Introduction to Team Training

1. Introduction to Team Training Colorado Patient Safety Coalition Carol Anne Tarrant, RN, MS, JD Jeffrey L. Varnell, MD, FACS

3. An Overview�Aviation & Healthcare

4. Aviation & Healthcare Both Have Preventable Errors�

5. Healthcare Statistics Regarding Preventable Errors� Healthcare research shows 70% of adverse events were preventable One study shows 54% of surgical errors are preventable Preventable errors cost $17 billion (IOM) ANNUALLY! 70-80% medical mishaps are caused by human factors issues related to interpersonal interaction So how applicable is the Aviation model to Healthcare ? Aviation & Healthcare have similar preventable errors. In aviation 73% accidents are due to crew, this increases to 85% as you include 11% by air traffic control. In a similar statistic, JCAHO has found that 70% of the time in wrong site surgery there was a person in the room either unable to speak or not allowed to speak who knew that the surgery was being done on the wrong side. So how applicable is the Aviation model to Healthcare ? Aviation & Healthcare have similar preventable errors. In aviation 73% accidents are due to crew, this increases to 85% as you include 11% by air traffic control. In a similar statistic, JCAHO has found that 70% of the time in wrong site surgery there was a person in the room either unable to speak or not allowed to speak who knew that the surgery was being done on the wrong side.

6. A Human Factors Expert Looks at Healthcare No one in charge Safety is not a corporate priority Failure to observe basic safety practices Tolerance of unsafe practices No systematic data collection No analytic response to accidents Reliance on training & punishment No training in safety, teamwork Human Factors as a term was coined after the first World War around 1930 when increasing assembly-line mechanization prompted studies of safety of work practices. It initially was focused on the interaction between humans & machines. It has now developed into a multifaceted discipline that concerns not only the psychology of human � machine interaction but also the human-human interactions as well : communication, teamwork & organizational culture.Human Factors as a term was coined after the first World War around 1930 when increasing assembly-line mechanization prompted studies of safety of work practices. It initially was focused on the interaction between humans & machines. It has now developed into a multifaceted discipline that concerns not only the psychology of human � machine interaction but also the human-human interactions as well : communication, teamwork & organizational culture.

7. Current Healthcare Mental Models Hierarchy One person responsible for knowing everything Machismo We can perform at maximum efficiency as long as needed Personal blame If something goes wrong, someone is to blame Speed is supreme Turnover time, etc. Dictatorial communication �I only have to say this once!� �If I speak up, I will be mocked or belittled!� Task compartmentalization �Don�t tell me what to do!� �I�m only responsible for my area!�

8. Case History 5:40 am - Pt. at 37 wks. gestation arrives at hospital with history of heavy bleeding 6:00 am - Attending notified, requests deck doc to evaluate Deck doc orders US; no sign of abruption, pt. still bleeding. Waits for attending to arrive. 7:00 am � Attending arrives. Dx abruption. 7:36 am - C/S accomplished. APGARs 1,1,1; infant survives with severe neurological impairment.

9. Our Conversation Why communication is the heart of the matter The limits of human performance Lessons from high reliability units Human Factors Skills Briefings � Time outs, pauses Assertion � It�s a hierarchical world! Situational Awareness Debriefing

10. Why Communication� The overwhelming majority of untoward events involve communication failure Somebody knows there�s a problem but can�t get everyone in the same �movie� The clinical environment has evolved beyond the limitations of individual human performance

11. What Happens Without Communication�

12. One of the key differences between high performing crews & low performing crews � the high performers talked more. One characteristic of ineffective teams is that when a problem arose, they simply stopped talking & communicated less. NASA Simulator Study Key point here is that the less effective teams stop communicating.Key point here is that the less effective teams stop communicating.

13. JCAHO Sentinel Events Communication breakdowns remain the primary root cause of more than 60% of the 2034 sentinel events analyzed. The majority of sentinel events (75%) resulted in a patient death.

15. Error is Inevitable Because of Human Limitations Limited memory capacity � 5 pieces of information in short term memory Negative effects of stress � error rates Tunnel vision Negative influence of fatigue & other physiological factors Limited ability to multitask � cell phones & driving Flawed judgment

16. Our Error Model Today Trained to be perfect - knowledge & competence are equated with the absence of error Healthcare culture rewards perfection & frowns upon error Individual agency - fix the person & the problem goes away

17. �Captain of the Ship� vs. �Team Leader� Knows everything Remembers everything Is responsible for everything Always does things �my way� Values & relies on input from other team members Recognizes limitations of workload, fatigue, stress, etc. Makes decisions based on all sources of info Sees value in consistent processes

19. Reoccurring Organizational Systems Problems Communication Shift reports, sign outs & hand-offs Inadequate, inaccurate information Task fixation, task overload Assertion, escalation of communication Supervision, leadership

