1. S trategies and T ools to E nhance P erformance and P atient S afety OWL # U:INSV727

2. T EAM STEPPS 05.2 Mod 1 05.2 Page 2Mod 1 06.2 Page 2 2 Objectives Describe the TeamSTEPPS training initiative Describe the impact of errors and why they occur Describe the TeamSTEPPS framework State the outcomes of the TeamSTEPPS framework

3. T EAM STEPPS 05.2 Mod 1 05.2 Page 3Mod 1 06.2 Page 3 How we communicate and work together can make the difference between life and death. This video exemplifies this impact. TeamSTEPPS is about reducing the likelihood of these stories recurring.. 3

4. T EAM STEPPS 05.2 Mod 1 05.2 Page 4Mod 1 06.2 Page 4 4 Sue Sheridan Sue Sheridan. 76 MB (Click camera to watch. Windows Only) Please wait patiently while movie is downloaded.

5. T EAM STEPPS 05.2 Mod 1 05.2 Page 5Mod 1 06.2 Page 5 5 2006 Patient Safety and Quality Improvement Act of 2005 Patient Safety Movement Executive Memo from President DoD MedTeams® ED Study Institute for Healthcare Improvement 100K lives Campaign “To Err is Human” IOM Report T eam STEPPS 199519992001200320042005 JCAHO National Patient Safety Goals Medical Team Training

6. T EAM STEPPS 05.2 Mod 1 05.2 Page 6Mod 1 06.2 Page 6 6 (Mann, 2006) Beth Israel Deaconess Medical Center Contemporary OB/GYN (Sexton, 2006) Johns Hopkins (Pronovost, 2003) Johns Hopkins Journal of Critical Care Medicine

7. T EAM STEPPS 05.2 Mod 1 05.2 Page 7Mod 1 06.2 Page 7 7 Why TeamSTEPPS For Us? 45 Staff = 1 million possible team combos 72% of medical errors directly linked to lack of clear communication $8 million settlement…… 1 family affected forever $8 million settlement…… 15 more RNs on 1 unit for next 10 years 7

8. T EAM STEPPS 05.2 Mod 1 05.2 Page 8Mod 1 06.2 Page 8 8 We know that communication is not straightforward. The following video clip exemplifies this reality. What happened in this video? It is a question of communication and assumptions.

9. T EAM STEPPS 05.2 Mod 1 05.2 Page 9Mod 1 06.2 Page 9 9

10. T EAM STEPPS 05.2 Mod 1 05.2 Page 10Mod 1 06.2 Page 10 Another example of lack of communication resulting from assumptions is contained in this video. We may chuckle at this honest miscommunication, but what can we do to make sure such a miscommunication does not happen while we are caring for our patients? 10

11. T EAM STEPPS 05.2 Mod 1 05.2 Page 11Mod 1 06.2 Page 11 11 Flowers. 8.7 MB (Click camera to watch. Windows Only) Please wait patiently while movie is downloaded.

12. T EAM STEPPS 05.2 Mod 1 05.2 Page 12Mod 1 06.2 Page 12 Let’s review our TeamSTEPPS tools and see how we can effect patient outcomes like other organizations who have improved patient outcomes. 12

13. T EAM STEPPS 05.2 Mod 1 05.2 Page 13Mod 1 06.2 Page 13 13 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

14. T EAM STEPPS 05.2 Mod 1 05.2 Page 14Mod 1 06.2 Page 14 14 The second tool is CUS, an acronym that helps us remember three key signal words which include: concerned, uncomfortable and safety. Signal words, such as “danger,” “warning,” and “caution” are common in the medical arena. They catch the reader's attention. “CUS” and several other signal phrases have a similar effect in verbal communication. When they are spoken, all team members will understand clearly not only the issue but also the magnitude of the issue. This is a way of getting someone’s attention without yelling or using unprofessional language. It has the advantage of not alienating others and perhaps reducing the likelihood they will contact you the next time an emergency occurs. 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. If the safety issue is not acknowledged, a supervisor should be notified. Regardless of which word is used, if we hear a someone use any CUS word, it is our cue to stop what we are doing and pay attention because patient safety is at risk.

15. T EAM STEPPS 05.2 Mod 1 05.2 Page 15Mod 1 06.2 Page 15 15 CUS

16. T EAM STEPPS 05.2 Mod 1 05.2 Page 16Mod 1 06.2 Page 16 16 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 Important to direct responsibility to a specific individual responsible for carrying out the task Avoid Thin Air Commands …On your unit, what information would you want called out?

17. T EAM STEPPS 05.2 Mod 1 05.2 Page 17Mod 1 06.2 Page 17 17 Read-Back is… Closing the loop on information exchange!

18. T EAM STEPPS 05.2 Mod 1 05.2 Page 18Mod 1 06.2 Page 18 Handoff The transfer of information and authority/responsibility during transitions in care. Includes SBAR information, giving an opportunity to ask questions, solicit a read- back/check back of information shared. Great opportunity for quality and safety!

19. T EAM STEPPS 05.2 Mod 1 05.2 Page 19Mod 1 06.2 Page 19 19 SBAR A technique for communicating critical information that requires immediate attention and action concerning a patient’s condition. Situation – What is going on with the patient? “I am calling about Mrs. L’s fetal heart rate tracing. Background – What is the clinical background or context? She is a primigravida who is being induced Assessment – What do I think the problem is? I think she is having late decelerations. I have stopped the Pitocin, and she is on her left side with oxygen on. Recommendation – What would I do to correct it? I am concerned. I would like you to come evaluate her tracing. When can I expect you?

20. T EAM STEPPS 05.2 Mod 1 05.2 Page 20Mod 1 06.2 Page 20 20 Vig3alg001parathyroidbad.mpeg : 26 MB (Click camera to watch. Windows Only) Please wait patiently while movie is downloaded.

21. T EAM STEPPS 05.2 Mod 1 05.2 Page 21Mod 1 06.2 Page 21 21 How could this be prevented? With better communication as shown in the next video.

22. T EAM STEPPS 05.2 Mod 1 05.2 Page 22Mod 1 06.2 Page 22 22 parathyroidgood.mpeg : 53 MB (Click camera to watch. Windows Only) Please wait patiently while movie is downloaded.

23. T EAM STEPPS 05.2 Mod 1 05.2 Page 23Mod 1 06.2 Page 23 23 How we communicate and work together can make a difference in the care of our patients. Thank you for taking time to view this TeamSTEPPS presentation.