for updating the
status as “obtained” once s/he draws blood).
In addition to these two specific new practices, the change team will model the
TeamSTEPPS strategies and behaviors in their team interactions, making use of all of the
tools as appropriate and explaining them to other staff (e.g., checkbacks, call-outs, good
leadership practices, two-challenge rule, CUS words, etc.). Since not all of the Pediatric
ED staff will have received TeamSTEPPS training at the time the intervention is
implemented, it will be especially critical for the change team to explain the benefits of
the two new practices, and to consistently demonstrate situational awareness and good
communication skills in their department interactions.
The change team will initiate these new practices on December 8, 2008 and will discuss
what revisions they should consider to the innovation during their February 2009 retreat
(unless an immediate need for a revision seems important).
Step 5. Develop a Plan for Testing the Effectiveness of your TeamSTEPPS
Intervention
To accomplish Step 5, the change team agreed upon several measures and data collection
strategies to determine whether their intervention was successful.
Planning Question
Plan
TeamSTEPPS
 Scheduled huddles/briefings occur 80% of the time (based on
Process Aim
calendar with checkboxes indicating whether huddle
occurred)
 White board up-to-date 85% of the time (based on self-report
or observations made by Celeste Mayer)
Staff responsible for  Robin Davis will create a calendar, with checkboxes for each
collecting data
designated briefing time, indicating whether huddle occurred
 Celeste Mayer will obtain a copy of the monthly calendar
 Celeste Mayer will collect data on white board usage through
phone calls and observations (white board should be up-todate during 85% of phone calls and visits)
Measures/target
 Scheduled huddles/briefings occur 80% of the time
ranges for the data
 White board up-to-date 85% of the time
Study Design
 Pre-post intervention study
Data Sources,
 Huddle/briefing calendar collected throughout implementation
collection methods,
period
and collection
 White board status checked by Celeste Mayer throughout
timeline
implementation period
 TBD observations by Wei-Ting Lin at baseline and postintervention
Analysis,
 Calendar and white board data assembled in Excel file and
interpretation, and
presented in graphical form (e.g., time by % of huddles
presentation
achieved)
 TBD, report summarizing findings of observations
Team Outcome Aim  Improve Pediatric ED staff’s situation awareness, mutual
support, communication and efficiency
Staff responsible for  RTI evaluation team
collecting data
 TBD, Wei-Ting Li, nurse observer, may conduct observations
(baseline and post-implementation)
Measures/target
 Staff perceptions of changes in situation awareness, mutual
ranges for the data
support, communication, and efficiency
Study Design
 Post-test only (given the quick start time of the
implementation it was not possible to collect baseline
interviews). Staff will be asked to recall their earlier
perceptions, as well as their current perceptions.
Data Sources,
collection methods,
and collection
timeline
Analysis,
interpretation, and
presentation
Clinical Outcome
Aims
Staff responsible for
collecting data
Measures/target
ranges for the data
Study Design
Data Sources,
collection methods,
and collection
timeline
Analysis,
interpretation, and
presentation
 Key informant interviews conducted 6 months postimplementation with Pediatric ED staff
 Observational data using the TENTS tool to assess use of
TeamSTEPPS tools and behaviors
 RTI evaluation team will transcribe and code interviews. Key
codes will be organized in an analytic matrix and summarized
across themes.
 Wei-Ting Lin will summarize and analyze her observational
data and RTI will incorporate it into their reports.
 RTI will present findings in a descriptive report.
 Decrease in length of stay (as compared to same six months of
previous year)
 Decrease in time to triage
 Decrease in time to see the doctor
 Decrease in time to disposition
 Decrease in time from disposition to discharge
 Celeste Mayer will contact Sergio Rabinovitz for data
(hospital currently collects this data)
 Decreases in each measure
 Pre- and post-intervention
 Hospital collected data
 Celeste Mayer will get the data from the hospital throughout
the implementation period
 Findings presented in most appropriate graphical form
Step 6. Develop an Implementation Plan
All Pediatric ED attendings and two ED nurses who work with the Pediatric ED received
training on November 18, 2008. Other ED nurses will receive training as the ED nursing
staff roll out TeamSTEPPS over the next two to three months. The Pediatric ED will
implement their innovations beginning December 8, 2008. Prior to their intended start
date, Cheryl Jackson will discuss the change team’s plans with Sandy Pabers, Nurse
Manager of the ED. Cheryl will also update the incoming residents and HUCs on this
practice. Nurses, present at the change team meeting, Wade Daniels, Becky Wheeler,
Chris Clarke, and Paula Toney, will describe the planned intervention at an upcoming
staff meeting and will encourage other nurses to visit the LMS TeamSTEPPS module.
Step 7. Develop a Plan for Sustained Continuous Improvement
In addition to documenting and measuring outcomes throughout the implementation, the
huddle/briefing calendar and white board, should they prove effective, will likely become
permanent fixtures. Staff can use their experience with the two innovations to consider
program revisions (e.g., if huddles do not routinely occur at 9AM, they can analyze the
reasons underlying that and change the time) and potential additions. To keep all staff
apprised of the department’s progress, the change team is considered hanging
conspicuous posters charting their rates of “compliance” with the two new practices (e.g.,
percentage of times the huddles were conducted). These timely updates may serve as a
reminder and motivator.
Celeste Mayer will share examples of the recognition cards that have been successfully
used to reinforce TeamSTEPPS behaviors in the PICU and SICU. The change team will
also discuss the program at faculty retreats (as well as consider future innovations, such
as implementing strategies to ensure consistent use of standing orders).
Step 8. Develop a Communication Plan
Celeste Mayer and Cheryl Jackson have communicated with Drs. Goldstein and Stiles
and Ms. Mary Tonges, RN about the program in the past. These stakeholders have
knowledge of the program through its earlier implementation in the Pediatric Intensive
Care Unit and Surgical Intensive Care Unit. They will continue to share information with
these stakeholders by sending short reports on a quarterly basis. As mentioned above,
Cheryl Jackson will speak with Sandy Pabers, Nurse Manger of the ED, and will advise
incoming residents and HUCs of the innovation. All change team members will wear
their TeamSTEPPS badges and strive to model TeamSTEPPS practices.