What can Healthcare Learn from Team Training and Other Domains? David P. Baker, Ph.D. American Institutes for Research

Session Objectives Demonstrate the importance of teamwork in healthcare Review the evidence on the effectiveness of team training Present guidelines for implementing effective team training programs Describe current initiatives in medical team training

Teamwork and Healthcare In most all cases, the delivery of healthcare involves: Two or more individuals (RNs, MD, PharmDs, etc.) Performing distinct tasks Working interdependently Ensuring a safe outcome (i.e., common goal) The delivery of healthcare requires teamwork! Team members come from different backgrounds, disciplines, and are seldom trained together The key characteristic that distinguishes teams for groups or collectives of people is TASK INTERDEPENDENCY Teams performs interdependent tasks!

What Do Effective Healthcare Teams Look Like? …have members who anticipate each other. …can coordinate without the need to communicate overtly. …can recognize and adjust their strategy under stress. …manage conflict well-team members confront each other effectively. …backup and fill in for each other.

What Do Effective Healthcare Teams Look Like? …communicate often "enough”. …effectively “span” boundaries with stakeholders outside the team. …regularly provide feedback to each other, both individually and as a team (“de-brief”). …have members who understand each others’ roles and how they fit together.

Producing Effective Teams Team membership-selection (Klimoski & Jones, 1995) Modify team tasks, workflow, structure (Campion et al, 1995) Provide support, resources, performance aids Build team member knowledge, skill, and attitude competencies (KSAs) - TRAINING (Salas & Cannon-Bowers, 2001) Selection – Can choose the right team members! Change the environment by structuring the work differently Provide tools or other aids to assist with teamwork Training Individual members – Individual Level KSA Intact teams – Team Level KSAs

Targets of Team Training Team Members Cognitions Behaviors Attitudes Knowledge Competencies—Principles and concepts that underlie a team’s performance (Know what team skills are required) Skill Competencies—A Learned capacity to interact with other team members at some level of proficiency Attitude Competencies– Internal states that influences team members choices or decisions. Two – Levels 1.Individual Level – The KSAs individuals possess to function effectively in a team 2 Team Level – The KSAs that are unique to a team – Knowledge of team member preferences Knowledge Skills Affect “Think” “Do” “Feel”

Team Process Developed by Salas and colleagues Mutual Trust Shared Mental Models Team Orientation Team Leadership Close Loop Comm. Back-Up Behavior MPM Adaptability THE CORE Developed by Salas and colleagues Reviewed the team research – meta analysis – and summarized it into a concise model – compiled all the evidence! Two components— The core of teamwork – what teams do The coordinating mechanisms – the glue that allows team members to coordinate

Meta Analysis Results (Salas) Team Training leads to improvements in: Attitudes Knowledge Skills Findings consistent across military, aviation, and emerging in healthcare Cross training, team self-correction, TDT, CRM Little evidence for organizational impact

Guidelines for Effective Team Training in Healthcare

Guideline 1 Engage Leadership (Physicians) If physicians do not believe that teamwork is critical it will be an uphill battle Physicians need to be included as team members and leaders Physicians must be champions for teamwork and training Physicians must value and reinforce team principles

Guideline 2 Develop Training Systematically Training development requires: Needs analysis Specification of objectives that are linked to desired outcomes Content development Delivery Evaluation Preparing the transfer environment

Guideline 3 Training Should be Scientifically Rooted There is a science of team performance and training (Baker et al. 2005, Advances in Patient Safety) There are principles, tools and strategies that have been shown to work

Guideline 4 Determine if Staff are Ready for Training Teamwork and training must be valued Trainees must be motivated to learn – negative pre-training experiences increase motivation Past experiences with training in the organization shape pre-training expectations Self efficacy is important

Guideline 5 Prepare the Learning Environment The organization must communicate that team training is important There should be systems in place to: Reinforce learned principles Transfer trained skills Establish coaches at the sharp end of care

Guideline 6 Incorporate Opportunities for Practice Practice is essential when developing team skills Simulation is an excellent tool for skills practice Simulation must incorporate sound learning strategies like scenario-based training Practice must be structured and paired with measurement and feedback to be effective

Guideline 7 Evaluate Training at Multiple Levels Evaluation involves systematic review of the training program to ensure it produces the desired outcome There are 4 levels of evaluation: Reactions (Did they like it? Find it useful?) Learning (What do they know?) Behavior (What can they do?) Outcomes (What impact has there been on the organization?)

