Strategies and Tools
to Enhance Performance
and Patient Safety
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”
2
OR Teamwork Climate and Postoperative Sepsis Rates
Length of ICU Stay After Team Training
2.4
(per 1000 discharges)
Avg. Length of Stay (days)
18
2.2
16
50
2
1.8
%
14
Re
du
cti
on
12
Group Mean
AHRQ National Average
10
1.6
Low Teamwork
Climate
8
1.4
6
1.2
Mid Teamwork
Climate
4
1
June
July
August
Sept
Oct
Nov
Dec
Jan
Feb
March
April
High Teamwork
Climate
2
May
0
(Pronovost, 2003)
Johns Hopkins
Journal of Critical Care Medicine
Teamwork Climate Based on Safety Attitudes Questionnaire
Low
(Sexton, 2006)
Johns Hopkins
Adverse Outcomes
Indemnity Experience
Pre-Teamwork Training
Post-Teamwork Training
25
20
50%
Reduction
20
15
50%
Reduction
11
10
5
0
(Mann, 2006)
Beth Israel Deaconess Medical Center
Contemporary OB/GYN
3
Malpractice Claims, Suits, and Observations

High
Why Do Errors Occur—Some Obstacles
• Workload fluctuations
4
• Interruptions
• Excessive professional
courtesy
• Fatigue
• Halo effect
• Multi-tasking
• Passenger syndrome
• Failure to follow up
• Hidden agenda
• Poor handoffs
• Complacency
• Ineffective
communication
• High-risk phase
• Not following protocol
• Task (target) fixation
• Strength of an idea
JCAHO Sentinel Events
5
What Comprises Team Performance?
Knowledge
Cognitions
“Think”
Attitudes
Affect
“Feel”
Skills
Behaviors
“Do”
6
…team performance is a
science…consequences of
errors are great…
Outcomes of Team Competencies
• Knowledge
– Shared Mental Model
• Attitudes
– Mutual Trust
– Team Orientation
• Performance
– Adaptability
– Accuracy
– Productivity
– Efficiency
– Safety
7
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)
8
Barriers to Team Performance
• Inconsistency in team
membership
• Lack of time
• Lack of information sharing
• Hierarchy
• Defensiveness
• Conventional thinking
• Varying communication styles
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• Conflict
• Lack of coordination
and follow-up
• Distractions
• Fatigue
• Workload
• Misinterpretation of
cues
• Lack of role clarity
Multi-Team System (MTS) for Patient Care
10
Team Failure Video
11
Effective Team Members
• Are better able to predict the needs of other team
members
• Provide quality information and feedback
• Engage in higher level decision-making
• Manage conflict skillfully
• Understand their roles and responsibilities
• Reduce stress on the team as a whole through better
performance
“Achieve a mutual goal through interdependent
and adaptive actions”
12
TeamSTEPPS
Leadership
13
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
14
Promoting & Modeling Teamwork
Effective leaders cultivate desired
team behaviors and skills through:
• 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
15
Briefs
Planning
• Form the team
• Designate team roles
and responsibilities
• Establish climate and
goals
• Engage team in short
and long-term
planning
16
Huddle
Problem solving
• Hold ad hoc, “touch-base”
meetings to regain
situation awareness
• Discuss critical issues
and emerging events
• Anticipate outcomes
and likely contingencies
• Assign resources
• Express concerns
17
Debrief
Process Improvement
• Brief, informal information exchange and
feedback sessions
• Occur after an event or shift
• Designed to improve teamwork skills
• Designed to improve outcomes
• An accurate reconstruction of key events
• Analysis of why the event occurred
• What should be done differently next time
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Facilitating Conflict Resolution
• Effective leaders facilitate conflict
resolution techniques through invoking:
• Two-Challenge rule
• DESC script
• Effective leaders also assist by:
• Helping team members master conflict
resolution techniques
• Serving as a mediator
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TeamSTEPPS
Situation
Monitoring
20
A Continuous Process
Situation
Monitoring
(Individual Skill)
Shared
Mental Model
(Team Outcome)
21
Situation
Awareness
(Individual
Outcome)
Situation Monitoring
(Individual Skill)
Process of actively scanning behaviors and
actions to assess elements of the situation or
environment
• Fosters mutual respect and team
accountability
• Provides safety net for team and patient
• Includes cross monitoring
… Remember, engage the patient
whenever possible.
22
Cross Monitoring
• Mechanism to help
maintain accurate
situation awareness
• Way of “watching each
other’s back”
• Ability of team members
to monitor each other’s
task execution and give
feedback during task
execution
23
Components of Situation
Monitoring:
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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)
25
Shared Mental Model?
26
How Shared Mental Models
Help Teams
• Help ensure that teams know what to expect, so if
necessary, can regroup to get on the “same page”
• Foster communication to ensure care is synchronized
• Ensure that everyone on the team has a picture of what it
should look like
• Enable team members to predict and anticipate better
• Create commonality of effort and purpose
“ Shared mental models help teams avoid errors that
place patients at risk.”
27
TeamSTEPPS
Mutual
Support
28
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!”
29
Feedback
• Can be formal or informal
• Constructive feedback
– Is considerate, task-specific, and focuses attention on
performance and away from the individual (Baron 1988)
– Is provided by all team members
• Evaluative feedback
– Helps the individual by comparing behavior to standards
or to the individual’s own past performance (London,
Larson, and Thisted 1999)
– Most often used by an individual in a coaching or
mentoring role
30
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.”
31
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
32
Two-Challenge Rule
1
33
2
Please Use CUS Words
but only when appropriate!
34
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.
35
Collaboration
• Achieves a mutually satisfying solution resulting
in the best outcome
– All Win!: Patient Care Team (team members, the
team, and the patient)
– Includes commitment to a common mission
• Meet goals without compromising relationships
“True collaboration is a process, not an event.”
36
TeamSTEPPS
Communication
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JCAHO: Importance of Communication
Ineffective communication is a
root cause for nearly 66 percent
of all sentinel events reported*
* (JCAHO Root Causes and Percentages for Sentinel Events (All
Categories) January 1995−December 2005)
38
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
• Offer and request information in an appropriate
timeframe
• Verify authenticity
• Validate or acknowledge information
39
SBAR provides…
• A framework for team members to effectively
communicate information to one another
• Communicate the following information:
– Situation―What is going on with the patient?
– Background―What is the clinical background or
context?
– Assessment―What do I think the problem is?
– Recommendation―What would I recommend?
40
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
41
Check-Back is…
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Handoff
•
•
•
•
•
•
•
Optimized Information
Responsibility– Accountability
Uncertainty
Verbal Structure
Checklists
IT Support
Acknowledgement
Communication Challenges
•
•
•
•
•
•
•
•
•
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Language barrier
Distractions
Physical proximity
Personalities
Workload
Varying communication styles
Conflict
Lack of information verification
Shift change
TeamSTEPPS
45
Team Formation Video
46