Teamwork and Human Factors in ED

1. Teamwork and Human Factors in ED

2. Goals for the Day • Describe role of teamwork to help reduce risk of errors due to human factors • Outline present initiatives for improving teamwork in ED • Learn evidence-based teamwork skills and strategies with focus on ED opportunities

3. Objective • Improve care of our patients • Improve efficiency and staff satisfaction Through teamwork • Within ED • Between ED and Other Teams (eg. MICU)

4. Human Characteristics • Perception • Memory • Decision-making • Physical Capabilities (skills to do tasks)

5. Perceptions REDYELLOWGREENBROWN BLUEREDBROWNBLUE BROWNGREENYELLOWBLUE GREEN BROWNBLUERED

6. RED YELLOWGREENBROWN BLUE REDBROWNBLUE BROWNGREENYELLOWBLUE GREENBROWNBLUERED

7. Memory F B I P H D T W A I B M FBI PHD TWA IBM

8. Nominal Error Rates(highly predictable) • General error of commission (eg. Misread label) 0.003 • General error of omission in absence of reminders (memory) 0.01 • General error of omission for 10 step process 0.1 • General error of omission when items are embedded in procedure 0.003 (cash card returned before money dispensed) • Staff on different shifts fail to correctly check hardware condition 0.1 unless required by checklist (eg. Defibs) • Monitor fails to recognize an error (vigilance) 0.1 • General error rate given very high stress levels where dangerous 0.25 activities are occurring rapidly

9. Need for Teamwork • Clinical Medicine is extremely complex: • Uncertainty • Incomplete Information • Interruptions and multitasking • Surprises • Human Factors

10. Promote Teamwork • Teams of individuals who effectively communicate and back each other up compensate for individual fallibility and dramatically reduce consequences of inevitable human error • Reality of modern medicine - “teams” of “teams”

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

12. Hierarchy and Behavior

13. Psychological Safety • Critical to Team Performance • People need to feel safe to speak up: • Does it feel safe to speak up? • Will I be treated with respect? • Will it help fix the problem? • If you don’t get the right answers, then it gets risky

14. Team Structure and Role Clarity The ratio of We’s to I’s is the best indicator of the development of a team. –Lewis B. Ergen NEXT:

15. Role Clarity – Have a Plan x Trauma Cons. X EM Cons. X Provider Doc. X RTX EM Res X Primary Recording RN X Team Leader X Assisting Provider X Assessing Provider X Left Arm Nurse X Right Arm Nurse

16. Multi-Team System (MTS) for Patient Care

17. Leadership

18. Effective Team Leaders • Articulate clear goals • “Know the Plan – Share the Plan” • Organize the team • Delegation is key • Seek input from team members • “Psychological Safety” • Flattening Hierarchy • Resolve questions/conflict

19. Team Leader Two types of leaders: • Designated – The person assigned to lead and organize a designated core team, establish clear goals, and facilitate open communication and teamwork among team members • Situational – Any team member who has the skills to manage the situation-at-hand

20. 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

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

22. Briefing Checklist • Introductions of core team (names) • Review roles and responsibilities (when new staff/ interns) • Room coverage • Coverage hours / shift changes • Teamwork focus for day • _____________________ • Plan of care / Resource issues • Charge RN briefs on staffing issues, inpatient bed situation, resource issues • Individual SBAR reports on patients (consultants report)

23. 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

24. 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

25. Leadership Exercise • Articulate clear goals • Organize the team • Seek input from team members • Resolve questions/conflict

26. Communication Assumptions Fatigue Distractions HIPAA

28. Brief Clear Timely

29. Barriers to effective communication • Poor communication habits • Social barriers such as hierarchy, modesty, culture and gender • Lack of respect and trust • Lack of “common language”

30. Let’s Watch an RRT in Action

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

32. SBAR – Situational Briefing Model • S – Situation – What’s the situation? • B – Background – How is the clinical background and context? • A – Assessment – What do I think is the problem? • R – Recommendation – What are we going to do to fix it? Predictable, Concise, Critical Thinking

33. SBAR • S- 67 yo male tachycardia, SOB and hematemesis / melena • B- 3 days post thoracic surgery for lung mass; PMHx CAD • HR 130, BP 100/70, T- 37, RR 22, SaO2=99% • A – The surgery fellow wanted to give metoprolol since he missed his dose, but I was not comfortable with this • R – Could you assess patient and see what you think?

34. Effective Communication and Teamwork Requires: • Structured communication – SBAR • Assertion/critical language – key words, the ability to speak up • Psychological safety – an environment of respect • Effective leadership – flat hierarchy, sharing the plan, continuously inviting other team members into the conversation, explicitly asking other people to share questions or concerns, using people’s names.- Dr. M. Leonard

35. Communication Example

36. Situation Monitoring “Attention to detail is one of the most important details ...” –Author Unknown

37. A Continuous Process SituationMonitoring(Individual Skill) SituationAwareness(Individual Outcome) Shared Mental Model(Team Outcome)

38. A Shared Mental Model is… The perception of, understanding of, or knowledge about a situation or process that is shared among team members through communication. “Teams that perform well hold shared mental models.” (Rouse, Cannon-Bowers, and Salas 1992)

39. Shared Mental Model Importance!

40. Collaborative Patient Assessment • Stresses importance of communication and SA for care team • Ensure patient provided information not lost • Improve patient perception of our teamwork • Include AIDET tool • Patient centered focus

41. 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)

42. When to Share? • Briefs • Huddles • Debriefs • Transitions in Care

43. “Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous” Chantler, 1999

44. Effective Planning/ResponseOrganizational CountermeasuresCulture of Safety • Understand barriers • Build system of people, equipment and environments to ensure safety • Work to break down silos, develop inter-team knowledge and support • Abandon “blame and punish” mentality

45. Every system is designed to achieve exactly the results it gets. - Donald Berwick