Integrating QSEN Competencies in the Workplace:

Teamwork and Collaboration

GNRS 586: LEADERSHIP & CARE MANAGEMENT IN PROFESSIONAL PRACTICE

The QSEN Project

Goal: to continue the improvement of both quality and safety in health care through properly preparing nurses using specific competencies

This goal ideally facilitates better health care delivery by considering the three necessary components of quality and safety (KSA):

-Knowledge-Skills-AttitudesThere are 6 competencies defined in the QSEN Project and each competency has its own individual set of KSAs.

QSEN Competencies

1) Patient-Centered Care

2) Teamwork and Collaboration

3) Evidence-Based Practice

4) Quality Improvement

5) Safety

6) Informatics

Teamwork and Collaboration

QSEN Definition: Functioning effectively within nursing and inter-

professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care

(QSEN Institute, 2014)

Teamwork and Collaboration KSAs

Knowledge Skills Attitudes

Discuss effective strategies for communicating and resolving conflict

Assume role of team member or leader based on the situation and demonstrate commitment to team goals

Respect the centrality of the patient/family as the core members of any health care team

Explain how authority gradients influence teamwork and patient safety

Solicit input from other team members to improve individual and team performance

Value both teamwork and relationships and respect the attributes that members bring to the team

Identify barriers and facilitators and examine strategies for improving systems to support team functioning

Participate in designing systems that support effective teamwork

Value the influence of system solutions in achieving effective team functioning

(QSEN Institute, 2014)

What is the problem?

There is a lack of team-based care, collaboration and teamwork among interdisciplinary teams in the healthcare field.

This lack of communication can lead to:-a decrease in patient safety-an increased number of medical errors-a decrease in efficiency in patient care/outcomes-an unsatisfactory work environment

Who does this problem involve?

Within a hospital there are multiple professions involved in the care of any given patient.

A multidisciplinary team providing care for a patient can/may include:-General practitioners as well as specialists

-Nursing staff (RNs, LVNs, CNAs etc.)

-Allied health professionals (physical therapists, respiratory therapists, occupational therapists, dieticians, psychologists, social workers/case managers)

Why is this a problem?

Patient safety should always be the main focus within a patient’s care plan.

Significance: The lack of teamwork and collaboration between

the disciplines creates various opportunities for errors in patient care, an increase in confusion of patient-specific goals, and a lack of appropriate opinions regarding a patient’s condition. Ultimately, this can lead to poorer patient outcomes, lengthier hospital stays, and a decrease in patient satisfaction.

What can we do?Suggestion for change: We are proposing the continuous implementation of a system called TeamSTEPPS within the hospital setting. This system is used to increase patient safety and quality of care while fostering not only a group setting, but a team mindset.

“The relationship between team communication and patient safety has increased the emphasis placed on training future health professionals to work within teams.” (Brock, 2013)

TeamSTEPPS Introduction Video

https://www.youtube.com/watch?v=DKkMcsfM5yA

Strategies and Tools to Enhance Performance and Patient Safety

-Communication-Leadership-Situation monitoring-Mutual Support

What is TeamSTEPPS?TeamSTEPPS is a set of communication tools that helps decrease patient errors and helps increase patient satisfaction. It works by providing materials to integrate principles of teamwork in all areas of health care and incorporates the use of department specific simulation-based training, scenarios, case studies and multimedia. (King, 2008)

There are 3 phases to the implementation of TeamSTEPPS:1) Assessment (Setting the stage): Determine organizational readiness

2) Planning, Training, and Implementation: Planning and execution; 2 ½ day

training (4 hour development of customized implementation/action plan)

3) Sustainment: sustain and spread improvements in teamwork, performance and

outcomes

Factors that enhance achievement:● Training● Realistic scenarios● Participation● Briefing ● Debriefing (i.e. discussion and/or

video)● Evaluation & feedback ● Reassessment ● Seeing results

Perceived organizational readiness (assessment available on TeamSTEPPS website)

Factors that detract from achievement:● Criticism● Stereotyping● Non-compliance● Lack of interest ● Resistance to change● Change overload● Viewing it as another time

requirement

Influencing Factors

Potential for successTeamSTEPPS is very adaptable and this increases its potential for success in various hospital units

TeamSTEPPS can be tailored to any specific department and include department-specific scenarios (rapid response, dental, primary/long term care, emergency, OB, pediatrics, etc.)

TeamSTEPPS utilizes an approach involving coaching and feedback, this presents an opportunity for staff/individual growth that stimulates progress and change.

