2. T EAM STEPPS 05.2 Mod 1 05.2 Page 2 Introduction Mod 1 06.2 Page 2 2 Module 1 Introduction

3. T EAM STEPPS 05.2 Mod 1 05.2 Page 3 Introduction Mod 1 06.2 Page 3 Exercise Instructions Goal: You have 1 minute to build the tallest tower. Roles: Runners and Builders Rules:  Blocks are located at the front and back of the room.  Runners retrieve blocks from bins but may only take 5 blocks at a time.  Builders build the tower using the pattern of 1 large, 3 small blocks, repeat.  No two blocks of the same color may touch.  Runners are not allowed to build/ builders are not allowed to run.  Any unused blocks that are not replaced in the storage bins before time is called will result in subtraction from the tower height; one block subtracted for each unused block. Report Out: Height of tower in blocks (minus unused blocks). 3

4. T EAM STEPPS 05.2 Mod 1 05.2 Page 4 Introduction Mod 1 06.2 Page 4 Exercise Instructions Debrief: What went well? What didn’t go well? What will you do differently? Same pattern we will follow in simulation − Plan (Brief), Do, Study (Debrief), Repeat 4

5. T EAM STEPPS 05.2 Mod 1 05.2 Page 5 Introduction Mod 1 06.2 Page 5 5 Objectives Describe the impact of errors and why they occur Describe the TeamSTEPPS framework Describe the TeamSTEPPS training initiative State the outcomes of the TeamSTEPPS framework

6. T EAM STEPPS 05.2 Mod 1 05.2 Page 6 Introduction Mod 1 06.2 Page 6 Sue Sheridan Video Videos must be saved in the same file as your power point before you can insert them. Click on insert tab in power point Click on Video Click on Video from file Click on Sue SheridanLg001 Click on Insert 6

7. T EAM STEPPS 05.2 Mod 1 05.2 Page 7 Introduction Mod 1 06.2 Page 7 7 Video Discussion Patients are harmed as a result of poor communication and teamwork that results in medical errors − How often do medical errors occur? − Why do medical errors occur? − How can we prevent medical errors? Applies to non-clinical situations…goals are not achieved …Improved teamwork and communications… Ultimately, a culture of safety Are you ready to be part of the transformation of health care?

8. T EAM STEPPS 05.2 Mod 1 05.2 Page 8 Introduction Mod 1 06.2 Page 8 How Often do Medical Errors Occur? 8 44,000 – 98,000 deaths per year in hospitals due to medical errors IOM (2000). To Err is Human: Building a Safer Health System Equal to one jumbo jet crashing EVERY DAY! Where is CNN? (Photo: Ezra Shaw, Getty Images) www.foxnews.com

9. T EAM STEPPS 05.2 Mod 1 05.2 Page 9 Introduction Mod 1 06.2 Page 9 Impact of Medical Errors From a 2010 analysis of a claims database − 1.8% of hospital admissions experience a medical error (a preventable adverse outcome of medical care) − Medical errors cost the US at least $19.5 billion/year From a random sample of 780 Medicare beneficiaries discharged Oct. 2008 − 13.5% of hospitalized Medicare beneficiaries experience an adverse event (44% were preventable) − 1.5% experienced an event that contributed to their deaths (projects to 15,000 total patients/month) 9 http://www.soa.org/files/pdf/research-econ-measurement.pdf http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf

10. T EAM STEPPS 05.2 Mod 1 05.2 Page 10 Introduction Mod 1 06.2 Page 10 Human Factors 10 Study of the interaction between humans and elements of the system in which they live/work – Physical environment – Tasks – Tools/technology – Organizational conditions Goal: achieve optimal interaction between social, technical, and physical elements of a system. https://www.hfes.org//Web/AboutHFES/about.html

