1. Strategies and Tools to Enhance Performance and Patient Safety

2. Team
Strategies & Tools to Enhance Performance & Patient Safety
“Initiative based on evidence derived from team performance…leveraging more than 25 years of research in military, aviation, nuclear power, business and industry…to acquire team competencies”
TeamSTEPPS focuses on specific skills supporting team performance principles
- training requirements
- behavioral methods
- human factors
- cultureal change
All designed to improve quality and patient safety
More than 25 years of research and evidence have been accumulated on teams and team performance including
- aviation
- military
- nuclear power
- healthcare
- business
TeamSTEPPS has evolved from research in these high-risk fields to the healthcare environment, which is a high-risk, high-stakes environment in which poor performance may lead to significant morbidity or mortality.
Based on research, we know what defines a team, what teamwork requires, how to train team members, and how to manage team performance. Researchers have linked team training programs to improved attitudes, increased knowledge, and improved behavioral skills.

3. (Pronovost, 2003)
Johns Hopkins
Journal of Critical Care Medicine
(Sexton, 2006)
Johns Hopkins
Through implementing teamwork initiatives, organizations have found significantly positive results:
Beth Israel Deaconess Medical Center found a 50% reduction in their adverse outcomes in the OB/GYN department, as well as a reduction in their malpractice clams
After implementation of a interdisciplinary communication tool to improve rounds, the average length of ICU stays were reduced by 50% at Johns Hopkins. There was no increase in mortality.
Also at Johns Hopkins, operating rooms with staff that report having the most teamwork aligned attitudes also have post-operative sepsis rates less than half of those where staff perceive the environment as being poorly conducive to teamwork.
Although the evidence is still evolving, these results to date help demonstrate that teamwork plays a critical role in providing healthcare. The investment of resources is trivial compared with the overall expenditures in healthcare resulting from medical errors.
(Mann, 2006)
Beth Israel Deaconess Medical Center
Contemporary OB/GYN

4. Why Do Errors Occur—Some Obstacles
Workload fluctuations
Interruptions
Fatigue
Multi-tasking
Failure to follow up
Poor handoffs
Ineffective communication
Not following protocol
Excessive professional courtesy
Halo effect
Passenger syndrome
Hidden agenda
Complacency
High-risk phase
Strength of an idea
Task (target) fixation
The science of human factors recognizes that a majority of these errors still affect units that are effectively practicing teamwork. However, in effective teams, mistakes are caught, addressed, and resolved before they compromise patient safety.
Excessive professional courtesy can be seen when team members are reluctant or hesitant to point out deficiencies in performance of someone of higher rank or status.
Passenger syndrome occurs when team members are “just along for the ride”, abdicating responsibility because they believe someone else is in charge.
Complacency is hazardous because individuals and teams lose their vigilance and situational awareness
Task fixation is seen when an individual’s or team’s focus on a task impairs their decision-making or makes them oblivious to “the big picture”. It is generally precipitated by a real or perceived pressure to perform, or by workload/stress related issues.

5. JCAHO Sentinel Events Targets for Teamwork
Joint Commission evaluated the contributing factors of sentinel events using Root Cause Analysis
Of the sentinel events voluntarily reported to the Joint Commission over a ten year period, the top contributing factor has been inadequate communication. Integrating teamwork principles into daily practice can help mitigate errors.

