Transcript TeamSTEPPS Everywhere: Implementing at the System Level

TeamSTEPPS Everywhere:
Implementing at the
System Level
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TeamSTEPPS System
Implementation Overview
Sustainment Strategies:
Collaborative Care
Councils
Lily Thomas, Ph.D., RN
Catherine Galla, MSN,
RN CENP
Implementing
TeamSTEPPS:
EMS
Implementing
TeamSTEPPS:
Ambulatory
Services
Implementing
TeamSTEPPS in
Home Care
Myrta Rabinowitz,
Ph.D., RN
Denise
Mazzapica, MSN,
RN -BC
Jayne O’Leary,
MSN, RN
2
North Shore – LIJ Health System
3
Our Journey
2009 – 2013
15 Hospitals, 2 LTCs
Ambulatory Care , EMS
33,000 Trained
TEAMSTEPPS
July 2007
Introduction to
TeamSTEPPS
Sept 2007 - 2008
Pilot Hospital
Implementation
NSLIJHS
IFN
5
TEAMSTEPPS IMPLEMENTATION
6
PHASE 1: PREPARATION
Meet with
Executive
Leadership
Provide Overview of
TeamSTEPPS
Identify:
• Organizational Goals
• Data/Measures
• Infrastructure for
Implementation
• Sequence of
Implementation
7
Determine Organizational Goals
TeamSTEPPS
Goals
Decide Change Type
Transformational
Change:
Incremental Change:
Changing the Culture to a
Culture of Safety
Problem Solving Using
TeamSTEPPS Core Skills
8
PHASE 1: ASSESSMENT
Site Assessment
Administration of ‘Hospital Culture of
Patient Safety Survey’
http://www.ahrq.gov/qualhospculture/hosp
sanform.pdf
Data / Measures
9
Begin with the End in Mind!
10
Collaborative Care Model
EXCELLENCE CARING
HONORING THE
COLLABORATION
HUMAN SPIRIT
PROFESSIONALISM
LEADERSHIP SAFETY
Health Care Team
PATIENTS
COME
FIRST
Practice Environment
(Structure)
Health Care Team
Outcomes
Patient Experience
Financial Performance
Quality
Copyright 2008 © North Shore -Long Island Jewish Health System Inc.
Care Delivery Model
(Process)
TEAMSTEPPS
11
Infrastructure for Implementation
Organizational Level
Executive Sponsor Team
System PICG
Service Level
Director Sponsor Team
Hospital PICG
Department/Unit Level
Collaborative Care
Council
Service PICG
12
ACTION PLANNING &
IMPLEMENTATION
13
Implementation Sequence
1
2
Medical
Surgical
Critical
Care
3
4
ED
Peri-Op
5
Peri-Natal
14
Hospital
Plainview
Schneider’s
LIJ
NSUH
SI North
SI South
Syosset
Southside
Franklin
Glen Cove
Huntington
Zucker
Forest Hills
Sterns
Orzc
20072008
Jan’09
Feb’09
Mar’09
Apr’09
May’09
June’09
Jul’09
Aug’09
Sep’09
Oct’09
Nov’09
Dec’09
TIMELINE
RAPID…
SYSTEMATIC…
STRUCTURED ROLLOUT…
Training
Implementation
(Adoption in
practice)
ORGANIZATIONAL
TIMELINE
MONTHS
WEEKS
1-2 3-4 2
3
4
5
6
7
8
9 10 11 12
•Preparation
•Planning /
Training
•Implementation
ON GOING
•Assessment
•Sustainment
•Post
Implementation
9 Months After Implementation
Copyright 2008 © North Shore -Long Island Jewish Health System Inc.
DEPARTMENT/
UNIT
BRIEF
HUDDLE
DEBRIEF
RAPID…SYSTEMATIC…STRUCTURED ROLLOUT
1
2
3
4
5
6
7
8
9 10 11 12
SITUATION
MONITORING
TASK ASSISTANCE
IPASSTHEBATON
SBAR
CALL OUT
CHECK BACK
TWO CHALLENGE
RULE
CUS, DESC
SCRIPT
Copyright 2008 © North Shore -Long Island Jewish Health System Inc.
