KAISER PERMANENTE
FONTANA - ONTARIO MEDICAL
CENTERS
TeamSTEPPS Journey
August 3, 2016
Kathy Christmas, RN, MSN, CPHRM – Director Risk Management & Patient Safety Bonnie Dean, RN - Project Manager, Risk Management & Patient Safety Joan Wheeler, RN - Project Manager, Risk Management & Patient Safety Shawn Winnick, MD - Physician Champion TeamSTEPPS
On the road to ZERO
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“Two Medical Centers, One Promise”
Service
Quality
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About Kaiser Permanente
Founded in 1945, Kaiser Permanente is a non-profit
health care organization serving more than 9.1 million
members in the US.
Kaiser Permanente has three entities:
Kaiser Foundation Health Plan
Kaiser Foundation Hospitals
SCPMG Permanente Medical Group
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Our Mission - Our Vision
Mission
Kaiser Permanente exists to provide high-quality,
affordable health care services and to improve the
health of our members and the communities we serve.
Vision
We are trusted partners in total health, collaborating
with people to help them thrive and creating
communities that are among the healthiest in the
nation.
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Our Integrated System
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Our Structure
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Fontana Medical Center
Since 1943, Kaiser Permanente has served
Fontana and the surrounding community with
quality care and service
Staff Beds 314
52 bed Emergency Department.
ED patients volume 2015 - 96,860
ED Non member visit volume - over 36%
Monthly ED volumes – 7600 +/month
700 + Physicians
1,100 Nurses
Specialty services: Neurosurgery,
Cardiovascular Surgery, Robotics, Level III
NICU, Pediatrics and PICU
Teaching facility: Internal & Family
Medicine Residency Programs & support
local residency programs
Southern California membership - 4,116,600
Service area membership - over 545,900
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Ontario Medical Center
Ontario Medical Center opened November 1, 2011.
176 licensed beds
37 bed Emergency Department
ED patients volume 2015 - 54,962
Non-member ED volume - 21%
Monthly ED volumes – 4361 +/month
Ambulatory Surgery Center on campus
700+ Physicians
557 Nurses
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Situation: 2015 SCAL Kaiser
Initiative
Developed Southern California strategy
Developed Infrastructure
Targeted Patient and Workplace Safety departments
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Preparation, Implementation and Sustainability
Step 1
Preparation
Simulation And Human Factors Education
Operations Committee
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Preparation, Implementation and Sustainability
Simulation And Human Factors Education
Operations Committee
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Preparation, Implementation and Sustainability
Simulation And Human Factors Education
Operations Committee
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SCAL Safety Structure through SAHFE
Regional SAHFE Steering Committee
Co-Leads: Jim Defontes
Rachel Mueller
Regional SAHFE Operations Committee
Co-Leads: Vu Nguyen,
Kathryn Schaivonne
Perinatal
Local SAHFE Operations Meetings
Physician Lead:
RM PS Lead:
Nursing Ed (amb/inpt) Lead:
Ambulatory
K
E
Y
Newly added Department
Local SAHFE Meetings
“Historical” Departments
Regional Structure
Monthly Meeting to Discuss Safety
Topic and current CSAs and events
from PSHC
Representation from Simulation,
Nursing Ed, Physician Ed and
every Med Center
Each of these areas has SME representation and reports out on Programs
Dx Imaging
Interventional Radiology
Perioperative
Emergency Department
Procedural Areas
Patient Advisory Team
Med Surg
Workplace Safety
Physician Education
Nursing Education
ICU / PICU / NICU
Each of these areas report into local SAHFE Operation Meetings
Simulation And Human Factors Education
Operations Committee
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Situation: 2015
Our medical center goal is to have zero significant
events by 2020.
Currently not at zero with opportunities identified in key areas
of the hospital and outpatient departments
Failure to speak up identified
Learning Climate (Staff Safety Survey) results
identified issues with Speaking Up
Minimal Patient Safety Training
Decline in Critical Events Training
National & SCAL KP support for TeamSTEPPS
On the Road to Zero
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Background: 2nd Quarter 2015
Three members of our Risk/Patient Safety Team
attended TeamSTEPPS training
In April, 2015 Patient Safety/Risk Management
Department identified TeamSTEPPS as a tool to
improve team performance & to enhance patient safety
Provided overview of TeamSTEPPS to Leadership:
Quality and Medical Executive Committees
3 OR leaders attended UCLA TeamSTEPPS Master
Training
In June, conducted 3.5 hour TeamSTEPPS course to
125 staff, physicians & leaders.
