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Strategies and Tools for Patient Safety
“Initiative based on evidence derived from team performance…leveraging
more than 25 years of research in military, aviation, nuclear power, business and industry…to acquire team
competencies”
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Understand the role of communication in patient safety
Acknowledge that conflict creates significant risk for patients
Gain a basic understanding of TeamSTEPPS tools and incorporate into patient care
Support co-workers in utilizing TeamSTEPPS tools to enhance patient safety
Objectives
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How Health Care Systems have measured success with TeamSTEPPS:
– Length of Stay – Reduction in sentinel events– Quality Patient Indicators- Culture of safety
– Staff retention– Event reporting (STARS)– Staff satisfaction– Patient satisfaction
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1
1.2
1.4
1.6
1.8
2
2.2
2.4
June July August Sept Oct Nov Dec Jan Feb March April May
Avg
. L
eng
th o
f S
tay
(da
ys)
Length of ICU Stay After Team Training
50% Reduction
(Pronovost, 2003)Johns HopkinsJournal of Critical Care Medicine
Length of ICU Stay After Team Training
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OR Teamw ork Climate and Postoperative Seps is Rates (per 1000 discharges)
Group Mean
Low Teamwork Climate
Mid Teamwork Climate
High Teamwork Climate
0
2
4
6
8
10
12
14
16
18
A HRQ National A verage
Teamwork Climate Based on Safety Attitudes Questionnaire
Low High
(Sexton, 2006)Johns Hopkins
OR Teamwork Climate and Postoperative Sepsis Rates
(per 1000 discharges)
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What Defines a Team?
Two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal, have specific roles or functions, and have a time-limited membership
“Individual commitment to a group effort—that is what makes a team work, a company work, a society work, a civilization work.”
–Vince Lombardi
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Team Structure
The ratio of We’s to I’s is the best indicator of the development of a team.
–Lewis B. Ergen
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High-Performing TeamsTeams that perform well:
– Have clear, valued, and shared vision– Engage in a regular discipline of feedback
• Briefs, huddles, debriefs
– Manage and optimize performance outcomes• Hold each other accountable• Give feedback and share information
(Salas et al. 2004)“The trick is understanding that only a special type of
teamwork and camaraderie can catch in time the types of medical errors a hospital will always generate.”
(Nance, 2009)“Why Hospitals Should Fly”
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Barriers to Team Performance
• Lack of information sharing
• Hierarchy• Defensiveness• Conflict• Distractions
• Fatigue• Workload• Lack of role clarity• Lack of coordination
and follow-up
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A Shared Mental Model is…
The perception of, understanding of, or knowledge about a situation or process that is shared among team members through communication.
“Teams that perform well hold shared mental models.”
(Rouse, Cannon-Bowers, and Salas 1992)
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How Shared Mental Models Help Teams
• Help ensure that teams know what to expect, so if necessary, can regroup to get on the “same page”
• Foster communication to ensure care is synchronized• Ensure that everyone on the team has a picture of
what it should look like• Enable team members to predict and anticipate
better• Create commonality of effort and purpose
“ Shared mental models help teams avoid errors that place patients at risk.”
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Eight Steps of Change• Create sense of urgency• Build the guiding team• Develop a change vision and strategy• Understanding and buy-in• Empower others• Short term wins• Don’t let up – Be relentless• Create a new culture
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Team Leader
Two types of leaders:– Designated – The person assigned to lead
and organize a designated core team, establish clear goals, and facilitate open communication and teamwork among team members
– Situational – Any team member who has the skills to manage the situation-at-hand
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Effective Team Leaders
• Organize the team• Articulate clear goals• Make decisions through collective input of
members• Empower members to speak up and
challenge, when appropriate• Actively promote and facilitate good
teamwork• Skillful at conflict resolution
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Promoting & Modeling Teamwork
Effective leaders cultivate desired team behaviors and skills through:– Open sharing of information– Role modeling and effectively cueing team
members to employ prescribed teamwork behaviors and skills
– Constructive and timely feedback– Facilitation of briefs, huddles, debriefs, and
conflict resolution
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Communication and Conflict Resolution Techniques
• Communication is a skill
• Communication starts with active listening
• Conflict resolution is a higher level skill built on effective communication and active listening plus….