Debriefing plays a key role in the success of the program as well as the cooperation of the entire health care team, this process ensures that everyone’s opinion is heard

Literature Review● Research shows that more than half of medical errors are caused by poor

communication and teamwork between healthcare professionals● 2008 study of nurse-physician interactions

o ineffective communicationo low to moderate levels of collaborationo physicians hold greater powero nurse must be more assertive when they communicate!

● A change in culture is needed:o culture of safetyo trust and mutual respect between team members

(Guimond, M., 2009)

Literature ReviewHow do interdisciplinary simulations improve teamwork?● Improve response to emergency situations● Improve effective communication

o Help teams discuss and analyze scenarios togethero Allow for open communication between physicians and other team

members● Reduce staff turnover● Improve staff morale● Improve attitude towards teamwork● Improved patient safety culture: reduced patient falls and aggression

(Stead, Pirone, Adams, Phillips, Kumar, & Schultz, 2009; Klipfel, Carolan, Brytowski, Mitchell, Gettmann, & Jacobsen, 2014; Vertino, 2014; Douglas, B. (2013)

Literature ReviewWhat is the advantage of on-site simulations?

● They provide a safe and familiar place to practice what is being learned● They increase transfer of knowledge to the local environment (i.e. the unit) ● They help providers identify barriers to practice

o i.e. lacking specialized equipment.

What is the attitude towards interdisciplinary simulations?

● Enhanced when simulations are realistic and include debriefing● Builds trust and confidence between team members● Improves discussion of cases with other team members ● Believed to be most effective when team members are coached and mentored

(Rosen, Hunt, Pronovost, Federowicz, & Weaver, 2012; Klipfel et al., 2014))

Change Theory

● Developed by Kurt Lewin in the mid-20th century● Three phases of change: unfreezing, movement, and refreezing● Unfreezing:

o Change agent gathers data and diagnoses the problemo Team members are made aware of change o Interest in change in assessed

● Movement:o Change agent creates and implements change strategieso Team members are included in change and resistance is addressedo Change is evaluated and modified

● Refreezing:o Change agent helps to stabilize system and ensure change is integrated

(Marquis & Huston, 2015)

Leadership● Communicator● Mentor● Risk taker● Critical thinker● Influencer● Change agent● Innovator● Role model● Visionary● Energizer

Management● Assigned position● Have power● Emphasize control● Achieve organizational goals● Direct subordinates● Have formal responsibility● Carry out specific functions

(Marquis & Huston, 2015)

Leadership vs. Management

A manager controls, plans, organizes, and directs the team members, while a leader take risks, inspire, and empowers others to do their best work.

Leadership & Management

“The integration of both leadership and management skills is critical to goal attainment” said Marquis and Huston (2015, p. 33).

When implementing a change, leader-managers must…● Recognize resistance to change● Identify which workers will promote or resist change● Understand how change will affect lives of the subordinates● Identify and implement strategies to reduce resistance● Encourage others to share ideas● Share vision for change with team members● Act as a role model ● Assist subordinates in making change in their work

(Marquis & Huston, 2015)

ResourcesBefore implementation for any given hospital unit there needs to be:

-A Needs Assessment (per department)-A set goal/objectives-Baseline observations

Since the implementation is department-specific there should be sufficient resources:-Personnel-Time (Avg. staff training time is 4-6 hours)-Resources (funding for establishment, training, identifying trainers/coaches, supportive infrastructure, time allowance for staff to train)

ResourcesPilot Implementation of TeamSTEPPS in any given department will occur over a 6 month period once trainers are sent to an official training center.

Example: Implementation in a Labor and Delivery Unit (January 2015)-There will be a Teamwork Perceptions Questionnaire of TeamSTEPPS 6 months after Intervention implementation (June 2015)

Evaulation of goals:(i.e. increased perception of teamwork/behavior and a 75% increase in use of SBAR between nurses and physicians within 6 month of implementation)

CostAccording to Institute of Medicine’s estimation, the cost necessary to implement TeamSTEPPS is minimal when compared to the cost of medical errors occurring due to lack of interdisciplinary communication.

It is estimated that the annual cost of preventable medical errors in US hospitals to be 98,000 in lives and $17-29 billion every year.

(Kohn, Corrigan, and Donaldson, 2000)

Calculating Costs

Trainer Staff Other Costs

Preparing Trainers

$A (hours x trainer’s pay rate)

$B (Travel/Trainer session)

Conducting Training

$C (hours x trainer’s pay rate)

$D ( # of staff x (hours) x pay rate)

$E (food, etc.)

