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The University of Nebraska Medical Center

AHRQ Annual Meeting Sept. 15, 2009

Measuring Improvement in Hospital

Teamwork: Diffusion of TeamSTEPPS

in Critical Access Hospitals

Katherine Jones, PT, PhDWendi Nordhausen, RN, BSNMark Goodridge, RT (R) (CT)

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Acknowledgements

Our Team• Anne Skinner, RHIA• Robin High, MS, MBA• Andrea Bowen, BA• 99 Master Trainers from

24 Critical Access Hospitals

Our Funding• AHRQ Office of

Communications and Knowledge Transfer

• Nebraska Dept of Health and Human Services

• Good Samaritan Health Systems Network

• St. Elizabeth CAH Link• Direct funds from 14

Critical Access Hospitals

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Medicare Rural Hospital Flexibility Program (Flex Program)

Objectives

• Describe a collaborative approach to implementing TeamSTEPPS within a state/region

• Use the AHRQ Hospital Survey on Patient Safety Culture (HSOPS) to plan and evaluate the implementation of TeamSTEPPS

• Use ‘Diffusion of Innovations,’ Kirkpatrick’s Taxonomy, and decision frame to explain variations in success implementing TeamSTEPPS

• Implement lessons learned from two Critical Access Hospitals to facilitate adoption of TeamSTEPPS

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TeamSTEPPS Background

• 05 – 07 AHRQ Partnerships in Implementing Patient Safety Grant (1 U18 HS015822)– Purpose: Implement patient safety practices of

voluntary medication error reporting and organizational learning in 24 CAHs

– Aim: Develop organizational infrastructure for reporting and analyzing medication errors needed to identify system sources of error

– Evaluate impact of this infrastructure change on safety culture with HSOPS

• HSOPS results revealed need for teamwork4

Implementation Background

• 3/2008 initial funding through AHRQ Office of Communications and Knowledge Transfer

• Purpose: Implement the patient safety practice of teamwork and communication training in 25 Critical Access Hospitals

• Aim: Evaluate impact of TeamSTEPPS training program on safety culture using our rural-adapted version of the AHRQ HSOPS

• Collaborative funding through 12/2010

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Collaborative Funding

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Implementation CycleCycle I 2007 – 2009 24 CAHsCycle II 2009 – 2010 15 CAHs

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Diffusion of TeamSTEPPS in Nebraska

8 NE TeamSTEPPS 35/65 CAHs, 1 Network Hospital, 3 IA CAHs, 1 LA CAH

Measuring to Implement TeamSTEPPS

TeamSTEPPS Tools to bridge gap between belief and behavior.•Situation Monitoring •Mutual Support… Seeking and offering Task Assistance•Briefs, Huddles, Debriefs

Teamwork Within Departments Chase County Community Hospital 2007

Percent Positive

1. People support one another in this department. (BELIEF) 81

2. When a lot of work needs to be done quickly, we work together as a team to get the work done.

89

3. In this department, people treat each other with respect. 70

4. When one area in this department gets really busy, others help out. (BEHAVIOR)

57

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Measuring to Implement TeamSTEPPSCommunication OpennessChase County Community Hospital 2007

Percent Positive

1. Staff will freely speak up if they see something that may negatively affect patient care. (BELIEF)

65

2. Staff feel free to question the decisions or actions of those with more authority. (BEHAVIOR)

36

R3. Staff are afraid to ask questions when something does not seem right.

57

TeamSTEPPS Tools to bridge gap between belief and behavior.•Advocacy and assertion•I’m Concerned, I’m Uncomfortable, Stop the procedure (CUS)

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Measuring to Implement TeamSTEPPS

TeamSTEPPS Tools to improve structured communication across shifts and departments.•SBAR, Closed loop communication, Seeking Clarification•Huddles and WalkRounds after shift change•I PASS the BATON 11

Hospital Handoffs and TransitionsClarinda Regional Health Center

Percent Positive

R1. Things “fall between the cracks” when transferring patients from one department to another.

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R2. Important patient care information is often lost during shift changes.

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R3. Problems often occur in the exchange of information across hospital departments.

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R4. Shift changes are problematic for patients in this hospital. 49

Measuring to Evaluate TeamSTEPPS

Team Behaviors Added to HSOPS•Use SBARw/in dept•Offer task assistance w/in dept•Use structured communication (SBAR, I PASS the BATON) across depts•Conduct a huddle in response to changing workloads•Conduct a debrief for improvement when things don’t go according to plan

Responses• Never• Rarely• Sometimes• Most of the Time• Always

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Evaluation: Adoption of Behavior

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Implementing TeamSTEPPS atClarinda Regional Health CenterClarinda, Iowa

Mark Goodridge, RT (R) (CT)

