Implementing Team Training at Duke

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Implementing Team Training at Duke

• Karen Frush, BSN, MD
• Duke University Health System

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Our Experience

• PICU
• Peri-operative Services
• GSK Collaborative
• NCHA Collaborative
• Implementation goals across Duke Medicine
• Full training (high acuity areas)
• Overview of concepts and tools (all employees and
  students)

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Four Phases of Team Training

• 1. Assessment (Pre-Training)
• 2. Training
• 3. Integration and Implementation
• 4. Sustainment and Evaluation

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Teamwork Training ProcessPhase I Pre-training

• Gather baseline data
• Knowledge test
• Attitude Sexton safety culture survey
• Behavior Conduct Real-time Observations
• Outcome data
• Processes
• Clinical outcomes
• Analyze Secondary Measures
• Staff satisfaction and work culture
• Patient satisfaction

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Teamwork Training ProcessPhase II Training

• Unit leaders involved with planning and
  implementation
• sessions to accommodate shifts
• Multidisciplinary group sessions
• Physician, nurse, and human factors facilitators
• Interactive session with hands-on tools
• Feedback allowed for further development
• Focused training for action at unit level
• Focused on tools and techniques to address units
  issues

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Focused Unit Training Tools

• Handoff Communication
• SBAR structured language
• Critical Language
• I need clarity assertion
• Sterile Cockpit
• Focused attention
• Limit interruptions during Rounds
• Huddles, Briefs and Debriefs
• White Boards

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Teamwork Training ProcessPhase III Integrate
training into practice

• Leadership role models
• Multi-disciplinary (internal) coaches
• Interval observations (external) with feedback
  (coaching)
• Integrate findings into unit safety meetings
• Phone calls at unit leaders preferred time, to
  review concerns and discuss barriers
• Train-the-trainer model used for new staff

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Teamwork Training Process Phase IV
Comprehensive Evaluation and Sustainment

• Immediate feedback of training session
• Change in Knowledge
• Change in Attitude Survey
• Behavior Change Observations
• Process or Practice Changes
• Impact on Clinical Outcomes
• Secondary measures

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TEAM TRAINING EVALUATION BASED ON KIRKPATRICKS
FOUR-LEVEL EVALUATION MODEL

• Patient satisfaction survey.
• Complication rate based on AHRQ PSI.
• Length of hospital stay.
• Adverse drug events.
• Patients claims.
• Staff satisfaction survey.
• Nurse turnover rates.

Level 4 Results whether the training has
affected process or outcomes such as increased
production, improved quality, reduced adverse
events, decreased costs, or return on investment.
Level 3 Behavior whether participants change
their behavior back in the workplace as a result
of training.

• Observation of teamwork behaviors during routine
  patient care.

• Teamwork knowledge test.
• Survey of attitude towards teamwork.
• Survey of self-perceived communication skills.

Level 2 Learning whether the training results
in an increase in knowledge, skills or attitudes.
Level 1 Reaction how did participants react to
the training?

• Post-training reaction survey

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Team Training Results Will this training impact
the way you do business?

Not Sure
Prob.
Def.
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Team Training Results Would you recommend this
course to your co-workers?

Not Sure
Prob.
Def.
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TEAM TRAINING EVALUATION BASED ON KIRKPATRICKS
FOUR-LEVEL EVALUATION MODEL

• Patient satisfaction survey.
• Complication rate based on AHRQ PSI.
• Length of hospital stay.
• Adverse drug events.
• Patients claims.
• Staff satisfaction survey.
• Nurse turnover rates.

Level 4 Results whether the training has
affected process or outcomes such as increased
production, improved quality, reduced adverse
events, decreased costs, or return on investment.
Level 3 Behavior whether participants change
their behavior back in the workplace as a result
of training.

• Observation of teamwork behaviors during routine
  patient care.

• Teamwork knowledge test.
• Survey of attitude towards teamwork.
• Survey of self-perceived communication skills.