11. T EAM STEPPS 05.2 Mod 1 05.2 Page 11 Introduction Mod 1 06.2 Page 11 11 Why Do Errors Occur—Some Human Factors Workload fluctuations Interruptions Fatigue Multi-tasking Failure to follow up Poor handoffs Ineffective communication Not following protocol Complacency Excessive professional courtesy Halo effect Passenger syndrome Rigid Hierarchies High-risk phase Strength of an idea Task fixation (lack of situational awareness)

12. T EAM STEPPS 05.2 Mod 1 05.2 Page 12 Introduction Mod 1 06.2 Page 12 Task Fixation and Situation Awareness 12 Your Environment Your Team Your Equipment You

13. T EAM STEPPS 05.2 Mod 1 05.2 Page 13 Introduction Mod 1 06.2 Page 13 Human Factors 1. Describe a human error that you made. I ran a stop light. Which human factors contribute to this error? 2. Describe a recent error made at your hospital. CNA had pt use IV pole to walk to bathroom; pt’s legs buckled and she fell. Walker & gait belt were in room. Which human factors contributed to this error? 13 Turn to your neighbor…

14. T EAM STEPPS 05.2 Mod 1 05.2 Page 14 Introduction Mod 1 06.2 Page 14 14 Joint Commission Sentinel Events http://www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_2004_2Q2012.pdf

15. T EAM STEPPS 05.2 Mod 1 05.2 Page 15 Introduction Mod 1 06.2 Page 15 15 The Problem… “The problem is not bad people; the problem is that the system needs to be made safer...” “People make fewer errors when they who work in teams.” IOM (2000). To Err is Human: Building a Safer Health System

16. T EAM STEPPS 05.2 Mod 1 05.2 Page 16 Introduction Mod 1 06.2 Page 16 16 Teamwork Is All Around Us Common purpose Performance goals Mutual accountability Clear role expectations Complementary skills Interdependent tasks

17. T EAM STEPPS 05.2 Mod 1 05.2 Page 17 Introduction Mod 1 06.2 Page 17 17 “Initiative based on evidence derived from team performance…leveraging more than 30 years of research in military, aviation, nuclear power, business and industry…to acquire team competencies” Team Strategies & Tools to Enhance Performance & Patient Safety

18. T EAM STEPPS 05.2 Mod 1 05.2 Page 18 Introduction Mod 1 06.2 Page 18 18 Evolution of TeamSTEPPS Curriculum Contributors Department of Defense Agency for Healthcare Research and Quality Research Organizations Universities Medical and Business Schools Healthcare Foundations Hospitals—Military and Civilian, Teaching and Community-Based Private Companies Subject Matter Experts in Teamwork, Human Factors, and Crew Resource Management (CRM)

19. T EAM STEPPS 05.2 Mod 1 05.2 Page 19 Introduction Mod 1 06.2 Page 19 Army aviation crew coordination failures in mid-80s contributed to 147 aviation fatalities and cost more than $290 million The vast majority involved highly experienced aviators Failures were largely attributed to crew communication, workload management, and task prioritization 19 Evolution of TeamSTEPPS: US Army Aviation

20. T EAM STEPPS 05.2 Mod 1 05.2 Page 20 Introduction Mod 1 06.2 Page 20 20 Evolution of TeamSTEPPS: US Air Force CRM History Mid to Late 80s AF bombers and heavy aircraft started CRM training 1992 Air Combat Command developed Aircrew Attention Management /CRM Training By 1998, CRM deployed uniformly across the AF Steady decline in human factors based mishaps since CRM training deployed AF Medical Service adapted training, rolled out in 2000

21. T EAM STEPPS 05.2 Mod 1 05.2 Page 21 Introduction Mod 1 06.2 Page 21 The Theory 21 Team Leadership Team Orientation Mutual Performance Monitoring Back-up Behavior Adaptability Shared Mental Models Mutual Trust Team Effectiveness Closed Loop Communication Salas, Sims, Burke. Is there a “Big Five” in teamwork? Small Group Research. 2005; 36:555-599. Big 5 Coord. Mechanism

