IMPROVING PATIENT SAFETY
WITH TEAM TRAINING
SANDON SAFFIER MD
Simulation User Network
OCTOBER 21, 2009
ssaffier@earthlink.net
Objectives
• Recall the overall risk for medical errors in the
hospital environment and the top 10 specific
Sentinel Events by type.
• Recall the purpose of the 2009 Hospital
National Patient Safety Goals.
• List the components necessary for an effective
team training program.
• List the biggest challenges to implementing
team training programs.
National Patient Safety Goals
Goal 2: Improve the effectiveness of
communication among caregivers
National Patient Safety Goal 2
• 2A For verbal or telephone orders or for telephonic reporting of
critical test results, verify the complete order or test result by
having the person receiving the information record and "read-back"
the complete order or test result.
• 2B Standardize a list of abbreviations, acronyms, symbols, and
dose designations that are not to be used throughout the
organization.
• 2C Measure and assess, and if appropriate, take action to improve
the timeliness of reporting, and the timeliness of receipt by the
responsible licensed caregiver, of critical test results and values.
• 2E Implement a standardized approach to “hand off”
communications, including an opportunity to ask and respond to
questions.
Sentinel Events
Communication
Breakdowns are
frequently the root
cause of…
undesirable
outcomes
6
Sentinel Event Experience
Sentinel events reviewed by the Joint Commission January
1995 through December 2006
531 events of wrong site surgery
520 inpatient suicides
488 operative/post op complications
385 events relating to medication errors
302 deaths related to delay in treatment
224 patient falls
153 deaths of patients in restraints
138 assault/rape/homicide
125 perinatal deaths/injury
94 transfusion-related events
85 infection-related events
72 deaths following elopement
66 fires
67 anesthesia-related events
51 retained foreign objects
763 “other”
=4064 RCA’s
PATIENT SAFETY MOVEMENT
“To Err
is Human”
IOM Report
MedTeams®
ED Study
1995
JCAHO National
Patient Safety
Goals
Institute for
Healthcare
Improvement
100K lives
Campaign
Executive Memo
from President
1999
2001
TeamSTEPPS
2003
2004
Patient Safety and
Quality
Improvement
Act of 2005
2005
2006
Medical Team Training
10
Slide 1-3
The Dynamic Research Corporation
US ARMY AVIATION EXPERIENCE
 Crew coordination failures (FY84-89)
 147 fatalities
 cost > $290 million.
 Mishaps involved highly experienced aviators with superior
flight skills
 Failures attributed to:
 workload management
 communication
 task prioritization errors.
MedTeams
Medical Errors Reduction Research
US Department of Defense
Dynamics Research Corporation
Harvard Risk Management Foundation
ORGANIZATION OF THE TCC®
• Maintain Team Structure and Climate
• Plan and Problem Solve
• Communicate With the Team
• Manage Workload
• Improve Team Skills
13
The MedTeamsTM Curriculum:
Five Team Dimensions
Team Dimension
1. Maintain Team
Structure and
Climate
Primary Descriptors
v
v
Establish leadership
Organize the team
v
v
Cultivate team climate
DESC2 Script
v
v
Situation Awareness
Apply decision making processes
v
Cross monitoring
3. Team
Communication
v
v
v
Maintain Situation Awareness
Board Rounds
Call Outs
v
v
Check Backs
Handoffs
4. Manage Workload
v
v
Implement plan of care
Prioritize tasks
v
Manage team resources
and workload
5. Improve Team Skills
v
v
Coaching
Performance Evaluation
v
Engage in formal team
improvement strategies
2. Plan & Problem
Solve
MedTeamsTM Concepts & Behaviors
•
•
•
•
•
•
•
•
Team Climate
DESQ2
Situational Awareness
Cross Monitoring
Advocacy & Assertion
Two Challenge Rule
Briefings
Board Rounds
•
•
•
•
•
Call Outs
Check Backs
Handoffs
Prioritization
Planning
Dr. Allen
16
Error Prevention Strategies
•
Cross-Monitoring
•
Advocacy and Assertion
•
Two-challenge Rule
17
Critical Language
