TeamSTEPPSEmergency Department Experience

Why a teamwork project at Mayo Clinic Emergency Dept.? Mayo Clinic - Integrated group practice of

over 1700 physicians ED in located in largest private hospital in the

world – St. Marys / Methodist sites 80,000 visits per year; Level 1 trauma center ED relatively new addition to concept of

“group practice” at Mayo

“Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective

and potentially dangerous” Chantler, 1999

Science of Human Factors

Human CharacteristicsPerceptionMemoryDecision-makingPhysical Capabilities (skills to do tasks)

Nominal Error Rates(highly predictable) General error of commission (eg. Misread label) 0.003

General error of omission in absence of reminders (memory) 0.01

General error of omission for 10 step process 0.1

General error of omission when items are embedded in procedure 0.003

(cash card returned before money dispensed)

Staff on different shifts fail to correctly check hardware condition 0.1

unless required by checklist (eg. Defibs)

Monitor fails to recognize an error (vigilance) 0.1

General error rate given very high stress levels where dangerous 0.25

activities are occurring rapidly

Culture and Human Factors: Mitigated Language

“We need to try strategy X.”

“Strategy X is going to beimplemented.”

“Why don’t we try strategy X?”

Command

Team Obligation Statement

Team Suggestion

Culture and Human Factors: Mitigated Language

“I wonder if we could runinto any roadblocks on

our current course?”

Hint

“Perhaps we should take a lookat one of these Y alternatives?”

Preference

“Do you think strategy X would help us in this

situation?”

Query

Why do we do this?

Respect Fear Embarrassment “No one likes a backseat driver.”

Culture factors leading to communication errors in medicine: Uncertainty avoidance

High power distance Independence versus collaborative culture Stress of workload History of tolerance or indifference to

disruptive behavior

MD—adaptive, independent

RN—Rule oriented

Need for Teamwork

Clinical Medicine is extremely complex:Uncertainty Incomplete Information Interruptions and multitasking SurprisesHuman Factors

Mayo tradition is to take advantage of cutting edge knowledge and research

Project #1:

Teamwork and Human Factors Training

Emergency Department

Interdisciplinary Collaborative:

Department of Emergency Medicine Mayo School of Continuing Professional

Development Department of Nursing Continuing Education Resuscitation Committee Mayo Clinic Quality Committee Division of Trauma and Critical Care General

Surgery American Institutes for Research

Objectives

Demonstrate an effective model for building multidisciplinary teamwork skills Multimodal Interdisciplinary Specifically address practice gaps Related to organizational outcomes like safety and

satisfaction

Scope of Project (June 2007) Goals:

Improve communication and teamworkPrevent potential precursors to medical errorDemonstrate the impact of team trainingCreate template and expertise for teamwork training

on wider scale Process

To disseminate teamwork training and human factor education to all ED staff

Focus on “Psychology of Change”

Outcomes of Team Competencies Knowledge

Shared Mental Model

Attitudes Mutual Trust Team Orientation Psychological Safety

Performance Adaptability Accuracy Productivity Efficiency Safety

Shift Towards a Culture of Safety

Phase I: Assessment

Step 1: Create Sense of Urgency

Key Stakeholders IdentifiedED Medical LeadershipED Nursing LeadershipAll ED Staff MembersAncillary Department LeadershipAncillary Department StaffED Patients

February/March 2008: Team STEPPS overview sessions delivered to ED Leadership and Ancillary Leadership (Stakeholders)

Step 2: Create a Change Team February 2008

Multidisciplinary groupConsultant (Attending) MDsResidentsMid Level ProvidersNursing LeadershipOperations StaffRegistered NursesRespiratory Therapists Nursing Assistants

Phase I: Assessment

Are you interested in Team Work?Background:

There is a Team Training project starting in the ED. The overall focus of the project will be to teach skills and strategies that improve teamwork and help reduce errors in the ED. As part of this project, we are seeking staff members

that would be interested in helping coach teamwork.What is a coach?

A coach will be a “lead by example” person who will help with the Team Training project during their regular hours of work. The coach will be a resource in which

others can come to with questions related to the Team Training project in the ED.

What are the requirements?Any member of the ED can be a coach. The coaches will be required to attend a one day Master Team Training session. The coach will not be required to attend weekly meetings. However, there may be occasional meetings for the coaches

on an as needed basis. Every effort will be made to accommodate coaches on all shifts.

What is the status of the Team Training project in the ED?Currently the Team Training project is in the data collection and planning phase.

Sufficient data is needed to identify areas of opportunity for Team Training. Once the areas of opportunity have been identified, the plan for the Team

Training can begin. Part of this phase includes gathering interested individuals to be coaches for the training which is estimated to begin in the early this fall.

