TeamSTEPPS Among Medical Students

Karyn Baum, MD, MSEd Shan-Pin Fanchiang, OTR/L, PhD Kevin Krane, MD

County of Los Angeles, Department of Health Services

I have no financial relationship to disclose.

Although attending this presentation may help you understand the relevant issue discussed, your use of this information is your own choice. If any organization/agency is referenced, it does not represent endorsement by or an official position of the organization I am affiliated with (i.e. Rancho Los Amigos National Rehabilitation Center, County of Los Angeles, Department of Health Services). Permission to copy and use the handouts is granted. References to it should cite “

Fanchiang, S. How do you see yourself using TeamSTEPPS ® ? The Third TeamSTEPPS National Conference, Minneapolis. 6/11/2014

” as the original source.

Disclosure

2014 National Conference Fanchiang

At the end of this presentation, you will be able to: a.

Understand how ETAC can be integrated in the teaching and learning TeamSTEPPS ® b.

Explore the outcomes (estimated impact & adherence) of learning TeamSTEPPS ® c.

Apply ETAC methodology in learning and teaching

Learning Objectives

[ETAC: Empowered-To-Act Consistently] 2014 National Conference Fanchiang

Knowledge Explosion

(Tyler, 1965)

Knowledge Management

(Davernport, 1994)

Background Knowledge Translation

(Davis et al., 2003)

Knowledge translation

is an appropriate process and strategy to address and

reduce the gap

between "what is known" and "what is currently done" in practice settings. Tyler, RW. The Knowledge Explosion: Implications for Secondary Education. Educational Forum, 1965, 29(2), 145. Davenport, TH. (1994). "Saving IT's Soul: Human Centered Information Management". Harvard Business Review 72 (2): 119–131. Davis et al., 2003; Grol & Grimshaw, 2003; Grol & Jones, 2000; cited in NCDDR, (2006) http://www.ncddr.org/knowledge_trans_over.html

Retrieved 10.20.2013.

2014 National Conference Fanchiang

Everyone is a learner.

Knowledge is a continuum.

Need-to-know

•

Action-based

•

What… Knowledge/ Information Nice-to-know

•

Rationale

•

Why…

2014 National Conference Fanchiang

Everyone is a learner.

What “should” happen when we, as learners, receive information?

Learners: To Imagine

Canadian National Breast Screening Study: 106 of 484 screen-detected cancers (21.9%) were over-diagnosed and treated for breast cancer unnecessarily Abolishing Mammography Screening Programs by the Swiss Medical Board. (NEJM, 2014; May) To

relate

to knowledge or information 2014 National Conference Fanchiang

How learners intentionally act on the newly acquired knowledge depends on how this relationship is situated in their daily routines . Learner-centered approach: “We don’t see things as they are, we see things as we are.” –French Diarist Anaïs Nin To

ask

learners to estimate their actions

Teachers: To Set the Stage

2014 National Conference Fanchiang

Specific brain regions activated during mental imagery depend on the content of the visual image.

(O'Craven & Kanwisher 2000 Journal of Cognitive Neuroscience, 12 (6), 1013 1023)

Theoretical Foundation

Similar to observing actions, observation. listening to sentences that explain actions engages the visuomotor circuits in brain which support action execution and (Tettamanti et al. 2005 Journal of Cognitive Neuroscience, 17(2), 273-281)

Invite Learners to Imagine

Task-relevant posterior brain regions was selectively enhanced; their functional connectivity to task relevant anterior brain regions strengthened when participants prepared for the cued task. (Shi et al. 2014, Brain and Cognition, 87,June, 39-51) 2014 National Conference Fanchiang

“How do you see yourself wearing that shoe?” Do you want to build a relationship?

A “Frozen” approach!

2014 National Conference Fanchiang

A.

I will not do it.

B.

I will think about it. C.

I will think about ways to help me start doing it.

D.

I’ll start doing it from now on.

E.

I’ve done some but can still do more.

F.

I am doing it as much as I can; no new actions are needed

.