6. What Comprises Team Performance?
Knowledge Cognitions “Think”
Attitudes Affect “Feel”
TeamSTEPPS is composed of four skills: leadership, situation monitoring, mutual support, and communication.
The red arrows depict a two-way dynamic interplay between the four skills and the team related outcomes. Interaction between the outcomes and the skills is the basis of a team striving to deliver safe, quality care.
Team competencies required for high performing teams can be grouped into the categories of knowledge, skills and attitudes. Team-related knowledge results in a shared mental model; attituds result in mutual trust and team orientation. Adaptability, accuracy, productivity, efficiency and safety are the performance outcomes of a high-performing team.
Skills Behaviors “Do”
…team performance is a science…consequences of errors are great…

7. Outcomes of Team Competencies
Knowledge
Shared Mental Model
Attitudes
Mutual Trust
Team Orientation
Performance
Adaptability
Accuracy
Productivity
Efficiency
Safety
Team members possessing strong leadership, situation monitoring, mutual support, and communication skills typically yield important team outcomes. The interrelationships are the foundation of a strong continuous improvement model. The knowledge, skills, and attitudes of teamwork will complement clinical excellence and improve patient outcomes by utilizing feedback cycles and clearly defined tools to communicate, plan and deliver better quality care.
Knowledge leads to shared awareness about what is going on with the team and its progress towards the goal. Team members will also be familiar with the roles and responsibilities of their teammates.
Teams possessing good leadership, situation monitoring, mutual support, and communication skills are more likely to have a positive experience, and develop better trust in the intentions of your teammates.
Overall, team performance will show adaptability when changes are required, and be more adept at backing each other up. Efficiency will improve, especially when you know what you are supposed to do, how you are supposed to do it, and what goal you are striving for. Finally, the team will be safer, as it is more readily able to identify and correct errors if they occur.
No amount of teamwork can compensate for clinical and technical proficiency. The foundation of teamwork builds on technical proficiency and protocol compliance.

8. High-Performing Teams
Teams that perform well:
Hold shared mental models
Have clear roles and responsibilities
Have clear, valued, and shared vision
Optimize resources
Have strong team leadership
Engage in a regular discipline of feedback
Develop a strong sense of collective trust and confidence
Create mechanisms to cooperate and coordinate
Manage and optimize performance outcomes
(Salas et al. 2004)
We will discuss several aspects of high-performing teams, which have several common traits
Clear roles and responsibilities allows all members to know who is responsible for what.
Clear, valued, shared vision unites the team to a shared purpose or goal
Regular feedback helps the team revise team goals and plans, helps establish priorities, provides mechanisms for anticipating and reviewing issues, and provides a mechanism for evaluation of the teams effectiveness.

9. Barriers to Team Performance
Inconsistency in team membership
Lack of time
Lack of information sharing
Hierarchy
Defensiveness
Conventional thinking
Varying communication styles
Conflict
Lack of coordination and follow-up
Distractions
Fatigue
Workload
Misinterpretation of cues
Lack of role clarity

10. Multi-Team System (MTS) for Patient Care
This is a model of a multi-team system. Each team within a multi-team system is responsible for various parts of patient care, but all must act in concert to ensure quality patient care.
The Core Team may be composed of the physician, nurse, and administrative staff member responsible for treating a patient. They will have direct contact with the patient. A contingency team is a team that comes together for a specific purpose – for example, the trauma team, a code team, or a surgical team.
The Coordinating Team might include the clerk checking in patients for the core team, the physician, nurse and enlisted person responsible for the day’s triage, resource management and promotion of teamwork for the clinic.

11. Team Failure Video

12. Effective Team Members
Are better able to predict the needs of other team members
Provide quality information and feedback
Engage in higher level decision-making
Manage conflict skillfully
Understand their roles and responsibilities
Reduce stress on the team as a whole through better performance
“Achieve a mutual goal through interdependent and adaptive actions”

13. TeamSTEPPS
Leadership

14. Effective Team Leaders
Organize the team
Articulate clear goals
Make decisions through collective input of members
Empower members to speak up and challenge, when appropriate
Actively promote and facilitate good teamwork
Skillful at conflict resolution
Evidence also suggests that effective team leaders:
-responsible for ensuring that team members are sharing information, monitoring situational cues, resolving conflicts, and helping each other when needed
-Manage resources to ensure team performance
-Facilitate team actions by communicating through informal exchange sessions
-Ensure that team members are aware of situational changes to plans