Lessons Learned
Ongoing
executive
leadership
support is
essential
Training:
Use
Multidisciplinary
approach
Use Stories
Redose
Standardize
implementation:
Rapid Systematic
and Structured
process
Transfer
responsibility &
accountability to the
facility
Cohort units to
rollout according
to planned
sequence
Physician
involvement is
crucial
Begin with the
end in mind!
- Connect to
organizational vision
and mission
-Customize
sustainment plans
Communicate!
-TS goals and benefits
-Implementation Plan
-Success stories
Drive & Monitor
-Processes
-Rounding with onsite
coaching
-Outcomes
Executive
Leadership Support
Drive & monitor the TS
implementation &
sustainment
Enable accountability
Participate in Collaborative
Care Council (CCC)
Create job descriptions to
include participation in
CCCs
Monitor outcomes &
design
interventions
Educate!
Orientation,
Annual Education
Hardwire
- Use TS processes to
optimize
improvements
- Integrate TS
competencies in
policies and
procedures
Celebrate Success
Share Best Practice
-Annual
Dissemination
SUSTAINMENT STRATEGIES 20
TRANSFORMATIONAL GOAL RESULTS:
PILOT HOSPITAL
2011
2007
11
Domains
9
Domains
Total = 12 Domains
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TRANSFORMATIONAL GOAL RESULTS:
Health System
2011
2009
7
Domains
9
Domains
Total = 12 Domains
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Transitions in Care
EMS
PAANS
TS
Integration
Acute
Care
Home
Care
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Team Training & Implementation
Permanent
Change Team:
Collaborative
Care Councils
Standard/
Customized
Curriculum and
Training
Understanding
the Culture
Executive
Overview
Toolkit
24
Transitions in Care
EMS
Acute
Care
PAANS
Home
Care
25
Acute Care Toolkit
•Standard TS Training
•Standard Scenarios
•Multi-Team System (MTS)
•Briefing Template
•Handoff
•Collaborative Care Council
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Acute Care MTS
RN, MD, RT, NM
RN, PCA, MD, SW, CM
NM, UR,
Hospitalist
RT, PT, OT, Food & Nutrition,
Environmental
Directors, Dept Heads, Chairmen,
CEO, CNO, CFO
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Transitions in Care
EMS
PAANS
TS
Integration
Acute
Care
Home
Care
28
29
30
CEMS Toolkit
•Customized TS Training
•Customized Scenarios
•Multi-Team System (MTS)
•Briefing template
•Handoff between EMS-ED
•Collaborative Care Council
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EMS Scenario
A civilian calls EMS to report a house fire.
People are still in the house and the fire
is still in progress. EMS dispatch elicits
information from the caller(situational
monitoring), and summons additional
resources as required (police, fire,
supervision.)Upon arrival EMS is
directed to stage at a determined
location and are briefed about the
situation(shared mental model). Multiple
patients are identified and triaged.
Treatments and transports proceed as
appropriate.
Skills needed: Situation Monitoring,
Shared Mental Model, Leadership-briefs,
huddles, debriefs
Created by CEMS
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Multi-Team System (MTS) for Patient Care in
CEMS
10-84 House Fire(on the scene)
EMT’s & Paramedics,
Supervisors
EMT’s & Paramedics
Police, FDNY
IT,
Dispatcher
Support ,Mechanic,
Pharmacy
Human Resources, Corporate
Compliance, CEMS Administration,
FDNY Administration
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Multi-Team System (MTS) for Patient Care in
CEMS
10-82 House Fire (scene to hospital)
EMT’s & Paramedics,
Supervisors
EMT’s & Paramedics
IT,
Dispatcher
Support,Mechanic,
Pharmacy
Human Resources, Corporate
Compliance, CEMS Administration
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Multi-Team System (MTS) for Patient Care in
CEMS
10-81 House Fire (arrival at the ED)
Respiratory
EMT’s, Paramedics
Triage RN, PCA, MD
IT, EVS, Security
Support, Mechanic,
Pharmacy
Human Resources, Corporate Compliance,
CEMS Administration, Receiving Hospital
Administration
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CEMS Brief Template
Topic
When
Reviewed
☑
1. Staff Assignments-EMT’s and
Paramedics/Staffing Concerns
□
2. Communication/Assignments
received from Dispatch and Call
center to the teams?
