1. “Turning a Team of Experts into an Expert Team”
KPSims
“Turning a Team of Experts into an Expert Team”
Jeff Convissar MD
National Risk Management
Nancy Corbett RN MHA
Regional Risk Management
Sybil Solis RN
Jeff
© 2009 The Permanente Medical Group

2. We are continually learning in the ever changing environment of healthcare and medicine. We are not perfect. We all may find or think that we have inadequacies during this course, but that is why we are here! None of us are perfect. This course is not to single anyone out or intimidate anybody, but to be used as a tool to keep us safe, competent, and competitive in this ever changing climate in the health care industry.
Rex Rasmussen RN, ANM SRO
Jeff
A quote from a SRO manager..
This can be used for all facilities.. Good quote

3. Hypothetical Work Environment
 Multiple information sources
 Incomplete, conflicting information
 Rapidly changing, evolving scenarios
 Fatigue, sustained operations
 Performance pressure, life/death outcome
 Time pressure
 Distractions & auditory overload
Jeff

4. We Are Wired To Fail: Nominal Human Error Rates
 Errors of commission, e.g., misreading a label .003
 Errors of omission without reminders .01
 Errors of omission with embedded item
 Simple arithmetic errors with self-checking .03
 Inspector failure to recognize an error .1
 Error rate under very high stress with danger .25
Handbook of Human Factors and Ergonomics
 Anesthesia drug administration errors- 1 in 130 cases
Self reported data, New Zealand, Alan Merry
Jeff

5.  Do you have to manage emergencies?
Why do Simulation?
 How many times do you get to practice a new procedure before you do it on a patient?
 Do you have to manage emergencies?
 Do you practice as teams for emergencies?
 Do you routinely debrief your real events?
Jeff

6.  No single human can do this job alone  Error Reduction
Why Teamwork?
 No single human can do this job alone
 Error Reduction
 In every complex environment studied, teams outperform individuals- including medicine!
 Improve patient Safety
Reduce cost of error to the organization
 Job Satisfaction
 We will stay if we are supported by a team
 Increases morale and staff retention
Jeff

7. Proven Training Techniques: Human Factors
 Skills that build teams, improve communication, reduce and trap the errors that will always occur
Briefings, Assertion, Situational Awareness
 Very trainable
 Measurable
Reduce accidents
Improve Staff Retention
Jeff

8. Briefing
 Conversation involving all team members about the plan for the patient.
 Allows for
Patient plan of care
team to think through situations and anticipate complications
be ready with additional equipment, personnel, e.g.
Jeff
May want to ask participants where else (outside of healthcare) they have seen or heard about briefings.
Connect to aviation if necessary – regardless of the length or difficulty of a flight, the pilot and co-pilot always conduct a briefing…always.

9. When to Brief  Start of work- Multidisciplinary Rounds
 New Team Members
 Pre- Procedure
 Change in Situation
Jeff

10. S-B-A-R: Structured Communication  Situation  Background
Situational Brief
S-B-A-R:
 Situation
 Background
 Assessment
 Recommendation
Jeff

11. Assertion Definition
“Individuals speak up, and state their information with appropriate persistence until there is a clear resolution.”
Jeff

12. Assertion Model to guide and improve assertion in
the interest of patient safety *
Jeff

13. Situational Awareness: An Overview
Situational Awareness Definition
Situational Awareness: An Overview
 A shared and accurate understanding of “what’s going on” and “what is likely to happen next”
Allows us to recognize events around us
Act correctly when things proceed as planned
React appropriately when they don’t
 SA is owned by the entire team, as with other Human Factors skills
Jeff
Key points
Sharing understanding with others - think out loud so others know where your mind is, what you plan to do next so they all can support you or help redirect you PRN
Humans are imperfect and have limits to information gathering and processing to be able to know everything that is going on in a complex situation - we must rely on each other to fill in the gaps to get the big picture.
If you know the “plan” you can effectively contribute to that plan and anticipate what is next and what to do if things go bad
SA does not replace clinical expertise but helps insure clinical activities are properly integrated and executed to deliver effective care
Gives more control over a constantly changing environment and safety net to protect patient and caregivers from inevitable system and human error