15. Promoting & Modeling Teamwork
Effective leaders cultivate desired team behaviors and skills through:
Open sharing of information
Role modeling and effectively cueing team members to employ prescribed teamwork behaviors and skills
Constructive and timely feedback
Facilitation of briefs, huddles, debriefs, and conflict resolution
Sharing information through the use of briefs, huddles, and debriefs
Delegation of tasks which helps promote mutual support
Facilitating situation awareness
- identifying important aspects of the plan

16. Briefs Form the team Designate team roles and responsibilities
Planning
Form the team
Designate team roles and responsibilities
Establish climate and goals
Engage team in short and long-term planning
Briefs are held for planning purposes. During these short 3-5 minute team meetings, essential information for the team is shared
- Who’s who, and who’s the leader
-What is the current clinical status of the patient
-Condition, diagnosis, plan, and status are reviewed
-Team goals are established, barriers and potential pitfalls are identified, assignment of tasks
-Issues affecting team operation – resources normally available that may be restricted during the current shift
The team leader facilitates the brief, and team members actively participate to establish both clinical and team work goals.

17. Huddle Problem solving
Hold ad hoc, “touch-base” meetings to regain situation awareness
Discuss critical issues and emerging events
Anticipate outcomes and likely contingencies
Assign resources
Express concerns
The huddle is a tool for reinforcing the plans already in place for the treatment of patients and assessing the need to change plans. It helps to develop shared understanding between team members. It also provides leaders with an opportunity to informally monitor patient and unit-level situations.
Information updates within the team should occur as often as necessary. Updates can take place in the form of a huddle at a status board, or can occur between individual team members whenever new information needs to be shared

18. Debrief Process Improvement
Brief, informal information exchange and feedback sessions
Occur after an event or shift
Designed to improve teamwork skills
Designed to improve outcomes
An accurate reconstruction of key events
Analysis of why the event occurred
What should be done differently next time
Debriefs can include:
Accurate recounting and documentation of key events
Analysis of why the event occurred, what worked, and what did not work
Discussion of lessons learned and how they will alter the plan next time
Establishment of a method to formally change the existing plan to incorporate lessons learned
Most effective when:
Occur in a timely manner
Conducted in environment where honest mistakes are viewed as learning opportunities
Facilitated by the team leader
Relate to specific team goals or address particular issues related to recent actions of the team
Do not assign blame or failure to an individual (focus on actions not the individual)

19. Facilitating Conflict Resolution
Effective leaders facilitate conflict resolution techniques through invoking:
Two-Challenge rule
DESC script
 Effective leaders also assist by:
Helping team members master conflict resolution techniques
Serving as a mediator
Conflict is inevitable and can be caused by differences in clinical knowledge, work approaches, values, opinions, or personality. Resolution of conflict is necessary in the delivery of safe, quality care. Leadership skill in conflict resolution can enhance team effectiveness and performance. An effective team leader does not allow interpersonal or irrelevant issues to negatively impact the team.
We will talk about the two challenge rule and the DESC script in a little while.

20. TeamSTEPPS
Situation
Monitoring

21. A Continuous Process Situation Monitoring (Individual Skill)
Situation Awareness (Individual Outcome)
Here we have a continuum that begins with the individual skill of situation monitoring which leads to situation awareness. Sharing that awareness with fellow team members results in the team outcome of a shared mental model.
Shared Mental Model (Team Outcome)

22. Situation Monitoring (Individual Skill)
Process of actively scanning behaviors and actions to assess elements of the situation or environment
Fosters mutual respect and team accountability
Provides safety net for team and patient
Includes cross monitoring
Situation monitoring is a skill team members can acquire, practice, and improve on. It enables team members to identify potential issues or minor deviations early enough so that they con correct and handle them before they become a problem or pose harm to the patient. Mutual respect and team accountability are cultivated because situation monitoring provides a safety net for both the patient and team members.
Example: Central Line Bundle – any team member can stop the procedure if they see that sterile field has been broken.
… Remember, engage the patient whenever possible.

