Strategies and Tools to Enhance Performance and Patient Safety

1. Strategies and Tools to Enhance Performance and Patient Safety

2. Objectives • Understand key components of Team STEPPS framework • Describe Team STEPPS communications • Explain how specific TeamSTEPPS tools can be integrated into everyday use in promoting Patient Safety

3. “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” Team Strategies & Tools to Enhance Performance & Patient Safety

4. Why Do Errors Occur—Some Obstacles • Excessive professional courtesy • Halo effect • Passenger syndrome • Hidden agenda • Complacency • High-risk phase • Strength of an idea • Task (target) fixation • Workload fluctuations • Interruptions • Fatigue • Multi-tasking • Failure to follow up • Poor handoffs • Ineffective communication • Not following protocol

5. JCAHO Sentinel Events Targets for Teamwork

6. What Comprises Team Performance? KnowledgeCognitions“Think” AttitudesAffect“Feel” SkillsBehaviors“Do” …team performance is a science…consequences of errors are great…

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

8. Teamwork Actions • Recognize opportunities to improve patient safety • Assess your current organizational culture and existing Patient Safety Program components • Identify teamwork improvement action plan by analyzing data and survey results • Design and implement initiative to improve team-related competencies among your staff • Integrate TeamSTEPPS into daily practice. “High-performance teams create a safety net for your healthcare organization as you promote a culture of safety."

9. Inconsistency in team membership Lack of time Lack of information sharing Hierarchy Defensiveness Conventional thinking Varying communication styles Conflict Lack of coordination and follow-up Distractions Fatigue Workload Misinterpretation of cues Lack of role clarity Barriers to Team Performance

10. Paradigm Shift to Team System Approach Dual focus (clinical and team skills) Team performance Informed decision-making Clear understanding of teamwork Managed workload Sharing information Mutual support Team improvement Team efficiency Single focus (clinical skills) Individual performance Under-informed decision-making Loose concept of teamwork Unbalanced workload Having information Self-advocacy Self-improvement Individual efficiency

11. Effective Team Members • Are better able to predict the needs of other team members • Provide quality information and feedback • Engage in higher level decision-making • Manage conflict skillfully • Understand their roles and responsibilities • Reduce stress on the team as a whole through better performance “Achieve a mutual goal through interdependent and adaptive actions”

12. Promoting & Modeling Teamwork Effective leaders cultivate desired team behaviors and skills through: • Open sharing of information • Role modeling and effectively cueing team members to employ prescribed teamwork behaviors and skills • Constructive and timely feedback • Facilitation of briefs, huddles, debriefs, and conflict resolution

13. Team Events • Briefs – planning • Huddles – problem solving • Debriefs – process improvement Leaders are responsible to assemble the team and facilitate team events But remember… Anyone can request a brief, huddle, or debrief

14. Briefs Planning • Form the team • Designate team roles and responsibilities • Establish climate and goals • Engage team in short and long-term planning

15. Briefing Checklist

16. Huddle Problem solving • Hold ad hoc, “touch-base” meetings to regain situation awareness • Discuss critical issues and emerging events • Anticipate outcomes and likely contingencies • Assign resources • Express concerns

17. Debrief Process Improvement • Brief, informal information exchange and feedback sessions • Occur after an event or shift • Designed to improve teamwork skills • Designed to improve outcomes • An accurate reconstruction of key events • Analysis of why the event occurred • What should be done differently next time

18. Debrief Checklist

19. Situation Monitoring(Individual Skill) Process of actively scanning behaviors and actions to assess elements of the situation or environment • Fosters mutual respect and team accountability • Provides safety net for team and patient • Includes cross monitoring … Remember, engage the patient whenever possible.

20. Cross Monitoring is… 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 Mutual performance monitoring has been shown to be an important team competency. (McIntyre and Salas 1995)

21. Conditions that Undermine Situation Awareness (SA) Failure to— • Share information with the team • Request information from others • Direct information to specific team members • Include patient or family in communication • Utilize resources fully (e.g., status board, automation) • Document

22. Shared Mental Model?

23. Mutual Support Mutual support is the essence of teamwork • Protects team members from work overload situations that may reduce effectiveness and increase the risk of error

24. Task Assistance Team members foster a climate in which it is expected that assistance will be actively sought and offered as a method for reducing the occurrence of error. “In support of patient safety, it’s expected!”

