newbref

2. DoD Patient Safety Program DoD Initiatives Data on Communication Failures/Mandates Health Care Team Coordination Program (HCTCP) What is teamwork? TEAMSTEPPS HCTCP Support A DoD Hospital Culture Change Planning Ahead AHRQ Collaboration Challenges / Lessons Learned Overview

3. DoD Patient Safety Initiatives Have identified key objectives for the PSP and need to incorporate them into team coordination. Team coordination and these other initiatives are key to combat patient safety errors. Have identified key objectives for the PSP and need to incorporate them into team coordination. Team coordination and these other initiatives are key to combat patient safety errors.

4. Top Contributing Factors of Sentinel Events from PSC Root Cause

5. Top 5 Causal Factors Reported for Communication/Inadequate Information

6. Top Contributing Factors of Sentinel Events from RCAs, FY02 – FY04

7. Top Contributing Factors of Sentinel Events from PSC Root Cause, FY02 – FY04

8. IOM Congress (NDAA 2001) DoD Directive & Regulation JCAHO DoD Patient Safety Center data Other Driving Factors

9. 2005 Hospitals’ National Patient Safety Goals (NPSGs): Goal #2: Improve the effectiveness of communication among caregivers Goal #8: Accurately and completely reconcile medications and other treatments across the continuum of care Standard RI.2.100: The hospital respects the patient’s right to and need for effective communication Standard LD.3.60: Communication is effective throughout the hospital JCAHO

10. HCTCP Mission Provide teamwork coordination to achieve safer patient care in MHS thru research, education, and training initiatives. Goals of Teamwork Reduce clinical errors Improve patient outcomes Improve process outcomes Increase patient satisfaction Increase staff satisfaction Reduce malpractice claims …ultimately achieve a culture change Health Care Team Coordination Program

11. Teamwork Lessons from Aviation-CRM and DoD Teams DoD has led the way on team research and innovations Combat Information Centers Joint Forces Operations Emergency Management Communities Army Special Forces Tank, Submarine, and Air Crews ED, OR, L&D, ICU, Dental Whole Hospital Combat Casualty Care Military aviation led the way toward dramatic improvement in flight safety. Commercial aviation instituted CRM (Crew Resource Management) in the late 70’s after some high profile airliner crashes. Commercial aviation is in the 4th or 5th iteration of CRM and has developed an extraordinary culture of safety and track record of success: 2002, 2003, 2004 – Zero deaths for jet airline operations in the U.S. DoD has invested extensively in teamwork and safety RESEARCH, team training and high fidelity simulation. $120 million dollars over past 30 plus years—huge investment in teamwork and safety! Over past 5 years: have trained more than 60 facilities, with over 800 instructors (went through train-the-trainer and/or certification). MEDICAL TEAM TRAINING STATS: (Spring 2005) Program Sites Trained Instructors MedTeams TM 31 288 Combat Care 3 68 L&D Research 6 35 MTM 36 252 TeamSTEPPS 10 120 Military aviation led the way toward dramatic improvement in flight safety. Commercial aviation instituted CRM (Crew Resource Management) in the late 70’s after some high profile airliner crashes. Commercial aviation is in the 4th or 5th iteration of CRM and has developed an extraordinary culture of safety and track record of success: 2002, 2003, 2004 – Zero deaths for jet airline operations in the U.S. DoD has invested extensively in teamwork and safety RESEARCH, team training and high fidelity simulation. $120 million dollars over past 30 plus years—huge investment in teamwork and safety! Over past 5 years: have trained more than 60 facilities, with over 800 instructors (went through train-the-trainer and/or certification). MEDICAL TEAM TRAINING STATS: (Spring 2005) Program Sites Trained Instructors MedTeams TM 31 288 Combat Care 3 68 L&D Research 6 35 MTM 36 252 TeamSTEPPS 10 120

12. Teams that demonstrate good teamwork… have a clear common purpose differentiate between higher and lower priorities ensure team member roles are clear but not overly rigid manage conflict well, team members confront each other effectively involve the right people in decisions in flexible manner examine and adjust the team’s physical workplace to optimize communication and coordination What does good teamwork look like?

13. Teams that demonstrate good teamwork… backup and fill in for each other distribute and assign work thoughtfully communicate often enough, and at the right time--ensure that fellow team members have the information they need to be able to contribute conduct effective team meetings establish and revise team goals and plans consciously integrate new team members Salas, funded by Army Research Institute, 2004 What does good teamwork look like?