□
3. Types of transport required:
•Cardiovascular
•Trauma
•Routine
5. Any equipment issues?
Ambulance’s adequately stocked?
□
6. How is internal communication with
our hospital sites?
7. Huddles as needed among
ambulances and across teams
□
Document Discussion
(if necessary)
□
□
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Communication- I PASS the BATON
A Handoff strategy designed to enhance information
exchange during transitions in care
I
P
A
S
S
Introduction
Patient
Assessment
Situation
Safety
Introduce yourself
& your role / job
Name, Identifiers, age,
sex, location
Chief complaint, VS,
symptoms & Dx
Current status, recent
changes & responses
Critical values, allergies,
alerts
B
A
T
O
N
Backgroun
d
Actions
Timing
Ownership
Meds, Family Hx,
Previous Hx, Comorbidities
Actins taken or
required w/rationale
Urgency &
prioritization of
actions
Who is
responsible?
Anticipated changes?
Plan? Contingency plan?
Next
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CEMS
Collaborative Care Council
Agenda Discussion
1:1’s
- Reviewed the purpose of the 1:1’s
and the importance of
bringing back the council minutes
to the team
Handoff - This is an important area to work
Commun- on and a tool that would
ication
improve communication from EMSED and vice versa
- Jayne asked if anyone was
attending the ED councils at our
15 sites. We also have a system ED
collaborative that all sites report to
- In order to improve/maintain
communication we need to
have EMS representatives
attend site CCC’s
Action Plan or
Follow-up
- Ask Elizabeth
and Sean to
assist
Discuss further
F/u with Elizabeth
Rob and Sean have
attended
Invite team to the
9/6 ED
collaborative:420
Lakeville RoadSuite
21
@
10:00am
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Transitions in Care
EMS
PAANS
TS
Integration
Acute
Care
Home
Care
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Home Health Care
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Home Care Toolkit
•Customized Scenarios
•MTS
•Briefing Template
•SBAR Tool
•Handoff: Clinical Information
Form I PASS
•Collaborative Care Councils
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Home Care Scenario
The physical therapist is in the home with a
new patient, post –op Total Hip Replacement
(THR) day 2.
While checking the orders, he notices there
are no hip precautions ordered. He calls the
MD’s office to clarify and after 5 minutes the
doctor answers the call. The physician starts
to yell, “Stop calling my office with stupid
questions! If you don’t know what THR
precautions are, then go back to PT school”.
Skills needed: Mutual Support – CUS, DESC
Created by NSLIJHS Home Care Network
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Multi-Team System (MTS) for Patient Care in
Home Health
Weekend Staff, Covering Staff,
Telehealth, Infusion Services
Visiting RN, PT, OT, MD, ST,
MSW, Infusion Case Manager,
Intake, Telehealth, HHA/PCA,
Family
DPS, Telehealth,Managers,
Receptionist, Billing Dept,
Insurance Verification
Team Secretary’s, DME and
Supplies, Infusion team,
Pharmacy Liaisons & Techs,
Service Reps, Coordinator of
Reimbursement
VP’s, DPS, Director’s, Managers, MD
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Briefing Template for Home Care
Topic
When
Reviewed
☑
1.Staff call in schedule or send via
voice mail/e-mail and/or in
person
2. Staff Assignments/Staffing
Concerns/”Call-in’s”
3. Weekend/Holiday
Issues/Coverage
4. Intake Concernsadmission’s/discharges and
recert’s. Case’s not open and
reason
5. Safety Issues-prioritize-lives
alone/no caregiver/falls
risk/pressure ulcer risk/ frequent
re-admissions
6. What teams need assistance?
Who can assist/float/admit
patients
7. Announcements/Updates
Document Discussion
(if necessary)
□
□
□
□
□
□
□
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SBAR :
A technique for communicating critical information that requires
immediate attention and action concerning a patient’s condition
Situation“I am calling about Mr.M who is
complaining of increased dyspnea”
Home Care Example:
Mr.M is a 74 yr old male that you
are admitting today
• The patient had CHF and COPD,
and is on Lasix 20 mg 1xday, Coreg
12.5 mg 2xday, Digoxin 0.25mg
1xday and MDI
• The patient has minimal edema to
both feet and decreased breath
sounds at the bases.
