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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 Regional.

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Presentation on theme: "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 Regional."— Presentation transcript:

1 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 Regional Risk Management KPSims © 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

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

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.003 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

5 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?

6 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

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

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.

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

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

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

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

13 Situational Awareness: An Overview A shared and accurate understanding of whats 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 dont SA is owned by the entire team, as with other Human Factors skills Situational Awareness Definition

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

15 Novice 3-Person Team Situation Awareness Shared Mental Model 1 2 3

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

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

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

19 CETT Simulation ONLY used as a training tool Video tapes erased Blame free, confidential training Dont Share Scenarios! Please share your learnings

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?

21 Take Home Message You can become a great team If you practice, you will get better Dont cover flaws in the facility- fix them Ask to debrief your real critical events Have Fun! Lets go meet our simulator

22 Simulation in Medicine KP Sims

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

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

25 High Risk Industries

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

27 Simulation Training Where should our educational efforts be focused?

28 NCALs 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

29 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

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

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 participants

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

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

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

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.

37 The Practical Side of Running a CETT KPSIMS

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

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

40 Team Roles & Positions 1 Airway Manager: Anesthesiologist/CRNA 6 Chest compressions 7 Procedure MD chest tubes, ABGs, etc. 2 Airway Assistant: RT draw ABGs 3 Bedside Nurse/Floor RN briefs team, IV, labs, dispense items, CPR 4 Critical Care RN prepare drugs, defib., ID & monitor rhythm 5 Team Leader 8 Recorder RN

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

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 TeamCETT 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 1Physician Lead CETT Team Trainers 9:45 a.m. to 10:15 a.m.Debrief for Simulation 1Physician Lead CETT Team Trainers 10:15 a.m. to 10:30 a.m.Break 10:30 a.m. to 11:05 a.m. Simulation 2Physician Lead CETT Team Trainers 11:05 a.m. to 11:45 a.m. Debrief for Simulation 2Physician Lead CETT Team Trainers 11:45 a.m. to 11:55 a.m. Post-Simulation SurveyEducator CETT Team Trainers 11:55 a.m. to 12:00 p.m.Closing CommentsPhysician Lead CETT Team Trainers

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,

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 Kaisers 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...

45 Unique to Kaiser Permanente Roseville Women and Childrens 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 couldnt believe how much we found on the first day, and how much better we look now

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

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

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