TEAMSTEPPS GOES TO WAR

SPRING 2008 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

INSIDE: DoD Combat Care Incorporates Patient Safety Fundamentals

SPRING 2008

Call for Patient Safety Awards5 Patient Safety Website 6

Simulation Training at Home, Hands-On Training in Iraq Make System Combat-Ready

TeamSTEPPS, the evidence-based team-training system developed by the DoD Patient Safety Program in collaboration with theAgency for Healthcare Research and Quality (AHRQ), is fast becoming an integral part of combat-casualty care in Iraq. The Team-STEPPS curriculum has been adapted to meet the needs of physicians, nurses, medics and other health-care professionals in the Iraq

theatre of operations. Providers are taught fundamental TeamSTEPPS concepts such as briefs, huddles and the SBAR handoff communi-cation model. State-side simulation training prior to deployment and real-time use of TeamSTEPPS in theatre are combining to makeTeamSTEPPS a combat-ready tool to improve patient safety at the earliest point of medical intervention.

The story of TeamSTEPPS at war is the story of military medical administrators and providers collaborating to offer wounded warriorsthe best and safest medical care from the moment of injury. The experiences described below — of the 86th Combat Support Hospital(CSH) in Baghdad and the 947th Forward Surgical Team (FST) training here at home — tell the TeamSTEPPS story best. In the telling,they affirm the power of TeamSTEPPS to improve patient safety and the determination, strength and dedication of the Military HealthSystem to the care of its patients.

Surgeons and support staff from the 86th CSH Task-Force Baghdad. Pictured left to right, front to back: CPT Dena George, COL PeterNapolitano, MAJ Kevin Chung, MAJ Brian Themann; (2nd row) MAJ Jeffrey Henning, MAJ Dawn Elliott, LTC Booker King, MAJ Patrick Hickey, LTCMichael Meyer (blue scrubs); (3rd row) LTC Jon Stineman, MAJ Mark Aierstok, LTC Steven Svoboda, LTC Anthony Allen, LTC Michael Mulreany, MAJ ToddBaker (by sign), MAJ William Ralston, CPT Jason Cohen, COL Richard Stack (blue scrubs).

Patient Safety Week Activities5

The 86th Combat Support Hospital,Baghdad, Iraq

Bringing TeamSTEPPS to the Front Lines

Since February of this year, the 86th Com-bat Support Hospital (CSH) Task-ForceBaghdad has enjoyed the extra Team-STEPPS advantage in its quest to safely treatand transport the casualties of war in Bagh-dad. February marked the arrival of COLPeter Napolitano, Director of the Maternal-Fetal Medicine Fellowship at MadiganArmy Medical Center and long-time Team-STEPPS champion. Prior to deployment forhis tour at the 86th CSH, COL Napolitanoassessed the use of TeamSTEPPS in theatre.Finding that there was no formal imple-mentation, he explored with Command thepossibility of introducing TeamSTEPPS.With the enthusiastic backing of leadership,COL Napolitano worked with the PatientSafety Program’s Health Care Team Coordi-nation Program (HCTCP) to have Team-STEPPS material shipped to Iraq. He thenfaced the challenge of how to train trainersand staff in the busiest combat hospital inthe world.

The traditional TeamSTEPPS two and onehalf day Train-the-Trainer course andfour to six hour Train-the Participantphase clearly would not fit the high acuityCSH environment. Over two weeks ofperiodic classes, COL Napolitano trainedforty-five representatives from every unitof the hospital, fashioning an intense fourhour combined fundamentals andinstructor curriculum. With this initialcadre of coaches in place, he began atwice weekly concept release program. Aseach TeamSTEPPS concept was intro-duced, coaches modeled behavior andstaff incorporated and adapted the tool totheir particular unit.