Ongoing Support $F (units participating X (hours of support) x trainer/coach hourly rate)

$G $H

Total $I $J $K

Resources and MarketingTeamSTEPPS resources for staff include:

-6 regional training centers (One in LA, CA at UCLA)

-Online user support network

-Multimedia course materials

TeamSTEPPS Implementation Guide

-Web site for updated resources and information: http://teamstepps.ahrq.gov/

Marketing:-Success stories/research statistics-EBP-Improving the work environment

Project Summary Implementation:● Need for improvement→ Change teams were developed→ Support of

leadership was gained → Master trainers underwent training (Doctors, RT’s, and RN’s) → Coaches were trained → Essential training course began → TeamSTEPPs was rolled out

Constraints: ● Staff interest

o Reading evidence based articles about TeamSTEPPS● Gaining leadership approval

o Go through the master trainer stage and have them present to leadership upon returning

● Getting budgetary approvalo Evidence based, patient safety is of the highest importance

Evaluation ● Several measurement tools are provided in the instruction manual for

TeamSTEPPS.

o Written evaluations measure: Overall course evaluation Teamwork attitude Learning benchmarks Performance observation Teamwork participation

Evaluation Course EvaluationTeamwork Attitude Evaluation

Evaluation Results ● Improve communication and teamwork skills among health care

professionals● Improve patient safety● Successfully integrate teamwork principles into every aspect of the health

care system ● Help teams utilize the right information, people, and resources for the best

clinical outcomes● Increase team awareness and clarify roles and responsibilities ● Resolve conflict and improve information sharing ● Help to eliminate barriers to quality and safety

Evaluation Factors that facilitate change

● An evidence based teamwork system ● Need for stronger teamwork and

safety culture● A desire for change and improvement ● Leadership support● Willing staff● Institutional support● Committee or personnel willing to

initiate TeamSTEPPS

Factors that inhibit change● Resistance to change ● Fear of another time requirement ● Not being a team player or seeing the

benefit or teamwork ● Lack of interest from various levels of

healthcare professionals ● Lack of leadership

Evaluation Suggested Alternative Approaches● New York City Health and Hospitals Corporation

o Suggests: Consider and financial implications including staff time, meals, and hotel expenses. Have a full budget allocation determined before launching.

● Kaleida Health:o Suggests: Channels for feedback be clearly defined. Listening to

those who are hesitant to buy-in often have valuable feedback. ● University of North Carolina Health Care

o Suggests: Support change at a pace that matches the facilities resources. Develop peer to peer coaching. Begin to integrate TeamSTEPPS into expectations of hiring, training, and performance review of new and existing staff.

ReferencesBrock, D. (2013). Interprofessional education in team communication: working together to improve patient safety. Postgradute Medical Journal 89(1057).

Klipfel, J. M., Carolan, B. J., Brytowski, N., Mitchell, C. A., Gettman, M. T., & Jacobson, T. M. (2014). Patient Safety Improvement Through In Situ Simulation Interdisciplinary Team Training. Urologic Nursing, 34(1), 39-46. doi:10.7257/1053-816X.2014.34.1.39 Rosen, M.A., Hunt, E.A., Pronovost, P.J., Federowicz, M.A., & Weaver, S.J. (2012). In Situ Simulation in Continuing Education for the Health Care Professions: A Systematic Review. Journal Of Continuing Education In The Health Professions, 32(4), 243-254. doi:10.1002/chp.21152 Freeth ,D., Ayida, G., Berridge, E., Mackintosh, N., Norris, B., Sadler, C., & Strachan, A. (2009). Multidisciplinary obstetric simulated emergency scenarios (MOSES): Promoting patient safety in obstetrics with teamwork-focused interprofessional simulations. Journal Of Continuing Education In The Health Professions, 29(2), 98-104. doi:10.1002/chp.20018 Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To Err Is Human:: Building a Safer Health System (627). National Academies Press.

Guimond, M. (2009). TeamSTEPPS. American Journal of Nursing: 109(11).

Vertino, K. A. (2014). Evaluation of a TeamSTEPPS© Initiative on Staff Attitudes Toward Teamwork. Journal Of Nursing Administration, 44(2), 97-102. doi:10.1097/NNA.0000000000000032

Marquis, B.L. & Huston, C.J. (2015). Leadership roles and management functions in nursing. Philadelphia: Wolters Kluwer.

QSEN Institute. (2014). Pre-Licensure KSAs. Retrieved October 10, 2014, from http://qsen.org/competencies/pre-licensure-ksas/

Stead, K., Pirone, C., Adams, R., Phillips, P., Kumar, S., & Schultz, T. (2009). TeamSTEPPS: Implementation of a teamwork programme into an Australian setting. Public report on pilot study. Safety and Quality Unit: Department of Health, SA.

TeamSTEPPS: National Implementation. (2014). Agency for Health Research and Quality. Retrieved on October 27, 2014. http://teamstepps.ahrq.gov/