20. Where Do Things Fall Through the Cracks ? Systems � information, tests, diagnoses Communication Hand-offs Failure of recognition Failure to rescue

21. Errors in Anesthesia Human error accounts for 80% Failure to perform normal check Lack of proficiency with equipment Lack of vigilance, distraction Haste Lack of experience with technique

22. JCAHO Patient Safety Goals Read-backs on verbal & telephone orders / test results Identify patient from 2 sources Verification of correct patient, correct site, correct procedure Briefings before procedures, operations Infusion pumps / monitor alarms Nosocomial infections Medication reconciliation / communication Actions to prevent risk of falls

23. Avoidance of Wrong Site Surgery � JCAHO Standards Patient to mark side of surgery Visit with patient pre-op & pre-anesthesia - �sign your site� Confirm with other information - e.g consent form �Time out� in OR to confirm correct patient, correct surgery, correct side or level

24. COPIC Wrong Site Surgery Statistics 2000-2004

25. First the Problem �Now the Solution!

26. Lessons from Aviation � Crew Resource Management Focus on teamwork,communication, flattening hierarchy, managing error, situational awareness, decision making Non-punitive reporting of near misses, 500,000 reports over 15 years Very open culture with regard to error & safety

27. Team Training � The Process Needs assessment Measure of culture � safety attitude questionnaires (SAQs) Training sessions � multidisciplinary, interactive Observation & coaching onsite Follow up training sessions Development of protocols � drills, debriefing sessions, simulations Follow up questionnaires (SAQs)

28. Team Approaches to Errors Culture Communication Skills SOAP for communication Briefing � debriefing Assertiveness skills Checklists Read-back Call out Outcomes: Errors, costs, turnover rates, satisfaction rates

29. Communication Skills S � Situation O � Objective findings A � Assessment P � Plan for action & recommendations

30. Briefings � Key Elements Checklist Got the person�s attention Made eye contact, faced the person Introduced self Used person�s name � familiarity is key ! Asked knowable information Explicitly asked for input Provided information Talked about next steps Encouraged ongoing monitoring & cross-checking

31. Debriefing An opportunity for individual, team & organizational learning The more specific, the better What did we do well? What did we learn? What would we do differently next time ? Who is accountable to making sure any changes are made?

32.  Focus on the common goal: quality care, the welfare of the patient, safety � it�s hard to disagree with safe, quality care Avoid the issue of who�s right & who�s wrong � concentrate on doing the right thing De-personalize the conversation Actively avoid being perceived as judgmental Be hard on the problem, not on the people Implement critical language � �CUS�

33. When Assertion is Difficult�

34. Situational Awareness The extent to which Team Members are aware of the status of a particular clinical event, patient status, or operational issues pertaining to the team�s overall tasks & goal. This is a general definition of Situational Awareness Situational awareness is primarily achieved through routine information sharing among team members. Briefings are one method of updating. Information to be monitored includes patient status, staff fatigue status & workload, communication failures, direction of task assignment, poor documentation. This is a general definition of Situational Awareness Situational awareness is primarily achieved through routine information sharing among team members. Briefings are one method of updating. Information to be monitored includes patient status, staff fatigue status & workload, communication failures, direction of task assignment, poor documentation.

35. Red Flags � Loss of Situational Awareness Ambiguity Reduced/poor communication Confusion Trying something new under pressure Deviating from established norms Verbal violence Doesn�t feel right Fixation Boredom Task saturation Being rushed / behind schedule

36. Expert Decision Making Expert � pattern matching against large mental library, quick, accurate if confirm correct answer Novice � library is empty � slow, error prone process Certain diagnoses are favored- frequent, recent, serious Trial & error/personal experience

37. Human Factors Briefings Appropriate assertion Situational awareness Debriefing Common mental model

38. Case History 5:40 am - Pt. at 37 wks. gestation arrives at hospital with history of heavy bleeding 6:00 am - Attending notified, requests deck doc to evaluate Deck doc orders US; no sign of abruption, pt. still bleeding. Waits for attending to arrive. 7:00 am � Attending arrives. Dx abruption. 7:36 am - C/S accomplished. APGARs 1,1,1; infant survives with severe neurological impairment.

39. Communication Skills S � Situation O � Objective findings A � Assessment P � Plan for action & recommendations

40. Characteristics of High Reliability Units Preoccupation with failure Refusal to simplify Commitment to resilience Deference to expertise Sensitivity to operations

41. Plan for Action �High Reliability Units Policy & protocol development Safety attitude surveys Teamwork training & follow-up Regular interdisciplinary debriefings/reviews Review of operative injuries Simulator training on known hazards Patient safety position

42. Measuring Success Patient injuries Team satisfaction Patient satisfaction Nurse / staff turnover Lawsuits & claims

43. Thank You! Questions???