Emergency Department Experience TeamSTEPPS Emergency 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 “Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous” Chantler, 1999

Science of Human Factors Human Characteristics Perception Memory Decision-making Physical 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 Command “Strategy X is going to be implemented.” Team Obligation Statement “We need to try strategy X.” Team Suggestion “Why don’t we try strategy X?”

Culture and Human Factors: Mitigated Language Query “Do you think strategy X would help us in this situation?” Preference “Perhaps we should take a look at one of these Y alternatives?” Hint “I wonder if we could run into any roadblocks on our current course?”

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 RN—Rule oriented MD—adaptive, independent

Need for Teamwork Clinical Medicine is extremely complex: Uncertainty Incomplete Information Interruptions and multitasking Surprises Human 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 teamwork Prevent potential precursors to medical error Demonstrate the impact of team training Create 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 Determine organizational (ED) readiness for a teamwork training initiative Assemble a change team Change team will identify opportunities for improvement Change team will be assisted by outside experts AIR for metrics support (American Institutes for Research)

Phase I: Assessment Jan-Mar 2008 TeamSTEPPS Master Trainer Course for Coaches Feb 2008 Change Team formed Stakeholders identified Data Review Apr 2008 AIR begins initial consultation Staff interviews Jun-Jul 2008 On-site Coach Training begins Teamwork Coaches” will be trained to assist with the initiative All staff multidisciplinary teamwork training will take place early this fall (September). Once all staff have been trained, teamwork skills and tools will be incorporated into daily practice in the ED. Change team will monitor and measure the ongoing effectiveness of the teamwork training intervention. 18

Step 1: Create Sense of Urgency Key Stakeholders Identified ED Medical Leadership ED Nursing Leadership All ED Staff Members Ancillary Department Leadership Ancillary Department Staff ED 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 group Consultant (Attending) MDs Residents Mid Level Providers Nursing Leadership Operations Staff Registered Nurses Respiratory Therapists Nursing Assistants

Phase I: Assessment Jan-Mar 2008 TeamSTEPPS Master Trainer Course for Coaches Feb 2008 Change Team formed Stakeholders identified Data Review Apr 2008 AIR begins initial consultation Staff interviews Jun-Jul 2008 On-site Coach Training begins Teamwork Coaches” will be trained to assist with the initiative All staff multidisciplinary teamwork training will take place early this fall (September). Once all staff have been trained, teamwork skills and tools will be incorporated into daily practice in the ED. Change team will monitor and measure the ongoing effectiveness of the teamwork training intervention. 22

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 Aug 2008 Conducted teamwork observations Identified the baseline for patient satisfaction and staff surveys Nov 2008 Completed the teamwork and safety surveys from AIR Teamwork Coaches” will be trained to assist with the initiative All staff multidisciplinary teamwork training will take place early this fall (September). Once all staff have been trained, teamwork skills and tools will be incorporated into daily practice in the ED. Change team will monitor and measure the ongoing effectiveness of the teamwork training intervention. 24

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 Findings Staff Assessments Pre Subscale Mean 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 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 Tool Pre-Training: 2 observers Post-Training: 1 additional observer (study novice)

Pre-Training Observations Findings Teamwork and Communication Behavior Pre-Training n Mean SD Establishes a leader 31 2.48 0.87 Assembles a team 2.37 0.93 General Rating Team Structure 2.22 0.81 Assigns roles and responsibilities 2.15 0.80 Identifies team goals and vision 2.11 0.74 Actively shares information among team members 2.02 0.79 Provides task-related support 32 2.00 Conducts briefs, huddles, and debriefs 0.76 General Teamwork Rating 1.99 0.64 Cross monitors fellow team members 1.98 1.02 Holds team members accountable 0.70 General Rating Leadership 1.92 0.71 Empowers team members to speak freely and ask questions 1.91 0.78 Delegates tasks or assignments, as appropriate 30 1.90 Utilizes resources efficiently to maximize team performance 1.89 Balances workload within the team 1.85 0.72 Effectively advocates for the patient 1.80 0.77 General Rating Situation Monitoring 1.77 0.67 General Rating Mutual Support 0.66 Collaborates with team members 1.73 Provides timely and constructive feedback to team members 1.72 0.62 Seeks information from all available sources 0.58 General Rating Communication 1.70 0.61 Applies the STEP process when monitoring the situation 1.67 Fosters communication to ensure team members have a shared mental model 0.63 Uses SBAR, call-outs, check-backs and handoff techniques to communicate effectively 1.66 0.55 Coaching feedback routinely provided to team members, when appropriate Provides brief, clear, specific and timely information to team members 1.59 Verifies information that is communicated Includes patient/family in communication 1.56 Uses the Two-Challenge rule, CUS, and DESC script to resolve conflict 1.52

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 Exchange SBAR model for info sharing Exchanges 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 EMS Checklist for EMS report to team

Specific Strategies Resource utilization Checklist for assessing need to interrupt patient care Checklist 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 times Checklist for need to interrupt ??IT solutions ??communication boards

Specific Strategies Conflict management Advocacy and assertion tools Improving feedback (giving and receiving) Debriefs

Project #2: Trauma Team Training Multidisciplinary Teamwork: Training Through Simulation

Scope of Project Baseline State Multidisciplinary 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

Most Improved Teamwork Behaviors Pre- or Post-Training? N Mean Mean Difference Conducts briefs, huddles, and debriefs Pre-Training 31 2.00 1.01 Post-Training 58 3.01 Empowers team members to speak freely and ask questions 1.91 1.24 3.16 General Rating Leadership 1.92 1.00 57 2.92 Fosters communication to ensure team members have a shared mental model 32 1.67 1.28 2.95 General Rating Situation Monitoring 1.77 1.09 2.85 Provides task-related support 1.17 3.17 Provides timely and constructive feedback to team members 1.72 1.15 2.87 Effectively advocates for the patient 1.80 1.45 3.25 General Rating Mutual Support 1.08 Provides brief, clear, specific and timely information to team members 1.59 1.23 2.82

Post-Training Survey Findings Staff Attitudes Pre Post t Significance Mean Std. 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 0.36 2.37 Safety perceptions 3.26 0.66 3.37 0.56 1.54 - Organizational learning 3.49 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 0.52 1.56 Error communication 2.95 3.13 2.15 Nonpunitive response 2.90 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 -0.12 Leadership 4.37 4.39 0.24 Situation monitoring 4.08 0.57 0.58 Mutual support 0.48 4.15 0.44 1.21

Trauma Sim Progress to Date 9 quarters completed Outcome assessment planning Qualitative assessment Translation 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

8 Steps of Change John Kotter

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 management support for patient safety Teamwork across hospital units Hospital handoffs and transitions 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 The patient safety “grade” the respondent would assign their work area/unit The number of events the respondent reported in the last 12 months Overall items

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 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 www.air.org