Key Words: A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing ETAC Scale To Estimate an Action

2014 National Conference Fanchiang

For learners estimate future actions A.

I will not do it.

B.

I will think about it. C.

I will think about ways to help me start doing it.

D.

I’ll start doing it from now on.

E.

I’ve done some but can still do more.

F.

I am doing it as much as I can; no new actions are needed

.

ETAC Scale To Estimate Impact

2014 National Conference Fanchiang

For learners estimate future actions A.

I will not do it.

B.

I will think about it. C.

I will think about ways to help me start doing it.

D.

I’ll start doing it from now on.

E.

I’ve done some but can still do more.

F.

I am doing it as much as I can; no new actions are needed

.

ETAC Scale To Estimate Adherence

2014 National Conference Fanchiang

Go beyond Knowing Focus on Doing Imagine a Context for Action Personalize Knowledge

ETAC is a tool to help Knowledge Translation

2014 National Conference Fanchiang

How did medical students (3 rd use of TeamSTEPPS ® ?

• During co re lectures • Handout: TeamSTEPPS ® yr) estimate their Fact Sheet

Quantitative:

• • How do you see yourself using the tool of “Leadership" in TeamSTEPPS ® ?

Also for Situation Monitoring, Mutual Support, & Communication 4 questions.

Qualitative:

• • If choosing A & B, “Tell us your concerns.” If choosing C, D, E, “What is applicable as a medical student at Rancho?”

ETAC for TeamSTEPPS ®

2014 National Conference Fanchiang

N=23

Leadership

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing

Estimated Impact

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing

69.6% Estimated Adherence

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing

43.5% Results

2014 National Conference Fanchiang

N=23

Situation Monitoring

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing

Estimated Impact

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing

65.2% Estimated Adherence

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing

69.6% Results

2014 National Conference Fanchiang

N=23

Mutual Support

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing

Estimated Impact

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing

73.9% Estimated Adherence

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing

73.9% Results

2014 National Conference Fanchiang

N=23

Communication

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing

Estimated Impact

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing

73.9% Estimated Adherence

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now

69.6%

E. Do more F. Max. doing

Results

2014 National Conference Fanchiang

Leadership

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing

Situation Monitoring

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing N=23

Mutual Support

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing

Communication

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% A. No B. Not sure C. Think doing D. Do now E. Do more F. Max. doing 2014 National Conference Fanchiang

To Estimate Using TeamSTEPPS ®

73.9% 73.9% 65.2% 69.6% 43.5% 69.6% 73.9% 69.6% Impact & Adherence

2014 National Conference Fanchiang

•

Leadership

To practice leadership skills among student peers • Can be situational leaders • Not sure how to start • Want to learn not being afraid to lead • Can lead patients

Communication

• Time can undermine communication • Being afraid to speak up • Consider using check list to ensure communications done • Use CUS and check back •

Situation Monitoring

See themselves as “information carriers” between nurses, PA, and physicians • Recognize opportunities • Unconformable to express themselves, want to be free • Not intuitive in medicine

Mutual Support

• Few see themselves in the team with healthcare staff • More than 50% want to help with their peers’ patient care load if needed • See how M.S. relates to S.M.

• Being “information carriers”…

Results What did they say?

2014 National Conference Fanchiang

2014 National Conference Fanchiang

TeamSTEPPS for Pre-Clinical Medical Students

N. Kevin Krane, MD Professor of Medicine, Vice Dean for Academic Affairs Tulane University School of Medicine

Teamwork Competencies in Outcome/Competency Frameworks in Undergraduate Medical Education

Olupeliyawa AM, et al., A Review of the Literature on Teamwork Competencies…SE Asia J Med Ed., 3(2):61; 2009.