Level 2 Learning whether the training results
in an increase in knowledge, skills or attitudes.
Level 1 Reaction how did participants react to
the training?

• Post-training reaction survey

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PICU Post-Training Survey Responses Summary
The physicians and nurses here work together as a
well-coordinated team (p value0.011).
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TEAM TRAINING EVALUATION BASED ON KIRKPATRICKS
FOUR-LEVEL EVALUATION MODEL

• Patient satisfaction survey.
• Complication rate based on AHRQ PSI.
• Length of hospital stay.
• Adverse drug events.
• Patients claims.
• Staff satisfaction survey.
• Nurse turnover rates.

Level 4 Results whether the training has
affected process or outcomes such as increased
production, improved quality, reduced adverse
events, decreased costs, or return on investment.
Level 3 Behavior whether participants change
their behavior back in the workplace as a result
of training.

• Observation of teamwork behaviors during routine
  patient care.

• Teamwork knowledge test.
• Survey of attitude towards teamwork.
• Survey of self-perceived communication skills.

Level 2 Learning whether the training results
in an increase in knowledge, skills or attitudes.
Level 1 Reaction how did participants react to
the training?

• Post-training reaction survey

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Improvement in Leadership
Overall Leadership (p value0.001)
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TEAM TRAINING EVALUATION BASED ON KIRKPATRICKS
FOUR-LEVEL EVALUATION MODEL

• Patient satisfaction survey.
• Process or practice changes.
• Length of hospital stay.
• Adverse drug events.
• Patients claims.
• Staff satisfaction survey.
• Nurse turnover rates.

Level 4 Results whether the training has
affected process or outcomes, such as increased
production, improved quality, reduced adverse
events, decreased costs, or return on investment.
Level 3 Behavior whether participants change
their behavior back in the workplace as a result
of training.

• Observation of teamwork behaviors during routine
  patient care.

• Teamwork knowledge test.
• Survey of attitude towards teamwork.
• Survey of self-perceived communication skills.

Level 2 Learning whether the training results
in an increase in knowledge, skills or attitudes.
Level 1 Reaction how did participants react to
the training?

• Post-training reaction survey

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Sterile Cockpit
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(No Transcript)
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Hand-Off Turnaround Time Before and After
Intervention
Turnaround Time (minutes)
Observations
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Critical Lab Draw Time Before and After
Intervention
Lab Draw Time (minutes)
Observations
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Results impact Sustainment

• Feedback on knowledge, skills and attitudes on
  teamwork reinforces the new learning
• Changes in practice to enhance teamwork tend to
  enhance job satisfaction as well
• Feedback on improved outcomes highly motivates
  staff and fuels sustainment of behavior and
  attitude change.
• Pilot unit (PICU) is now providing team training
  to all new staff on unit, and providing annual
  updates to existing staff.

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Operational Changes, Improvements in Outcomes

• Briefings and debriefings implemented SBAR
  communication for nursing report, telephone
  communication
• Decrease in infection rates (3 to 1)
• Decrease LOS (0.6 days) and increased throughput
  (10)
• Patient Satisfaction score exceeded target
• Work Culture survey score increased by 16

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Implementing Team Trainingacross Duke Medicine

• TeamSTEPPS has helped us overcome some initial
  barriers to team training
• 4 phase approach to be undertaken at targeted
  high acuity areas at DUH, DRH and DRaH
• Training with specific tools and concepts
  (modules) in intermediate units and non-clinical
  areas
• Collaborative with UNC SoM, SoN
• GME including some of TeamSTEPPS for residents
• Coordinating with CME and CEU

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Future of TeamSTEPPS at Duke

• Simulation scenarios, in Sim Center and in units
• Virtual team training 3DiTeams
• Integration of TeamSTEPPS content into existing
  training ACLS, drills.
• Integration of TS with other safety culture
  initiatives Just Culture, Disclosure, metrics
• Further study of observation methodologies and
  effective evaluation of teamwork behaviors