Transcript Team STEPPS

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Team Strategies and Tools to Enhance
Performance and Patient Safety
› Evidence-based teamwork system
› Optimizes patient outcomes
 Communication skills
 Team work skills
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Focuses on specific skills that support
team performance
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Department of Defense
 Agency for Healthcare Research and
Quality
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› 20 years of research from High-Reliability
Organizations (HROs)
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Produce highly effective medical teams
 Optimize use of information, people, and
resources
 Achieve best clinical outcomes
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Chesley Sullenberger, 1-25-09
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“JUST A ROUTINE OPERATION”
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...Improved teamwork and communications...Ultimately a
culture of safety
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IOM Report: To Error is Human, 1999
› 44,000-98,000 deaths/year
› Cost $17-29 billion/year
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As of 2005 national estimates have
shown “little improvement” (Leape &
Berwick, JAMA May 2005.)
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65% sentinel events over the past 10
years (Joint Commission, 2005, n= 3548)
 80% of 6000 root cause analyses of
adverse events and close calls (VA
Center for Patient Safety)
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Workload fluctuations. 
Interruptions.
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Fatigue.
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Multi-tasking.
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Failure to follow up.
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Poor handoffs.
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Ineffective
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communication.
Not following
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protocol.
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Excessive professional
courtesy.
Halo effect.
Passenger syndrome.
Hidden agenda.
Complacency.
High-risk phase.
Strength of an idea.
Task (target) fixation
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Reduce consequences of human error by:
› Communicating effectively with team
› Backing team members up
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Emergency Department
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Improved observed team behaviors
Enhanced staff attitudes toward teamwork
Reduced observed clinical errors
Morey, JC, Simon, R, Jay GD, et al. Error reduction and performance improvement in
the emergency department through formal teamwork training: Evaluation results of
the MedTeams project. Health Serv Res. 37:1553-1581, 2002
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Clinical Units in a Medical Center
After implementation of SBAR:
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Reduced rate of adverse drug events (from
30 to 18 per 1,000 patient days)
Improved medication reconciliation at
patient admission from 72% to 88% and at
discharge from 53% to 89%
Haig, K., Sutton S, Whittington, J. SBAR: A shared mental model for
improving communication between clinicians. JL Comm J Qual
Patient Saf 32(3):167-75, March 2006
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Operating Rooms (OR)
After implementation of a “pre-op” brief:
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Increased OR communication
Increased administration of properly timed prophylactic
antibiotics prior to incision from 84% to 95%
Increased pre-op deep vein thrombosis prophylaxis prior
to induction from 92% to 100%
Error avoidance: Pre-op brief revealed seven patients
(3.3%) with previously unidentified severe surgical risks —
surgery cancelled
16% reduction in nursing turnover rate
19% increase in OR employee satisfaction
Awad, SS, Fagan, SP, Bellows, C., Albo, D, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg 190(5): 7704, Nov 2005.
Leonard, M,, Graham, S, Bonacum, D. The human factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf
Health Care 13 Suppl 1:i85-90, Oct 2004
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Patient safety culture through
› Leadership
› Situational monitoring
› Mutual support
› Communication
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Knowledge
Shared Mental Model
Attitudes
Mutual Trust
Team Orientation
Performance
Adaptability
Accuracy
Productivity
Efficiency
Safety
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Two types of leaders:
 Designated—The person assigned to
lead.
 Situational—Any team member.
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Attention to detail is one of the most important details...
— Author Unknown
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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)
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Help ensure that teams know what to expect,
so if necessary, can regroup to get on the
"same page"
 Foster communication to ensure care is
synchronized
 Ensure that everyone on the team has a
picture of what it should look like
 Enable team members to predict and
anticipate better
 Create commonality of effort and purpose
"Shared mental models help teams avoid errors
that place patients at risk."
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"A chain is only as strong as its weakest
link." –Author Unknown
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Mutual support is the essence of teamwork
 Protects team members from work
overload situations that may reduce
effectiveness and increase the risk of
error
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Communication is the response you get from the
message you sent regardless of its intent.
— Author Unknown
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The process by which information is
exchanged between individuals,
departments, or organizations
 The lifeline of the Core Team
 Effective when it permeates every
aspect of an organization
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Reduce clinical errors.
 Improve outcomes.
 Increase patient & staff satisfaction.
 Reduce malpractice claims.
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Shared mental models.
 Clear roles and responsibilities.
 Shared vision.
 Optimization of resources.
 Strong team leadership.
 Feedback.
 Collective trust and confidence.
 Cooperation and coordination.
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 Conflict.
Inconsistency in
team membership.  Lack of
 Lack of time.
coordination and
follow-up.
 Lack of information
sharing.