23. Cross Monitoring
Mechanism to help maintain accurate situation awareness
Way of “watching each other’s back”
Ability of team members to monitor each other’s task execution and give feedback during task execution
Staff members need to constantly be aware of the situation, anticipate next steps, “watch each other’s back” and take appropriate self-coreective action to prevent errors from reaching the patient.

24. Components of Situation Monitoring:
One way to develop a trained eye is to use the STEP process…
Status of the patient – minor changes in the patient’s vitals may require dramatic changes in the teams’ actions and urgency of response. Is the patient not acting as they had on previous interactions? Have the patient’s vitals changed? Is there a change in the way the patient is eating / drinking?
Team members – monitoring team members for fatigue level, workload, task performance, skill level, and stress level. Teams that recognize and maintain an awareness of their individual team members’ functioning are more likely to lend support or assistance. Observing the actions of fellow team members is a safety mechanism that can be used to mitigate error before the patient is harmed.
Environment – Is the needed equipment present, is it functioning? Is there enough staff to tend to all the patients? Is there enough room to perform a particular procedure?
Progress toward the goal – By monitoring progress toward the team’s established and agreed-on goals, team members will be able to alert the team when strategies or the plan of care may need to be reconsidered or revised or when additional resources are needed. The team needs to consider the status of the patient, the goals of the team, the tasks that have been completed and are yet to be done, and the continued appropriateness of the plan.
Example: Respiratory distress, plan made to intubate patient, decision made to proceed with RSI, patient becomes unconcious

25. A Shared Mental Model is…
The perception of, understanding of, or knowledge about a situation or process that is shared among team members through communication.
A mental model is a mental picture of the relevant facts and relationships defining an event, situation, or problem. Sharing your situation awareness with fellow team members results in a shared mental model or “getting everyone on the same page.”
Shared mental models are knowledge structures of the relevant facts and relationships about tasks or situations that the team is engaged in, and about the way the team members interact. These enable the team to anticipate and predict each other’s needs; identify changes in the team, task, or teammates; and adjust the course of action or strategies as needed.
Sustaining a shared mental model includes – planning, team decision making, and vocalizing. Being able to maintain shared mental models is a crucial team skill.
“Teams that perform well hold shared mental models.”
(Rouse, Cannon-Bowers, and Salas 1992)

26. Shared Mental Model?
Obviously we have a lack of a shared mental model in this picture. Think about how not having a shared mental model can affect our patients’ safety.

27. How Shared Mental Models Help Teams
Help ensure that teams know what to expect, so if necessary, can regroup to get on the “same page”
Foster communication to ensure care is synchronized
Ensure that everyone on the team has a picture of what it should look like
Enable team members to predict and anticipate better
Create commonality of effort and purpose
Shared mental models:
Lead to a mutual understanding of problems, goals, team strategies, patient’s condition, and plan of care
Lead to more effective communication to ensure that team members have the necessary information for task performance
Enable team members to back up and fill in for one another
Help team members understand each other’s roles and how they interplay
Improve ability of individual team members to predict and anticipate the needs of the team
Create commonality of effort and purpose
Most importantly, they help teams avoid errors that put patients at risk
“ Shared mental models help teams avoid errors that place patients at risk.”