14. We must understand team competency requirements: How do we design and conduct training? What do we use to assess team performance? How do we initiate a change within the culture? Team Competencies TO ACCOMPLISH OUR MISSIONS/GOALS WE MUST UNDERSTAND…TO ACCOMPLISH OUR MISSIONS/GOALS WE MUST UNDERSTAND…

15. Team Competencies Team competencies are the knowledge, skills, and attitudes (KSAs) required to be an effective team member Knowledge: The principles and concepts that underlie a team’s effective performance Skill: The learned capacity (psychomotor and cognitive) to interact with other team members Attitude: Internal states that influence team members to act in a particular way Cannon-Bowers et al. (1995) Used this approach to determine the team KSA competencies required for ATC tower cab teams. Cannon-Bowers et al. (1995) Used this approach to determine the team KSA competencies required for ATC tower cab teams.

16. Knowledge Shared Mental Models Attitudes Mutual Trust Team Orientation Performance Adaptability Accuracy Productivity Efficiency Safety Outcomes of Team Skills

17. TEAM Strategies and Tools to Enhance Performance and 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” TEAMSTEPPS Independent analysis of DoD medical team training offerings__--MedTeams and Medical Team ManagementIndependent analysis of DoD medical team training offerings__--MedTeams and Medical Team Management

18. The TEAMSTEPPS Approach: Introduce key team concepts and behavioral skills Utilize lecture, discussion, vignettes, teamwork failures, demonstration, case studies Interactive learning and practice-based application (role play, simulation) Opportunity to practice thru feedback session Develop coaching and facilitation skills Include strategies for transition and sustainment Customize to unique needs of your institution Medical Teamwork System Adult learning model is utilized. It has been found, however, that learning that results in increased self-awareness, changed behavior, and the acquisition of new skills must actively engage the individual in the learning process. In particular, adults have been found to learn more effectively by doing or experiencing. True learning means you do things in a new way. We know a good deal about what helps people to learn. People will learn faster and better when they: Want to learn; Know why it is important for them to learn Believe that what they will learn will help them in real ways Are in a supportive environment and are free from threat Feel good about themselves and feel able to learn what is expected of them Are provided the information they are to learn in several different ways Learn by doing the task; Have a chance to practice what they have learned Are given feedback on their performance Are praised when doing things well The kind of training and coaching people are given makes a big difference in how much they will retain. In general people in a learning situation retain: 10% of what they read; 20% of what they hear; 30% of what they see; 50% of what they see and hear; 70% of what they talk over with others; 80% of what they use and do in real life; 95% of what they teach someone else to do (ms) Composed of a variety of teaching activities that appeal to students with different learning styles, including role-playing to reach kinesthetic learners in the hands-ons approach that they prefer. Adult learning model is utilized. It has been found, however, that learning that results in increased self-awareness, changed behavior, and the acquisition of new skills must actively engage the individual in the learning process. In particular, adults have been found to learn more effectively by doing or experiencing. True learning means you do things in a new way. We know a good deal about what helps people to learn. People will learn faster and better when they: Want to learn; Know why it is important for them to learn Believe that what they will learn will help them in real ways Are in a supportive environment and are free from threat Feel good about themselves and feel able to learn what is expected of them Are provided the information they are to learn in several different ways Learn by doing the task; Have a chance to practice what they have learned Are given feedback on their performance Are praised when doing things well The kind of training and coaching people are given makes a big difference in how much they will retain. In general people in a learning situation retain: 10% of what they read; 20% of what they hear; 30% of what they see; 50% of what they see and hear; 70% of what they talk over with others; 80% of what they use and do in real life; 95% of what they teach someone else to do (ms) Composed of a variety of teaching activities that appeal to students with different learning styles, including role-playing to reach kinesthetic learners in the hands-ons approach that they prefer.

19. TEAMSTEPPS TEAMSTEPPS includes video examples, which show how to put the tools and strategies into action.

20. TEAMSTEPPS

21. “Train the Trainer” - 83 sites In-patient & Out-Patient Setting Specialty units include ED, OR, ICU, L&D, and Dental Combat Casualty Care organizations ˜ 750 Team Instructors (physicians, nurses, and other health care professionals) Ongoing consultative services with facilities: Work with leadership and change teams Conduct site readiness assessments Follow on coaching with Patient Safety offices and champions What We Do…

22. Surgical Services for: 20 OR rooms 13,000 cases/Yr 30 Instructors 875 Staff trained Staff Make-up: 43% Surg/Anes 29% Nurses 28% Techs Sample DoD Hospital

23. Huddle Cards Debriefing Tool Designed to TEACH MEASURE INSPIRE Paper-based, inexpensive, simple 30 – 45 seconds to complete

24. 6 months Valid Surveys: N=223 N=139 Greater than 10 percent improvement in 23 questions Improvement in all but one Greatest improvement The team can measure its performance effectively (21.5%) The team members communicate well with one another (18.2%) Team Self AssessmentPre-training…Follow-up (ms) In case they asked – The one there wasn’t an improvement in was ‘The team has a positive reputation in the organization”, which decreased 2.1%, and “The team has a positive self image”, which didn’t show any change. (ms) In case they asked – The one there wasn’t an improvement in was ‘The team has a positive reputation in the organization”, which decreased 2.1%, and “The team has a positive self image”, which didn’t show any change.