22. T EAM STEPPS 05.2 Mod 1 05.2 Page 22 Introduction Mod 1 06.2 Page 22 22 The Framework: What Comprises Team Effectiveness? Knowledge Cognitions “Think” …team performance is a science…consequences of errors are great… Attitudes Affect “Feel” Skills Behaviors “Do”

23. T EAM STEPPS 05.2 Mod 1 05.2 Page 23 Introduction Mod 1 06.2 Page 23 More Evidence Exploding Literature − Patient Care Team + Evidence-Based Practice = 1,128 − Patient Care Team + Evaluation Studies = 843 Studies in diverse patient populations demonstrate relationship between teamwork and − Improved clinical processes − Reduction in medical errors − Improved surgical team performance − Increased adherence to guidelines − Decreased length of stay − Increased functional status − Decreased mortality Salas et al. What are the critical success factors for team training in health care? Jt Comm Jrnl Qual Safe. 2009;35:398-405.

24. T EAM STEPPS 05.2 Mod 1 05.2 Page 24 Introduction Mod 1 06.2 Page 24 Your Contribution to the Evidence Team training can result in transformational change in safety culture when the work environment supports the transfer of learning to new behavior. Hospital Survey on Patient Safety Culture conducted in 24 hospitals before training one year after training To successfully implement and sustain new behaviors − Stay connected to the community via monthly calls − Train supervisors/managers first so they can role model behaviors − Provide multiple follow-up learning opportunities − Job descriptions/performance evaluations include use of team skills 24 Jones KJ, Skinner AM, High R, Reiter-Palmon R. A theory-driven longitudinal evaluation of the impact of team training on safety culture in 24 hospitals. BMJ Qual Saf. 2013;22:394-404.

25. T EAM STEPPS 05.2 Mod 1 05.2 Page 25 Introduction Mod 1 06.2 Page 25 Supported by AHRQ Duke TRC Minnesota -TRC North Shore Long I. TRC Tulane TRC Washington -TRC UNMC 18 10 58 5 1 1 http://teamstepps.ahrq.gov/aboutnationalIP.htm

26. T EAM STEPPS 05.2 Mod 1 05.2 Page 26 Introduction Mod 1 06.2 Page 26 SHIFT TOWARDS A CULTURE OF SAFETY HOW DOES TEAMSTEPPS WORK?

27. T EAM STEPPS 05.2 Mod 1 05.2 Page 27 Introduction Mod 1 06.2 Page 27 27 HSOPS Teamwork Practices/skills that bridge the gap Identify team leaders Set team goals Use briefs, huddles, debriefs Cross monitor (“watch each others’ back”) (Belief/Attitude) (Behavior) 32% GAP

28. T EAM STEPPS 05.2 Mod 1 05.2 Page 28 Introduction Mod 1 06.2 Page 28 28 Agenda DAY 1 Module 1—Introduction Module 2—Team Structure Module 3—Leadership Module 4—Situation Monitoring Module 5—Mutual Support Module 6—Communication Module 7—Summary— Putting It All Together DAY 2 Coaching Workshop High Fidelity Simulation − Practice team skills − Coach team skills − Identify team skills Webinars to Complete Requirements for Master Trainer Certification Wed. Oct. 16 10 - 11 a.m. Thurs. Nov. 21 2 – 3 p.m.

29. T EAM STEPPS 05.2 Mod 1 05.2 Page 29 Introduction Mod 1 06.2 Page 29 29 Training TOOLS and STRATEGIES Brief Huddle Debrief Situational Monitoring Situational Awareness 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!! BARRIERS to Team Performance 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

30. T EAM STEPPS 05.2 Mod 1 05.2 Page 30 Introduction Mod 1 06.2 Page 30 Impact of errors…patients are harmed, non-clinical teams do not achieve goals TeamSTEPPS Framework − Safety net for fallible human beings TeamSTEPPS training meets a need − Diffuse evidence-based training program nationally and internationally http://teamstepps.ahrq.gov/ Outcomes of TeamSTEPPS Shared Mental Model Adaptability Team Orientation Mutual Trust Team Performance Patient Safety!! Summary 30