TeamSTEPPS in the Med Ed Literature

• •

Sawyer T, et al. Interprofessional Teamwork Training in Neonatal Resuscitation using TeamSTEPPS and Event-based Approach Simulation. MedEdPORTAL; 2013. (MD, RN, RX, RT students)

– After completing the course participants will demonstrate improvements in teamwork knowledge, as measured by increased scores on the TeamSTEPPS ® Learning Benchmarks exam. – After completing the course participants will demonstrate changes in attitudes towards teamwork, as measured by changes in scores on the TeamSTEPPS ® Teamwork Attitudes Questionnaire. – After completing the course participants will demonstrate improvements in teamwork skills during simulated neonatal resuscitations, as measured by team scores on the TeamSTEPPS Performance Observation Tool. ® Team – At the conclusion of the course the student will be able to apply what they have learned during the course to real life neonatal resuscitations.

Atallah H, et al. Interprofessional Team Training Scenario. MedEdPORTAL; 2009. (Third yr MD students and fourth year RN students.)

– To be able to understand the impact of communication and coordination on efficiency and effectiveness of care implementation. – To be able to identify the performance of team skills in the area of leadership, communication, mutual support and situational monitoring. – To be able to perform team skills in the area of leadership, communication, mutual support and situational monitoring.

• • •

TeamSTEPPS in the Med Ed Literature

Spector N, et al. I-PASS Handoff Curriculum: Core Resident Workshop. MedEdPORTAL;

– To describe the importance of effective communication in reducing medical errors.

– To apply effective team training strategies to improve handoffs.

– To detail the essential content and sequence of effective handoffs.

– To practice handoff skills.

Brock D, et al., Interprofessional education in team communication: working together to improve patient. Postgrad Med J. 2013 Nov; 89(1057):642-51.

– 4 h training that included a 1 hTeamSTEPPS didactic session and three 1 h team simulation and feedback sessions with MD RN, RX and PA students – Significant attitudinal shifts for team structure, situation monitoring, mutual support and communication. – Significant shifts for knowledge of TeamSTEPPS, advocating for patients and communicating in interprofessional teamms.

Baker MJ, Durham CF. Interprofessional education: a survey of students' collaborative competency outcomes.J Nurs Educ. 2013 Dec ;52(12):713-8.

– RN, MD, RX students in IPE course with TeamSTEPPS as central material – Students' perceptions of their development of IPE and IPC competencies significantly improved after course completion.

TeamSTEPPS at Tulane

• • Pre-Clinical Education – Interprofessional patient safety curriculum with nursing students – Team training with anatomy students Clinical Education – Interprofessional seminars with RN, MD, RX students – Planned: Training of hospitalist teams

Inter-Professional Education

• Foundations in Medicine – Tulane’s Introduction to Clinical Medicine course – Tulane students and students from Delgado Nursing School (not directly affiliated with Tulane) – Patient Safety component • Foundational self-learning using the IHI Open School • 1-2 hr didactic presentations with MD/RN’s sitting in teams followed by discussion followed by case & video based small group discussion • Teams then participate in simulation exercise

Inter-Professional Education

• • Benefits – Students enter with patient safety knowledge from IHI Open School – Opportunity for RN/MD students to engage – Presentations focus on TeamSTEPPS language and principles – Opportunity to apply principles with Sim Activity Challenges: Logistics, logistics, logistics

Team Training in Anatomy: Background

• • – Gross Anatomy is taught mostly in dissecting lab; teams of 6 students/cadaver Approx 190 total student – Over 30 dissecting teams Would TeamSTEPPS training to these teams improve attitudes towards teamwork and/or student performance in gross anatomy?

Team Training in Anatomy: Methods

• • • • • There are 7 dissecting labs with 5-6 cadavers/lab. Students in 4 labs received two presentations on TeamSTEPPS, focusing on teamwork strategies useful for dissecting teams. The remaining 3 labs received a patient case presentation unrelated to patient safety. Pre/post data were collected using the Value of Teams, Team Performance Survey (TPS), and the Teamwork & Emotions (WEIPS) instruments. Survey data and anatomy final grades were analyzed using t-tests.