Currently about one-half of the total CSHstaff in Baghdad has received formalTeamSTEPPS training. An active interestin TeamSTEPPS is palpable throughoutthe hospital. COL Napolitano believes theCSH, despite its challenges and unpre-dictable routine, is uniquely suited toembrace the TeamSTEPPS system. Withtheir sharp focus on casualty care and sin-gle-minded purpose, staff members unite

2 SPRING 2008 PATIENT SAFETY

TEAMSTEPPS GOES TO WARContinued from Page 1

Hospital staff see soldier off to next echelon of care in Balad after stabilization and treat-ment at the 86th CSH Task-Force Baghdad.

TEAMSTEPPS ON THE LANDING ZONETools Adapt To Any Setting

On a typical day the Combat Support Hospital receives several MASCALs with little down time inbetween. All operating rooms are in use. The transport system is in full swing. Black Hawk heli-copters are standing by to move patients to the Air Force’s Expeditionary Medical Group Hospital,the next echelon of care on their journey to Landstuhl and eventually back home.

On this day two soldiers arrived at the staging area for transport, accompanied by ICU nurses, whowould fly with them and respond to any emergencies in flight. The flight-line check list had beenreviewed. The patients were ready for loading. Before they were settled in the chopper, the attend-ing ICU physician unexpectedly arrived at the flight line. She hurriedly explained that she hadmissed her usual TeamSTEPPS-inspired huddle before the patients left the ICU and that she wantedto review the patients one last time with the nurses.

During the huddle she reminded the flight nurses that one of the patients had especially severe res-piratory injuries. A special piece of equipment was determined to be necessary should he need tobe resuscitated in flight. This equipment, because it is rarely needed, is not included in standardflight resuscitation sets. After the huddle, the crew made a special effort to find one and bring it onboard.

Fifteen minutes into the thirty minute flight,the soldier suffered a respiratory arrest. The accompany-ing ICU nurse used the equipment in a successful resusitatation. In this case, the TeamSTEPPS hud-dle highlighted an important piece of information for this soldier's care. In the combat care settingsuccess is not about a predetermined process, but is achieved by learning the TeamSTEPPS con-cepts and adjusting them to work in the midst of the unexpected. The ICU physician's huddle onthe landing zone, right at the chopper door, underscores the adaptability of TeamSTEPPS tools andtheir readiness for combat.

around the same goal. They are particular-ly open to trying new things and are able tolearn at an accelerated rate in the some-what self-contained CSH environment.Deputy Commander of Nursing (DCN)COL Stephen W. Lomax, new to Team-STEPPS himself, says he was quickly wonover to a system he feels improves patientcare. His nursing staff is receptive to thingsthey feel give them an advantage, especiallyin the frequently high-stress atmosphere ofthe CSH.

The practical application and value ofTeamSTEPPS in the combat zone has beenaffirmed in the daily experiences of the 86thCSH. With several hundred confirmedrocket and mortar attacks in the Baghdadarea since January 2008, providers havebeen known to receive two to five massivecasualty events (MASCALs) on a given day.The hospital fills and empties daily. Victimsreceive life-saving surgery and treatmentand then are transported to the next eche-lon of care within one to twenty-four hours.In this extremely high acuity atmosphere anindividual patient may be involved in ten tofifteen handoffs. There is an understandablyincreased risk of losing or overlooking acritical piece of medical informationbetween a soldier’s transport from the bat-tlefield by medical evacuation (MEDEVAC)to the time he or she leaves the CSH fromthe helicopter landing zone (LZ). Team-STEPPS tools such as the SBAR, I PASS THE

BATON, briefs, huddles, check back and theI’M SAFE check on situational awarenessprovide structure and reliability in themidst of such intense trauma.

