Teamwork and Transparency

1. Teamwork and Transparency Jill Marsteller, PhD, MPP David Thompson, DNSc, MS, RN On the CUSP: Stop BSI Tuesday, February 9, 2010

2. Learning Objectives • You should be able to • Explain transparency and the need for it in this project • Describe importance of strong teamwork on CUSP/CLABSI team and in unit generally • Provide examples of teamwork-enhancing tools 2

3. Transparency • Make harm visible • Share stories • Discuss BSI rates • Link to patients • Need to share data with • The unit • Executive partner • Board 3

4. Transparency • Track progress visibly • Bulletin boards that show improvements • Memos • Announcements at meetings • Milestone celebrations • Recognition of people’s efforts • Frequent reminders, keep in the front of caregivers’ minds 4

5. Percent Understanding Patient Care Goals 5

6. Transparency’s Link to Teamwork • Be open about issues and problems, challenges • Confront the elephant in the room • Be explicit about sharing a common goal • Admit we all need each other 6

7. Available Tools to Enhance Transparency • Executive Senior Leader Checklist • Infection Preventionist Checklist • Weeks with CLABSI Banner • Staff Safety Assessment • Team Check Up Tool • Central Line Audit Forms

8. Teamwork • Effective communication • Closed loop communication/active listening • Responsiveness of team members • Communication skill set • Situational awareness • Shared mental model • Mutual support • Teamwork and communication tools 8

9. Communication Breakdowns are frequently the root cause of… undesirable outcomes 9

10. Teamwork Climate Across Michigan ICUs % of respondents within an ICU reporting good teamwork climate

11. No BSI = 5 months or more w/ zero No BSI 21% No BSI 44% No BSI 31% Teamwork Climate Across Michigan ICUs The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care % of respondents within an ICU reporting good teamwork climate

12. Impact on Healthcare • ‘Caregiver interaction’ aka effective teamwork • Reduced length of stay • Lower nurse turnover • Higher quality of care • Greater ability to meet family member needs (Shortell et al, Med Care;1994:508-25.) 12

13. Impact on Healthcare • Effective teamwork in ICU reduced risk of readmission or death--16% to 5% (Baggs, Heart Lung 1992;21:18-24.) • Ineffective collaboration & communication in OR = retained sponges, mismatched blood transfusion & wrong extremity nerve blocks (Gawande, NEJM 2003;348:229-35. Edmonds, Reg Anesth Pain Med 2005;30:99-103. Gibbs, AHRQ report 2001;2557.) 13

14. Percent Understanding Patient Care Goals 14

15. Impact on ICU Length of Stay Daily Goals 654 New Admissions: 7 Million Additional Revenue 15

16. What Are the Required Teamwork Competencies? • Skill requirements in teams: • Mutual performance monitoring and adaptability • Supporting/back-up behavior • Team leadership • Task-related assertiveness • Conflict resolution • Closed-loop communication 16

17. Strategies to achieve a “shared mental model” What we can do to stay on the same page… Group Strategies Environmental support Individual Strategies Situation Monitoring Brief Debrief Huddle Meetings Documentation Hand-offs Call Out Know the patient care plan Active listening Read back Verify Cross monitoring Self monitoring Visual management tools Checklists Distraction control Technology aids 17

18. Situational Awareness • Members of the team have an understanding of “what’s going on” and “what is likely to happen next.” • Teams are alert to developing situations, sensitive to cues and aware of their implications. 18

19. Focus is Preparation/planning and vigilance Workload distribution Distraction avoidance Situational Awareness 19

20. Elements That Affect Situational Awareness • Interruptions • Task absorption • Verbal abuse • Fatigue • Not following plan of care • Ambiguous orders/directions • Change in team member • Work load • Skill level 20

21. Improving Situational Awareness • Know the game plan – through briefings and team management (e.g., workload & workflow management, task coordination) • Anticipate next steps and possible events • Follow known policies and procedures • Cross-check and verify • Provide ongoing updates – call-outs, cross-talk, and briefings • Implement team huddles 21

22. Team Huddle • Pulling together members of the team to review patient data and decide on the course of action • Can be prearranged like evening rounds or as needed when a patient’s condition requires a change in course of action • May involve strategies to plan oversight, physician availability • ANYONE CAN ASK FOR A TEAM HUDDLE, ANYTIME 22

23. Active Listening • Focused on the speaker • “Actively” listening and processing the information being presented • Used to retain information and gain knowledge • Goal: The ability to repeat the sender’s message-“read back” 23

24. Cross Monitoring • Process of monitoring the actions of other team members for the purpose of sharing the workload and reducing or avoiding errors • Mechanism to help maintain accurate situation awareness • Way of “watching each other’s back” • Ability of team members to monitor each other’s task execution and give feedback during task execution (McIntyre and Salas 1995) 24

25. Call Out • Statements of action or description of what you are seeing to keep people informed: “The patient is experiencing runs of v-tach despite the medication…” • Can be used for routine care such as checking an alarm • Can be used during a procedure or arrest situation to let members of the team know what has been completed 25

26. Briefing Defined A briefing is a discussion between two or more people, often a team, using succinct information pertinent to an upcoming event. 26

27. The SBAR Briefing SITUATION driven-Structure based • Situation - Current situation that needs reporting • Background - Pertinent history and treatment • Assessment - Diagnosis of categorization of the current situation • Recommendation - Proposed plan of care 27

28. Conflict Resolution Tools • DESC script (Describe, Express, Specify, Consequences) • Two-challenge rule • Mediation 28

29. What makes up an effective team? Effective Team Members Effective Team Leaders Healthy and productive interactive process

30. Another way of looking at it • Any team member may be called upon to be leader in a given situation/or subpart of the effort. • Designated team leaders are always team members at the same time. Effective Team Members Effective Team Leaders

31. Leaders Organize the team Articulate clear goals Make decisions through collective input of members Empower members to speak up and challenge Actively promote and facilitate good teamwork Assist in conflict resolution Members Understand their role Agree on the goals Provide input to decisions, assert their case Speak up and challenge Actively promote and facilitate good teamwork Be open to conflict resolution Effective team member-leaders 31

32. Leaders Share information openly Act as role models and cue team members to use teamwork skills Offer constructive and timely feedback Facilitate briefings, huddles, debriefs, and conflict resolution Members Share information openly Use teamwork skills and cue other team members to also do so Offer constructive and timely feedback Participate actively in briefings, huddles, debriefs, and conflict resolution Effective team member-leaders 32

33. Leaders Initiate planning and include team members Delegate tasks What, to whom State clear expectations Ask for feedback Facilitate conflict resolution Two-attempt rule DESC script Helping team members practice techniques Serving as a mediator Members Contribute to planning process, initiate subparts of the plan Accept delegation, be accountable, provide feedback Practice and use conflict resolution techniques Mediate among coworkers informally Effective team member-leaders 33

34. Key Benefits of Effective Teamwork • Ability to predict the needs of other team members/fewer surprises • Decisions use better, complete information • Conflict management provides more pleasant environment/fewer hurt feelings and grudges • Better accountability for team performance • Reduced stress on the team as a whole • Better experience for patients/improved safety 34

35. Available Resources to Improve Team Communication • Science of Safety Video • CUSP Toolkit: • Staff Safety Assessment • Daily Goals Checklist • Safety Issues Worksheet • Culture Check-up Tool • Team Stepps

36. AHRQ Team Stepps • http://teamstepps.ahrq.gov/abouttoolsmaterials.htm