14. Novice to Expert Skill Acquisition in Two Domains
Technical Skills
Novice
Advanced
Beginner
Competent
Proficient
Expert
Jeff
Teamwork &
Communication Skills

15. Novice 3-Person Team Situation Awareness1 3
Shared
Mental
Model
Jeff 2

16. Expert 3-Person Team Situation Awareness
Briefings and SBAR rapidly increase team members shared mental model 1 2
Shared
Mental
Model
Jeff 3

17. CRITICAL EVENT DRILLS: What are they?
 Lifelike
 Real time
 Normal noise - confusion - resources
 Situation must be diagnosed and managed by team exactly as in real life
 Real equipment and meds will be used
 You will be doing your usual job at all times
Jeff

18. Key Crisis Management Skills
 Declaring emergency: SBAR
Early and clearly
 Leadership, optimal team structure
 Attention allocation
 Task prioritization and distribution
 Effective, efficient resource use
 Clear orders, cross check and verification
Jeff

19. CETT Simulation  ONLY used as a training tool  Video tapes erased
 Blame free, confidential training
 Don’t Share Scenarios!
 Please share your learnings
Jeff

20. CRITICAL EVENT DEBRIEFING
Debriefing #1 Rule
Critique the performance … not the person
 What went well?…… Why?
 What could be better?……Why?
 What systems’ problems did we find?
 What communication problems did we find?
 What teamwork glitches did we find?
Jeff

21. Let’s go meet our simulator
“Take Home Message”
 You can become a great team
 If you practice, you will get better
 Don’t cover flaws in the facility- fix them
 Ask to debrief your real critical events
 Have Fun!
Let’s go meet our simulator
Jeff

22. Simulation in Medicine
KPSims
Simulation in Medicine

23. Objectives
Understand the importance of in-situ simulation to create expert teams and test system
Learn the components of a Critical Event Team Training
Nancy

24. 10 Years Ago... Simulation seemed like a really good idea!
There was not much data supporting this
Relied on faith in the experts
Trusted the instincts of our people
Before the IOM report
Stanford Sim Center
Wow! Where can we find $2 million?
University of Washington
A Modest Center, with great training taking place
“Help them become better, NOT worse”
Nancy
Define simulation and it’s role in providing safe, reliable care
Discuss what is going on outside KP in this area and what another leading organizations are doing
Discuss the state of simulation in KP – who has what equipment, how are they using it and what they are doing
Discuss the future of simulation in KP

25. High Risk Industries
Nancy

26. Simulation Questions
How many times have you done a procedure and how recently?
Do we teach hazardous procedures on real patients?
Is this OK?
Do our teams have to manage emergencies?
Do we learn from a near miss? Would our systems change?
This was all about supporting our people to do their best possible work, in a great system
Nancy

27. Where should our educational efforts be focused? Simulation Training
Nancy
Simulation Training

28. NCAL’s History of Simulation
2002 – In-situ simulation required element for Perinatal Patient Safety Project
CETT T3 trainings for perinatal domain
One medical center across all domains
Trained over 200 CETT facilitators
13 medical centers have monthly or quarterly CETT
Domains - Critical care, Perinatal, Periop, Pedi, Med-Surg & ED
Nancy

29. 2007 - Grass roots effort to standardize scenarios and training
KPSims Collaborative
Grass roots effort to standardize scenarios and training
Develop Regional P and P
Equipment handling and use
Standards for CETT Workshops
Qualifications of facilitators
Standardized and validated scenarios in six domains
Nancy

30. Critical Event Team Training ( CETT) Training Strategy
Training includes
Human factors and team skills
Reality and types of Human Errors
Orientation to Simulator
In-situ simulation training
Actual occurrences used as basis for scenarios
Focus on apparent system
weaknesses
Situations where assessments &
communication are important
Blame free, confidential training
Nancy
Lifelike real-time critical events
Normal noise, confusion, & resources
Problem is NOT announced
Must be diagnosed and managed by team exactly as in real life