25. Interviews: “Noticeable difference” in atmosphere and climate. Better communication at all levels Better equipment availability (planning) and less frustration/blame No negative comments Much less anger; more respect Juniors ARE willing to speak out General Comments

26. Collaborative effort with RAND Corporation thru AHRQ Purpose: Develop a set of measures that represent important patient safety or quality of care outcomes that can be expected to improve as a result of effective teamwork in delivering health care services Process & Outcome Measures for Effective Teamwork in Health Care … in Development Tasks for Selection of Outcome Indicators: Select the settings or situations for which teamwork is most important Develop an inventory of possible outcomes of effective teamwork for each health care situation Perform a preliminary assessment of the capability of measuring each identified outcome Rank the measures based on their improtance as outcomes of effective teamwork Use DoD data to test the measurement feasibility for the outcome measures rated highest by the working clinical groups Reassess outcome measures based on empirical results Literature review Identification and selection of patient safety and quality measures for specific health care settings Comparative analysis of selected measures using DoD data Recruitment of a Clinical Advisory Panel Tasks for Selection of Outcome Indicators: Select the settings or situations for which teamwork is most important Develop an inventory of possible outcomes of effective teamwork for each health care situation Perform a preliminary assessment of the capability of measuring each identified outcome Rank the measures based on their improtance as outcomes of effective teamwork Use DoD data to test the measurement feasibility for the outcome measures rated highest by the working clinical groups Reassess outcome measures based on empirical results Literature review Identification and selection of patient safety and quality measures for specific health care settings Comparative analysis of selected measures using DoD data Recruitment of a Clinical Advisory Panel

27. Shift Towards a Culture of Safety

28. Model for Change To be understood and evaluated, these recommendations for leaders and staff had to come together into one cohesive yet dynamic model. The purpose of a model is to: Provide a shared mental model for an evidence-based, evaluation driven, heuristic system for change Pull together the theories of leading team and culture change researchers (Salas, Kirkpatrick, and Kotter) Pull together the input and lessons learned of leaders and staff training and implementing behaviors on site Remain sufficiently broad and flexible to adapt to a variety of settings and specialities yet Remain focused enough to effectively train individuals to the specific behaviors shown to improve outcomes in aviation Provide process and outcomes founded on core leader and staff actions necessary to train, implement, and sustain Undergo 4 level - whole organization - evaluation The top (big box) establishes the three levels within the org where change needs to occur and the essential actions each must assume. At the level of the organization patients and staff must feel the system (of safety) is transparent and trustworthy. The leadership level identifies the accountabilities and responsibilities for a culture change and at the individual level the real work is to deliver excellent clinical out of the context of the behaviors and attitudes essential to teamwork. The bottom of the graphic illustrates the intervention and evaluation that occur and are necessary to make all this happen. To be understood and evaluated, these recommendations for leaders and staff had to come together into one cohesive yet dynamic model. The purpose of a model is to: Provide a shared mental model for an evidence-based, evaluation driven, heuristic system for change Pull together the theories of leading team and culture change researchers (Salas, Kirkpatrick, and Kotter) Pull together the input and lessons learned of leaders and staff training and implementing behaviors on site Remain sufficiently broad and flexible to adapt to a variety of settings and specialities yet Remain focused enough to effectively train individuals to the specific behaviors shown to improve outcomes in aviation Provide process and outcomes founded on core leader and staff actions necessary to train, implement, and sustain Undergo 4 level - whole organization - evaluation The top (big box) establishes the three levels within the org where change needs to occur and the essential actions each must assume. At the level of the organization patients and staff must feel the system (of safety) is transparent and trustworthy. The leadership level identifies the accountabilities and responsibilities for a culture change and at the individual level the real work is to deliver excellent clinical out of the context of the behaviors and attitudes essential to teamwork. The bottom of the graphic illustrates the intervention and evaluation that occur and are necessary to make all this happen.