25. Types of Feedback • Can be formal or informal • Constructive feedback • Is considerate, task-specific, and focuses attention on performance and away from the individual (Baron 1988) • Is provided by all team members • Evaluative feedback • Helps the individual by comparing behavior to standards or to the individual’s own past performance (London, Larson, and Thisted 1999) • Most often used by an individual in a coaching or mentoring role

26. Characteristics of Effective Feedback Good Feedback is— • TIMELY • RESPECTFUL • SPECIFIC • DIRECTED toward improvement • Helps prevent the same problem from occurring in the future • CONSIDERATE “Feedback is where the learning occurs.”

27. Two-Challenge Rule Invoked when an initial assertion is ignored… • It is your responsibility to assertively voice yourconcern at least two times to ensure thatit has been heard • The member being challenged must acknowledge • If the outcome is still not acceptable • Take a stronger course of action • Use supervisor or chain of command

28. Two-Challenge Rule “Empower any member of the team to “stop the line” if he or she senses or discovers an essential safety breach.” This is an action never to be taken lightly, but it requires immediate cessation of the process and resolution of the safety issue.

29. 2 Challenge Scenario • A 66 year old male is hospitalized for pneumonia. Sputum cultures have tested positive for respiratory MRSA and the patient is productively coughing. A contact precautions sign has been placed on the patient’s door in addition to hand sanitizer, gloves, masks, and gowns, outside of the patient’s room. • The patient has been on the call light excessively and his assigned CNA, John has been in and out of the room frequently. Mary, the unit clerk observes John peaking his head into the room or quickly stepping into the patient’s room to address his concerns and by passing the precautions to save time. • Mary pulls John aside to discuss her observations, She states" John, I’ve noticed that you have not consistently been gowning up to go into room 2. John’s response is bristled and he replies that it’s perfectly ok to step in, if he doesn't touch anything……

30. Please Use CUS Wordsbut only when appropriate!

31. A CUS Scenario • At General Hospital, they have implemented a premade CVC kit for the nursing staff to perform central line care. As part of a hospital wide initiative, one -on- one training at the bedside has been provided to nursing staff on the proper way to change and apply a Central Line dressing. • Linda, an infection control nurse observes Nurse Jackie changing a central line dressing as part of follow-up for training. Nurse Jackie has correctly followed the established hospital protocol until she begins to cleanse the area of insertion. She is observed cleaning outward from the insertion site, however instead of allowing the area to air dry for 30 seconds, Nurse Jackie blows on the site to make it dry faster….

32. Conflict ResolutionDESC Script A constructive approach for managing and resolving conflict D—Describe the specific situation E—Express your concerns about the action S—Suggest other alternatives C—Consequences should be stated Ultimately, consensus shall be reached.

33. DESC-It Let’s “DESC-It!” • Have timely discussion • Frame problem in terms of your own experience • Use “I” statements to minimize defensiveness • Avoid blaming statements • Critique is not criticism • Focus on what is right, not who is right

34. A DESC Scenario Ann works as a nurse on a general medicine floor. She recently attended an educational session on infection control techniques and the importance of hand washing. She noticed one of the doctors, Dr. Smith, while doing rounds went from patient to patient without washing his hands. Later that day, she encounters Dr. Smith in the hallway and pulls him aside. ………..

35. Communication Challenges • Language barrier • Distractions • Physical proximity • Personalities • Workload • Varying communication styles • Conflict • Lack of information verification • Shift change GreatOpportunity for Quality and Safety

36. Information Exchange Strategies • Situation–Background– Assessment– Recommendation (SBAR) • Call-Out • Check-Back • Handoff

37. SBAR provides… • A framework for team members to effectively communicate information to one another • Communicate the following information: • Situation―What is going on with the patient? • Background―What is the clinical background or context? • Assessment―What do I think the problem is? • Recommendation―What would I recommend? Remember to introduce yourself…

38. Call-Out is… A strategy used to communicate important or critical information • It informs all team members simultaneously during emergency situations • It helps team members anticipate next steps …On your unit, what information would you want called out?

39. Check-Back is…

40. Handoff The transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify, and confirm

41. Handoff • Optimized Information • Responsibility– Accountability • Uncertainty • Verbal Structure • Checklists • IT Support • Acknowledgement Great opportunity for quality and safety

42. Resources • http://teamstepps.ahrq.gov/abouttoolsmaterials.htm • http://kotterinternational.com/KotterPrinciples/OurIceberg.aspx

43. Mary Funseth, CSW, CIRS-A Quality Consultant mfunseth@metastar.com MetaStar, Inc. 2909 Landmark Place Madison, WI 53713 www.metastar.com Carrie Finley, RN BSN Quality Consultant cfinley@metastar.com Gail Wietor, RN, MS-OLQ, CPHQ, Quality Consultant Gwietor@metastar.com Contact Information