As the TeamSTEPPS champion prepares forhis June departure, COL Napolitano hasgreat confidence that TeamSTEPPS willbecome an organic part of the medical sideof Operation Iraqi Freedom (OIF). COLPatrick D. Sargeant, Commander of the62nd Medical Brigade, is an enthusiasticadvocate of its widespread use throughoutthe theatre of operations. COL Napolitanohas assembled a strong support staff. MAJMichelle Munroe, a nurse Midwife fromMadigan Army Medical Center serves asEmergency Medicine and DeploymentCombat Casualty Research Team (DCCRT)Research Nurse at the 86th. She has beencritical to the success of TeamSTEPPS intheatre and will become its Nurse Champi-on going forward. MAJ Munroe, with theassistance of COL Lomax and LTC Vivian

Ludi, Patient Safety Process ImprovementOfficer, will expand the TeamSTEPPS train-ing to the five other CSH units, eight For-ward Surgical Teams and one Air Force hos-pital in OIF.

With its champions in place, COL Napoli-tano credits the dedicated health careproviders deployed to OIF as the real powerbehind the TeamSTEPPS difference. In thismost challenging of all situations, heexplains “TeamSTEPPS provides workabletools to an already strong system. It rein-forces good teamwork behavior that goodleaders are already doing. TeamSTEPPS for-malizes the good work we do and ensuresthat we do it all the time”.

The 947th Forward Sugical Team Training at Home to Deploy as a Team

The 947th Forward Surgical Team (FST)from the West Hartford Reserve Center par-ticipated in the first fully dedicated Team-STEPPS simulation training March 7-9 atthe National Capital Area Medical Simula-tion Center in Silver Spring, Maryland. Pro-nounced a “fabulous success” by MAJMichael Gutman, 947 FST CommandingOfficer, team members spent a full dayworking through scenarios that simulatedfield experiences from triage to resuscita-tion to transport.

The 947th FST is in year three of a five yeartraining cycle, thus not in line for the ArmyTrauma Training Center (ATTC) coursewhich integrates TeamSTEPPS concepts inthe intensive trauma curriculum offered todeploying surgical teams. MAJ Gutman,long interested in Crew Resource Manage-ment, set out to explore team trainingoptions available to the 947th as they honetheir clinical skills. He worked with Ms.Heidi King, Director of the DoD PatientSafety Program Health Care Team Coordi-nation Program (HCTCP) and the Nation-al Capital Area Medical Simulation Center(Sim Center) staff to develop a Team-STEPPS simulation experience aimed atteaching team dynamics and communica-tion skills to the FST. In December 2007,HCTCP taught the FST TeamSTEPPS fun-damentals in a weekend-long course adapt-ed to support its up-coming simulationtraining.

Upon arrival at the Sim Center on March7th, the FST received a two hour refreshercourse, along with an orientation to the SimCenter. Saturday, March 8th was SIM DAY— nine hours of training, broken into three“Days”, each Day representing an increasing-ly complex combat scenario. Battlefieldauthenticity was achieved using the SimCenter’s high-tech resources — a Wide-AreaVirtual Environment (WAVE) for triage

The 947th Forward Surgical Team “brief”, assigning roles and responsibilities prior toDay 2 of TeamSTEPPS Simulation training.

PATIENT SAFETY SPRING 2008 3

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training, with front line background, light-ing and sound effects; a two-patient Resusci-tation Bay and holding area; and a fully-equipped Clinic. Twenty patients had beenhired, pre-trained and expertly made-up as

trauma victims for the day. In addition to theregular complement of Sim Center staff, thefaculty included three visiting physicianswho role-played, observed and critiqued theteam’s performance. Further input was pro-

vided using the Sim Center’s computerizedmonitoring and evaluation process.

Debriefs following each “Day”, facilitated bySim Center staff, encouraged FST membersto reflect on their performance. Physicianfaculty members and a nurse monitor whohad been briefed on TeamSTEPPS addedtheir observations, which were detailed andprocess-directed. With comments such as “Ididn’t hear a callback” or “Did you use thehuddle”, they kept the focus on teamworkfundamentals. They also challenged the FSTmembers on how they interacted with theirrole-playing faculty. One physician, explain-ing that she had been simulating a distract-ing physician presence, encouraged teammembers to rely on their teamwork skillsespecially in the face of stressful, unantici-pated challenges. As FST members movedthrough their various scenarios, both theyand the Sim Center staff and faculty agreedthat communication improved and the useof TeamSTEPPS-related tools increased.

