Patient Safety through Team Training in Healthcare

1. Patient Safety through Team Training in Healthcare Stephen A. Knych, MD, MBA Division Chief, Patient Safety and Quality Office: 407-303-4607

2. On 9/11/01 The World Changed … We Cannot: • Wait for perfect information • Stay in your stovepipes • Be complacent … again • Forget about lessons learned • Debate and delay the issues • Marginalize solutions • Dwell on constraints or concerns

3. Patient Safety: Scope of Problem • Human Costs: • Estimated as many as 44,000 to 98,000 deaths each year • More than motor vehicle accidents, breast cancer and AIDS combined annually • The total number of deaths that would occur if a 747 airplane crashed killing all aboard every other day for one year! ** • Source: “To Err is Human”, Institute of Medicine, 1999 * • Source: Newhouse et.al., Measuring Patient Safety, 2005**

4. Patient Safety • Financial Cost of Medical Errors: $29 billion each year in the United States alone • Doctors, patients, insurers and hospital systems play a role in eradicating errors

5. Patient Safety: Scope of the Problem • 1 out of every 5 people says that they or a family member experienced a medical mistake • 51% reported the error as serious • 28-35% of admissions experience an event that causes HARM ( IHI, Dec 2007, Global Trigger Tool, Roger, Resar, MD) • Source: Commonwealth Fund 2001 Health Care Quality Survey

6. Patient Safety: CMS Actions • Serious preventable event—object left in place during surgery • Serious preventable event—air embolism • Serious preventable event—blood incompatibility • Catheter-associated urinary tract infections • Pressure ulcers (decubitus ulcers) • Vascular catheter–associated infection • Surgical site infection—mediastinitis after coronary artery bypass graft surgery • Hospital-acquired injuries – fractures, dislocations, intracranial injuries, burn

7. Patient Safety: Leadership Role • “Our systems are too complex to expect merely extraordinary people to perform perfectly 100 percent of the time. We as leaders have a responsibility to put in place systems to support safe practice.” * • .90 X .90 X .90 X .90 = .65 or 65% ** • Law of Composite Reliability • Leadership Guide to Patient Safety, Institute for Healthcare Improvement, 2005* • James Conway, former VP and COO of the Dana-Farber Cancer Institute* • Frederick Ryckman, MD, Cincinnati Children’s Hospital **

8. Patient Safety Culture • System of shared values (what is important) and beliefs (how things work) that interact with a company's people, organizational structures, and control systems to produce behavioral norms (the way we do things around here). • Webster’s Dictionary online

9. Team Training - Why Now? • Significant performance gaps • Sentinel Events • Baldrige requires aligned, systematic and fully deployed approach • Growing regulatory & national expectations • Patient Experience on Public Web • Joint Commission Leadership Std 2009 • NQF Safe Practice 1.3 Requirement • IHI 5 million Lives Campaign • CMS New Scope of Work • ACGME and Professional Organizations

10. What is the Evidence? • Teamwork is a key initiative within patient safety that can transform the culture within health care • 27% reduction in nurse turnover (Dimeglio, 2005) • 31% to 4% decrease in clinical error (Morey, 2002) • Communication & other teamwork skills are essential to prevent & mitigate medical errors and harm • 50% Less Adverse Outcomes (Mann 2006) • 50% Less Post-Op sepsis (Sexton 2006)

11. RESULTS OF TEAMWORK IN THE HEALTHCARE ENVIRONMENT (Sexton, 2006) Johns Hopkins (Pronovost, 2003) Johns Hopkins Journal of Critical Care Medicine (Mann, 2006) Beth Israel Deaconess Medical Center Contemporary OB/GYN 11

12. Believe that decisions of the “leader” should not be questioned Surgeons Pilots Sexton, BMJ, 2000

13. BEST TEAM Least Experience Surgeon Cohesive Team Simulation Pre case planning Debriefing Results tracked Removed hierarchy WORST TEAM Most experienced surgeon Team members changed No (de)briefing No tracking of results No preplanning Hierarchical Bohmer, R. Harvard Bus.School TEAM FUNCTION & SAFETY

14. High-Performing Teams Teams that perform well: Hold shared mental models Have clear roles and responsibilities Have clear, valued, and shared vision Optimize resources Have strong team leadership Engage in a regular discipline of feedback Develop a strong sense of collective trust and confidence Create mechanisms to cooperate and coordinate Manage and optimize performance outcomes (Salas et al. 2004) 14

15. Definition of a Team Two (2) or more individuals with specific tasks that are interdependent who cooperate and coordinate their activities, able to adapt and have a shared end goal