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Background: 3rd Quarter 2015
July & August – 6 additional physicians and leaders
attended UCLA TeamSTEPPS Master Training
course
August/September – Trained Ontario & Fontana
Rapid Response Teams on TeamSTEPPS (3.5 hour
class)
September – Fontana ICU Charge Nurses – 3.5 hour
TeamSTEPPS Course
Completed TeamSTEPPS Training Plan:
Departments
Reporting Culture UOR-
O 1st Q16 Red = 0-1
Yellow = 2 - 5
Green = 6 or more
Near Misses 1st
Q16
Red = 0
Yellow = 1 - 3
Green = 4 or more
Learning Culture -
2014
Red = <74
Yellow = 74 - 83
Green = >83
Human
Factors Trng CETT
SE 2014-2015
Red = 2 or more
Yellow = 1
Green = 0
Untimely Reviews- July
15 (11 day report)
Red = 6 or more
Yellow = 2 - 5
Green = 0 - 1
1 0 69% 0 0
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Background: 4th Quarter 2015
October – Highly Reliable Surgical Team
TeamSTEPPS Offsite
> 500 physicians, staff & managers attended
OR, Interventional Radiology and L&D
Focus on Debriefing
Launch of CETT training
November – Planning for 2016, Memorandum Of
Understanding Submitted
December – 10 physicians, managers, educators &
staff completed TeamSTEPPS Train the Trainer
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Background: 1st Quarter 2016
Conducted Mutual Support Training in Radiology
March – 12 managers, educators & staff completed
Train the Trainer
Held Patient Safety Fair
Launched Simulation Committee
NICU/L&D conducted Mutual Support Training
Launched Monthly TeamSTEPPS Messaging in Staff
Meeting Template
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Background: 2nd Quarter 2016
Simulation & Human Factors Education Committee
Established Steering Committee
Selected Physician Lead
Development Team Charter
Identified membership
Developing Simulation Lab Strategy
OR & OVASC TeamSTEPPS Training
Launched Critical Events Training in Emergency
Department
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Background: 3rd Quarter 2016
Simulation & Human Factors Education Committee
Establish monthly meeting
Launched Critical Events Training in Interventional Radiology
TeamSTEPPS training for Unit Based Teams Co-Chairs
TeamSTEPPS Train the Trainer class
CETT Training the Trainer class for Educators
Update Plan
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Assessment:
Have we made an impact?
Increased team training
Significantly improved Speak Up scores
on Staff Survey
Decrease in significant events
Identified challenges in linking training to
outcomes
Difficulty in defining metrics prior to training
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Assessment: Impact on Surgical
Departments
Time out
Introduction of Debriefing
Hardwiring debriefing results
Introduction of CETT training
All specialties involved
Scenarios based on actual events or issues
Reduction of significant events
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Assessment: Impact on Rapid
Response Teams
Introduced proactive rounding with coaching
Introduced debriefing after each event & satisfaction
surveys
Reduced Code Blues outside the ICU in 2016
Track days between Codes Outside ICU in Daily Operations
Briefings
Increase in staff satisfaction
Proactive rounds
Happy Staff
Debriefing
Less Codes
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Assessment: Impact on Radiology
& Emergency Departments
Radiology - Goals
Improve Speak up culture
Improved Consistency of Time Out processes
Reduced events
Emergency Department - Goals
Increase comfort & competency with Pediatric Emergencies
Improve Speak up culture
Establish Debriefing of Code Blue Events
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Recommendations: Lessons
Learned
Leadership buy-in (Top down, Bottom up)
Communication strategy
Link with events
Link with quality & patient / staff safety goals
Expectations for trainersg
Logistics:
Planning
Goals
Metrics
Meeting management
Follow up
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Questions
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Finding
the
way