Implementing Team Training at Duke

Karen Frush, BSN, MDChief Patient Safety Officer

Duke Medicine

THE JOURNEY

• PICU

• Peri-operative Services

• GSK Collaborative

• NCHA Collaborative

• Comprehensive Implementation across Duke Medicine

Team Training: One more initiative??

• Time and workload– Adding one more assignment onto

everything else• Best model?

– Lack of data to demonstrate improved outcomes

– Many consultants and approaches• Required for all team members?

– Logistics: Shut down the ORs?• Cost vs benefit

Teamwork Training ProcessPhase I: Pre-intervention

• Chose to work with consultants• Gathered pre-training data

– Knowledge test– Attitude: Sexton Teamwork and Safety Climate

survey– Behavior: Conducted Real-time Observations– Outcome data

• Processes• Clinical outcomes

• Analyzed Secondary Measures– Staff satisfaction and work culture– Patient satisfaction

Teamwork Training ProcessPhase II: Training

• Unit leaders involved with planning and implementation (J Mericle, J Meliones, K Mistry)– 3 sessions to accommodate shifts

• Multidisciplinary group sessions• Physician, nurse, and human factors facilitators• Interactive session with hands-on tools• Feedback allowed for further development• Focused training for action at unit level

– Focused on tools and techniques to address unit’s issues

Focused Unit Training Tools

• Handoff Communication– SBAR: structured language

• Critical Language– “I need clarity”: assertion

• “Sterile Cockpit”– Focused attention– Limit interruptions during Rounds

• Huddles for better planning• White Boards

Teamwork training processPhase III: Implementing change

• Leadership role models• Multi-disciplinary (internal) coaches• Interval observations, coaching by

consultants • Active participation of consultant experts in

unit-based safety team meetings• Phone calls at unit leaders’ preferred time,

to review concerns and discuss barriers• Train-the-trainer model used for new staff

Teamwork Training ProcessPhase IV: Comprehensive Evaluation

• Immediate feedback of training session• Change in Knowledge• Change in Attitude: Survey• Behavior Change: Observations• Process or Practice Changes• Impact on Clinical Outcomes

– Secondary measures

Level 1 – Reaction: how did participants react to the training?

Level 2 – Learning: whether the training results in an increase in knowledge, skills or attitudes.

Level 3 – Behavior: whether participants change their behavior back in the workplace as a result of training.

Level 4 – Results: whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment.

TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL

• Post-training reaction survey

• Teamwork knowledge test.• Survey of attitude towards teamwork.• Survey of self-perceived communication skills.

• Observation of teamwork behaviors during routine patient care.

• Patient satisfaction survey.• Complication rate based on AHRQ PSI.• Length of hospital stay.• Adverse drug events.• Patients’ claims.• Staff satisfaction survey.• Nurse turnover rates.

Team Training Results: Will this training impact the way you do business?

5

35

60

0

10

20

30

40

50

60

70

80

90

100

NotSure

Prob.

%

Def.

Team Training Results: Would you recommend this course to your co-workers?

100

0

10

20

30

40

50

60

70

80

90

100

NotSure

Prob.

%

Def.

Level 1 – Reaction: how did participants react to the training?

Level 2 – Learning: whether the training results in an increase in knowledge, skills or attitudes.

Level 3 – Behavior: whether participants change their behavior back in the workplace as a result of training.

Level 4 – Results: whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment.

TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL

• Post-training reaction survey

• Teamwork knowledge test.• Survey of attitude towards teamwork.• Survey of self-perceived communication skills.

• Observation of teamwork behaviors during routine patient care.

• Patient satisfaction survey.• Complication rate based on AHRQ PSI.• Length of hospital stay.• Adverse drug events.• Patients’ claims.• Staff satisfaction survey.• Nurse turnover rates.

PICU Post-Training Survey Responses Summary. Question: “The physicians and nurses here work together as a well-coordinated team (Fisher Exact Test p value=0.011)”

86.9%

67.3%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Before (N=55) After (N=61)

% Agree slightly or strongly

93.4%

75.4%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Before (N=57) After (N=61)

% Agree slightly or strongly

PICU Post-Training Survey Responses Summary. Question: “I know the proper channels to direct questions regarding patient safety in this clinical area (p value=0.007)”

Level 1 – Reaction: how did participants react to the training?