• • • •

Team Training in Anatomy: Results

Survey response rate was 53%. There was no significant difference between control vs. intervention groups on either the TPS or Value of Teams instruments. Two WEIPS subscales showed a significant increase in the intervention group compared to control: the Management of own emotions (intervention 4.4% vs. control 2.0%, p=0.042) and the Management of others' emotions (intervention 9.3% vs. control 1.2%, p=0.027). Analysis of grade performance revealed that students in the team-training group had significantly higher final anatomy scores (p=0.013).

Team Training in Anatomy: Conclusions

• • • • Ratings of utility of teams were not significant.

May be due to response bias in which asking if teams are valuable, provides results that all cluster around strongly affirmative values However those with team training demonstrated some perceived improvement involving managing emotions within the team.

Student performance also improved in those receiving teamwork training.

Collaborators: Chayan Chakraborti, MD, Director Foundations in Medicine and David Jerrett, DMD, PhD, Director, Gross Anatomy

Interdisciplinary Seminar with RN, MD, RX Students

• • As part of their third/fourth year, Tulane students must complete 5 “interdisciplinary” seminars from a menu of topics, one being TeamSTEPPS ™ training.

TeamSTEPPS participated.

™ training was provided for 6 medical students. Additionally, 6 volunteers each from Xavier School of Pharmacy and Our Lady of the Lake Nursing School also

Methods

• • • • The Readiness for Interprofessional Learning Scale (RIPLS) was administered pre/post training. (Reid et al., Medical Education 2006;40:415-422) – Teamwork and collaboration – Patient-centerdness – Sense of professional identity Mean pre/post values were obtained and differences between groups were evaluated by ANOVA 5 questions regarding patient safety were added to the survey Overall seminar evaluations were obtained

3,80 3,60 3,40 3,20 3,00 2,80 2,60 2,40 2,20 2,00 5,00 4,80 4,60 4,40 4,20 4,00 Medicine: N=31 Nursing: N=30 Pharmacy: N=35

4,10 4,28

Pre-training

Results

RIPLS Mean Score (pre/post TeamSTEPPS Training) 4,30 4,27 4,48

Post-training

*p<.01

4,50

5,00 4,80 4,60 4,40 4,20 4,00 3,80 3,60 3,40 3,20 3,00 2,80 2,60 2,40 2,20 2,00

4,16 4,60 4,77

Results

Educational Training & Question Differences 4,29 4,47 4,67 4,17 3,58 3,46

17 25

RIPLS Question

29 17: I don’t want to waste my time learning with other healthcare students 25: Shared learning will help me communicate better with patients and other professionals.

29: The function of nurses and therapists is mainly to provide support for doctors 31: I have to acquire much more knowledge and skills than other healthcare students

2,42 *p<.05

Medicine: N=31 Nursing: N=30 Pharmacy: N=35

3,50 3,37

31 5=Strongly Disagree 4=Disagree 3=Neither Agree nor Disagree 2=Agree 1=Strongly Agree

5,00 4,50 4,00 1,50 1,00 0,50 0,00 3,50 3,00 2,50 2,00

Results

Patient Safety Awareness

"If I was in a situation where a patient safety issue occurred, I would know how to handle it"

*p<.01

Medicine: N=31 Nursing: N=30 Pharmacy: N=35

4,00 4,07 4,26 3,71 3,47 3,10

Pre-training Post-training

1,50 1,00 0,50 0,00 5,00 4,50 4,00 3,50 3,00 2,50 2,00

Patient Safety Awareness

"I am comfortable communicating patient safety issues to those to whom I report"

Medicine: N=31 Nursing: N=30 Pharmacy: N=35

4,23 4,06 4,10 3,84 3,80 *p<.01

4,37

Pre-training Post-training

Results: Data on 96 Students

• • • • Repeated measures ANOVA: significant improvement pre/post student mean RIPLS scores (p<.01) Students reported feeling significantly more comfortable addressing and communicating patient safety issues after training (p<.01). On specific RIPLS questions: – Nursing and pharmacy students placed greater value on working with other healthcare professionals than medical students (p<.01).

