1. Implementing Team Training at Duke Karen Frush, BSN, MD Chief Patient Safety Officer Duke Medicine

2. THE JOURNEY PICU Peri-operative Services GSK Collaborative NCHA Collaborative Comprehensive Implementation across Duke Medicine

3. Team Training: One more initiative?? Time and workload –Adding one more assignment onto everything else Best model? –Lack of data to demonstrate improved outcomes –Many consultants and approaches Required for all team members? –Logistics: Shut down the ORs? Cost vs benefit

4. Teamwork Training Process Phase I: Pre-intervention Chose to work with consultants Gathered pre-training data –Knowledge test –Attitude: Sexton Teamwork and Safety Climate survey –Behavior: Conducted Real-time Observations –Outcome data Processes Clinical outcomes Analyzed Secondary Measures –Staff satisfaction and work culture –Patient satisfaction

5. Teamwork Training Process Phase II: Training Unit leaders involved with planning and implementation (J Mericle, J Meliones, K Mistry) –3 sessions to accommodate shifts Multidisciplinary group sessions Physician, nurse, and human factors facilitators Interactive session with hands-on tools Feedback allowed for further development Focused training for action at unit level –Focused on tools and techniques to address unit’s issues

6. Focused Unit Training Tools Handoff Communication –SBAR: structured language Critical Language –“I need clarity”: assertion “ Sterile Cockpit ” –Focused attention –Limit interruptions during Rounds Huddles for better planning White Boards

7. Teamwork training process Phase III: Implementing change Leadership role models Multi-disciplinary (internal) coaches Interval observations, coaching by consultants Active participation of consultant experts in unit-based safety team meetings Phone calls at unit leaders’ preferred time, to review concerns and discuss barriers Train-the-trainer model used for new staff

8. Teamwork Training Process Phase IV: Comprehensive Evaluation Immediate feedback of training session Change in Knowledge Change in Attitude: Survey Behavior Change: Observations Process or Practice Changes Impact on Clinical Outcomes –Secondary measures

9. Level 1 – Reaction : how did participants react to the training? Level 2 – Learning : whether the training results in an increase in knowledge, skills or attitudes. Level 3 – Behavior : whether participants change their behavior back in the workplace as a result of training. Level 4 – Results : whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment. TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL Post-training reaction survey Teamwork knowledge test. Survey of attitude towards teamwork. Survey of self-perceived communication skills. Observation of teamwork behaviors during routine patient care. Patient satisfaction survey. Complication rate based on AHRQ PSI. Length of hospital stay. Adverse drug events. Patients’ claims. Staff satisfaction survey. Nurse turnover rates.

10. Team Training Results: Will this training impact the way you do business? Not Sure Prob. % Def.

11. Team Training Results: Would you recommend this course to your co-workers? Not Sure Prob. % Def.

12. Level 1 – Reaction : how did participants react to the training? Level 2 – Learning : whether the training results in an increase in knowledge, skills or attitudes. Level 3 – Behavior : whether participants change their behavior back in the workplace as a result of training. Level 4 – Results : whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment. TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL Post-training reaction survey Teamwork knowledge test. Survey of attitude towards teamwork. Survey of self-perceived communication skills. Observation of teamwork behaviors during routine patient care. Patient satisfaction survey. Complication rate based on AHRQ PSI. Length of hospital stay. Adverse drug events. Patients’ claims. Staff satisfaction survey. Nurse turnover rates.

13. PICU Post-Training Survey Responses Summary. Question: “The physicians and nurses here work together as a well-coordinated team (Fisher Exact Test p value=0.011)”

14. PICU Post-Training Survey Responses Summary. Question: “I know the proper channels to direct questions regarding patient safety in this clinical area (p value=0.007)”

15. Level 1 – Reaction : how did participants react to the training? Level 2 – Learning : whether the training results in an increase in knowledge, skills or attitudes. Level 3 – Behavior : whether participants change their behavior back in the workplace as a result of training. Level 4 – Results : whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment. TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL Post-training reaction survey Teamwork knowledge test. Survey of attitude towards teamwork. Survey of self-perceived communication skills. Observation of teamwork behaviors during routine patient care. Patient satisfaction survey. Complication rate based on AHRQ PSI. Length of hospital stay. Adverse drug events. Patients’ claims. Staff satisfaction survey. Nurse turnover rates.

16. Overall Teamwork in PICU (p value=0.0001, fisher’s exact test)

17. Level 1 – Reaction : how did participants react to the training? Level 2 – Learning : whether the training results in an increase in knowledge, skills or attitudes. Level 3 – Behavior : whether participants change their behavior back in the workplace as a result of training. Level 4 – Results : whether the training has affected process or outcomes, such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment. TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL Post-training reaction survey Teamwork knowledge test. Survey of attitude towards teamwork. Survey of self-perceived communication skills. Observation of teamwork behaviors during routine patient care. Patient satisfaction survey. Process or practice changes. Length of hospital stay. Adverse drug events. Patients’ claims. Staff satisfaction survey. Nurse turnover rates.

19. Observations OR – PICU Hand-Off Turnaround Time: Before and After Intervention Turnaround Time (minutes)

20. Operational Changes, Improvements in outcomes Time to critical labs drawn at hand-off Briefings and debriefings implemented; SBAR communication for nursing report, telephone communication Decrease in infection rates Decrease LOS and increased throughput Patient Satisfaction score exceeded target (Press Ganey) Work Culture survey score increased

21. Implementing TeamSTEPPS across Duke Medicine TeamSTEPPS has helped us overcome some initial barriers to team training 4 phase approach to be undertaken throughout high acuity areas at DUH, DRH and DRaH Training with specific tools and concepts (modules) in intermediate units and non-clinical areas Collaborative with UNC SoM, SoN –Assertion and speaking up TeamSTEPPS and simulation, virtual training