HANYS Teamwork – Technique: Achieving Critical Care Excellence Teambuilding for Critical Care Teams

Objectives Use four leadership strategies to structure the organization to permanently support and enable effective teamwork among caregivers State the benefits of effective teamwork among critical care teams; Use five key action steps to create and maintain great teamwork; Understand how to hardwire teamwork behaviors into daily operations;

The 4 P’s Philosophy Policy Procedure Practice Four leadership strategies to structure the organization to permanently support and enable effective teamwork among caregivers

Understand that Great Teamwork (as a Key Component of Safety and Quality) in Critical Care is a Function of Philosophy, Policy, Procedure, and Practice

Philosophy An over-arching view of how the business of the hospital will be conducted

Sample Philosophy Statements “General Hospital provides care that is safe, efficient, patient-centered, timely, effective, and equitable. To do this, we will excel technically, be experts in teamwork, and follow our policies, procedures, and protocols to provide the highest standard of care.” “Memorial Hospital provides safe, efficient, compassionate care of the highest standard through teamwork, technical proficiency, and adhering to guidelines, policies, and procedures.” Notice that each statement has two parts: “What” and “How”

Policy Broad specifications of the manner in which management expects things to be done

“ All members of the surgical services team at Vanderbilt will be trained in CRM skills and are expected to use these CRM skills in their daily work and in their professional communication with other members of the Vanderbilt healthcare organization.” Vanderbilt University OR Guidelines Sample Policy Statement

“ All on-duty members of the NICU team at General Hospital are expected to attend and participate in the Morning Shift Briefing. The Briefing shall be conducted using the approved briefing guide.” General Hospital NICU Guidelines Sample Policy Statement

Procedures An established or correct way of doing something

Sample Procedure

What the human operator actual does in the daily work environment Practices

Encompass every activity conducted in the hospital: Correct execution of a procedure Deviation from a procedure Omission of a procedure The use of a technique (authorized or not) The human operator’s decisions and actions determine the system outcome

Conforming To, or Deviating From Cannot assume that teams will follow any given procedure dictated by management –Must be checked or measured through “rounding” or data collection/analysis Practices

Team Deviate Conform Practices

Goal of Leadership/Management –Minimize deviations in Practices by… Promoting good practices by specifying coherent procedures Ensuring Procedures are consistent with Policy Ensuring Policy is consistent with Philosophy Practices

Leadership Actions to Minimize Deviations Rounding (Checking) Project Interviews Reinforcing and Publicizing Positive Behavior Dealing With Low Performers Measuring Practices

Creating the “Chemistry” Needed for Great Teamwork

Study of 23 NBA teams from 1980 – 1994 Results? Greater roster stability (fewer trades and player turnover) = better won/loss record (Berman et al, 2002) Basketball is a “Chemistry Sport”

Commercial Aviation is a “Chemistry Sport” Risk Factors First day First flight Night time Visual approach flown by Captain

Video Does this team have the “Chemistry” for a safe flight?

Is Healthcare a “Chemistry Sport?” Harvard study of 38,577 procedures by 203 surgeons in 43 hospitals Compared outcomes at facilities where surgeons do a lot of procedures vs. where they do fewer Surgical skill is “not portable” Better pt. outcomes where surgeons have more experience with their teams “Familiarity helps the surgeon perform better.” (Huckman & Pisano, 2006)

The Value of Creating “Chemistry” Creating and tapping the “Collective Mind” to detect & correct potential errors Relevant information Mastery of tools and knowledge Understanding of tasks (Liang et al, 1995) Better Care Better teams have 12% fewer avoidable complications and 21% fewer avoidable deaths (Gallop, 2006)

How can you build team chemistry in a reliable and repeatable way?

Building Team Chemistry Use inter-personal skills Introduce yourself Make eye contact when communicating Learn names so they can be used during the procedure or critical times during the shift

Building Team Chemistry Clearly provide / understand the big picture in a “Pre-Brief” Outline the procedure / situation Discuss critical points Specify duties Anticipated outcome Plan / discuss most likely contingencies

Building Team Chemistry Invite participation from the Team Explicitly ask team members to provide information, express their concerns, and speak up when necessary Encourage the team to ask questions to verify their understanding

Building Team Chemistry Ask questions to check understanding and begin two-way communication Set up a “pattern of response” Ask questions that require more than a “Yes” or “No” response

Building Team Chemistry Acknowledge all communication Close the “loop” Confirms understanding

Using these skills “at the bedside” Implement an Expanded Briefing conducted with a Checklist Why? Better performance and care Kaiser Permanente reported 50% cut in unexpected delays, RN turnover from 19% to zero, elimination of wrong surgeries (Defontes, 2004) “…useful quality improvement tool…” (Altpeter et al, 2007) “…effective tool in promoting teamwork among surgery staff members…” (Makary et al, 2007)

Model Briefing Format Offered by JACS  Names & roles of team members  Conduct Time Out procedures  Antibiotics  Review of critical steps  Review potential problems  Safety Statement* (Markary et al, 2007)

Evaluate this team…

Evaluate this team Used interpersonal skills? Eye contact, body language, names, etc. Provided Big Picture – contingencies etc? Invited participation? Asked open ended questions? Acknowledged communications?

Action List Determine your philosophy of care – get it in writing Revise your P&P Manual or Department Policies to support the teamwork behavior you desire Ensure your care givers are trained in the desired teamwork skills Create “hardwired tools” to require and support the use of those teambuilding behaviors Build a system of “rounding” to check and reinforce the desired behaviors

Thank You