Level 2 – Learning: whether the training results in an increase in knowledge, skills or attitudes.

Level 3 – Behavior: whether participants change their behavior back in the workplace as a result of training.

Level 4 – Results: whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment.

TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL

• Post-training reaction survey

• Teamwork knowledge test.• Survey of attitude towards teamwork.• Survey of self-perceived communication skills.

• Observation of teamwork behaviors during routine patient care.

• Patient satisfaction survey.• Complication rate based on AHRQ PSI.• Length of hospital stay.• Adverse drug events.• Patients’ claims.• Staff satisfaction survey.• Nurse turnover rates.

Overall Teamwork in PICU (p value=0.0001, fisher’s exact test)

0.0%

27.8%

50.0%

22.2%

0.0%0.0% 0.0%

10.5%

52.6%

36.8%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Expected butnot observed

Observed butpoor

Observed butmarginal

Observed andacceptable

Observed andgood

% o

f to

tal e

ven

ts

Before (N=18)

After (N=19)

Level 1 – Reaction: how did participants react to the training?

Level 2 – Learning: whether the training results in an increase in knowledge, skills or attitudes.

Level 3 – Behavior: whether participants change their behavior back in the workplace as a result of training.

Level 4 – Results: whether the training has affected process or outcomes, such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment.

TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL

• Post-training reaction survey

• Teamwork knowledge test.• Survey of attitude towards teamwork.• Survey of self-perceived communication skills.

• Observation of teamwork behaviors during routine patient care.

• Patient satisfaction survey.• Process or practice changes.• Length of hospital stay.• Adverse drug events.• Patients’ claims.• Staff satisfaction survey.• Nurse turnover rates.

CT Patient in the OR

SBAR Report Attending

anesthesiologist to admitting nurse

“Rolling Call” Notification

Circulating nurse to unit clerk

Unit clerk notifies PCICU team

Direct Notification:

Charge NursePCICU Fellow

Batch Page:PCICU Attending

PCICU FellowNurse Practitioner

Respiratory TherapistCardiology Fellow

Primary nurse

Prepare for Patient Arrival at

BedsidePCICU team

Scripted template used in OR

Patient Stabilization Directed by

anesthesia & CT surgery teamsPatient

Transported to PCICU

Anesthesia & CT surgical teams

Admitting Nurse:

Performs brief ABC assessment

Secondary Nurse(s):

1. Places chest tubes to suction2. Obtains initial lab draw3. Documents

Respiratory Therapist:

1. Assumes airway mangement2. Places pulse oximetry & CO2 monitoring devices

Anesthesia: Transfer of physiological

monitoring to PCICU bedside system

Enter “Sterile Cockpit” *

Are all team members ready

for hand-off?

Scripted Report CT surgery

PCICU Providers:

Provides situational monitoring and

feedback

Scripted Report Anesthesia

Questions?Clarifications

Exit “Sterile Cockpit”Hand-off to PCICU team

complete

Cardiothoracic Surgical Hand-OffOperating Room to Pediatric Cardiac Intensive Care Unit (PCICU)

“Off Bypass” Notification

Circulating nurse to admitting nurse

* “Sterile Cockpit”

A safety concept borrowed from the aviation industry to ensure optimal focusby minimizing unnecessary distractionsduring critical processes

Observations

OR – PICU Hand-Off Turnaround Time:

Before and After Intervention

0

5

10

15

20

25

30

35

40

45

50 Interventions

Tur

naro

und

Tim

e (m

inut

es)

Operational Changes, Improvements in outcomes

• Time to critical labs drawn at hand-off• Briefings and debriefings implemented; SBAR

communication for nursing report, telephone communication

• Decrease in infection rates• Decrease LOS and increased throughput • Patient Satisfaction score exceeded target

(Press Ganey)• Work Culture survey score increased

Implementing TeamSTEPPSacross Duke Medicine

• TeamSTEPPS has helped us overcome some initial barriers to team training

• 4 phase approach to be undertaken throughout high acuity areas at DUH, DRH and DRaH

• Training with specific tools and concepts (modules) in intermediate units and non-clinical areas

• Collaborative with UNC SoM, SoN– Assertion and speaking up

• TeamSTEPPS and simulation, virtual training