1. PHOTO GOES HERE (Need higher resolution The University of Nebraska Medical Center AHRQ Annual Meeting Sept. 15, 2009 Measuring Improvement in Hospital Teamwork: Diffusion of TeamSTEPPS in Critical Access Hospitals Katherine Jones, PT, PhD Wendi Nordhausen, RN, BSN Mark Goodridge, RT (R) (CT) 1

2. Acknowledgements Our Team Anne Skinner, RHIA Robin High, MS, MBA Andrea Bowen, BA 99 Master Trainers from 24 Critical Access Hospitals Our Funding AHRQ Office of Communications and Knowledge Transfer Nebraska Dept of Health and Human Services Good Samaritan Health Systems Network St. Elizabeth CAH Link Direct funds from 14 Critical Access Hospitals 2 Medicare Rural Hospital Flexibility Program (Flex Program)

3. Objectives Describe a collaborative approach to implementing TeamSTEPPS within a state/region Use the AHRQ Hospital Survey on Patient Safety Culture (HSOPS) to plan and evaluate the implementation of TeamSTEPPS Use ‘Diffusion of Innovations,’ Kirkpatrick’s Taxonomy, and decision frame to explain variations in success implementing TeamSTEPPS Implement lessons learned from two Critical Access Hospitals to facilitate adoption of TeamSTEPPS 3

4. TeamSTEPPS Background 05 – 07 AHRQ Partnerships in Implementing Patient Safety Grant (1 U18 HS015822) – Purpose: Implement patient safety practices of voluntary medication error reporting and organizational learning in 24 CAHs – Aim: Develop organizational infrastructure for reporting and analyzing medication errors needed to identify system sources of error – Evaluate impact of this infrastructure change on safety culture with HSOPS HSOPS results revealed need for teamwork 4

5. Implementation Background 3/2008 initial funding through AHRQ Office of Communications and Knowledge Transfer Purpose: Implement the patient safety practice of teamwork and communication training in 25 Critical Access Hospitals Aim: Evaluate impact of TeamSTEPPS training program on safety culture using our rural- adapted version of the AHRQ HSOPS Collaborative funding through 12/2010 5

6. Collaborative Funding AHRQ OCKT $36,000 NE DHHS $80,000 2 CAH Networks $31,000 14 Individual CAHs $24,000 6

7. Implementation Cycle Evaluate Culture w/ HSOPS TeamSTEPPS Train the Trainer Action Plan and Implement Supporting Conference Calls Additional Training & Lessons Learned Conf Future: Patient Level Outcomes Cycle I 2007 – 2009 24 CAHs Cycle II 2009 – 2010 15 CAHs 7

8. Diffusion of TeamSTEPPS in Nebraska 8 NE TeamSTEPPS 35/65 CAHs, 1 Network Hospital, 3 IA CAHs, 1 LA CAH

9. Measuring to Implement TeamSTEPPS TeamSTEPPS Tools to bridge gap between belief and behavior. Situation Monitoring Mutual Support… Seeking and offering Task Assistance Briefs, Huddles, Debriefs Teamwork Within Departments Chase County Community Hospital 2007 Percent Positive 1. People support one another in this department. (BELIEF) 81 2. When a lot of work needs to be done quickly, we work together as a team to get the work done. 89 3. In this department, people treat each other with respect. 70 4. When one area in this department gets really busy, others help out. (BEHAVIOR) 57 9

10. Measuring to Implement TeamSTEPPS Communication Openness Chase County Community Hospital 2007 Percent Positive 1. Staff will freely speak up if they see something that may negatively affect patient care. (BELIEF) 65 2. Staff feel free to question the decisions or actions of those with more authority. (BEHAVIOR) 36 R3. Staff are afraid to ask questions when something does not seem right. 57 TeamSTEPPS Tools to bridge gap between belief and behavior. Advocacy and assertion I’m Concerned, I’m Uncomfortable, Stop the procedure (CUS) 10

11. Measuring to Implement TeamSTEPPS TeamSTEPPS Tools to improve structured communication across shifts and departments. SBAR, Closed loop communication, Seeking Clarification Huddles and WalkRounds after shift change I PASS the BATON 11 Hospital Handoffs and Transitions Clarinda Regional Health Center Percent Positive R1. Things “fall between the cracks” when transferring patients from one department to another. 48 R2. Important patient care information is often lost during shift changes. 53 R3. Problems often occur in the exchange of information across hospital departments. 46 R4. Shift changes are problematic for patients in this hospital. 49

12. Measuring to Evaluate TeamSTEPPS Team Behaviors Added to HSOPS Use SBARw/in dept Offer task assistance w/in dept Use structured communication (SBAR, I PASS the BATON) across depts Conduct a huddle in response to changing workloads Conduct a debrief for improvement when things don’t go according to plan Responses Never Rarely Sometimes Most of the Time Always 12

13. Evaluation: Adoption of Behavior 13

14. 14 Implementing TeamSTEPPS at Clarinda Regional Health Center Clarinda, Iowa Mark Goodridge, RT (R) (CT)