31. Standardized Regional CETT Train-the-Trainer
3 day Train-the-Trainer Program includes participation from all medical center domains
Must include physician leads
Nurse educators
Manager/Assist. managers
Front-line staff; RNs, RTs,
CRNAs, CNMs
20-25 participants
Nancy

32. Simulation Scenarios

33. No Technology
Standardized Patient: an “actor” who has coached to portray a patient
Role Playing: instructor and participant(s) are assigned specific “roles”
Uses
Design of new workflows
Training workflows/communication skills
New staff/providers
Annual staff/provider training
Competency Assessments
Privileging
Nancy
Standardized patient interviews are one of several methods for teaching clinical skills and measuring the abilities of medical students and doctors in training. These simulated interactions help students identify the symptoms (subjective patient experiences) and signs (objective abnormalities) of a particular disease. The student is able to improve his or her physical examination skills in order to aid in making an accurate diagnosis. In addition, standardized patients come from diverse backgrounds and expose students to important cultural issues. Thus, the medical student can learn how to identify and understand the physical, emotional, social, and cultural impact of illness. Standardized patients are often trained to measure the interviewing and examining skills of the student with whom they interact. In addition, experienced instructors may observe the standardized patient interview and physical examination to evaluate clinical skills and recommend improvements. To become a licensed physician in the United States, medical students are now required to pass a clinical skills assessment with standardized patients as part of their medical licensing examinations.
for the instruction, assessment, or practice of communication and/or examining skills of a health care provider. In the health and medical sciences, SPs are used to provide a safe and supportive environment conducive for learning or for standardized assessment. SPs can serve as practice models, or participate in sophisticated assessment and feedback of one's abilities or services. The use of simulated scenarios involving humans is rapidly expanding to meet the needs of many high-risk service fields outside of human health care."
Standardized Patients supplement, rather than replace, real patients. They are specifically trained to present the medical history, simulate the physical symptoms, and portray the emotions of the original patient upon whom their case was based. SPs are also trained to give students immediate, one-to-one rating and feedback on their performance.
The role play gives the training participants opportunities to act out various roles chosen to represent actual roles that would be in the field situation.
Role playing/simulation is an extremely valuable method for L2 learning. It encourages thinking and creativity, lets students develop and practice new language and behavioral skills in a relatively nonthreatening setting, and can create the motivation and involvement necessary for learning to occur.

34. Hybrid Birthing Simulator
Uses
Human Factors training
Skill-based/Task training
Team training
Development of protocols and guidelines
Cultural change
Improved patient outcomes
Nancy

35. Task Training Blue Phantom and SimMan
Central Line Placement
Reasonably Hi-fidelity replication of task
Realistic setting, or actual clinical area
In-Situ tests systems and processes supporting task
Objective, predetermined passing criteria
Training expectations
Standardized scoring sheets
Expert analysis of performance with immediate repetition of task
Nancy

36. High Fidelity Simulators
Uses
 Ideal modality for team training
 Dynamic decision-making in stressful critical scenarios
 Require use of critical equipment in a stressful environment
 Identify system issues which can impact performance
 Provide opportunity for part to execute skills taught in ACLS/PALS, etc.
Nancy
Team Training
Incorporates communication skills, human factors, and teamwork – all of which have major impact on team performance
Wide spectrum of “fidelity” and team members possible.
Critical equipment – traditional inservices do not translate into expert performance during real cases
Offers the opportunity to identify system issues that impact performance
i.e. “Glitch Book”
Empowers staff to make meaningful changes in their work environment 36

37. The Practical Side of Running a CETT
KPSIMS
The Practical Side of Running a CETT
Nancy

38. CETT Planning Team Chief of Services Nurse Managers
Nursing Services Director
Nurse Educators
House Supervisors
ACLS Instructor
NRP/PALS Instructor
Perinatal Safety Team
Med-Surg Safety Team
ED Team
Highly Reliable Surgical Team
Nancy

39. First Steps in Planning CETT
Identify date
3-4 month lead-time
Need to schedule conference room
Hold providers’ schedules
Identification of CETT objectives
What is the knowledge gap?
What is the ROI
Identification of participants
Staff members
RRT Responsibilities Grid, Code C grid, Shoulder dystocia grid
Code Blue Roles and Responsibilities
List of Team Members who need to participate
Nancy