28. TeamSTEPPS Mutual Support
Mutual support is critical to the social and task performance aspects of teams. The construct suggests some degree of task interchangeability among members because they must fully understand what each one of the others does. To compensate for individual differences in team performance, constant vigilance is required of all team members.
Mutual support enables teams to function effectively, and is the essence of teamwork. It provides a safety net to help prevent errors, increase effectiveness, and minimize strain caused by work overload. Over time, mutual support fosters team adaptability, mutual trust and team orientation.
Mutual
Support

29. Task Assistance
Team members foster a climate in which it is expected that assistance will be actively sought and offered as a method for reducing the occurrence of error.
“In support of patient safety, it’s expected!”
Task assistance is guided by situation monitoring because situation awareness allows team members to effectvely identify the need to assistance by others on the team. To a certain degree, some of us have been conditioned to avoid asking for help because of the fear of suggesting lack of knowledge or confidence. Many people refuse to seek assistance when overwhelmed by tasks. In support of patient safety, however, task assistance is expected.
One of the most important concepts of task assistance is that assistance should be actively given and offered whenever there is a concern for patient safety related to workload. The focus should be on patient safety rather than the individuals need for task assistance.

30. Feedback Can be formal or informal Constructive feedback
Is considerate, task-specific, and focuses attention on performance and away from the individual (Baron 1988)
Is provided by all team members
Evaluative feedback
Helps the individual by comparing behavior to standards or to the individual’s own past performance (London, Larson, and Thisted 1999)
Most often used by an individual in a coaching or mentoring role
Feedback can be provided by anyone on the team, formal or informal, constructive or evaluative.
Constructive feedback is task-specific, focuses on performance, provided by all team members, and is most beneficial when focused on team processes and is provided regularly
Evaluative feedback helps an individual understand performance by comparing behavior with standards or with the individuals own past performance. It should not be a comparision of an individuals performance with that of other team members

31. Characteristics of Effective Feedback
Good Feedback is—
TIMELY
RESPECTFUL
SPECIFIC
DIRECTED toward improvement
Helps prevent the same problem from occurring in the future
CONSIDERATE
“Feedback is where the learning occurs.”
Timely – Too much time elapsing, and the feedback loses its “punch”.
Respectful – “It’s not personal, it’s business”. Focus on the behavior not the individual. One on one feedback should occur in private as well, not in a public forum.
Specific – Should be about a specific situation or task. Helps the receiver to anchor the feedback to specific skills.
Directed – set goals for improvement
Considerate – Be cognizant of team members’ feelings when providing feedback, and remember feedback both help correct actions but also reinforce actions. Don’t forget to comment on the actions that you want to reinforce.

32. Advocacy and Assertion
Advocate for the patient
Invoked when team members’ viewpoints don’t coincide with that of a decision maker
Assert a corrective action in a firm and respectful manner
In advocating for the patient and asserting a corrective action, the team member has an opportunity to correct errors or the loss of situation awareness. Failure to employ advocacy and assertion has been frequently identified as a primary contributor to the clinical errors found in malpractice cases and sentinel events.
You should advocate for the patient even when your viewpoint is unpopular, in in opposition to another person’s view, or questions authority. When advocating, assert your viewpoint in a firm and respectful manner. You should also be persistent and persuasive, provideing evidence or data for your concerns.
An assertive statement opens the discussion, states the concern, states the problem (real or perceived), offers a solution, and ends with the obtaining of an agreement.

33. Two-Challenge Rule 1 2
The two challenge rule was developed in the aviation industry to prevent disasters caused when otherwise excellent decision makers experience momentary lapses in judgment. In the clinical environment, team members should challenge colleagues if requesting clarification, and confirmation does not alleviate the concern regarding potential harm to a patient.
The first challenge should come in the form of a question, the second challenge should provide some support for your concern.
If the challenges are ignored, and concern still exists, a team member may need to manage up – however this should be communicated to members of the team, that additional input has been solicited.

34. Please Use CUS Words but only when appropriate!
The CUS technique is another framework for expressing concern to the team. Signal phrases like “CUS” catch the attention of team members, help them to understand clearly the issues and the magnitude of the issue.
First, state your concern
Then state why you are uncomfortable
If the conflict is not resolved, state that there is a safety issue. Discuss in what way the concern is related to safety. Again, if the concern continues to go unacknowledged, then manage up.

