Teamwork and Transparency
Jill Marsteller, PhD, MPP
David Thompson, DNSc, MS, RN
On the CUSP: Stop BSI
Tuesday, February 9, 2010
Learning Objectives
• You should be able to
– Explain transparency and the need for it in
this project
– Describe importance of strong teamwork on
CUSP/CLABSI team and in unit generally
– Provide examples of teamwork-enhancing
tools
2
Transparency
• Make harm visible
– Share stories
– Discuss BSI rates
– Link to patients
• Need to share data with
– The unit
– Executive partner
– Board
3
Transparency
• Track progress visibly
– Bulletin boards that show improvements
– Memos
– Announcements at meetings
– Milestone celebrations
– Recognition of people’s efforts
• Frequent reminders, keep in the front of
caregivers’ minds
4
Percent Understanding Patient
Care Goals
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Implemented patient
goals sheet
Residents
Nurses
1
2
3
4
5
6
5
Transparency’s Link to
Teamwork
• Be open about issues and problems,
challenges
• Confront the elephant in the room
• Be explicit about sharing a common goal
• Admit we all need each other
6
Available Tools to Enhance
Transparency
•
•
•
•
•
•
Executive Senior Leader Checklist
Infection Preventionist Checklist
Weeks with CLABSI Banner
Staff Safety Assessment
Team Check Up Tool
Central Line Audit Forms
Teamwork
• Effective communication
– Closed loop communication/active listening
– Responsiveness of team members
– Communication skill set
•
•
•
•
Situational awareness
Shared mental model
Mutual support
Teamwork and communication tools
8
Communication
Breakdowns are
frequently the
root cause of…
undesirable
outcomes
9
% of respondents within an ICU reporting good teamwork climate
Teamwork Climate Across Michigan ICUs
100
90
80
70
60
50
40
30
20
10
0
Teamwork Climate Across Michigan ICUs
% of respondents within an ICU reporting good teamwork climate
100
90
80
The strongest predictor of clinical excellence:
caregivers feel comfortable speaking up if they
perceive a problem with patient care
70
60
50
40
30
20
10
0
No BSI = 5 months or more w/ zero
No BSI 21%
No BSI 31%
No BSI 44%
Impact on Healthcare
• ‘Caregiver interaction’ aka effective
teamwork
– Reduced length of stay
– Lower nurse turnover
– Higher quality of care
– Greater ability to meet family member
needs
(Shortell et al, Med Care;1994:508-25.)
12
Impact on Healthcare
• Effective teamwork in ICU reduced risk of
readmission or death--16% to 5% (Baggs, Heart Lung
1992;21:18-24.)
• Ineffective collaboration & communication
in OR = retained sponges, mismatched
blood transfusion & wrong extremity nerve
blocks (Gawande, NEJM 2003;348:229-35. Edmonds, Reg Anesth Pain Med 2005;30:99103. Gibbs, AHRQ report 2001;2557.)
13
Percent Understanding Patient
Care Goals
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Implemented patient
goals sheet
Residents
Nurses
1
2
3
4
5
6
14
Impact on ICU Length of Stay
2.5
Avg. LOS (days)
2
Daily Goals
1.5
ICU LOS
1
0.5
0
ne uly gust ept Oct Nov Dec Jan Feb rch pril ay
u
J u
S
M
a A
J
M
A
654 New Admissions: 7 Million Additional Revenue
15
What Are the Required
Teamwork Competencies?
• Skill requirements in teams:
– Mutual performance
monitoring and adaptability
– Supporting/back-up
behavior
– Team leadership
– Task-related assertiveness
– Conflict resolution
– Closed-loop communication
16
Strategies to achieve a
“shared mental model”
What we can do to stay on the same page…
Individual Strategies
Situation Monitoring
Know the patient care plan
Active listening
Read back
Verify
Cross monitoring
Self monitoring
Group Strategies
Brief
Debrief
Huddle
Meetings
Documentation
Hand-offs
Call Out
Environmental
support
Visual management
tools
Checklists
Distraction control
Technology aids
17
Situational Awareness
• Members of the team have an understanding
of “what’s going on” and “what is likely to
happen next.”
• Teams are alert to developing situations,
sensitive to cues and aware of their
implications.
