Strategies and Tools
to Enhance Performance
and Patient Safety
Introduction
®
Objectives
 Describe the importance of communication
 Recognize the connection between communication
and medical error
 Discuss The Joint Commission national patient safety
goals
 Define communication and discuss the standards of
effective communication
 Describe strategies for information exchange
 Identify barriers, tools, strategies, and outcomes to
communication
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Introduction
®
Teamwork Is All Around Us
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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
®
Introduction
Evolution of TeamSTEPPS
Curriculum Contributors
• Department of Defense
• Agency for Healthcare
Research and Quality
• Research Organizations
• Healthcare Foundations
• Private Companies
• Universities
• Medical and Business
Schools
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• Hospitals—Military and
Civilian, Teaching and
Community-Based
TEAMSTEPPS 05.2
• Subject Matter Experts in
Teamwork, Human Factors,
and Crew Resource
Management (CRM)
5
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
®
Patient Safety Movement
“To Err
is Human”
IOM Report
DoD
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
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Introduction
®
The Components of a
Patient Safety Program
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Introduction
®
Why Do Errors Occur—Some Obstacles
 Workload fluctuations
courtesy
 Interruptions
 Fatigue
 Halo effect
 Multi-tasking
 Passenger syndrome
 Failure to follow up
 Hidden agenda
 Poor handoffs
 Complacency
 Ineffective
 High-risk phase
 Strength of an idea
communication
 Not following protocol
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 Excessive professional
TEAMSTEPPS 05.2
 Task (target) fixation
9
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…
10
Introduction
®
Outcomes of Team Competencies
 Knowledge

Shared Mental Model
 Attitudes


Mutual Trust
Team Orientation
 Performance





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Adaptability
Accuracy
Productivity
Efficiency
Safety
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Introduction
®
Teamwork Actions
 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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Introduction
®
Teamwork Encompasses CRM
DoD has led the way in team research and innovations
 Non-Healthcare
 Combat Information Centers
 Joint Forces Operations
 Emergency Management Communities
 Army Special Forces
 Tank, Submarine, and Air Crews
Team
Training
 Healthcare
 ED, OR, L&D, ICU, Dental
 Whole Hospital
 Combat Casualty Care
…striving to be a high reliability healthcare system…
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Introduction
®
Background: US Army Aviation
 Army aviation crew coordination failures in mid-80s
contributed to 147 aviation fatalities and cost more
than $290 million
 The vast majority involved
highly experienced aviators
 Failures were attributed largely
to crew communication,
workload management, and
task prioritization
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Introduction
®
US Navy Breakthroughs: Tactical
Decisionmaking Under Stress (TADMUS)
 Cross-Training
 Stress Exposure Training
 Team Coordination
Training (CRM)
 Scenario-Based Training
and Simulation
 Team Leader Training
 Team Dimensional Training
 Team Assessment
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Introduction
®
US Air Force CRM History
 Mid to Late 80s AF bombers
and heavy aircraft started
CRM training
 1992 Air Combat Command
developed Aircrew Attention
Management /CRM Training
 By 1998, CRM deployed
uniformly across the AF
 Steady decline in human
factors based mishaps since
CRM training deployed
 AF Medical Service adapted
training, rolled out in 2000
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Introduction
®
Eight Steps
of Change
John Kotter
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Introduction
®
Monitor, Integrate, Continuous
Process Improvement
Celebrate wins!
Staying the course
Sustaining
Roadmap to a
Culture of Safety
Implement Action Plan,
Train, Empower Others
Test
Intervention
(Outcomes)
I’m staying
right here.
Yeah they’ll be
back.
What
are they
doing?
FUTURE
Why do
we need
change
?
Develop Action
Plan
Prepare
the Climate
Build team,
strategy, buy-in,
establish goals
Catalytic event drives
need for change
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TeamSTEPPS
Change
Coaching
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Introduction
®
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”
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Introduction
®
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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
®
Briefs
Planning
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
Form the team

Designate team roles
and responsibilities

Establish climate and
goals

Engage team in short
and long-term planning
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Introduction
®
Planning Essentials for Teams
 Leader usually initiates the planning process
 Team members are included in the planning
process
 Team members have a common
understanding of the problem and their roles
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Introduction
®
Briefing Checklist
TOPIC
Who is on core team?
All members understand
and agree upon goals?
Roles and responsibilities
understood?
Plan of care?
Staff availability?
Workload?
Available resources?
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Introduction
®
Huddle
Problem solving
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
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
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Introduction
®
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
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
An accurate reconstruction of key events