15. TeamSTEPPS at Clarinda Regional Health Center Critical Access Hospital – 25 Beds Average daily census 7- 8 Census can vary from 4 -14 in 24 hours 85% of services are out- patient 400-500 ED visits per month 600-700 specialty clinic visits per month 225 employees – FT & PT 15 Page County Iowa Pop. 15,664 Density 32/sq mi

16. TeamSTEPPS Training—Master Trainers 3 Master Trainers trained April 2008 with UNMC Collaborative – Senior Staff member Elaine Otte COO – Frontline staff Mark Goodridge RT (R) (CT) Jennifer Chambers RN (ED) 16

17. TeamSTEPPS Training—Leadership Leadership Development Training Department managers Senior Staff members Board of Trustees Fundamentals Course One time training session off campus Managers required to submit action plans to COO 17 Role Play during Leadership Development

18. TeamSTEPPS Training—All Staff Nov & Dec 2008 15 – 20 staff per class All classes interdisciplinary Essentials course Team building exercises Goal to train all staff within 2 weeks by Master Trainers & Education Director 18 Team Building Exercise during Staff Training

19. We Defined TeamSTEPPS as a Change We created a Sense of Urgency – Results from the 2006 Patient Safety Survey – Sue Sheridan video We ensured staff viewed TeamSTEPPS as consistent with our mission to provide exceptional care in a safe environment TeamSTEPPS is better than our “old way of communicating” – Shared stories of impact of our “old way” – TeamSTEPPS videos and role playing 19

20. We Obtained Management Support Senior leaders are educated and supportive of the TeamSTEPPS initiative – COO trained as Master Trainer The board is educated and supportive of the TeamSTEPPS initiative – Included in the Leadership Fundamentals Training Session Medical Staff education—in progress; goal is to shift from “I” to “We” 20

21. Our Champions Led the Way Mark (Radiology) & Jennifer (Nursing)- front line champions – Led the organization by training staff & mentoring department managers – Use TeamSTEPPS language – Overcome resistance by engaging key employees and managers 21

22. Resources Used for Implementation UNMC’s support – conference calls – sharing tools – Lessons Learned Conference Nov 2008 Senior Staff support Funds allocated for the program by COO 22 Our Poster at UNMC Lessons Learned Conf Nov. 2008

23. We are Sustaining TeamSTEPPS “Not a flavor of the month” Senior Staff and Board of Trustees buy-in Use TeamSTEPPS tools and language—role models Focus on Debriefs for drills and code alerts Part of new employee orientation – COO introduces concept to all new employees – Biannual Essentials Course – All receive a pocket guide 23

24. Lessons Learned and Next Steps Support of Board of Trustees – Attended Leadership training Next Steps – Medical Staff training – Sustainment – Use TeamSTEPPS tools in specific areas – Communicate use of TeamSTEPPS by professional organizations (AORN) 24

25. We are Measuring to Identify Improvement How do we know our training program resulted in change in culture, learning and behavior? – Data from HSOPS – Observed Changes in process and behavior 25

26. 26 Implementing TeamSTEPPS at Chase County Community Hospital Imperial, Nebraska Wendi Nordhausen, RN, BSN

27. TeamSTEPPS at Chase County Community Hospital 25 Bed – Critical Access Hospital Average Daily Census – 2 to 6 patients Staff 105 employees Attached clinic 3 physicians, 2 physician assistants, 2 nurse practitioners Chase County Pop. 3,269 Density 4/sq mi 27

28. TeamSTEPPS Training 4 Master Trainers - April 23 - 25 th, 2008 as part of UNMC Collaborative Included ALL staff and medical staff Board informed Included all modules in Fundamentals Course– adapted to our specific needs Offered 4 to 5 times each week in 60 – 90 minute sessions for 7 weeks Included one 6 hour make-up day 28

29. We Defined TeamSTEPPS as a Change We created a sense of urgency… We ensured staff viewed TeamSTEPPS as consistent with our mission and vision We ensured staff saw TeamSTEPPS as better than our “old way of communicating” – Started with SBAR and trauma debriefs 29

30. We Obtained Management Support Senior leaders are educated and supportive of the TeamSTEPPS initiative The board is educated and supportive of the TeamSTEPPS initiative Medical Staff is educated and supportive of the TeamSTEPPS initiative 30

31. Our Champions Led the Way CEO – Master Trainer, Leader Physician - QI background Linda (Resp. Therapist), Lori (Lab Coord.), Wendi (QI Coordinator) – Interdisciplinary Master Trainers 31

32. We are Sustaining TeamSTEPPS Employees know TeamSTEPPS is a priority – Use the tools and language – Scenarios brought to manager & dept meetings TeamSTEPPS changed day to day processes – SBAR – Trauma Debriefs Our organization supports and rewards involvement in TeamSTEPPS 32