•
Background“Patient is a 74yr old male
discharged from the hospital with
acute exacerbation of CHF”
Assessment“Breath sounds are decreased at
the bases and the patient has
bilateral edema of the feet”
Recommendation“Would you like to increase the
daily Lasix dose?”
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Handoff : (I PASS for Home Care)
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Collaborative Care Council Invitation
SCRIPT FOR CONVERSATION WITH COUNCIL
MEMBERS
“We are establishing a Collaborative Care Council for the North
Shore Westbury branch and we want you to be part of it. This is a
great opportunity to use your knowledge to make North Shore
Home Care better. You will be meeting with your workgroup
every month for an hour and it is a mandatory meeting.
Eventually everyone will take part in the council, but I have
selected you for this first one.
This will be ongoing for a term of 6-9 months and you will be
expected to participate in discussions, different tasks and the
development of a pilot project.
Betty Popp, our Service Excellence Coordinator, will be reaching
out to you shortly with more information so make sure to check
your email and respond.”
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Presenter
Discussion
1:1 Report
Betty
Clinical
Quality
Items:
TeamSTEPPS
Betty
Check the
Managers to
lists
f/u
developed
for each
team and
distribute to
staff
>60% of all
teams have
been trained
and are
using
briefing,
huddles,
SBAR
Link to
other
Initiativ
e
Home Care
Collaborative Care
Council
Agenda Item
ACTION- F/U
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Transitions in Care
EMS
PAANS
TS
Integration
Acute
Care
Home
Care
49
PAANS=Physicians
and Ambulatory Network Service
Ambulatory
Services
Business
Development
NSLIJ
Physician
Enterprise
NSLIJ
Medical
Group
50
PAANS Toolkit
•Customized Scenarios
•MTS for Ambulatory Services
•Briefing Template
•SBAR
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Front Office Scenario
Jack, an elderly man who just had cataract surgery, cannot
drive. Jack was taken to the clinic by his son for a follow-up on
his blood pressure and diabetes. While Jack was in the
examination room, his son was called away on an
emergency. When Jack finished his appointment and found that
his son was not waiting for him, he was very upset. The front desk
administrator realized that Jack had no way to get home(situation
monitoring) and called a quick huddle with the nurse and the
billing specialist. Together they decided to arrange for a taxi to
take Jack home. The front desk administrator then called Jack
after he arrived home to make sure all was well.
Skills needed: Situation Monitoring, Situation Awareness,
Leadership - Huddle
TeamSTEPPS Primary care Version
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Primary Care Scenario
Susan was due for a mammogram and the provider ordered it. Upon
arrival at the mammography service, Susan was told that she would have
to pay for the mammogram, since her insurance company did not cover
it. Confused, Susan returned to the primary care clinic and told the
administrative assistant that she did not have the money to pay for
this. She was especially upset because her mother was a breast cancer
survivor. The administrative assistant assessed (1) the status of the
situation, that a billing specialist (2) team member was needed, (3) the
environment (the patient was upset), and (4) the progress towards the
goal (patient was being denied access). The billing specialist then called
the insurer and clarified that the insurer had the wrong dates and Susan’s
mammogram was due. The insurer realized their error and covered the
mammogram.
Skills needed: Situation Monitoring-STEP, Leadership
TeamSTEPPS Primary care Version
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Multi-Team System (MTS) for Patient Care
Sr. Directors,
Administrators,
Supervisors,
Managers, MOA’s
Physician, Fellow,
Resident, NP,RN, PA, RT
Front Desk,
Secretary, File Clerk,
Biller, Coder, IT
Executive Leadership, Medical Directors, Sr.