29. Expert Panel Comprehensive Literature Review Edited Handbook Journals/Articles Presentations Patient Safety Officer Team Training Toolkit Medical Team Training Curriculum AHRQ/DoD Teamwork Initiatives DoD/AHRQ Collaboration: Advances in Patient Safety: From Research to Practice Comprised of three volumes Findings to be in a Report to Congress ($165M) Highlights research findings to include methodological perspectives, implementation issues, lessons learned, and tools and products in patient safety 234 abstracts received, 28 are from DoD Quality and Safety in Health Care Journal Supplement Focuses on medical team training and simulation Includes 23 manuscripts by experts within patient safety, medical team training, and education Technical reports Medical Teamwork and Patient Safety: The Evidence-Based Relation Case Study Analysis DoD/AHRQ Collaboration: Advances in Patient Safety: From Research to Practice Comprised of three volumes Findings to be in a Report to Congress ($165M) Highlights research findings to include methodological perspectives, implementation issues, lessons learned, and tools and products in patient safety 234 abstracts received, 28 are from DoD Quality and Safety in Health Care Journal Supplement Focuses on medical team training and simulation Includes 23 manuscripts by experts within patient safety, medical team training, and education Technical reports Medical Teamwork and Patient Safety: The Evidence-Based Relation Case Study Analysis

30. Deployments Buy-in at all levels of leadership Competing priorities Sustainment / “sticking power” Measurement Transfer of Training Effectiveness on patient outcomes Challenges Plans for 2005: Ambulatory care unit training to be piloted in February New Program of Instruction to be piloted in January in DoD and Harvard Health System Develop multimedia materials (website, videos, hybrid/distance learning) Once piloted, all medical teamwork system materials (didactic curriculum, scenarios, vignettes, case studies, etc.) to be made available through AHRQ (public domain) Establish specifications Plans for 2005: Ambulatory care unit training to be piloted in February New Program of Instruction to be piloted in January in DoD and Harvard Health System Develop multimedia materials (website, videos, hybrid/distance learning) Once piloted, all medical teamwork system materials (didactic curriculum, scenarios, vignettes, case studies, etc.) to be made available through AHRQ (public domain) Establish specifications

31. Simplify a critical patient safety initiative on an overburdened healthcare system Dynamic environment, requires various levels of training Definitive metrics for all levels of evaluation Engage senior leadership prior to training On-going coaching of teamwork behaviors post-training Integration of teamwork principles within other PS initiatives in medical facilities and institutes of learning Key Lessons Learned

32. Teamwork in DoD

33. Heidi King Deputy Director, Patient Safety Program Program Manager, Health Care Team Coordination Heidi.king@tma.osd.mil 703-681-0064 Contact Information

34. BACKUP SLIDES

35. To determine whether MedTeamsTM training in L&D Departments can improve: Maternal and neonatal outcomes Process measures - proxy for efficiency of care Staff and patient satisfaction Cluster-based randomized controlled trial Data base: Total 45,622; 28,356 deliveries pre & post intervention Team Intervention in Labor and Delivery Environment Study Cluster-based randomized controlled trial 7 hospitals received team training 8 hospitals control arm Inclusion: All women admitted in active labor >20 weeks gestation Power: *80% powered to detect 40% decrease in Adverse Outcomes Index if: AOI = **2.6% Intra-class correlation coefficient (***ICC) = 0.001 Data base: 45,622 - 28,356 deliveries pre & post intervention *alpha = 0.05, two tailed test **based on incidence of the index outcome measure gathered prior to the study at the pilot hospital *** Outcomes within a particular hospital tend to be more similar (correlated) to each other than to outcomes in different hospitals. The larger the correlation (the larger the ICC), the larger the sample size required to detect a given difference. Cluster - level analysis of covariance Power: ICC = 0.02 (needed ICC 0.001) No significant difference between intervention and control groups in : AOI AOI weighted scores Process measures except time to perform stat Cesarean delivery 95% confidence intervals rule out a 50-60% or greater difference, but do not rule out a 40% difference Wide range in clinical outcomes Cluster-based randomized controlled trial 7 hospitals received team training 8 hospitals control arm Inclusion: All women admitted in active labor >20 weeks gestation Power: *80% powered to detect 40% decrease in Adverse Outcomes Index if: AOI = **2.6% Intra-class correlation coefficient (***ICC) = 0.001 Data base: 45,622 - 28,356 deliveries pre & post intervention *alpha = 0.05, two tailed test **based on incidence of the index outcome measure gathered prior to the study at the pilot hospital *** Outcomes within a particular hospital tend to be more similar (correlated) to each other than to outcomes in different hospitals. The larger the correlation (the larger the ICC), the larger the sample size required to detect a given difference. Cluster - level analysis of covariance Power: ICC = 0.02 (needed ICC 0.001) No significant difference between intervention and control groups in : AOI AOI weighted scores Process measures except time to perform stat Cesarean delivery 95% confidence intervals rule out a 50-60% or greater difference, but do not rule out a 40% difference Wide range in clinical outcomes

36. Results were inconclusive, except for the 12th measure Time from decision to incision for a stat cesarean section was statistically significantly --shorter time in the intervention group (P=0.04) Need for follow-up study: Assess transfer of training and determine sustainability of behaviors Site visits, refresher courses & evaluate lessons learned Continue research consortium of 15 military & civilian hospitals for patient safety research Trend data over time Team Intervention in Labor and Delivery Environment Study

37. Study Timeline