16. Why TeamSTEPPS • 5 to 7 years DOD world-wide experience • Civilian Spread funded by AHRQ • Master TeamSTEPPS Training Free • National Network • All Education Material provided at cost • Based on Evidence-Based Practices • Growing national recognition and movement toward TeamSTEPPS • Florida Hospital joins Pacesetting Hospitals • UCF-Ed Salas expert mentor and consultant

17. Outcomes of Team Performance • Knowledge • Shared Mental Model • Attitudes • Mutual Trust • Team Orientation • Performance • Adaptability • Accuracy • Productivity • Efficiency • Safety

18. 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 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 OUTCOMES • Shared Mental Model • Adaptability • Team Orientation • Mutual Trust • Team Performance • Patient Safety!! Barriers to Team Effectiveness

19. TeamSTEPPS

20. Impact Evaluation • In FY 08-09, TeamSTEPPS will: • Continue to collect quantitative data for Level 1 and Level 2 evaluation • Develop and implement standardized Level 3 & 4 assessment tools • Include sustainment as part of system-wide evaluation Level 5 – Return on Investment Was the training worth the cost? Kirkpatrick’s Model Level 4 – Results Did the change in behavior positively affect the organization? Level 3 – Behavior / Training Transfer Did the participants change their behavior on-the-job based on what they learned? Level 2 – Learning What skills, knowledge, or attitudes changed after training? By how much? Level 1 – Reaction Did the participants like the training? What do they plan to do with what they learned?

21. TeamSTEPPS Pilot/Research Project at Celebration Health Current Status – report from the work of the FH (system, CH, WP) and UCF Research Teams

22. Celebration HealthOR Pilot Milestones • Assessment/Project Charter/Metrics – Feb • Baseline Observations – Mar • Instructor Training – Mar • Coach/Mentor Training- Mar • Start Project – Apr • On-Going Observations–Apr - Dec • Complete Pilot Project – Dec 2008

23. Phased Implementation • Phase 1 (April – June) • OR – wheels in to wheels out • Mon – Fri, 7:30 – 3:30 start times • General Surgery, Orthopedic, Bariatric Surgical Teams • Phase 2 (July – August) • Disseminate to all surgeons • 24/7 includes all cases, emergent, weekend, holiday • Phase 3 (handoffs & transitions) (Aug – Dec) • Pre-op to OR • OR to PACU

24. TeamSTEPPS Current Status • Phase 1 baseline completed • 3 complete surgical teams trained • Orthopaedics, Bariatric Surgery, Minimally Invasive General Surgery teams • 4 hours of Fundamentals Training • 3 surgeons, 1 PA, 1 First Assist • 6 nurses and scrub techs • 18 anesthesiology providers (CRNA/MD) • 35 CH Council members 1hr Essentials • FH sent 13 people for 2.5 day Master Trainer Certification

25. TeamSTEPPS Current Status • Phase 1 baseline completed • Observations of 30 surgical cases at CH and 30 surgical cases at WP (control group) • Baseline surveys included • AHRQ Patient Safety Culture Survey • *ORMAQ (assess attitudes towards teamwork and current perceptions of teamwork) • Stress • Job satisfaction • Others *Operating Room Management Attitudes Questionnaire (ORMAQ)

26. TeamSTEPPS Current Status • TeamSTEPPS training completed - General reactions were positive

27. TeamSTEPPS Current Status Trainee comments included: • “Better ways to collaborate and facilitate communication.” • “Improving communication, decreasing barriers based upon hierarchy.” • “Great training - needs to be given to all staff - mostly surgeons” • “More interaction and exercise ‘hearing’ about it, is way different than performing it.” Did training meet your expectations, why or why not?” • “Yes. Good information. Patient safety is our ultimate goal. It needs to be preserved above all.” • “Yes, it actually exceeded my expectations since practical examples were used throughout.”

28. TeamSTEPPS Current Status • What we Learned • OR team members do find TeamSTEPPS training helpful and find the concepts viable for their work. • Simulation or practice is important to training effectiveness and perceptions of trainees that they are ready to implement teamwork behaviors covered in training in the OR. • It is vital the physicians champion training efforts with their team, their buy-in is crucial to success.

29. TeamSTEPPS Current Status • Next Steps • Impact of training on culture, stress, teamwork perceptions and actual behavior in the OR will be analyzed in August • Cost Analysis is underway for current Project • Follow up is scheduled for Oct-Nov 2008. It will consist of observations and surveys • 2009 • Spread to different location and/or service line? • Continue evaluation at different location and/or service line? • Implement simulation as part of future training roll-out • Implement formalized coaching plan for future roll-out • Develop a “GLITCH” database for system-wide use

30. Patient Safety “Knowing is not enough; we must apply. Willing is not enough; we must do” Goethe

31. QUESTIONS? THANK YOU FOR THE INVITATION TO SPEAK TO YOU TODAY!