33. Resources Used for Implementation UNMC conference calls Administrative Support Lessons Learned Conference Critical Access Hospital Network Meeting Additional Master Trainers could make a difference 33 Our Poster at UNMC Lessons Learned Conf Nov. 2008

34. Lessons Learned and Next Steps Most effective aspect of implementation- trained all staff in Fundamentals Least effective aspect…change team function Current and Future Focus – Orient new employees, Quarterly refresher courses, higher level of implementation and integration of the tools. 34

35. We are Measuring to Identify Improvement How do we know our training program resulted in change in culture, learning and behavior? – Data from HSOPS – Observed Changes in process and behavior… mails structured by SBAR, conversations about “processes” and communication 35

36. 36 Measuring to Evaluate for Individual Hospitals and the Collaborative Katherine Jones, PT, PhD

37. 37 Measuring to Evaluate Alliger et al. A meta-analysis of the relations among training criteria. Personnel Psychology. 2006, 50: 341-358. Kirkpatrick’s Taxonomy of Training Criteria

38. Rural HSOPS Spring 2009 Population Surveyed – 24 Hospitals evaluate impact of TeamSTEPPS Implementation 2008 – 2009 (2,137 respondents) – 13 Hospitals obtain baseline prior to TeamSTEPPS Implementation (1,328 respondents) – Added Teamwork Related Items to HSOPS Overall Response Rate for 37 Hospitals 3465/4601 = 75.3% Range 51% - 96% 38

39. Added HSOPS Knowledge & Behavior Items Knowledge Teamwork experience Define brief Define SBAR Define CUS Apply CUS Behavior Use SBARw/in dept Offer task assistance w/in dept Use structured communication (SBAR, I PASS the BATON) across depts. Conduct a huddle in response to changing workloads Conduct a debrief for improvement when things don’t go according to plan 39

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43. 43 Huddle Task Assist Advocate 2 Challenge CUS BELIEF

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45. Decision Frame Revealed in HSOPS Decision frame: mental structures people use to organize the world – Reference point changes with knowledge If behaviors change to reflect change in knowledge… Belief may not change – Consider item level scores not just dimension scores to track change over time If behavior not consistent with new knowledge…HSOPS results less positive after training – Seek higher standard based on new knowledge Tversky A, Kahneman D. Science. 1981;211:453-458. Wright G. Goodwin, P. Strategic Management Journal, Strat Mgmmt J. 2002;23:1059-1067. 45

46. Debriefs 46 Change In Frame?

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48. Evaluation: Training - Knowledge 48

49. Evaluation: Knowledge - Behavior 49

50. EVALUATION: TRANSFER OF TRAINING TO BEHAVIOR USING 5 BEHAVIOR ITEMS ADDED TO HSOPS Odds Ratio of Reporting Behavior Most of time/ Always for those Completing Some Modules* (n=752) Odds Ratio of Reporting Behavior Most of time/ Always for those Completing All Modules or Master Trainer* (n=459) Use structured communication within department ** 1.671.87 Offer task assistance to stressed team member within department** 1.401.77 Use structured communication across departments** 1.922.32 Call a huddle in response to changing information or workload within department** 1.541.36 Debrief within department for quality improvement*** 1.251.57 *Reference Group is those reporting no training in TeamSTEPPS Modules **p< 0.0001, ***p=0.0012 50

51. Evaluation: Behavior - Safety 51

52. Measuring Improvement Summary HSOPS Overall Perceptions of Safety Behavior Leadership, Situation Monitoring, Mutual Support, Communication Seeking Consistency Knowledge Immediate (post-training)Retained (> 3 mos post training) Training Some ModulesAll Modules/Master Trainer r = 0.79 r = 0.52 r = 0.59 52

53. Diffusions of Innovation Theory Explains why training/knowledge does not always result in changes in behavior Change clearly defined; better than old way – Trialable, Observable Management is supportive; – Change is a clear priority and is rewarded – Resources are available Champion(s) overcome resistance Policy/procedure/job descriptions sustain Effectiveness is evaluated Rogers EM. Diffusion of Innovations. 5th ed. New York: Free Press; 2003. Helfrich et al. Med Care Res Rev. 2007;64:279-303. Saint S et al. Jt Comm J Qual Patient Saf. 2009;35:239-246. 53

54. Summary and Next Steps Collaboration across state and local organizations can leverage resources to diffuse TeamSTEPPS across a state and region Use AHRQ HSOPS to plan and evaluate TeamSTEPPS as a patient safety innovation Diffusion of innovations theory, Kirkpatrick’s Taxonomy of Training Criteria, and decision frame are concepts needed to interpret measurement of teamwork with HSOPS Next Steps: More training, physician engagement, link teamwork to patient outcomes 54

55. Contact Information Katherine Jones, PT, PhD kjonesj@unmc.edu Wendi Nordhausen, RN, BSN wnccch@gpcom.net Mark Goodridge, RT (R) (CT) goodridge_mark@yahoo.com Web site where safety culture tools and rural-adapted version of HSOPS are posted www.unmc.edu/rural/patient-safety 55