Moving From a Team of Experts to an Expert Team

1. Moving From a Team of Experts to an Expert Team Highly Reliable Surgical Teams (HRST) Critical Events Team Training (CETT)

2. The Challenges of Teamwork:

3. Critical Events Team Training: Rehearsing Emergencies with Simulation • These sessions will be designed to: • help staff prepare to deal with unanticipated medical events • develop teamwork and communication skills • increase confidence and improve performance

4. Background:The Patient Safety Movement • IOM Report • ( IOM,2000,Thomas and IOM,2000;Center for Disease Control & Prevention,National Center for Health Statistics) • Errors are a leading cause of death • 44,000-98,000 die each year • Other leading causes of death • MVA 43,458 • Breast CA 42,297 • AIDS 15,516

5. High Reliability Organization(HRO) • HRO recognize that human beings performing complex tasks, errors will occur • Important Question is • “How will the inevitable errors be detected and mitigated before they cause harm” • How are they managed?

6. The Reality of Errors • 95% of errors are made by capable, conscientious individuals • 70- 80% of medical errors are system and human factors derived • Williamson, JA Resuscitation 1994(28):221-225 • Bad things can happen to good people!

7. Medical Errors: The Human Condition and Modern Medicine • Human Factors: • Limited memory capacity – 5-7 pieces of information in short term memory • Negative effects of stress – error rates • Tunnel vision • Negative influence of fatigue and other physiological factors • Limited ability to multitask • Clinical medicine is an extremely complex environment with: • Surprises & uncertainty • Incomplete information • Interruptions and multitasking • Very sick patients • Rapidly changing technology

8. What Will Work if it’s not “Trying Harder”?

9. Why Is This So Hard ? The Fallacies We Hold on To • Strong history and culture: we are trained to be perfect • Being good at what you do is enough to prevent error • Error=negligence in most people’s minds • Safety is often assumed at the level of expert individuals, not assured through effective teamwork and communication • Lack of role models that reinforce the truth about human limitations • Error can be eliminated • Trying harder will eliminate errors

10. Key Principles of Human Factors • Recognizes that a “team of experts” is not the same as an “expert team” • Erases the fallacy that being good at what you do will prevent error • Performance and outcome is dependent on how the team functions • Communication and coordination of teams is the key feature

11. Teamwork • “A group with complementary skills who are • committed to a common purpose and • performance goals, for which they hold • themselves mutually accountable” • Requires clear exchange of information that results in appropriate • action. • Benefits from well-defined roles and responsibilities. • Doesn’t require that we like each other, does require mutual respect.

12. Recipe for Successful High Performing Teams • All members of the team can: Identify the team leader Describe both their own and teammates roles Describe the team’s norms and what is not tolerated Use communicationskills to share, facilitate, voice concern, and create action • All members of the team feel: Respected Supported (have the resources to “get the job done”) Accountable Safe in speaking up (i.e., psychological safety)

13. Teamwork in Action • High performing teams - • Train together • Provide and welcome feedback • Measure their performance and strive to improve • Encourage the continual sharpening of each individual team member’s skills • Communicate, Communicate, Communicate

14. Psychological Safety • It is critically important that people feel safe • speaking up. Psychological safety has a • profound impact on team performance. • Does it feel safe to speak up ? • Will I be treated with respect? • Will they help fix my problem? • If you don’t get the right answers, then it gets risky.

15. Leadership • Effective Leaders: • Set the stage actively and positively. • Support an environment of psychological safety. • Use peoples names. • Flatten the hierarchy. • Share the plan. • Continuously invite the other team members to offer input and voice concerns.

16. “I don’t have any pride invested here. I just want to get this right, so if you think of anything helpful or see me doing anything wrong, please let me know.” --Vascular surgeon doing new, complicated procedure -- endovascular aortic stent – in CV lab

17. Common Mental Models

18. Situational Awareness & Red Flags • Definitions • Situational Awareness: A shared understanding of “what’s going on” and “what is likely to happen next” • Red Flag: An indicator of loss / potential loss of situational awareness. May indicate something is wrong. • Potential Solutions: • Call outs • Cross checking • Critical language to “Stop the Line”

19. Red Flags New Staff Interruptions Rushing Pre-occupation Ambiguity Fatigue Deviating from Normal Procedure This isn’t right Task Saturation Task Fixation Poor communications Trying something new Unresolved Issues Handoffs

20. Communication

21. Communication • Breakdowns in communication may be the single most important factor to preventing patient injury. • Virtually all instances of unexpected adverse events involve communication failures. • JCAHO Sentinel Event data - > 2400 severe cases – 75% mortality – in their analysis communication failures were the primary root cause in over 70%. • When everyone shares the same mental model, the chance of unpleasant surprises decreases dramatically.