35. Conflict Resolution DESC Script
A constructive approach for managing and resolving conflict
D—Describe the specific situation
E—Express your concerns about the action
S—Suggest other alternatives
C—Consequences should be stated
Ultimately, consensus shall be reached.
If a conflict has become personal in nature, the DESC script can be used. This is typically used in the more conflicting scenarios in which behaviors aren’t practiced, hostile or harassing behaviors are ongoing, and safe patient care is suffering.
Again remember to focus on the behavior.

36. Collaboration
Achieves a mutually satisfying solution resulting in the best outcome
All Win!: Patient Care Team (team members, the team, and the patient)
Includes commitment to a common mission
Meet goals without compromising relationships
“True collaboration is a process, not an event.”
Collaboration takes time and effort, and in critical situations may not always be feasible. If that occurs, take the time later to address how to handle the situation in the future.

37. TeamSTEPPS
Communication

38. JCAHO: Importance of Communication
Ineffective communication is a root cause for nearly 66 percent of all sentinel events reported*
* (JCAHO Root Causes and Percentages for Sentinel Events (All Categories) January 1995−December 2005)

39. Standards of Effective Communication
Complete
Communicate all relevant information
Clear
Convey information that is plainly understood
Brief
Communicate the information in a concise manner
Timely
Offer and request information in an appropriate timeframe
Verify authenticity
Validate or acknowledge information
Complete
- All relevant information, avoid unnecessary details that lead to confusion
- Leave enough time for questions, and answer questions completely
Clear
- When dealing with patients and families – use layman’s terms
- Use common or standard terminology when communicating with team members
Timely
- Avoid delays in relaying information that could compromise a patient’s situation
- Document observations and interventions in the patient’s record
- Update patients and families frequently

40. SBAR provides…
A framework for team members to effectively communicate information to one another
Communicate the following information:
Situation―What is going on with the patient?
Background―What is the clinical background or context?
Assessment―What do I think the problem is?
Recommendation―What would I recommend?
SBAR is for use when wanting to communicate changes in patient status, etc.

41. Call-Out is…
A strategy used to communicate important or critical information
It informs all team members simultaneously during emergency situations
It helps team members anticipate next steps
Call-out communication also benefits a recorder when present during a code or other emergent event.
One important aspect is directing the information to a specific individual.

42. Check-Back is…
Check-back is a closed loop communication strategy used to verify and validate information exhcanged.
An example would be during a code:
Leader calls for 0.5 ml of 1:10,000 epinephrine. Pharmacist drawing the medication repeats the dosing, leader confirms.
Pharmacist hands the dose to the nurse, repeating the dose, nurse out-loud confirms reception of the dose, then states when she has given the dose. This helps close the loop for the team that the epinephrine has been given.

43. Handoff Optimized Information Responsibility– Accountability
Uncertainty
Verbal Structure
Checklists
IT Support
Acknowledgement
Hand-offs occur at shift change, when a patient is moving from one unit to another.
Ideally, limited to no interruptions, quiet and free of distractions.
Responsibility – When handing off, it is your responsibility to know that the person who must accept responsibility is aware that they are assuming responsibility.
Accountability – You are accountable until both parties are aware of the transfer
Uncertainty – It is your responsibility to clear up all ambiguity of responsibility before the transfer is complete
Communicate verbally – Ideally hand off should include both written and verbal communication. Written communication needs to be legible, and verbal communication needs to be clear. Use of hand off tools such as I PASS THE BATON or DATA can help structure communication that occurs during a hand off into an orderly, clear, and standardized way.
Acknowledge – until the handoff is understood and accepted, you cannot relinquish your responsibility
Opportunity – Handoffs are a good time to review and have a new pair of eyes evaluate the situation for both safety and quality.

44. Communication Challenges
Language barrier
Distractions
Physical proximity
Personalities
Workload
Varying communication styles
Conflict
Lack of information verification
Shift change

45. TeamSTEPPS

46. Team Formation Video