Phase I: Assessment

Teamwork Survey Items and TeamSTEPPS Observations

Observations of Teamwork vs. Perceptions

Ideally, the survey items (perceptions) would be closely related to teamwork observation data

Survey perceptions revealed moderate level of teamwork

Teamwork observations revealed very few team behaviors taking place

Mayo ED Survey (teamwork and communication)

TeamSTEPPS Teamwork Attitude 5 subscales (6 questions each)

AHRQ HSOPS Factors 7/9 unit-level subscales (3-4 questions)

Army Medical Daily Teamwork 1 scale (6 questions)

MEDCOM Organization Citizenship 1 scale (3 questions)

Pre-Training Survey FindingsStaff Assessments

Pre Subscale

MeanStd.

DeviationMean

Std. Deviation

“Attitude” to teamwork (TeamSTEPPS score)

4.11 0.31

Leadership 4.37 0.41

Communication

3.97 0.43

Patient safety culture (AHRQ)

3.25 0.39

Unit teamwork 3.56 0.62

Nonpunitive response 2.90 0.71

Organization Citizenship (MEDCOM)

3.22 0.71

Daily teamwork (Army Medical)

3.17 0.54

Mayo Teamwork Observations

Observations of Teamwork are designed to identify actual performance of team behaviors.Used the TeamSTEPPS Performance

Observation ToolPre-Training: 2 observersPost-Training: 1 additional observer (study

novice)

Pre-Training Observations FindingsTeamwork and Communication Behavior

Pre-Trainingn Mean SD

Establishes a leader 31 2.48 0.87

Assembles a team 31 2.37 0.93General Rating Team Structure 31 2.22 0.81Assigns roles and responsibilities 31 2.15 0.80Identifies team goals and vision 31 2.11 0.74Actively shares information among team members 31 2.02 0.79Provides task-related support 32 2.00 0.80Conducts briefs, huddles, and debriefs 31 2.00 0.76

General Teamwork Rating 32 1.99 0.64Cross monitors fellow team members 32 1.98 1.02Holds team members accountable 31 1.98 0.70General Rating Leadership 31 1.92 0.71Empowers team members to speak freely and ask questions 31 1.91 0.78Delegates tasks or assignments, as appropriate 30 1.90 0.70Utilizes resources efficiently to maximize team performance 31 1.89 0.78Balances workload within the team 31 1.85 0.72Effectively advocates for the patient 32 1.80 0.77General Rating Situation Monitoring 32 1.77 0.67General Rating Mutual Support 32 1.77 0.66Collaborates with team members 32 1.73 0.71Provides timely and constructive feedback to team members 32 1.72 0.62Seeks information from all available sources 32 1.72 0.58General Rating Communication 32 1.70 0.61Applies the STEP process when monitoring the situation 32 1.67 0.62Fosters communication to ensure team members have a shared mental model 32 1.67 0.63Uses SBAR, call-outs, check-backs and handoff techniques to communicate effectively 32 1.66 0.55Coaching feedback routinely provided to team members, when appropriate 32 1.66 0.72Provides brief, clear, specific and timely information to team members 32 1.59 0.71Verifies information that is communicated 32 1.59 0.61

Includes patient/family in communication 32 1.56 0.67

Uses the Two-Challenge rule, CUS, and DESC script to resolve conflict 31 1.52 0.64

Gap Analysis and Specific Strategies

10+ key behaviors needing improvement from observation tool Information exchange behaviors Resource utilization behaviors Conflict management behaviors Interruptions and distractions

Specific Strategies

Information ExchangeSBAR model for info sharingExchanges across “silos”

Multidisciplinary briefs near shift change Communication protocols for nursing (others) to

address physicians Huddles during treatment or condition changes (?

other tools IT or communication board?) Structured handoff tools for transfer to inpatient

Information Exchange

Specific Recommendations for EMSChecklist for EMS report to team

Specific Strategies

Resource utilizationChecklist for assessing need to interrupt patient

careChecklist for assessing need to interrupt each

other Identification of coordinating team Interdisciplinary briefs/huddles for coordinating

team Scheduled during high volume/code 90

Departmental/Leadership Team Behaviors Resource Utilization

Conducting debriefings to ensure flow is managed effectively and staff needs are met

Coordination high flow / disaster management states

Specific Strategies Interruptions and Distractions

Sterile Cockpit timesChecklist for need to interrupt??IT solutions ??communication boards

Specific Strategies

Conflict managementAdvocacy and assertion tools Improving feedback (giving and receiving)Debriefs

Project #2: Trauma Team Training

Multidisciplinary Teamwork:

Training Through Simulation

Scope of Project

Baseline StateMultidisciplinary trauma response in ED involves

many disciplines (TCGS, ED, Radiology, Lab, etc.).

Roles defined and described through high level leadership meetings and education done within each separate group.