• Key phrases understood by all to mean “stop and
listen to me – we have a potential problem”
– When you hear this phrase, grab an elbow and join in
the request for clarity
• Allina – “ I need some clarity”
• United Airlines CUS program – “I’m
concerned…I’m uncomfortable…this is unsafe…
I’m scared”
• Politely Persist
Information Transfer Techniques
• Check-back
• Call-out
• Hand-off
• SBAR
19
S-B-A-R
• Situation
• Background
• Assessment
• Recommendation
S-B-A-R
• Technique for communication between
member of healthcare team
• Framework for any conversation
• Focused
• Easy to remember
• Esp. good for critical conversations
Shared Mental Models
•
A mental model is a mental picture or
sketch of the relevant facts and
relationships defining an event, situation,
or problem
•
The same mental model held by members
of a team is referred to as a shared mental
model
22
Shared Mental Model
23
Situational Awareness
…the state of knowing the current
conditions affecting the team’s work
25
RED FLAGS FOR LOSS OF SITUATIONAL
AWARENESS
• Ambiguity
• Reduced/poor
communication
• Confusion
• Trying something new
under pressure
• Deviating from
established norms
Michael Leonard, MD
•
•
•
•
•
•
Verbal violence
Doesn’t feel right
Fixation
Boredom
Task saturation
Being rushed/behind
schedule
Pre-procedural Briefing
27
Briefing
• An exchange of concise and relevant
information-getting on the same page
• Communicating the plan
• Briefings aid in:
– Knowing the plan
– Allowing for anticipation of problems with
contingency plans
– Monitoring a situation, watching for red flags
Briefing
• Other Situations to Consider Briefing
– New Team Members
– Fatigue or staffing challenges
– Experienced and novices working side by side
– Cultural differences
Briefing
• Key Elements
–
–
–
–
–
–
–
–
–
Got person’s attention
Made eye contact, faced person
Introduced self
Use person’s name--familiarity is key
Asked knowable information
Explicitly asked for input
Provided information
Talk about next steps
Encourage ongoing monitoring and cross checks
Debriefing
•
•
•
•
Plus / Delta
Event Review
Shift Review
Situational Teaching
Dr. Bridgeton
32
Comprehensive Unit Safety
Program (CUSP)
1. Assess culture of safety -SAQ
• Engage
2. Educate on Science of Safety
3. Identify unit safety concerns
• Educate 4. Executive adopts a unit –Executive
WalkRounds
• Execute 5. Prioritize improvement efforts
6. Implement improvements
• Evaluate 7. Share stories / disseminate results
8. Reassess culture - SAQ
Reference: Peter Pronovost, et al. Implementing and Validating a Comprehensive Unit-Based Safety Program.
SAQ Background
• The SAQ collects input from “front-line” personnel to determine the
strengths and weaknesses of organizations.
– Used in medical, aviation, maritime, rail & military settings
• Administered in over 500 hospitals (USA, United Kingdom, Switzerland,
Germany, Italy, Turkey and New Zealand)
– SAQ is a reliable tool and formally validated:
• Aviation: linked to pilot performance, # of errors, % errors trapped (Helmreich, Foushee, Benson & Roussini, 1986;
Sexton & Klinect, 2001)
• High Speed Rail: linked to train incident and accident rates (Itoh & Andersen, 1999)
• Medicine: linked to LOS, error rates & nurse turnover rates (Pronovost et al. 2002; Sexton, 2002)
Bryan Sexton, Ph.D
Teamwork Disconnect
•RN: Good teamwork means I am
asked for my input
•MD: Good teamwork means the
nurse does what I say
•MD –RN: Different
Communication Styles
• Nurses are trained to be narrative and descriptive
• Physicians are trained to be problem solvers “
what do you want me to do” – “ just give me the
headlines”
• Complicating factors: gender, national culture, the
pecking order, prior relationship
• Perceptions of teamwork depend on your point of
view
Physicians and RN Collaboration
100
90
88%
80
83%
70
90%
93%
60
50
40
48%
48%
54%
59%
30
20
10
0
RN rates Physician
Bryan Sexton, Ph.D.
