1. TeamSTEPPS Planning…Training…Implementation

2. PLANNING

3. Change team began discussions in April 2008 Aim(s) to be determined by August 2008 Action Plan Step 1: Define the Aim(s) of the TeamSTEPPS Intervention

4. Step 2: Design a TeamSTEPPS Intervention Began and completed design discussion September 2008

5. Step 3: Develop a plan to test effectiveness During September surveys distributed and observations report reviewed with Coaches and Change Team

6. Step 4: Development an Implementation Plan Part A: 4-hour fundamentals course given to all staff –This occurred in October 2008 Part B: Begin actual TeamSTEPPS Interventions –Began when fundamentals course was done

7. Step 5: Develop a plan for sustained continuous improvement Planning began in October and was implemented in January 2009

8. Project Sponsors: Provide resources and reviews high level goals. Reviews project at regular intervals with Project Leader. Supports and facilitates the project as a priority for the institution. Emergency Executive Committee, IIMF (Incented Investments in Mayo’s Future) Committee, Nursing Education and Professional Development Project Champion: Owns the prioritization process of clinical projects with in the ED. Endorses the high level project goals. Assist the project leader in removing barriers to project implementation. ED Practice Committee Project Owner/Leader: Responsible for overseeing the implementation of the project and the control plan with the project is over. Key driver to achieve significantly- improved levels of quality and efficiency in the process. Nicola Schiebel, M.D. (CI Physician Leader – ED) Project Manager/Educator: Creates and maintains initial charter and project plan including required tasks. Schedules and facilitates meetings, organizes agendas, and creates periodic status reports. Responsible to provide and create staff education plans and oversees and facilitates training of teams & staff. Plans for team celebrations and recognition. Kimberly Moore MS, RN (Nurse Education Specialist) Improvement Process/Metric Specialist: Facilitates the teams’ use of methods and tools. Provides “just in time” training of process improvement tools/processes. Assists team in developing process and outcomes metrics that are effective in showing movement toward goals. Assists in data collection plans and assist in data analysis. Lori Scanlan-Hanson MS (CI Specialist ED) PhD Consultant from AIR (American Institute of Research) Content Experts: Crucial for creating process maps, action plans, and planning pilots. Provides expert knowledge of process being evaluated for change. Can be ad hoc and changes based on specific needs of the project as it moves ahead. Change Team and Coaches for Team Training Initiative

9. Training

10. Three Levels of Training 1.TeamSTEPPS Master Training for Core Group 2.ED Staff Coach Training 3.Fundamental TeamSTEPPS content for the multidisciplinary team All levels of training included didactic, videotape, case studies and application of content.

11. Master Training Approximately 6 individuals received Master Training conducted by Agency for Healthcare Research and Quality (AHRQ) and Department of Department of Defense (DoD) The education is 2.5 days in length

12. ED Coach Preparation-Agenda One Eight Hour Educational Day Psychology of Change and Change Management- 45” Essentials of Team Training – Key Principles-120” Team Structure Leadership Situation Monitoring Mutual Support Communication Human Factors-60” Coaching Workshop-60” Coach Break out Sessions-90”

13. Teamwork Coach Tips for Success 1. Do… Actively monitor and assess team performance Support established performance goals and expectations Acknowledge desired teamwork behaviors and skills through tactful and thoughtful feedback Coach by example; be a good mentor 2. Don’t… Coach from a distance Coach only to problem-solve Lecture instead of Coach 3. When providing feedback… Be descriptive and non-evaluative Allow for two-way interaction, which allows team members the opportunity to interact and ask questions This was a ‘tip card’ for the coaches

14. Coach Breakout Sessions- Coaching Exercise Example Scenario 1 You are assigned to coach day shift staff in the Emergency Department (ED) on teamwork skills. When you arrive at 0900, the department is very busy and there is no evidence that teams have been formed. You locate the coordinating team nurse in the department for an update, and she tells you, “We’re not doing teamwork today, the ED is just too busy. I have made the assignments, and we are going to manage things ‘the good old fashioned way today’.”

15. Coach Breakout Sessions- Coaching Exercise Example Scenario 2 A staff member comes to you complaining of being put on the team in the West corridor with a “slacker”. She says, “Joan makes herself scarce and almost never offers to help her teammates, even when she has down time. I’ve had it!”

16. ED Teamwork Scenario: (Brief) –Situation: You are about to start your shift in the West hallway today. –Background: The hallway is fully staffed with 3 RNs, 1 LPN, 1 PCA, 1 Ops CA, 1 ED Consultant, and 2 ED Residents. –Assessment: There are only 3 patients in the hallway this morning who have all been seen and are awaiting test results. –Recommendation: A shift brief should be done. Follow the briefing checklist within your group to practice the shift brief. Coach Breakout Sessions-Brief

17. ED Teamwork Scenario: (Huddle) –Situation: There is a 3 car rollover accident with multiple trauma victims coming to the ED with a 20 min ETA. From the scene it was reported that 3 adults were severe enough to be considered a level 1 trauma. 2 more adults were considered to be less severe and likely to be a level 3 trauma status. –Background: The ED is busy today yellow light status is observed and critical is full with only one bed available. It seems like a three ring circus type of atmosphere in the entire department. –Assessment: On quick assessment it appears that there is only one critical bay available and 3 rooms in the west hall available. One good thing is that the ED is fully staffed today. –Recommendation: What would you recommend? Demonstrate within your group your teamwork action plan for this situation. Be able to share/discuss your teamwork action. Coach Breakout Sessions-Huddle