No specific training on teamwork skills.No opportunity for multidisciplinary team training.

Project Plan

Design, implement and evaluate a multidisciplinary team training curriculum.

Integrate with teamwork training project underway in ED.

Coordinate with Mayo Multidisciplinary Simulation Center to provide high-fidelity experience in “safe” learning environment.

Results

Post-Training Survey Findings

Staff Attitudes

Pre Post

t SignificanceMean

Std. Deviation

MeanStd.

Deviation

Daily teamwork 3.17 0.54 3.35 0.47 3.21 **

Organizational Citizenship 3.22 0.71 3.43 0.69 2.53 *

Overall patient safety 3.25 0.39 3.35 0.36 2.37 *

Safety perceptions 3.26 0.66 3.37 0.56 1.54 -

Organizational learning 3.49 0.54 3.65 0.49 2.99 **

Unit teamwork 3.56 0.62 3.70 0.60 1.82 - Communication openness

3.03 0.63 3.19 0.64 1.79 -

Staffing 3.38 0.64 3.49 0.52 1.56 -

Error communication 2.95 0.63 3.13 0.64 2.15 *

Nonpunitive response 2.90 0.71 2.74 0.65 -2.04 *

Overall TeamSTEPPS score 4.11 0.31 4.17 0.40 1.23 -

Communication 3.97 0.43 4.13 0.46 2.49 *

Team structure 4.07 0.41 4.06 0.60 -0.12 -

Leadership 4.37 0.41 4.39 0.62 0.24 -

Situation monitoring 4.08 0.40 4.13 0.57 0.58 -

Mutual support 4.07 0.48 4.15 0.44 1.21 -

Post CPA Implementation 2009 N = 1341

40%

40%

15%

4%1% Separate Interviews

Cummunicated in Writing

Shared Verbal Reports

Joined Assessment inProgress

Entered/Assessed Together

Baseline 2007 N=99

76%

9%1%

0%

14%

Census and Length of Stay

150

160

170

180

190

200

210

220

230

240

Pt Count LOS

Team Stepps Implemented

Trauma Sim Progress to Date

9 quarters completed Outcome assessment planning

Qualitative assessmentTranslation into practice

Through coaching / debriefs Video reviews (Trauma Center QI) Observational tool derivation / calibration

Trauma Experience Identified 6 key behaviors to reinforce

Briefs for pre-arrival planning Role clarity PPE with names on front Plan based on EMS info Equipment set-up; where to find equipment that might be

needed 4 key leadership behaviors Check –backs (closed-loop communication) “TV” voice (audible communication) Crowd / Noise control Primary surveyor accountability for “Positives”

END

Slides for potential questions

What behaviors did we target?Needed Improvement

Cross monitors fellow team members

Utilizes resources efficiently to maximize team performance

Collaborates with the team members

Fosters communication to ensure team members have a shared mental model

Applies a monitoring process or checklist when monitoring the situation

Coaching feedback routinely provided to team members, when appropriate

Verifies information that is communicated

Provides brief, clear, specific, and timely information to team members

Includes patient/family in communication

Uses known conflict resolution strategies to resolve conflict

John Kotter

8 Steps of Change

Opportunity for Improvement

Safety culture concepts:Shared beliefs and behaviors that reflect your

willingness to learn from mistakes.Culture of safety is informed. It never forgets

to be afraid.What is the next thing that is going to happen

to harm a patient in your area?

Components of Safety Culture

Informed = SAFE

Learning

Flexible

Just (mistake, recklessness, sabotage)

Report

AHRQ HSOPS Factors: Twelve areas of patient safety and two overall items

Unit-level safety areas Hospital-wide safety areas

Overall perceptions of safety Frequency of events reported Supervisor/manager expectations and

actions promoting safety Organizational learning-continuous

improvement Teamwork within units Communication and openness Feedback and communication about

error Non-punitive response to error Staffing

• Hospital management support for patient safety

• Teamwork across hospital units

• Hospital handoffs and transitions

Overall items

• The patient safety “grade” the respondent would assign their work area/unit

• The number of events the respondent reported in the last 12 months

CPA

Clear correlation of CPA with patient satisfaction scores

Collaborative Patient Assessment Patient ratings

identified a decline in repeated questioning by providers (3.72vs4.24, p=0.008).

trend for improvement for the item “The nurse and resident clearly established roles during their assessment process” (4.00vs4.32, p=0.056).

RN ratings nursing perceived improvement in communication

between the nurse and resident (3.62vs4.13, p=0.011).

Army Medical Department Command Climate Survey

www.air.org

• Questions• Staff constructively resolves conflicts• Staff share information with one another• Staff use established protocol for communication• Staff openly discuss differences of opinion• Staff listen to one another• Staff offer assistance even if not requested

www.air.org

mean = 3.22, α = .81