TeamSTEPPS at Clarinda Regional Health Center• Critical Access Hospital – 25

Beds• Average daily census 7- 8 • Census can vary from 4 -14 in

24 hours• 85% of services are out-

patient• 400-500 ED visits per month• 600-700 specialty clinic visits

per month• 225 employees – FT & PT

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Page County Iowa Pop. 15,664Density 32/sq mi

TeamSTEPPS Training—Master Trainers

• 3 Master Trainers trained April 2008 with UNMC Collaborative –Senior Staff member

• Elaine Otte COO

–Frontline staff • Mark Goodridge RT (R) (CT)• Jennifer Chambers RN (ED)

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TeamSTEPPS Training—Leadership

Leadership Development Training•Department managers•Senior Staff members•Board of Trustees•Fundamentals Course•One time training session off campus•Managers required to submit action plans to COO

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Role Play during Leadership Development

TeamSTEPPS Training—All Staff

• Nov & Dec 2008• 15 – 20 staff per class• All classes

interdisciplinary• Essentials course • Team building exercises• Goal to train all staff

within 2 weeks by Master Trainers & Education Director

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Team Building Exercise during Staff Training

We Defined TeamSTEPPS as a Change

• We created a Sense of Urgency– Results from the 2006 Patient Safety Survey – Sue Sheridan video

• We ensured staff viewed TeamSTEPPS as consistent with our mission to provide exceptional care in a safe environment

• TeamSTEPPS is better than our “old way of communicating”– Shared stories of impact of our “old way”– TeamSTEPPS videos and role playing

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We Obtained Management Support

• Senior leaders are educated and supportive of the TeamSTEPPS initiative– COO trained as Master Trainer

• The board is educated and supportive of the TeamSTEPPS initiative– Included in the Leadership Fundamentals

Training Session• Medical Staff education—in progress; goal is to

shift from “I” to “We”

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Our Champions Led the Way

• Mark (Radiology) & Jennifer (Nursing)- front line champions

– Led the organization by training staff & mentoring department managers

– Use TeamSTEPPS language– Overcome resistance by engaging key employees

and managers

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Resources Used for Implementation

• UNMC’s support– conference calls– sharing tools– Lessons Learned

Conference Nov 2008

• Senior Staff support

• Funds allocated for the program by COO

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Our Poster at UNMC Lessons Learned ConfNov. 2008

We are Sustaining TeamSTEPPS

• “Not a flavor of the month”• Senior Staff and Board of Trustees buy-in• Use TeamSTEPPS tools and language—role

models • Focus on Debriefs for drills and code alerts• Part of new employee orientation

– COO introduces concept to all new employees– Biannual Essentials Course– All receive a pocket guide

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Lessons Learned and Next Steps

• Support of Board of Trustees– Attended Leadership training

• Next Steps– Medical Staff training– Sustainment – Use TeamSTEPPS tools in specific

areas– Communicate use of TeamSTEPPS by professional

organizations (AORN)

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We are Measuring to Identify Improvement

• How do we know our training program resulted in change in culture, learning and behavior?

– Data from HSOPS – Observed Changes in process and behavior

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Implementing TeamSTEPPS atChase County Community HospitalImperial, Nebraska

Wendi Nordhausen, RN, BSN

TeamSTEPPS at Chase County Community Hospital

• 25 Bed – Critical Access Hospital

• Average Daily Census – 2 to 6 patients

• Staff 105 employees• Attached clinic• 3 physicians, 2 physician

assistants, 2 nurse practitioners

Chase County Pop. 3,269Density 4/sq mi

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TeamSTEPPS Training

• 4 Master Trainers - April 23 - 25th, 2008 as part of UNMC Collaborative

• Included ALL staff and medical staff• Board informed• Included all modules in Fundamentals Course–

adapted to our specific needs• Offered 4 to 5 times each week in 60 – 90

minute sessions for 7 weeks• Included one 6 hour make-up day

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We Defined TeamSTEPPS as a Change

• We created a sense of urgency…

• We ensured staff viewed TeamSTEPPS as consistent with our mission and vision

• We ensured staff saw TeamSTEPPS as better than our “old way of communicating”– Started with SBAR and trauma debriefs

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We Obtained Management Support

• Senior leaders are educated and supportive of the TeamSTEPPS initiative

• The board is educated and supportive of the TeamSTEPPS initiative

• Medical Staff is educated and supportive of the TeamSTEPPS initiative

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Our Champions Led the Way

• CEO – Master Trainer, Leader

• Physician - QI background

• Linda (Resp. Therapist), Lori (Lab Coord.), Wendi (QI Coordinator) – Interdisciplinary Master Trainers

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We are Sustaining TeamSTEPPS

• Employees know TeamSTEPPS is a priority– Use the tools and language– Scenarios brought to manager & dept meetings

• TeamSTEPPS changed day to day processes– SBAR– Trauma Debriefs

• Our organization supports and rewards involvement in TeamSTEPPS

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Resources Used for Implementation

• UNMC conference calls • Administrative Support• Lessons Learned

Conference• Critical Access Hospital

Network Meeting• Additional Master

Trainers could make a difference

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Our Poster at UNMC Lessons Learned ConfNov. 2008

Lessons Learned and Next Steps

• Most effective aspect of implementation- trained all staff in Fundamentals

• Least effective aspect…change team function

• Current and Future Focus – Orient new employees, Quarterly refresher courses, higher level of implementation and integration of the tools.

