1. Strategies and Tools to Enhance Performance and Patient Safety 1 Cindy Brach Agency for Healthcare Research and Quality

2. Culture Change 06.2 Page 2 Health Care and Teamwork Communication failures account for the overwhelming majority of adverse events Medical care is complex and human performance has inherent limitations Effective teamwork can prevent mistakes Embedding evidence-based training and team behaviors can enhance safety Leonard, Graham, & Bonacum, 2004 Team training has a positive impact on work force retention Pronovost in press Leonard, Graham in press 2

3. Culture Change 06.2 Page 3 AHRQ/DoD Partnership Activities began in 2002 Expert Panel Comprehensive literature review and case study analysis Clinical measures of teamwork (RAND evaluation contract Mod) Medical Team Training Curriculum TeamSTEPPS Edited Handbook National Implementation Evidence- Based Methods Tools for Training and Measurement Principles and Guidelines 3

4. Culture Change 06.2 Page 4 Easy-to-Use Multimedia Kit Contains Instructors/Leader’s Guide Camera ready materials for handouts Presentation materials (PowerPoint slides & videos) Evaluation instruments Battles JB, Sheridan MM The FLEXTRA Kit: a model for instructor support materials. J Biocommunication; 1989:6;3;1-13. 6

5. Culture Change 06.2 Page 5 National Implementation Project Created a national infrastructure to support the adoption of TeamSTEPPS Quality Improvement Organizations Hospital Engagement Networks ACTION Partners Academic Medical Centers Other Countries (Japan, Australia, Netherlands) Spread TeamSTEPPS: trained over 5000 Master Trainers who trained 25,000 trainees to date 10

6. Culture Change 06.2 Page 6 7 Products and Materials Core TeamSTEPPS Rapid Response Systems (RRS) Module Limited English Proficiency (LEP) Module Primary Care Long-term Care

7. Culture Change 06.2 Page 7 More Information For more information about TeamSTEPPS, the TeamSTEPPS National Implementation Project or to find out if your organization is eligible to receive Master Trainer training preparation under the TeamSTEPPS National Implementation Project, please email us at AHRQTeamSTEPPS@aha.org/ http://teamstepps.ahrq.gov/ 14