MAJ Gutman believes the combined Team-STEPPS/Simulation exposure at this timein his FST’s training cycle is beneficial for anumber of reasons. The training strength-ens the team bonds among members(many of whom are new to the FST); itbreaks down barriers to communicationinherent in the military hierarchy which attimes are impediments to clinical care,especially in high-stress situations; and itintegrates clinical skills in the environmentwhere the team will be receiving patients.His goal, says MAJ Gutman, is to try to getthe FST members totally comfortableworking with each other well before theydeploy. Once they are in theatre, surgeonsor other officers will be plugged into theteam and rotated every few months. Insuch a fluid environment, where a certainamount of change is built in, the presenceof a shared mental model of performanceamong the forward surgical team membersencourages skillful, reliable interactiontime after time, regardless of external chal-lenges. This early training of a unified corewhich has learned to function together willincrease the functionality of the FST, theimplementation of TeamSTEPPS tools andthe safety of patients and providers alike inthe real world of combat trauma care.

MAJ Michael Gutman, Commanding Officer of the 947th Forward Surgical Team observ-ing teamwork skills while FST members work on a patient in the Resuscitation Bay.

Members of the 947th FST practicing battlefield triage in the Wide Area Virtual Environ-ment (WAVE) setting of the National Capital Area Medical Simulation Center.

PATIENT SAFETY SPRING 2008 5

Experiences and Suggestions From the FieldPATIENT SAFETY IN ACTION

March 2–8, 2008 Observed With Posters, Awards, Games and Patient/Provider CamaraderieMTFs CELEBRATE NATIONAL PATIENT SAFETY AWARENESS WEEK

20 MDG: Shaw AFB, South CarolinaPoster from Shaw AFB, where the NationalPatient Safety Week (NPSW) poster contest wasinspired by information included in the Ambula-tory Patient Safety Goals. Congratulations toTSgt Ollet who received a one-day pass for hisfirst-place effort, shown above.

Munson Army Health ClinicFort Leavenworth, KansasMunson Army Health Center, Fort Leavenworth,KS recognized three services for outstandingachievement in Patient Safety during NationalPatient Safety Week: Radiology — highest nearmiss/good catch reporting; Laboratory — high-est over-all reporting of Patient Safety events;Operating Room — 100% compliance with TheJoint Commission’s Universal Protocol for allsurgical procedures. Each Service was presentedwith a specially designed plaque featuring theDoD and AMEDD crests. Pictured are staffmembers from the three clinics.

90 MDG: Warren AFB, WyomingCapt. Lisa Lee, Clinical Pharmacy ServicesChief, 90th Medical Support Squadron, instructspre-schoolers from the F.E. Warren Child Devel-opment Center on the fundamentals of cleanhands as part of the 90th MDG NPSW outreachefforts. In addition to hand hygiene, the 90thMDG encouraged patients to share responsibili-ty for satisfactory clinic appointments by bring-ing a list of medications and by keeping anappointment notebook.

377 MDG: Kirtland AFB, New MexicoTerry Duke, Patient Safety Manager, meets Ms.Doris Joy, the Medical Group’s Health BenefitsAdvisor to plan the distribution of the NationalPatient Safety Foundation brochure on thepatient’s role in making healthcare safer. DuringSafety Week, the brochure was given to patientswhile they waited for appointments and pre-scriptions and explored their TriCare benefits.

27 SOMDG: Cannon AFB, New MexicoPediatric dosing spoons, pill containers and poison control brochures were displayed anddistributed during National Patient Safety Weekin the atrium of the 27SOMDG. Staff observedthe week with daily patient safety emails andan electronic patient safety Trivia Contest.

