TeamSTEPPS Introduction

Krista J. McMonigle, MSHM, CHRM, ParalegalDirector, Risk Management

And Lynn Sauers, RN, CAPA, Nurse ParalegalClinical Coordinator, Risk Management

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TeamSTEPPSS=Strategies &T=Tools toE=EnhanceP=Performance &P=PatientS=Safety

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TeamSTEPPS

• TeamSTEPPS is an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and other teamwork skills among healthcare professionals.

• Goal: to produce highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for their patients.

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Video: Carolyn Clancy, MD (2 minutes)

Director, Agency for Healthcare Research & Quality (AHRQ) Department of Health & Human Services

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High Reliability Organizations

• TeamSTEPPS is scientifically-rooted in over 20 years of research and lessons learned

• Based on teamwork principles identified in Crew Resource Management (CRM) and within High-Reliability Organizations (HRO’s)

• High-Reliability work units thrive on teamwork

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High Reliability Organizations

• Wikipedia:• A High Reliability Organization (HRO) is an

organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity.

• The most important early work in HRO research was organizational sociologist Charles Perrow’s work on the Three Mile Island nuclear incident in 1979.

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High Reliability Organizations

• There are 5 characteristics of High Reliability Organizations that have been identified as responsible for the "mindfulness" that keeps them working well when facing unexpected situations.

• Preoccupation with failure• Reluctance to simplify interpretations• Sensitivity to operations• Commitment to resilience• Deference to expertise

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TeamSTEPPS

• Human factors research has shown that even highly skilled, motivated professionals are vulnerable to error due to inherent human limitations.

• Teamwork skills are not innate- they must be learned and practiced.

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1999 Institute of Medicine (IOM) Report

• “To Err is Human: Building a Safer Health System’

• Preventable medical errors in US hospitals cost 98,000 lives and $17-$29 billion annually

• Key Recommendation- “establish interdisciplinary team training programs for providers that incorporate proven methods of team training…….”

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JCAHO

• Analysis of sentinel events over 10 years

• Data from over 250 US hospitals

• Sentinel event = events where patient suffer serious harm or death due to medical error

• Identified communication failure as the #1 root cause

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Veterans’ Administration (VA) National Center for Patient Safety Database

• Communication failure cited as primary contributing factor in nearly 80% of over 6,000 root cause analyses of adverse events and close calls

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Labor & Delivery Units

• After implementation of multiple teamwork strategies and tools:– A 50% reduction in the Weighted Adverse

Outcome Score (WAOS). The WAOS describes the adverse event score per delivery- 10 potential adverse events weighted by severity.

– A 50% decrease in the Severity Index- which measures the average severity of each delivery with an adverse event.

Video: Labor & Delivery scenario (4 minutes)

Before TeamSTEPPS training

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Video: Labor & Delivery scenario with TeamSTEPPS (4 minutes)

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“Barriers” Exercise:

• Inconsistency in team membership

• Lack of Time• Lack of Information

sharing• Defensiveness• Hierarchy • Conventional thinking• Complacency• Varying Communication

Styles

• Conflict• Lack of Coordination and

follow-up with Co-workers• Distractions• Fatigue• Workload• Misinterpretation• Lack of role clarity

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Video: Karen Frush, MD (1 minute) Chief Patient Safety Officer Duke University Health System

Video: Peter Napolitano, MD Lieutenant Colonel, MC, USA Director, Maternal-Fetal Medicine Fellowship

Dept. of Obstetrics & Gynecology Madigan Army Medical Center

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10 minute break

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TeamSTEPPS

• Built on the framework of four core competencies:

–Leadership

–Situation Monitoring

–Mutual Support

–Communication

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Handouts:

• TeamSTEPPS Barriers, Tools & Strategies Grid

• TeamSTEPPS Tools Descriptions

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Video: Sue Sheridan, MIM, MBA (9 minutes)

President, Consumers Advancing Patient Safety

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Phase I: Assessment

• An organization is ready if it has:

a) A climate conducive to change• Leadership and key staff are committed to

making a change• And dedicate the necessary time, resources

and personnel

b) Objective Information to support the need for a TeamSTEPPS Intervention

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Phase I: Gathering Objective Information:

• Adverse event and near miss reports• Reports of root cause analysis• Reports of failure mode and effect analysis• AHRQ Patient Safety Culture Survey• Staff satisfaction survey• Patient satisfaction survey• Team Assessment Questionnaire• Site specific process and outcome measures

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Phase I: Creating a Change Team

• Includes leaders and key staff• Determines organizational readiness• Conducts a Site Assessment• Reviews available organizational data• Collaborate to co-determine and communicate a vision

for enhanced medical team performance• Identify opportunities for process improvement with team

strategies and tools• Cultivate ideas• Collectively gain a shared focus of the opportunities for

improvement within the organization

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Phase I: Discussion Questions for the Change Team

• Why implement a TeamSTEPPS initiative?• Do we have any data to support the need?• Why now?• What process are we trying to fix? Who

will be involved? Where will it occur?• What do we hope to achieve with a

TeamSTEPPS intervention?• How will we know that we were

successful? What measures will we use?

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Phase I: Discussion Questions for the Change Team

• How will we conduct medical team training- initial, newcomer’s, and refresher? Who will do it?

• What resources and personnel can we allocate to this effort? Is it feasible?

• Can we achieve our goals in a timely fashion?• How will we spread and maintain the change

throughout key areas of the organization?

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Exercise:

• Worksheet #1 Create a Change Team

• Next Meeting- July