22. Communication skills that can avoid or minimize error • Briefing:A conversation and dialogue (two-way) of concise and relevant information • SBAR:A structured method to communicate important information in a succinct manner for the purpose of getting action • Assertion:To have individuals speak up, and state their information with appropriate persistence until there is a clear resolution. • Readbacks:To ensure that verbal instructions between healthcare professionals were heard and understood correctly • Callouts:The active sharing of information that is known by one team member for the benefit of other team members • Debriefing:Team-based discussion & review of a shared experience to learn from

23. Briefings • Step Back. Be sure everyone’s “on the same page”.

24. What is a Briefing? • Definition • A briefing is a dialogue between two or more people using concise and relevant information. • Briefings help us to: • Facilitate clear, effective communication. • Foster an environment where team members can and do speak up if they see a problem.

25. Briefings - When to Brief Start of Shift Prior to Procedures On the spot - As need arises Handoffs • Breaks • Shift Changes • Across continuum When new staff arrive to help

26. Briefings – How To Checklist • Get the team’s attention, set a positive tone, introduce yourself and use people’s names. • Describe the plan, including relevant background information…and contingencies. • Explicitly ask for input – have a 2-way conversation – effective leaders continuously invite the other team members into the conversation. • Encourage ongoing monitoring and cross-checking. • Specifically ask team members to speak up if they have a question or concern.

27. Poor Communication

28. SBAR • SBAR provides structure to the communication of • critical information to help ensure it is: • Action-oriented • Concise • Complete • Instances when it might be appropriate to use: • Conversations with a physician, either in person or over the phone • Conversations with peers - Change of shift report • Escalating a concern • Discussions with ancillary departments (lab, pharmacy…

29. Situational Brief • S-B-A-R: • Situation(the problem, what is going on) • Background( pertinent, brief, related to the point) • Assessment(what you found/think is going on) • Recommendation(what you want, request/recommend) • Followed by respectful response, discussion and plan

30. Assertion - What is it? • “Individuals speak up, and state their information with appropriate persistence until there is a clear resolution.”

31. Assertion - What it’s not

32. Why is Assertion So Hard ? • Hierarchy and power distances are inherent in medicine. • Lack of common mental model – if you don’t know what the plan, it’s hard to speak up. • No one wants want to look dumb or to announce they don’t know what’s going on.

33. Helpful Hints for the Difficult Conversation Focus on the common goal: quality care, the welfare of the patient, safety – it’s hard to disagree with safe, high quality care Avoid who’s right / who’s wrong De-personalize the conversation Actively avoid being perceived as judgmental Use SBAR to help effectively communicate the concerns • Be hard on the problem, not the people

34. Assertion Model to guide and improve assertion in the interest of patient safety 2 Challenge Rule ESCALATE (if necessary)

35. Readbacks

36. Readbacks • Readbacks are used routinely in other high-reliability industries. • Readbacks provide assurance to both the sender and the receiver of verbal communication that we’ve got it right. • Like all redundancies, they should be used selectively, but rigorously. • Should be “Write down – Readbacks” unless not feasible. • Use key words or phrases such as: • "Please give me a readback on that", or • "Can I have a readback“

37. Call-Outs • The active sharing of information that is known by one team member, for the benefit of other team members. • Used routinely in other high-reliability industries, and less routinely in ours. • Helps keep team on the same page. • May be used for information only, soliciting input, or creating action.

38. Call-Outs • May be used: • To announce key milestones (e.g. “1 mg of Epi is in”) • To note an unexpected complication (e.g. “the O2 sat is dropping”) • To update the team when there is a change in plans (e.g. “please call the ICU as it looks like we may need to bring this patient there”)

39. Debriefing • An opportunity for individual, team, • and organizational learning • The more specific, the better • The basic questions: • What did we do well? • What didn’t work as well? • What systems problems did we find? • What teamwork glitches did we find? • What will we do differently next time ?

40. Effective Debriefing • Do it when the experience is fresh. • Everyone gets a chance to speak. • Start with the junior folks – otherwise they can be overshadowed by the veterans. • Be crisp and to the point. • Avoid judgment – this has to be a positive learning experience.

41. Successful teams: • Have clear roles, goals and objectives • Communicate well and often • Respect and listen to each other • Realize that patients and members are an essential part of the team and to engage them • Practice together

42. Critical Event Drills • Drills offer a “safe” learning environment • Drills safely reveal positive and negative communication patterns/teamwork • Drills safely reveal system strength and weaknesses • Lifelike in real time • Normal noise -- confusion -- resources • Situation must be managed by team exactly as in real life • You will be doing your usual job at all times

43. What might you see? • Errors and excellence in management • System weaknesses • Good and bad communication • Good and bad teamwork • A free and open learning discussion • No patient at risk

44. How To Look Great (and rescue your patients) • Optimum location, people and equipment • Brief the Team • Know the environment, clearly delegate tasks • Clear Leader- (This may change!) • Regain Situational Awareness • Chaos is Never OK

45. “The Take Home Messages” • You are already a great team • If you practice, you will get better • Debrief your real cases! • Have fun!