18
Situational Awareness
• Focus is
– Preparation/planning and vigilance
– Workload distribution
– Distraction avoidance
19
Elements That Affect
Situational Awareness
•
•
•
•
•
•
•
•
•
Interruptions
Task absorption
Verbal abuse
Fatigue
Not following plan of care
Ambiguous orders/directions
Change in team member
Work load
Skill level
20
Improving Situational
Awareness
• Know the game plan – through briefings and team
management (e.g., workload & workflow
management, task coordination)
• Anticipate next steps and possible events
• Follow known policies and procedures
• Cross-check and verify
• Provide ongoing updates – call-outs, cross-talk,
and briefings
• Implement team huddles
21
Team Huddle
• Pulling together members of the team to
review patient data and decide on the
course of action
– Can be prearranged like evening rounds or as
needed when a patient’s condition requires a
change in course of action
– May involve strategies to plan oversight,
physician availability
– ANYONE CAN ASK FOR A TEAM HUDDLE,
ANYTIME
22
Active Listening
• Focused on the speaker
• “Actively” listening and processing the
information being presented
• Used to retain information and gain
knowledge
• Goal: The ability to repeat the sender’s
message-“read back”
23
Cross Monitoring
• Process of monitoring the actions of other
team members for the purpose of sharing
the workload and reducing or avoiding
errors
– 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
(McIntyre and Salas 1995)
24
Call Out
• Statements of action or description of what
you are seeing to keep people informed:
“The patient is experiencing runs of v-tach
despite the medication…”
– Can be used for routine care such as
checking an alarm
– Can be used during a procedure or arrest
situation to let members of the team know
what has been completed
25
Briefing Defined
A briefing is a discussion
between two or more people,
often a team, using succinct
information pertinent to an
upcoming event.
26
The SBAR Briefing
SITUATION driven-Structure based
1. Situation - Current situation that needs reporting
2. Background - Pertinent history and treatment
3. Assessment - Diagnosis of categorization of the current
situation
4. Recommendation - Proposed plan of care
27
Conflict Resolution Tools
• DESC script (Describe, Express, Specify,
Consequences)
• Two-challenge rule
• Mediation
28
What makes up an effective
team?
Effective
Team
Members
Effective
Team
Leaders
Healthy and
productive
interactive process
29
Another way of looking at it
• Any team member
may be called upon to
be leader in a given
situation/or subpart of
the effort.
Effective
Team
Members
Effective
Team
Leaders
• Designated team
leaders are always
team members at the
same time.
30
Effective team member-leaders
Leaders
• Organize the team
• Articulate clear goals
• Make decisions through
collective input of
members
• Empower members to
speak up and challenge
• Actively promote and
facilitate good teamwork
• Assist in conflict
resolution
Members
• Understand their role
• Agree on the goals
• Provide input to
decisions, assert their
case
• Speak up and challenge
• Actively promote and
facilitate good teamwork
• Be open to conflict
resolution
31
Effective team member-leaders
Leaders
• Share information openly
• Act as role models and
cue team members to
use teamwork skills
• Offer constructive and
timely feedback
• Facilitate briefings,
huddles, debriefs, and
conflict resolution
Members
• Share information openly
• Use teamwork skills and
cue other team members
to also do so
• Offer constructive and
timely feedback
• Participate actively in
briefings, huddles,
debriefs, and conflict
resolution
32
Effective team member-leaders
Leaders
• Initiate planning and
include team members
• Delegate tasks
– What, to whom
– State clear expectations
– Ask for feedback
• Facilitate conflict
resolution
– Two-attempt rule
– DESC script
– Helping team members
practice techniques
– Serving as a mediator
Members
• Contribute to planning
process, initiate subparts
of the plan
• Accept delegation, be
accountable, provide
feedback
• Practice and use conflict
resolution techniques
• Mediate among
coworkers informally
33
Key Benefits of Effective Teamwork
• Ability to predict the needs of other team
members/fewer surprises
• Decisions use better, complete information
• Conflict management provides more pleasant
environment/fewer hurt feelings and grudges
• Better accountability for team performance
• Reduced stress on the team as a whole
• Better experience for patients/improved
safety
34
Available Resources to Improve
Team Communication
• Science of Safety Video
• CUSP Toolkit:
– Staff Safety Assessment
– Daily Goals Checklist
– Safety Issues Worksheet
– Culture Check-up Tool
• Team Stepps
AHRQ Team Stepps
• http://teamstepps.ahrq.gov/abouttoolsmate
rials.htm