Leadership
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Briefing Template
Topic
When
Reviewed
☑
1.Welcome/Encourage all team to attend
□
2. Staff Assignments/Staffing Concerns
Sick calls, meetings, break coverage
Roll of each staff member for the day
Room assignments
Who can provide translation assistance
3. Patient Alerts/Safety Concerns:
Patient’s identified at “high risk” or need to be triaged/
changes in scheduling: cancellations/”no shows”/testing/all
staff informed of changes?
Any cancellations
Electrical / technical outages:
o
Lab slips
o
Appointment cancellation notification
o
Microwave: lunch plan
Special concerns
4. Status of the team:
MD/PA/NP coverage: who/how many
Who is Post-call
Who is covering emergencies
Billing issues
IC issues
5. Have all members of the team been included in the
brief?
If not, identify the designated staff who will “brief” or
“debrief” staff as needed
6. Announcements/Updates
□
7. Did you Huddle today?
Outcomes of Debriefing after Huddles
□
Document Discussion
(if necessary)
□
□
□
□
55
SBAR :
A technique for communicating critical information that requires
immediate attention and action concerning a patient’s condition
• The electronic health records system was
not functioning
• Alice had an appointment for follow-up of
labs and x rays. Since there was no way to
access the diagnostic data, the provider
asked the administrative assistant to call
both the laboratory and the radiology
service to get the results via telephone
• The administrative assistant called and
requested the necessary information
using the SBAR technique
• The provider was then able to see Alice
on time and discuss her lab and x ray
results
Situation
Electronic health records system
is not functioning
Background
Patient has an appointment for
follow-up of lab and x-rays.
Assessment
There is no way to access the
diagnostic data
Recommendation
Request the necessary
information from the lab and
radiology by phone
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PAANS
Collaborative Care Council
Agenda
Discussion
1:1’s
- Reviewed the purpose
of the 1:1’s and the
importance of
bringing back the
council minutes to the
team
-Everyone trained in TS
SBAR
to
communicate
with depts.
and MDs
Action Plan or
Follow-up
Jerry will assist
Managers will
follow up with
-Will have managers review staff
with staff\
To review
-Post SBAR cards by all
phones
Jayne and Lynn
-Practice scenarios will be will create
done at next staff meeting
scenarios for next
staff meeting
-Review of last week’s
incident with staff and point
out how SBAR would have
prevented problem
Begin with the end in mind!
S Covey, The 7 Habits of Highly Effective People (Habit 2)
- - Secret of Sustainment - -
Connect TeamSTEPPS
to
Organizational
Vision & Mission
58
COLLABORATIVE CARE MODEL
EXCELLENCE
CARING
HONORING THE
HUMAN SPIRIT
COLLABORATION
PROFESSIONALISM
LEADERSHIP
SAFETY
Health Care Team
PATIENTS
COME
FIRST
Practice Environment
(Structure)
Ex: Resources:
Human
Equipment
Supplies
Financial
CCCs
Copyright 2008 © North Shore -Long Island Jewish Health System Inc.