Physician rates RN
Teamwork level felt to be “high”
Sexton, British Medical Journal, 2000
Believe that decisions of the “leader”
should not be questioned
Sexton, BMJ, 2000
Executive Perceptions vs.
Frontline Perceptions:
Executives overestimate:
Teamwork Climate 4X
Safety Climate 2.5X
Executive Confidence vs.
Executive Accuracy:
-Often wrong but rarely in doubt…
-Currently no incoming data-streams
-Halo Effects
-Frontline data fills the gap
40
Recommendations for Improving
Teamwork & Safety Climate
(For Clinical Areas With < 60% Agreement)
TEAMWORK CLIMATE










Morning/Shift Briefings
Daily Goals
Shadowing Exercise
OR Briefings
SBAR
Use Critical Language (Start a “Grab
an Elbow” campaign)
Simulation
Team Training
Culture Checkup Tool
Reach out within this hospital
• Consult with other clinical areas that
have 80% teamwork climate or higher,
as they have a consensus of
excellence
SAFETY CLIMATE
 Executive Partnership Training and certification
program
• Use this for your lowest scoring clinical areas first, as
it is a powerful intervention, more targeted than
traditional executive walkrounds
 Hero Form (Feedback from Frontline Workers)
 Root Cause Lite
 Science of Safety Training
• 45 Minute online course; free registration is required
• http://distance.jhsph.edu/trams/index.cfm?event=tr
aining.launch&trainingID=72
• Culture Checkup Tool
Reach out within this hospital
• Consult with other clinical areas that have
80% safety climate or higher, as they have
a consensus of excellence
41
Bryan Sexton, Ph.D
So Where’s the Proof?
Proven Results and Patient Safety
ED Observed Errors
Length of ICU Stay After Team Training
35
30
Avg. Length of Stay (days)
Average Rate of Errors
2.4
Exp
25
Control
55%
Reduction
20
15
10
5
2.2
1.8
Pre-Teamwork
Training
Post-Teamwork
Training
%
Re
du
cti
on
1.6
1.4
1.2
1
0
50
2
June
July
August
Sept
Oct
Nov
Dec
Jan
Feb
March
April
May
(Pronovost, 2003), Johns Hopkins
Journal of Critical Care Medicine
(Morey, 2002), Dynamics Research Corporation
Health Services Research
L&D Adverse Outcomes
OR Teamwork Climate and Postoperative Sepsis Rates
(Weighted Adverse Outcome Score)
(per 1000 discharges)
18
16
50%
Reduction
14
12
Group Mean
AHRQ National Average
10
Low Teamwork
Climate
8
6
Mid Teamwork
Climate
4
High Teamwork
Climate
2
0
(Sexton, 2006), Johns Hopkins
Teamwork Climate Based on Safety Attitudes Questionnaire
Low

High
(Mann, 2002), Beth Israel Deaconess Medical Center
43
Contemporary OB/GYN
Benjamin P. Sachs, MB, BS
Perinatal Research Outcomes
• Beth Israel Deaconess (Sachs)
– Reduced rate of adverse outcomes
• 53% over 4 years
– Reduced cases in litigation
• 30-40% in 2yrs
– “Severe” cases reduced
• from 45% to 25%
– Able to reduce reserves
• by 50%
– Process Measures: emergency Cesarean-Sections
“Decision to Incision” 18 minutes
CHW Perinatal Patient Safety
Pursuit
• Assess– Climate of Safety Scores--SAQ
– Facility Readiness
• Education
– Teamwork/Communication
– Executive Walk Rounds
– NICHD Language
– Fetal Monitoring Competence
• Clinical Practice
Teamwork Training & Simulation: C+
• Emerging evidence is mixed but hopeful
• Lots of targets
– Improve procedures
– Standardize
communications
– Dampen down
hierarchies
• Where is the money?
Robert Wachter, MD
Observation I
50
Observation II
51
Grassroots Patient Safety
Tell me and I forget,
Show me and I remember,
Involve me and I understand.
-Chinese Proverb
53