40. Team Roles & Positions 2 Airway Assistant: RT draw ABGs
Airway Manager:
Anesthesiologist/CRNA
2 Airway Assistant: RT draw ABGs
6 Chest compressions
3 Bedside Nurse/Floor RN
briefs team, IV, labs, dispense items, CPR
7 Procedure MD
chest tubes, ABG’s, etc.
Nancy
4 Critical Care RN
prepare
drugs, defib., ID
& monitor rhythm
8 Recorder RN
5 Team Leader

41. Back Counter/Cupboards
Baby Warmer
RN #C
(Circulate)
Pedi Team
Bucket/Lap Bags
RN #B
(Body)
Back
Table
OBT OR
Table
Nancy
Bovie/Suction
RN #A
(Airway)
OR 1
Anesthesia

42. Critical Events Team Training Morning Agenda
Time Topic Presenter
8:00 a.m. to 8:10 a.m Welcome Physician lead
Review Objectives for the Day CETT Team Trainers
8:10 a.m. to 8:50 a.m “Turning a Team of Experts Team” Physician Lead
into an Expert Team” CETT Team Trainers
8:50 a.m. to 9:00 a.m Pre-Simulation Survey Educator
CETT Team Trainers
9:00 a.m. 9:45 a.m Simulation 1 Physician Lead CETT Team Trainers
9:45 a.m. to 10:15 a.m. Debrief for Simulation 1 Physician Lead CETT Team Trainers
10:15 a.m. to 10:30 a.m. Break
10:30 a.m. to 11:05 a.m. Simulation 2 Physician Lead CETT Team Trainers
11:05 a.m. to 11:45 a.m. Debrief for Simulation 2 Physician Lead CETT Team Trainers
11:45 a.m. to 11:55 a.m. Post-Simulation Survey Educator CETT Team Trainers
11:55 a.m. to 12:00 p.m. Closing Comments Physician Lead CETT Team Trainers
Nancy

43. Identify CETT Support Staff
Two local or regional instructors
Familiar with Simulators
ACLS/PALS/NRP instructor
Someone to identify and corral participants for each scenario
Confederates e.g. Chief of Service, nurse manager/director, patient safety team member
Scribe for debriefing - recommend administration
Manager to monitor patient workflow and notify patients simulation is occurring,
Nancy

44. Few Weeks Prior to CETT Letter to CETT Attendees
Critical Event Team Training Invitation
“Turning a Team of Experts into An Expert Team”
You are invited to participate in Kaiser’s Critical Event Team Training (CETT) class. This class will equip you with strategies and skills that will help you to function on a team effectively. We will examine team communication & performance in the Med-Surg setting.
Background. CETT resulted from teamwork observations made in acute care settings requiring proficient decision-making, action, and communication by individuals working together to achieve high quality clinical outcomes while minimizing avoidable adverse outcomes. Critical event team performance is highly visible in the obstetrical acute care settings at most hospitals; our Kaiser hospitals are no exception. However, team performance has only recently been
Nancy

45. Unique to Kaiser Permanente
 Roseville Women and Children’s Center
12 days of testing prior to opening
All Staff run though drills
 Modesto Medical Center
CETT T3 prior to opening
 Vacaville Outpatient Surgery
Maligent Hyperthermia
 Santa Clara- Testing of
new cardiac cath and surgical capabilities
“ I couldn’t believe how much
we found on the first day, and how
much better we look now”
Nancy

46. Unique Kaiser Opportunities
 Extraordinary Leadership from National and Regional Risk- equipment, time and support
 Appreciation for systems- role of simulation in testing facilities, fixing systemic problems, training new teams, hospital and tech design
 Unified systems
 Increasing capability to track
outcome data
 A remarkable cadre of dedicated trainers
Jeff – Conclusion after panel?

47. Contacts
Nancy Corbett RN, Regional Risk Management,
Jeff Convissar MD, National Risk Management,