– Pharmacy students felt more strongly than medical students that shared learning with other health care students would help them communicate better with patients and other health care professionals (p<.05). – In comparison to nursing students, medical and pharmacy students more strongly viewed a nurse’s role as that of support for physicians (p<.01). – Medical students felt they had to acquire more knowledge than pharmacy and nursing students (p<.01).

Overall rating of sessions was 4.69/5.00. Students frequently commented that training with other healthcare professional students was the most valuable part of the seminar.

Future Plans at Tulane

• • Continue to expand Team Training in curriculum using TeamSTEPPS Overall curriculum moving to outcomes, competency based – Creates opportunity to address required behaviors and skills – Need to continue to develop assessment of team skills – Need to improve overall healthcare environment so TeamSTEPPS skills are modeled for students

TeamSTEPPS Among Medical Students

Karyn Baum, MD, MSEd June 11, 2014

Teams and teamwork

• Increasing emphasis at UME and GME levels – Including accreditation • Increasingly common in the medical school curriculum

IPEC

Liaison Committee on Medical Education July 2013

• • ED19. The curriculum of a medical education program

must

include specific instruction in

communication skills

as they relate to physician responsibilities, including communication with patients and their families, colleagues, and other health professionals.

ED19A. The core curriculum of a medical education program

must

prepare medical students to function

collaboratively on health care teams

other health professions.

that include health professionals from other disciplines as they provide coordinated services to patients. These curricular experiences include practitioners and/or students from

Graduate Medical Education (ACGME)

• Residents must care for patients in an environment that maximizes effective communication. This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty.

Next Accreditation System

• • Milestones – Ex: IM “works effectively within an interprofessional team” Clinical Learning Environment Review (CLER) visits – – – On-site visits, JC-style Patient safety, handoffs, communication Reality of the environment examined

SO HOW COMMON IS TEAM TRAINING IN MEDICAL SCHOOL?

National Survey

• Online survey sent to all allopathic medical schools in US in 2012 • • 15 question survey Anonymous though could give school name if willing • 55/128 (43%) responded

Who responded?

• • • • • Largely part of an AMC (81.8%) All over US but few from Western US Most class sizes between 50-199/year 61.8% public 58% with 1 campus, 34.5% with 2-3

74.1% had formal team training

Does your school provide any formal curriculum specific to teamwork or team training? For purposes of this survey, team training is defined as using a specifically designed curriculum to train medical students to work as a team in health care.

Yes No

Hours

How many hours of teamwork or team training are included for the students?

1-2 hours 3-4 hours 5-6 hours 7-10 hours 11-15 hours More than 15 hours

90,0% 80,0% 70,0% 60,0% 50,0% 40,0% 30,0% 20,0% 10,0% 0,0%

When does it take place?

In what year(s) is this curriculum delivered (please select ALL that apply)?

1 2 3 4

Required or elective

Is your team training course or curriculum required or elective for the MEDICAL STUDENTS?

Required ONLY for medical students Elective ONLY for medical students Both required and elective options are available

Who do they learn with?

• • • • • • • • • • • MD students only: 13.9% Nursing students: 83.3% Pharmacy: 44.4% PT/OT: 27.8% Dental: 13.9% Public Health: 13.9% Physician assistant: 13.9% Social work: 11.1% Business or admin: 5.6% Law: 2.8% Nutrition/dietetics: 5.6%

Curricula used

What teamwork or team-training curriculum do you use (Please check ALL that apply)?

90,0% 80,0% 70,0% 60,0% 50,0% 40,0% 30,0% 20,0% 10,0% 0,0% Something developed by your school TeamSTEPPS Crew Resource Management IHI Open School material

Future plans for those without curricula

Are you planning on offering a team training or teamwork curriculum within the next two or three years?

Yes No

Barriers to implementation

No other students Not necessary Leadership No expert to teach No champion No time 0 20 40 60 80 100 Percent response

Conclusions

• • • • Team training is now commonly taught in medical school Most common curriculum is home-grown; TeamSTEPPS is next-most common Most students are learning in an interprofessional setting Barriers are lack of time, champion, or leader