 Distractions.
 Hierarchy.
 Fatigue.
 Defensiveness.
 Workload.
 Misinterpretation of
 Conventional
cues.
thinking.
 Lack of role clarity.
 Varying
communication
styles.
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TeamSTEPPS Tools/Strategies:
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Brief
Huddle
Debrief
STEP
Cross Monitoring
Feedback
Advocacy & Assertion
Two-challenge Rule
Call-out
Check-back
CUS
DESC
Collaboration
SBAR
Handoff
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TeamSTEPPS tools:
› Huddle
› SBAR
› CUS
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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.
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http://www.ahrq.gov/video/teamsteppsto
ols/ts_Huddle_ER/huddleER-400-300.html
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SBAR
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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 do to
correct it?
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http://www.ahrq.gov/video/teamsteppsto
ols/ts_SBAR_NurseToPhysician/SBAR_Nurs
eToPhysician-400-300.html
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Some situations may get a quicker
response when the provider knows early
on what it is that you feel the patient
requires.
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Mutual respect and support
 Clearly assert concerns and suggestions
 Use an assertive statement
(nonthreatening and ensures that critical
information is addressed)
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Make an opening
State the concern
State the problem
Offer a solution
Reach an agreement
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Always remember there is a
‘Cusser’(Clarifier) and a ‘Cussee’
(Clarifiee).
 The appropriate response for Cussee to
say is “Thank you” (for raising that
concern/speaking up/letting me know
you were worried/sharing with me the
patient’s situation/etc.)
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http://www.ahrq.gov/video/teamsteppsto
ols/ts_CUS_LandD/CUS_LandD.html
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BREAK
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Cross-sectional survey prevalence, characteristics, and risk
factors for conflicts in 323 ICUs/24 countries (7,498 ICU staff)
Intra-team disputes majority of conflicts
Poor communication within the ICU team( in general or
during EOL care) was perceived as common
Conflicts were less likely to occur in ICUs that held regular
interprofessional staff meetings
Respondents were asked to report conflicts that occurred
within the last week
fewer than half reported the conflict was resolved at time of study
80% believed that the same type of conflict was likely to recur
20% indicated reported conflict was related to a previous conflict
Azoulay, et al. AJRCCM 2009; 180(9), pp. 853-860
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How would your team answer this
question?
Will staff freely speak up if they see
something that may negatively impact
patient care?
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Survey data 1,700 nurses, physicians, clinical care
staff and administrators plus focus groups,
interviews, and observations ( only 100 MDs )
 13 urban, suburban, and rural sites
 50% RNs and 80% MDs witness colleagues break
rules, make mistakes, fail to offer support, or
appear critically incompetent
 For half, concerns persisted ≥ 1 year
 20% of MDs saw harm result from their observations
 23% of RNs reported considering leaving job
because of their concerns
 Yet, only 10% spoke up
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The 10% who do speak up:
 observe better patient outcomes
 work harder
 are more satisfied
 are more committed to staying in their
jobs
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Need healthcare professionals who speak up.
Also need to listen when others speak up.
Cost of entrenched conflict:
 Patients: increased errors, poorer outcomes
 Individual: lower job commitment, lower job
satisfaction, moral distress, burnout
 Organization: higher turnover
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Patient safety lens:
 Two kinds of errors: Honest mistake vs.
undiscussables
 Highlights tension between systems view
of errors versus personal accountability
 Task-based problem vs relationshipbased problem
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Undiscussables (organizational silence)
When people know of risks and do not speak up
 Calculated decision to avoid or back down from
conversation
 Dangerous shortcuts, incompetence, disrespect
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Solving undiscussables requires deeper changes to
cultural practices, social norms, and personal skills
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Personal motivation: moral obligation vs
annoyance
Personal ability: Knowledge/skills to handle
speaking up
Social motivation: People they respect speaking
up
Social ability: Coaching/advice/support
Structural motivation: Performance reviews-reward
Structural ability: Times/places/tools for speaking
up
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Seven categories of problems that are
frequently encountered, yet rarely addressed
 Broken rules
 Mistakes
 Lack of support
 Incompetence
 Poor teamwork
 Disrespect
 Micromanagement
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Share your facts
Tell your story
Ask for others’
paths
Talk tentatively
Encourage testing
Controls emotions
Promotes dialogue
Builds relationships
VitalSmarts
Crucial Conversations
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Inevitable
Can be healthy, but often leads to
negative patient, clinician, and
organizational outcomes
Task-based versus relationship based
conflicts
Challenge of the universal attribution error
(“I’m busy/you’re lazy” ; “I’m stressed/
You’re rude”)
To address patient safety, need skills for
both types of conflicts
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I WILL …
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