1. Emergency Department Experience
TeamSTEPPS
Emergency Department Experience

2. 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

3. “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

5. Science of Human Factors
Human Characteristics
Perception
Memory
Decision-making
Physical Capabilities (skills to do tasks)

6. Nominal Error Rates (highly predictable)
General error of commission (eg. Misread label)
General error of omission in absence of reminders (memory)
General error of omission for 10 step process
General error of omission when items are embedded in procedure
(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)
General error rate given very high stress levels where dangerous
activities are occurring rapidly

7. 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?”

8. 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?”

9. Why do we do this? Respect Fear Embarrassment
“No one likes a backseat driver.”

10. 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

11. 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

12. Project #1: Teamwork and Human Factors Training
Emergency Department

13. 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

14. Objectives
Demonstrate an effective model for building multidisciplinary teamwork skills
Multimodal
Interdisciplinary
Specifically address practice gaps
Related to organizational outcomes like safety and satisfaction

15. 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”

16. Outcomes of Team Competencies
Knowledge
Shared Mental Model
Attitudes
Mutual Trust
Team Orientation
Psychological Safety
Performance
Adaptability
Accuracy
Productivity
Efficiency
Safety

17. 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)

18. 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

19. 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

20. February/March 2008: Team STEPPS overview sessions delivered to ED Leadership and Ancillary Leadership (Stakeholders)

21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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)

27. 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

28. 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)

30. 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

31. 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

33. 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

34. Information Exchange Specific Recommendations for EMS
Checklist for EMS report to team

35. 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

36. 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

37. Specific Strategies Interruptions and Distractions
Sterile Cockpit times
Checklist for need to interrupt
??IT solutions
??communication boards

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

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

40. 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.

41. 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.

42. Results

44. 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

45. 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

50. 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

51. 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”

53. END

54. Slides for potential questions

57. 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

58. 8 Steps of Change
John Kotter

59. 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?

60. Components of Safety Culture
Informed = SAFE
Learning
Flexible
Just (mistake, recklessness, sabotage)
Report

61. 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

62. CPA
Clear correlation of CPA with patient satisfaction scores

63. 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).

64. 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

65. mean = 3.22, α = .81