Care Delivery Model
(Process)
Outcomes
Patient Experience
Financial Performance
Quality
Ex: Human Caring Model
Patient Safety Model
Ex: Patient Satisfaction,
Evidence Based Practice
Microsystems,
Six Sigma, Lean,
Capstone, FTD
Staff Engagement,
Patient Safety,
Quality Outcomes,
Productivity & Efficiency,
Predictability,
Documentation
Team STEPPS
59
Making It Real:
Collaborative Care Councils
 Collaborative Care Councils
provide a networking
infrastructure for
interdisciplinary colleagues
at all levels
 Address practice issues
related to quality
 Improving care and service
 Developing leaders
 Tapping into
individual gifts and
collective capacity
 Enhancing
relationships
 Having meaningful
conversations
 Achieving shared
mission and vision
Collaborative Care Council Model
Work Team
Unit/Dept
Collaborative
Care Council
Central Hosp
Collaborative Care
Council
One-On-One
System
Collaboratives
61
Council Impact Areas
What Councils Work On
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Patient Safety
Clinical Quality Improvement
Recruitment and Retention
Patient / Staff Satisfaction
Use of Financial Resources
Staff Competency Improvements
Healthy Work Environment
Work of / with Other Councils
Connecting Health Care Settings
Process Improvement
62
Key Council Success
Strategies
Multi-modal
Communication plan
Advanced
scheduling of
meetings
63
1:1
Critical to Sustainability and Growth
Staff build relationships one
person at a time
Enhances interpersonal
relationships
Everyone feels connected
and a part of decisions
Accountability increases becomes “our decision”
64
Evolution of Collaborative Care
Councils
All Inpatient Units in
16 Hospitals
Outpatient
Clinics
2 LTC / Rehab
CEMS
PAANS (Physician and
Ambulatory Network
Services)
Home Care Network
All sites have a Central
Council
System wide Behavioral Health Collaborative
Emergency Services Collaborative
Allied Health, Ancillary &
Support Service Councils
Social Work
Food and Nutrition
Radiology
Laboratories
Rehab Services
In & Outpatient
Respiratory
Pharmacy
Environmental
Case Management
Central Sterile & Supply
HIM (Medical Records)
Faculty Practice
Admitting
Security
Engineering
Telecommunications
65
TeamSTEPPS Showcases
66
Success Factors Unique to NSLIJ
Implementation
across a
diverse care
continuum
67
Success Factors Unique to NSLIJ
Hospitals:
Tertiary
Community
Specialty –
Pediatrics
, Behavioral Health
Ambulatory
Care /
Medical
Offices
Long Term
Care /
Rehab
Ambulance
Services /
Home
Health Care
Network
68
Unique to NSLIJ
CCCs =
Change
Team is
Permanent
Videos
Leaders
Physicians
& Staff
Leadership
Support &
Engagement
69
Unique to NSLIJ
All Clinical
Leaders / Dept
Heads attend
Master Training
All Clinical
Leaders / Dept
Heads become
Trainers or
Coaches
System Policy /
Procedure
Human
Resources
TeamSTEPPS
Tools & Strategies
anchored in daily
practice …
Orientation
Simulation
scenarios
70
Organizational Goals
TeamSTEPPS
Goals
Decide Change Type
Transformational
Change:
Incremental
Change:
Changing the Culture to a
Culture of Safety
Problem Solving Using
TeamSTEPPS Core Skills
71
Incremental Change Example 1 –
Inpatient Med Surg CCC
Reduce the risk of CLABS in Patients outside the ICU
Interventions
•Handoff used to communicate patients with CLs
•Cross Monitoring using daily check backs on patients with
CLs to ensure dressing changes and line care
•Briefs discussing the number of infection free days
Results
•Number of line days decreased by 50%
•43% reduction in the CLABS rate
72
Incremental Change Example 2 –
Inpatient Med Surg CCC
Decreasing Bed
Turn around Time
• Discharge readiness
packets
• Multidisciplinary
rounds
• Afternoon discharge
huddle
• Discharge magnet
• Communication with
patient and family re
discharge times
Press Ganey Scores
Pre
Post
Discharge
82.4
90.6
Likelihood to
recommend 82.7
91.7
Percentile Ranking
Pre
Discharge
3rd
Likelihood to
recommend
2nd
Post
99th
89th
73
Incremental Change Example 3 –
Inpatient Med Surg CCC
Decreasing Catheter –Associate Infections
Interventions
• Situation Monitoring by interdisciplinary staff
• Collaboration: Daily Patient Care Rounds
• Assessment Tool developed to track foley catheters
• Implemented CAUTI Bundle
Results
CAUTI Rate: 1st Quarter 10.6
2nd Quarter 11.9
3rd Quarter 3.15
74
TeamSTEPPS:
The glue that binds it all together…
75
The only way to discover the
limits of the possible is to go
beyond them into the
impossible. ~ Arthur C. Clarke
76
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