35 MDG: Misawa AFB, JapanPatient Safety Manager Paul Sayles is inter-viewed by the local Air Force Network morningDJ about Patient Safety Week and medicationreconciliation. The station aired spot patientsafety announcements during Patient Safetyweek. The 35 MDG also hosted a staff treasurehunt for patient safety errors and sponsored abulletin board contest featuring application ofpatient safety goals within the hospital units.

CALL FOR PATIENT SAFETY AWARD SUBMISSIONSDeadline is September 10, 2008

The Office of the chief Medical Officer (OCMO) at TRICARE Management Activity (TMA), sponsor ofthe Department of Defense (DoD) Patient Safety Awards, is calling for submissions for the 2008 PatientSafety Awards. Now in their sixth year, the Patient Safety Awards recognize efforts designed to improvethe care delivered within the Military Health System.

The deadline for awards submissions is SEPTEMBER 10, 2008. The awards will be presented at theannual Military Health System (MHS) Conference, which is scheduled from November 30 to December5, 2008. Access the Patient Safety Website: http://dodpatientsafety.usuhs.mil/patientsafetyawards todownload an Application Guide.

As the revised Patient Safety Website marksits first year in operation, a review of its useand improvements underscores the integralrole it plays in communicating key elementsof the DoD Patient Safety Program (PSP).

Soon after its April 2007 launch, the websiterecorded 2,000 plus visits per month.March 2008 saw over 9,000 visitors, repre-senting world-wide contacts ranging fromEnglish-speaking countries like Australia,Canada and the U.K., to the more exoticlocales of Europe, Asia and the Middle East.Although the greatest percentage of visitors(38%) come from U.S. Military sites, 29%represent U.S. commercial users, withsmaller numbers from non-profit organiza-tions and U.S. government sites. Informa-tion relating to TeamSTEPPS is frequentlyaccessed, as is the DoD Fall Reduction Tooland PSP education modules.

For those users who are part of the DoD Mil-itary Health System, the website offers entryto the full range of PSP initiatives, achieve-ments and plans. User-group log-in capabili-ty is now an established function on the web-site. Interactive features have become a reali-ty. The TeamSTEPPS Learning Action Net-

work (LAN) regularly posts its agenda andpower-point presentations on the website forparticipants to access during conference callslinking any number of remote sites.

The Patient Safety website is not resting onits accomplishments. Under the directionof PSP Webmaster/Developer Vienkhanh(Khanh) Nguyen the site continues to addcontent and new features. Going forward,look for an even more user-friendly, visual-ly arresting format. "It's all about the peo-ple and making it easier for them to findthe information they're looking for", saysWebmaster Khanh.

March 2–8, 2008 Observed With Posters, Awards, Games and Patient/Provider Camaraderie Continued from Page 5

MTFs CELEBRATE NATIONAL PATIENT SAFETY AWARENESS WEEK

3 MDGElmendorf AFB, AlaskaJeopardy host Jim Cahill, Director of Perfor-mance Improvement, listens to an answerfrom Capt Corey during a Squadron Jeopardygame on March 5th. The game was designedto help staff prepare for a summer Joint Com-mission/ HIS inspection, with questions andanswers related to Joint Commission hot top-ics and general HIS information. Staffresponse was so enthusiastic that ExecutiveLeadership has requested another game bescheduled in May.

Naval Hospital, BremertonBremerton, WashingtonCommanding Officer Catherine Wilson offi-cially opens the Bremerton Patient Safety Cir-cus by cutting the ribbon to the quarterdeckdisplay. Inside, patients and staff found circusthemed boards and props with patient safetyinformation, a Patient Safety Goal toss-a-crossgame and a Circus “Side Show” featuring apetri dish sampler showing pre and posthand-washing germ growth.

Published quarterly by the Department of Defense(DoD) Patient Safety Center to highlight the progress

of the DoD Patient Safety Program.