Analysis of why the event occurred

What should be done differently next time
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Introduction
®
Debrief Checklist
TOPIC
Communication clear?
Roles and responsibilities
understood?
Situation awareness
maintained?
Workload distribution?
Did we ask for or offer
assistance?
Were errors made or
avoided?
What went well, what
should change, what
can improve?
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Introduction
®
Facilitating Conflict Resolution
 Effective leaders facilitate conflict
resolution techniques through invoking:

Two-Challenge rule

DESC script
 Effective leaders also assist by:
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
Helping team members master conflict
resolution techniques

Serving as a mediator
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Introduction
®
Leadership
BARRIERS
TOOLS and
STRATEGIES
 Hierarchical
Culture
 Lack of Resources
 Shared Mental
Brief
or Information
 Ineffective
Huddle
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Model
 Adaptability
 Team Orientation
Communication
 Conflict
OUTCOMES
Debrief
TEAMSTEPPS 05.2
 Mutual Trust
29
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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Communication
Assumptions
Fatigue
Distractions
HIPAA
®
Introduction
®
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Introduction
®
The Joint Commission:
Importance
of Communication
Ineffective communication is a
root cause for nearly 66 percent
of all sentinel events reported*
* (The Joint Commission Root Causes and Percentages
for Sentinel Events (All Categories) January
1995−December 2005)
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Introduction
®
Joint Commission Goals That Relate
To Communication
National Patient Safety Goals (NPSGs) related to
communication:

Improve the effectiveness of communication among
caregivers



Accurately and completely reconcile medications and
other treatments across the continuum of care


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Read-Back
Handoff
Address specifically during handoff
Encourage the active involvement of patients and their
families in the patient’s care, as a patient safety strategy
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Introduction
®
Communication is…
 The process by which information is exchanged
between individuals, departments, or organizations
 The lifeline of the
Core Team
 Effective when it
permeates every
aspect of an
organization
Assumptions
Fatigue
Distractions
HIPAA
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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
®
Brief
Clear
Timely
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Introduction
®
Information Exchange Strategies
 Situation–Background– Assessment–
Recommendation (SBAR)
 Call-Out
 Check-Back
 Handoff
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Introduction
®
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?
Remember to introduce yourself…
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Introduction
®
SBAR Example
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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
The transfer of information (along with authority and
responsibility) during transitions in care across the
continuum; to include an opportunity to ask questions,
clarify, and confirm
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Introduction
®
Reporting Tools:Handoff
 Optimized Information
 Responsibility– Accountability
 Uncertainty
 Verbal Structure
 Checklists
 IT Support
 Acknowledgement
Great opportunity for
quality and safety
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TEAMSTEPPS 05.2
Introduction
®
“I PASS THE BATON”
Introduction:
Introduce yourself and your role/job (include patient)
Patient:
Identifiers, age, sex, location
Assessment:
Present chief complaint, vital signs, symptoms, and
diagnosis
Situation:
Current status/circumstances, including code status,
level of uncertainty, recent changes, and response to treatment
Safety:
Critical lab values/reports, socio-economic factors, allergies, and alerts
(falls, isolation, etc.)
THE
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Background:
Co-morbidities, previous episodes, current medications, and family history
Actions:
What actions were taken or are required? Provide brief rationale
Timing:
Level of urgency and explicit timing and prioritization of actions
Ownership:
Who is responsible (nurse/doctor/team)?
Include patient/family responsibilities
Next:
What will happen next? Anticipated changes?
What is the plan? Are there contingency plans?
TEAMSTEPPS 05.2
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Introduction
®
ISHAPED – Another Report Tool
 I:
Introduction
 S: Story
 H: History
 A: Assessment
 P: Plan
 E: Error-Prevention
 D: Dialogue

* From Inova/Picker Institute available at: http://alwaysevents.pickerinstitute.org/?p=1251
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Introduction
®
Communication Challenges
 Language barrier
 Distractions
 Physical proximity
 Personalities
 Workload
 Varying communication styles
 Conflict
 Lack of information verification
 Shift change
Great
Opportunity for
Quality and Safety
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Introduction
®
Barriers to Team Effectiveness
BARRIERS
 Inconsistency in Team














Membership
Lack of Time
Lack of Information Sharing
Hierarchy
Defensiveness
Conventional Thinking
Complacency
Varying Communication Styles
Conflict
Lack of Coordination and
Follow-Up with Co-Workers
Distractions
Fatigue
Workload
Misinterpretation of Cues
Lack of Role Clarity
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TOOLS and
STRATEGIES
Brief
Huddle
Debrief
STEP
Cross Monitoring
Feedback
Advocacy and Assertion
Two-Challenge Rule
CUS
DESC Script
Collaboration
SBAR
Call-Out
Check-Back
Handoff
TEAMSTEPPS 05.2
OUTCOMES
 Shared Mental Model
 Adaptability
 Team Orientation
 Mutual Trust
 Team Performance
 Patient Safety!!
48
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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