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Communication 101
DEPERSONALIZE: The more inappropriate communication is, the less you have to own it!!!!”
“No one can make me feel inferior without my consent” Eleanor Roosevelt
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Communication 101
• Being able to depersonalize inappropriate communication and/or behavior allows us to effectively begin the process of conflict resolution
• When we do not feel diminished or upset we can focus on the goal
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Communication 101
Two goals of any conversation
including conflict resolution:
• Good working relationships with co-workers
• Safe and optimal patient care
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Conflict resolution 101
• Make positive assumptions• Keep goal of communication in mind• If you meet with resistance…”I don’t know
what you’re talking about”, “whatever”..,” you’re crazy”, don’t respond to the words, respond to the feelings and keep focused on goal, “You’re getting upset, that’s not my intent”.
• Repeat goal of conversation
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Communication Breakdown
Reasons for communication breakdown between nurse and physician
• Disagreement over discharge orders• Disagreement over treatment plan• Misunderstanding the other’s rationale for
action or for delay in meds or treatmentsFocus on:• Patient safety, danger or harm to patient• Ethical considerations
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Delegation• Process includes 4
steps:– Decide what to
delegate– Decide to whom to
delegate – Communicate
clear expectations– Request feedback
Why is it such a problem?
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Standards of Effective Communication
• Complete– Communicate all relevant information
• Clear– Convey information that is plainly understood
• Brief– Communicate the information in a concise manner
• Timely– Offer and request information in an appropriate timeframe– Verify authenticity– Validate or acknowledge information
• Respectful– Critical aspect of effective delegation
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Tools for Conflict Resolution
DESC
D escribe the situation
E xpress concerns
S uggest alternatives
C onsequences of actions
CUS I am Concerned!
I am Uncomfortable!
This is a Safety issue!
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SBAR provides…
• A framework for team members to effectively communicate information to one another
• Communicate the following information:– Situation - What is going on with the patient?– Background - What is the clinical background or
context?– Assessment - What do I think the problem is?– Recommendation - What would I recommend?
Remember to introduce yourself . . .
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HandoffThe transfer of information (along with authority
and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify, and confirm
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Handoff• Optimized Information
• Responsibility– Accountability
• ELIMINATE Uncertainty
• Verbal Structure
• Checklists
• Acknowledgement of Understanding, Feedback
Great opportunity for quality and safety
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Additional TeamSTEPPS Team Communication Tools
• Briefs – planning
• Huddles – problem solving
• Debriefs – process improvement
Leaders are responsible to assemble the team and facilitate team events
But remember…
Anyone can request a brief, huddle, or debrief
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Briefs
Planning– Form the team– Clarify team roles
and responsibilities– Establish goals
(shift, patient,unit)– Engage team in short
and long-term planning
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Briefing Checklist
TOPIC
Who is on team?
All members understandand agree upon goals?
Roles and responsibilitiesunderstood?
Plan of care?
Staff availability?
Workload?
Available resources?
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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
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Debrief
Process Improvement• Brief, informal information exchange and
feedback sessions• Occur after an event or shift• Designed to improve teamwork skills• Designed to improve outcomes
– An accurate reconstruction of key events– Analysis of why the event occurred– What should be done differently next time
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Debrief ChecklistTOPIC
Communication clear?
Roles and responsibilities understood?
Situation awarenessmaintained?
Workload distribution?
Did we ask for or offerassistance?
Were errors made or avoided?
What went well, what should change, what can improve?
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The primary role of all Healthcare providers is patient advocacy
• Effective communication and conflict resolution are essential
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“When each member accepts full responsibility and strives for excellence…trust and performance increase exponentially…the team is ready to take off.”
- Scott ‘Yogi’ Beare
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Kaleida Health Patient Safety Initiative 2010
• Educate staff on TeamSTEPPS tools*– Brief– Debrief– Huddle– Handoff– Situation monitoring
*Orientation, Preceptor Workshop, PICU at WCHOB
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