DoD Patient Safety ProgramOffice of the Assistant Secretary

of Defense (Health Affairs)TRICARE Management Activity

Skyline 5, Suite 810, 5111 Leesburg PikeFalls Church, Virginia 22041

703-681-0064

PATIENT SAFETY PROGRAM NEWSLETTER

Forward comments and suggestions to:DoD Patient Safety Center

Armed Forces Institute of Pathology1335 East West Highway, Suite 6-100

Silver Spring, Maryland 20910Phone: 301-295-7242

Toll free: 1-800-863-3263DSN: 295-7242 • Fax: 301-295-7217

E-Mail: patientsafety@afip.osd.milWebsite: http://dodpatientsafety.usuhs.mil

E-Mail to editor: poetgen@aol.com

DIVISION DIRECTOR,PATIENT SAFETY PROGRAM

COL Steve GrimesDIRECTOR, PATIENT SAFETY CENTER

Geoffrey Rake, MDDIRECTOR, CENTER FOR EDUCATION

AND RESEARCH IN PATIENT SAFETYEric S. Marks, MD

DIRECTOR, HEALTHCARE TEAM COORDINATION PROGRAM

Ms. Heidi King

SERVICE REPRESENTATIVESARMY

LTC Robert DurkeeNAVY

Ms. Carmen BirkAIR FORCE

Lt Col Anne CoynePATIENT SAFETY PROGRAM NEWSLETTER EDITOR

Phyllis M. Oetgen, JD, MSW

6 SPRING 2008 PATIENT SAFETY

374 MDG National Patient Safety Week Treasure Hunt List

1. List the location of at least two fire extinguishers in or closest to yourdepartment.

____________________________________________________________________________________________

2. What is the middle initial of the Patient Safety Manager?_________

3. Locate a Patient Rights Poster. What is the 4th right listed?

____________________________________________________________________________________________

4. What MDGI empowers staff to notify his/her supervisor if he/she hasconflict caring for a patient? What is the MDGI and paragraphnumber? (Hint: staff rights and organization ethics)

____________________________________________________________________________________________

5. If applicable, where is the main 02 shut-off within your department?Who can shut it off in the event of an emergency?

____________________________________________________________________________________________

6. When is the next Hospital Newcomer’s Orientation held? _________

7. Where is the shredder closest to your department?

____________________________________________________________________________________________

8. Locate your nearest Crash cart. What items are kept in Drawer C?

_________________________________________________________

9. What is the memo called to report an unusual occurrence, amedication error or clinical mishap? (Hint: mnemonic describing

situation, recommendation, follow up and trends)?___________

10. Where is the Medical Control Center set up in a disaster? (Hint: TheDisaster Team Chief Emergency Plan binder).

____________________________________________________________________________________________

11. Find the TeamSTEPPS™. What is the tool listed on page 27 (17for 1st Edition pocket guide) used to help communicate criticalinformation that requires immediate attention and action requiring apatient’s condition? (Hint: can be used during hand-offs)______________________________________________________

12. How long do you have to complete an Event Report? (Hint: MDGI44-138 Patient Safety Program)____________________________

13. How do you know if a provider or surgeon is privileged to perform aspecific procedure? (Hint: Can Dr. Pike do an appendectomy?)

______________________________________________

374 MDGYokota AB, JapanThe 374th MDG staged a facility-wide treas-ure hunt for patient safety-related clues duringtheir National Patient Safety Week obser-vance. The Pediatrics Department won thecontest with 100% participation from doctorsto administrators. Stress balls and pens withthe logo "Deliver Safe, Compassionate QualityHealthcare" were given to all staff membersduring the week.

US Military 38%US Commercial 20%Network 15%Unresolved/Unknown 15%Non-Profit Organization 5%US Educational 3%US Government 1%Australia 1%Other 2%

http://dodpatientsafety.usuhs.milBusier and Better Than Ever

PATIENT SAFETY WEBSITE

Website usage by Country for March 2008