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We are Measuring to Identify Improvement

• How do we know our training program resulted in change in culture, learning and behavior?

– Data from HSOPS – Observed Changes in process and

behavior… mails structured by SBAR, conversations about “processes” and communication

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Measuring to Evaluate for IndividualHospitals and the Collaborative

Katherine Jones, PT, PhD

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Measuring to Evaluate

Alliger et al. A meta-analysis of the relations among training criteria. PersonnelPsychology. 2006, 50: 341-358.

Kirkpatrick’s Taxonomyof Training Criteria

Rural HSOPS Spring 2009

• Population Surveyed– 24 Hospitals evaluate impact of TeamSTEPPS

Implementation 2008 – 2009 (2,137 respondents)– 13 Hospitals obtain baseline prior to TeamSTEPPS

Implementation (1,328 respondents)– Added Teamwork Related Items to HSOPS

• Overall Response Rate for 37 Hospitals 3465/4601 = 75.3%

• Range 51% - 96%38

Added HSOPS Knowledge & Behavior Items

Knowledge• Teamwork

experience• Define brief• Define SBAR• Define CUS• Apply CUS

Behavior• Use SBARw/in dept• Offer task assistance w/in dept• Use structured communication

(SBAR, I PASS the BATON) across depts.

• Conduct a huddle in response to changing workloads

• Conduct a debrief for improvement when things don’t go according to plan

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40

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HuddleTask Assist

Advocate2 ChallengeCUS

BELIEF

BELIEF

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Decision Frame Revealed in HSOPS• Decision frame: mental structures people use to

organize the world– Reference point changes with knowledge

• If behaviors change to reflect change in knowledge… Belief may not change– Consider item level scores not just dimension scores

to track change over time

• If behavior not consistent with new knowledge…HSOPS results less positive after training– Seek higher standard based on new knowledge

Tversky A, Kahneman D. Science. 1981;211:453-458. Wright G. Goodwin, P. Strategic Management Journal, Strat Mgmmt J.

2002;23:1059-1067.

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Debriefs

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ChangeIn Frame?

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Evaluation: Training - Knowledge

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Evaluation: Knowledge - Behavior

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EVALUATION: TRANSFER OF TRAINING TO

BEHAVIOR USING 5 BEHAVIOR ITEMS ADDED

TO HSOPS

Odds Ratio of Reporting Behavior Most of time/ Always for those Completing Some Modules* (n=752)

Odds Ratio of Reporting Behavior Most of time/ Always for those Completing All Modules or Master Trainer* (n=459)

Use structured communication within department **

1.67 1.87

Offer task assistance to stressed team member within department**

1.40 1.77

Use structured communication across departments**

1.92 2.32

Call a huddle in response to changing information or workload within department**

1.54 1.36

Debrief within department for quality improvement***

1.25 1.57

*Reference Group is those reporting no training in TeamSTEPPS Modules **p< 0.0001, ***p=0.0012

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Evaluation: Behavior - Safety

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Measuring Improvement Summary

r = 0.79

r = 0.52

r = 0.59

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Diffusions of Innovation Theory• Explains why training/knowledge does not always result in

changes in behavior• Change clearly defined; better than old way

– Trialable, Observable

• Management is supportive; – Change is a clear priority and is rewarded– Resources are available

• Champion(s) overcome resistance• Policy/procedure/job descriptions sustain• Effectiveness is evaluatedRogers EM. Diffusion of Innovations. 5th ed. New York: Free Press; 2003.Helfrich et al. Med Care Res Rev. 2007;64:279-303. Saint S et al. Jt Comm J Qual Patient Saf. 2009;35:239-246.

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Summary and Next Steps• Collaboration across state and local organizations

can leverage resources to diffuse TeamSTEPPS across a state and region

• Use AHRQ HSOPS to plan and evaluate TeamSTEPPS as a patient safety innovation

• Diffusion of innovations theory, Kirkpatrick’s Taxonomy of Training Criteria, and decision frame are concepts needed to interpret measurement of teamwork with HSOPS

• Next Steps: More training, physician engagement, link teamwork to patient outcomes

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Contact Information Katherine Jones, PT, PhDkjonesj@unmc.edu

Wendi Nordhausen, RN, BSNwnccch@gpcom.net

Mark Goodridge, RT (R) (CT)goodridge_mark@yahoo.com

Web site where safety culture tools and rural-adapted version of HSOPS are posted

www.unmc.edu/rural/patient-safety 55