TeamSTEPPS

1. TeamSTEPPS A new tool to improve patient care in Franklin County Lindsay Sherrard, MD CFMH Medical Staff Meeting May 27, 2009

2. What is TeamSTEPPS? • teamwork system • evidenced-based • developed by the DoD and AHRQ • Used in numerous hospitals and clinics across the country • It’s all about improving patient safety and quality of care

3. Why improve patient safety? • annual cost of medical errors • 44-98K lives • $38 billion • Most errors are preventable • Root cause of errors usually communication, a learnable skill

4. Why did CFMH choose TeamSTEPPS? • Teamwork skills must be practiced • “Our malpractice suits, high severity case claims, and the associated reserves required were reduced by 50% over a 3-year period after training teamwork in our Labor and Delivery Units.” -Benjamin P. Sachs, MD, BS Chief of Ob/Gyn, Beth Israel Deaconess Medical Center

5. Case Study • 38y G1 at 41 weeks, BP 144/85, preeclampsia labs negative and NST/AFI ok • Given misoprostol at 10pm and sent home with BP 124/90 • Returned in active labor at 12m, BP 174/104 • SROM at 1:30, ctx q1-2 min, epidural at 3:30 • FWB nonreassuring at 4:30 • Started pushing at 5:20, late decels at 5:30, FHR continued to slow • Forceps delivery attempted at 6:20 • Emergency c-section at 6:45, stillborn (FHR was in 130s prior to c-section) • Uterus had ruptured; placenta was in the abdomen

6. Case Study • Postpartum hemorrhage from uterine atony; got hysterectomy 3 hours after delivery • Severe DIC, ARDS, sepsis, wound infection • 3 week hospitalization, still not completely recovered 3 years later

7. Case Study: What went wrong? • 4 errors in judgment: • Should not have been sent home with high BP • Later, with high BP and non-reassuring FHTs a clear plan was not developed, discussed with patient, or documented • C-section should have been done at 5:30 at the lastest for non-reassuring FHTs • Forceps should have been attempted in OR (if at all)

8. Case Study: What went wrong? • 6 system failures: • Poor communication b/t doctors, nurses, patient • Lack of mutual performance cross-monitoring • Inadequate conflict resolution • Poor situational awareness • Physician workload too high • Attending on call for 21 very busy hours

9. This is the sort of situation we hope to prevent with TeamSTEPPS!

10. What does TeamSTEPPS teach? • Four areas in which a team must be competent • leadership • situation monitoring • mutual support • communication

11. Leadership • each team needs at least one leader • direct others, delegate tasks, manage resources • provide encouragement and performance expectations • facilitate problem solving and conflict resolution

12. Situation Monitoring • being aware of the needs of others in one’s team and other teams • watching each others’ backs

13. Mutual Support • helping others do tasks to evenly distribute work • giving and receiving constructive feedback

14. Communication • using structured techniques to communicate critical information • acknowledgement of understanding the information

15. So, what is different at CFMH?

16. Leadership at CFMH • You may notice people leading team events: • Brief (planning) • Huddle (problem solving) • 8am and 8pm daily with representatives from all departments • Debrief (process improvement)

17. Situation Monitoring at CFMH • We should all be considering “STEP”: • Status of the patient • Team members’ (fatigue, workload, skill, etc) • Environment (equipment, bed availability) • Progress towards the goal (plan still appropriate?)

18. Situation Monitoring at CFMH • I’M SAFE Checklist • Illness • Medication • Stress • Alcohol/Drugs • Fatigue • Eating/Elimination • We should be looking out for one another!

19. Mutual Support at CFMH • Task assistance: it is expected that assistance will be actively sought and offered • Feedback: provided for the purpose of improving team performance, this should be timely, respectful, specific, directed towards improvement, and considerate • Advocacy for the patient: using the “two challenge rule” which is everyone’s responsibility

20. Mutual Support at CFMH • DESC Script • Describe the situation • Express concerns • Suggest alternatives • Consensus should be sought to meet team goals with commitment to a common mission

21. Communication at CFMH • Specific communication strategies have been taught to staff • These are designed to be clear and concise

22. Communication at CFMH • Nurses will call using the SBAR technique: • Situation • “I’m calling about Ms. Hodges in room 102 because she is having shortness of breath” • Background • “She is the 62-year-old female POD#1 from abdominal surgery with no history of cardiac or lung disease • Assessment • “Breath sounds are decreased on the right and I’m concerned about pneumothorax.” • Recommendation • “I feel strongly the patient needs to be assessed now; are you available to come in?”

23. Communication at CFMH • In critical situations the “Call-Out” strategy may be used. Example: • Leader: “Airway status?” • EMT: “Airway clear.” • Leader: “Breath sounds?” • EMT: “Breath sounds decreased on right” • Leader: “Blood pressure?” • Nurse: “BP is 96/62”

24. Communication at CFMH • Check-back for closed-loop communication: • Doctor: “Give 25mg Benadryl IV push” • Nurse: “25mg Benadryl IV push” • Doctor: “That’s correct”

25. Communication at CFMH • I PASS the BATON (handoff technique) • Introduction (your role) • Patient (identifiers) • Assessment (diagnoses) • Situation (current status) • Safety concerns (allergies, critical labs) • Background (past history, medications) • Actions (what was done today, needs to be done?) • Timing (prioritize actions) • Ownership (who is responsible for what?) • Next (the plan?)

26. Barriers to Teamwork • Team member changes • Lack of time • Poor communication • Hierarchy and lack of role clarity • Defensiveness • Conventional thinking • Complacency • Conflict • Lack of coordination and follow up • Distractions, fatigue, workload • Misinterpretation of cues

27. Tools and Strategies for Teamwork • Brief, huddle and debrief • STEP • Two challenge rule • DESC script • SBAR • Call-out • Check-back • Handoff

28. Good Teamwork Outcomes • Shared goals • Adaptability • Mutual trust • Team performance • Patient safety and outcomes!

29. References • TeamSTEPPS Curriculum. Agency for Healthcare Research and Quality, 2006. • Kohn LT, et al, ed. To Err is Human: Building a Safer Health System. Institute of Medicine. Washington: National Academy Press, 1999. • Sachs BP. A 38-year-old woman with fetal loss and hysterectomy. JAMA: 2005 Aug 17;294(7):833-40.