18. Fundamentals For All Staff Class Objectives Four hour interactive session –Describe role of teamwork to help reduce risk of error due to human factors –Explain the IIMF Teamwork Project –Recall and discuss opportunities for improving teamwork in the ED –Learn and demonstrate evidence-based teamwork skills and strategies with focus on ED opportunities –Define psychology of change

19. Exercise from Fundamentals Non-clinical Staff Example: You work in operations in the control room and you notice that a patient has been mis-identified. The patient is in east hallway and the clinical team is extremely busy today. You have gone to the nurse taking care of the mis-identified patient and he requested that you “hang on a second because he is busy giving a med”. You wait for 5 minutes and then see him going to another room. It seems like he has forgotten you are there. As a group formulate a statement/question using “advocacy/assertion” language to express your need.

20. Implementation

21. Critical Care Brief Trauma Brief Sharing Patient Info Shift Brief

22. Go Live Priorities Provide Tools –Brief Checklist –SBAR Triage Form –AIDET Pocketcard Facilitate Briefs Coach Presence Feedback

23. Brief Checklist Introductions of core team (names) –Review roles and responsibilities (when new staff/ interns) –Room coverage –Coverage hours / shift changes Teamwork focus for day –________________________________________ Plan of care / Resource issues –Charge RN briefs on staffing issues, inpatient bed situation, resource issues –Individual SBAR reports on patients (consultants report)

24. Template used for Patient Brief

25. Example of Checklist Coordinating Team Area Summary of Brief/Huddle Staffing Issues (e.g. shortage or surplus) Time intensive patient care procedures (e.g. Moderate Sedations) Elopement or Safety Concerns (e.g. need for security ) Patient Care Triggers (e.g. acuity concerns) Potential patient delays (e.g. multiple CTs, off- service consultations, inpatient bed delays) Substantive issues needing follow-up (e.g. Charge Nurse, NM, CNS, NES, Social Services, MD Chair etc…)

26. SBAR Triage Form

27. AIDET A Acknowledge: Greet the pt/family. Call them by name, establish a connection. When possible, sit down to interact with the patient. I Introduce- Who are you, your role. Look for opportunities to reassure pt about skills, knowledge of yourself and other staff. (Manage Up) D Duration- Always give an estimate of how long elements of care will take or how long a wait might be. Give updates if timeline changes E Explanation- What is the plan of care, what can a patient expect at CT, or other tests, Do they feel comfortable with D/C instructions. etc… TTime for You and/or Thank You I have TIME if you have questions or need anything. Before pt leaves area: THANK YOU for your trust in us

28. Nurse or MD/PA starts assessment. Other team member enters room as soon as available & is given quick update on the assessment performed so far. Options for Patient Assessment In Order of Preference Nurse & MD/PA enter together Nurse or MD/PA not available initially Complete written SBAR form Direct communication to other team member: SBAR format Explain to patient & give option to assess patient now or step out to talk to other team member 5 1 4 3 2 Nurse or MD/PA not available Nurse or MD/PA not available & form not completed “Hello Mr./Mrs... _____. I am _________ and I will be the nurse/resident/PA taking care of you. I realize you have shared information with my co-worker. I apologize but they are with another patient right now so I have not had a chance to find out what they know from you already. I am free now if you don’t mind repeating yourself, otherwise I can step out and try to find them. What would you prefer?”

29. Brief Times Posted Broadly Chronological Brief Times 0800-West/South 0815-Critical 0830-Pediatrics 0915-East 1545-West/South 1600-East/EDOU 1615-Pediatrics 1630-Critical 2300-West/South 2345-Critical Nights: Huddle PRN when West Consultant goes home

30. Objectives for Coaches Objectives for Shift Facilitate scheduled briefs. Facilitate huddles for: –Traumas –Codes Assess and facilitate white board (collect data) use: –Names –VS –Orders Observe overall teamwork and roles performed. Take note and document who is doing well! Send me their names for awards. Facilitate observations and debriefs for traumas and resuscitations (as coaches comfort level allows) Provide feedback on whom and why unwilling to participate using the attached log. Please keep this confidential.

31. Feedback Obtained by Coaches Issues List –Short term problemsolving –Long term problemsolving IssueProposed Solutions Fragmentation in gathering all members of the team to the brief. Immediate: Overhead page Long-term: Electronic alert on YES or overhead chimes. Other: Reminder sent to Consultant by pager. If EDOU is busy, the team focuses efforts on clearing patients there delaying the East brief. EDOU RN should not attend the East brief but give SBAR to Consultant at 0800 when they assume care. Consider developing SBAR sheet for EDOU specifically. Mixed compliance with names on the White Boards. Peds and East are the least compliant. Verbal reminders to staff Enhanced visual remindersLaminated times on the computers.

32. Positive Feedback Coaches recognized staff that were doing a great job with Briefs, Huddles, Teamwork Names were submitted and displayed on computer screens Prizes were awarded to recipients

33. “Don’t Let Up—Be Relentless”

34. Summary-Key Factors for Success 1.Active, dedicated “Change Team” 2.Coach presence at bedside 3.Pocketcards, checklists, posters 4.Positive feedback for all 5.Ongoing communication regarding status and changes 6.Knowledge that you must not let up, but be relentless 7.Constantly be receptive of feedback