Guideline 8 Training is not a One-Time Event Refresher training is required Medicine is an evolving field More and more research is focused on healthcare teams New training strategies are being develop, tested and validated Want to produce a learning organization

Guideline 9 Training Must be Aligned Team training will reduce but not eliminate error Human failure is inevitable Team training must align with the organization’s broader patient safety program

TeamSTEPPSTM Scientifically rooted Customizable Publicly available Evidenced – based Scientifically rooted Customizable Publicly available Multiple strategies Evaluation tools

Advocacy and Assertion Course Summary BARRIERS Inconsistency in Team Membership Lack of Time Lack of Information Sharing Hierarchy Defensiveness Conventional Thinking Complacency Varying Communication Styles Conflict Lack of Coordination and Follow-Up with Co-Workers Distractions Fatigue Workload Misinterpretation of Cues Lack of Role Clarity TOOLS and STRATEGIES Brief Huddle Debrief STEP Cross Monitoring Feedback Advocacy and Assertion Two-Challenge Rule CUS DESC Script Collaboration SBAR Call-Out Check-Back Handoff OUTCOMES Shared Mental Model Adaptability Team Orientation Mutual Trust Team Performance Patient Safety!!

Three Critical Phases Pre-Training Assessment-Readiness Kick-Off plan Senior Leadership involvement Executive Sponsor & Change Team Mentor and Role-model Behaviors Training Classes Metric Reinforcement through Post-training Assessment Essentials course for support staff Web-based teamwork updates Learning Action Network for follow-up and Information Sharing Pre-Training Assessment-Readiness Train-the-Trainer: Train the Participants Implementation & Sustainment Selection of Instructors/Coaches Supporting training materials provided Train-the-Trainer Fundamentals Course Implementation Workshop Culture Change Workshop Practice teaching Establishment of Training and Implementation Timelines Implementation Roll-out Plan Observation Toolkits Site assessment AHRQ Hospital Survey on Patient Safety Culture Executive Brief to gain Senior Leadership buy-in Selection of Executive Sponsor and Change Team Members Establishment of Goals/Values Communication Campaign Pre-training (baseline) Assessment Implementation plan

TRANSFORMATIONAL CHANGE FACTORS Leadership Level Individual Level Org Level Safety Culture Transparency/Trust Systems-Efficacy Learning Environment “Report Card” Leadership Level Lead the Way Establish the Sense of Urgency Create a Vision or Gain-Plan & Prepare Develop a Coalition-Assess Environment Communication Process Enable Change to Last Improve Systems and Structures Improved Patient Outcomes Improved Staff and Patient Satisfaction Processes Staff Retention Individual Level Self Efficacy Training Motivation Pre-training Experience Level IV Evaluation Intervention Sentinel Event Pre-Training Measurement -Knowledge -Skills -Attitudes Post-Training Measurement -Knowledge -Skills -Attitudes Training Transfer To be understood and evaluated, these recommendations for leaders and staff had to come together into one cohesive yet dynamic model. The purpose of a model is to: Provide a shared mental model for an evidence-based, evaluation driven, heuristic system for change Pull together the theories of leading team and culture change researchers (Salas, Kirkpatrick, and Kotter) Pull together the input and lessons learned of leaders and staff training and implementing behaviors on site Remain sufficiently broad and flexible to adapt to a variety of settings and specialities yet Remain focused enough to effectively train individuals to the specific behaviors shown to improve outcomes in aviation Provide process and outcomes founded on core leader and staff actions necessary to train, implement, and sustain Undergo 4 level - whole organization - evaluation The top (big box) establishes the three levels within the org where change needs to occur and the essential actions each must assume. At the level of the organization patients and staff must feel the system (of safety) is transparent and trustworthy. The leadership level identifies the accountabilities and responsibilities for a culture change and at the individual level the real work is to deliver excellent clinical out of the context of the behaviors and attitudes essential to teamwork. The bottom of the graphic illustrates the intervention and evaluation that occur and are necessary to make all this happen. Tools Methods Level II Evaluation Level II Evaluation Level III Evaluation Training Training Objectives Competencies -Knowledge -Skills -Attitudes Level I Evaluation

American Institutes for Research 1000 Thomas Jefferson Street, NW David P. Baker, PhD American Institutes for Research 1000 Thomas Jefferson Street, NW Washington, DC 20007 202-264-0659 dbaker@air.org