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Does Team Training Make a Difference in
Delivering Safe Care? AHRQ Patient Safety and
Health Information Technology Conference Ms.
Heidi King DoD Patient Safety Program Health
Care Team Coordination June 6, 2005

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Overview

• DoD Patient Safety Program
• DoD Initiatives
• Data on Communication Failures/Mandates
• Health Care Team Coordination Program (HCTCP)
• What is teamwork?
• TEAMSTEPPS
• HCTCP Support
• A DoD Hospital
• Culture Change
• Planning Ahead
• AHRQ Collaboration
• Challenges / Lessons Learned

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DoD Patient Safety Initiatives
Innovations/ Lessons Learned
Regulatory Compliance
PATIENT SAFETY
Data Collection Metrics
Service Integration
Outside Agency Collaboration
Research Development
Education Training
Mandated by National Defense Authorization Act
2001
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Top Contributing Factors of Sentinel Events from
PSC Root Cause
Source DoD Patient Safety Center
Number of RCAs Reviewed, 2004
43
Inadequate Communication
40
Policy / Procedure not followed
29
Inadequate Documentation
27
Inadequate Training
23
No Policy / Procedure in Place
Equipment Malfunction / Unavailable
22
n 73
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Top 5 Causal Factors Reported for
Communication/Inadequate Information
Number of RCAs
Source DoD Patient Safety Center (From a total
of 43 Root Cause Analyses)
35
Lack of communication among department staff
Lack of communication between services and
departments
12
Lack of assertiveness in going up the chain of
command
6
Lack of communication between nurse and physician
4
n 43
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Top Contributing Factors of Sentinel Events from
RCAs, FY02 FY04
n54
n81
n73
Source DoD Patient Safety Center
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Top Contributing Factors of Sentinel Events from
PSC Root Cause, FY02 FY04
2002
n54
2003
n81
2004
n73
Inadequate Communication
Policy/ Procedure Not Followed
Inadequate Documentation
Equipment Malfunction/ Unavailable
No Policy / Procedure in Place
Inadequate Training
Source DoD Patient Safety Center
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Other Driving Factors

• IOM
• Congress (NDAA 2001)
• DoD Directive Regulation
• JCAHO
• DoD Patient Safety Center data

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JCAHO

• 2005 Hospitals National Patient Safety Goals
• (NPSGs)
• Goal 2 Improve the effectiveness of
  communication among caregivers
• Goal 8 Accurately and completely reconcile
  medications and other treatments across the
  continuum of care
• Standard RI.2.100 The hospital respects the
  patients right to and need for effective
  communication
• Standard LD.3.60 Communication is effective
  throughout the hospital

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Health Care Team Coordination Program

• HCTCP Mission
• Provide teamwork coordination to achieve safer
  patient care in MHS thru research, education, and
  training initiatives.
• Goals of Teamwork
• Reduce clinical errors
• Improve patient outcomes
• Improve process outcomes
• Increase patient satisfaction
• Increase staff satisfaction
• Reduce malpractice claims
• ultimately achieve a culture change

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Teamwork Lessons from Aviation-CRM and DoD Teams

• DoD has led the way on team research and
  innovations
• Combat Information Centers
• Joint Forces Operations
• Emergency Management Communities
• Army Special Forces
• Tank, Submarine, and Air Crews
• ED, OR, LD, ICU, Dental
• Whole Hospital
• Combat Casualty Care

Non-Health Care
Health Care
Learning and Safety Culture
MHS striving to be a high reliability health
care system
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What does good teamwork look like?

• Teams that demonstrate good teamwork
• have a clear common purpose
• differentiate between higher and lower priorities
• ensure team member roles are clear but not overly
  rigid
• manage conflict well, team members confront each
  other effectively
• involve the right people in decisions in flexible
  manner
• examine and adjust the teams physical workplace
  to optimize communication and coordination

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What does good teamwork look like?

• Teams that demonstrate good teamwork
• backup and fill in for each other
• distribute and assign work thoughtfully
• communicate often enough, and at the right
  time--ensure that fellow team members have the
  information they need to be able to contribute
• conduct effective team meetings
• establish and revise team goals and plans
• consciously integrate new team members
• Salas, funded by Army Research Institute, 2004

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Team Competencies

• We must understand team competency requirements
• How do we design and conduct training?
• What do we use to assess team performance?
• How do we initiate a change within the culture?

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Team Competencies

• Team competencies are the knowledge, skills, and
  attitudes (KSAs) required to be an effective team
  member
• Knowledge The principles and concepts that
  underlie a teams effective performance
• Skill The learned capacity (psychomotor and
  cognitive) to interact with other team members
• Attitude Internal states that influence team
  members to act in a particular way

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Outcomes of Team Skills

• Knowledge
• Shared Mental Models
• Attitudes
• Mutual Trust
• Team Orientation
• Performance
• Adaptability
• Accuracy
• Productivity
• Efficiency
• Safety

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TEAMSTEPPS

• TEAM Strategies and Tools
• to Enhance Performance and Patient Safety
• Initiative based on evidence derived from
  team performance leveraging more than 25 years
  of research in military, aviation, nuclear power,
  business and industryto acquire team
  competencies

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Medical Teamwork System

• The TEAMSTEPPS Approach
• Introduce key team concepts and behavioral skills
• Utilize lecture, discussion, vignettes, teamwork
  failures, demonstration, case studies
• Interactive learning and practice-based
  application (role play, simulation)
• Opportunity to practice thru feedback session
• Develop coaching and facilitation skills
• Include strategies for transition and sustainment
• Customize to unique needs of your institution

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TEAMSTEPPS

• DESC Script
• SBAR
• Check-Back
• Hand-Off
• Call-Out
• Cross-Monitoring

• Team Huddles
• Debriefs
• STEP
• Feedback
• Two-Challenge Rule

• TEAMSTEPPS includes video examples, which show
  how to put the tools and strategies into action.

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TEAMSTEPPS
Mary If the video isnt playing Delete the
placeholder in center of slide (where it says
TeamSTEPPS) (menu bar) -gt Insert -gt Movies and
Sounds -gt Movie From File (Find Movie, click
OK) Dialog will pop up If you want the movie
to play automatically, click Yes - done - Movie
should be in center of screen. Right-click on it
and select Play Movie to play it from design
view
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What We Do

• Train the Trainer - 83 sites
• In-patient Out-Patient Setting
• Specialty units include ED, OR, ICU, LD, and
  Dental
• Combat Casualty Care organizations
• 750 Team Instructors (physicians, nurses, and
  other health care professionals)
• Ongoing consultative services with facilities
• Work with leadership and change teams
• Conduct site readiness assessments
• Follow on coaching with Patient Safety offices
  and champions

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Sample DoD Hospital

• Surgical Services for
• 20 OR rooms
• 13,000 cases/Yr
• 30 Instructors
• 875 Staff trained
• Staff Make-up
• 43 Surg/Anes
• 29 Nurses
• 28 Techs

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Huddle Cards

• Debriefing Tool
• Designed to
• TEACH
• MEASURE
• INSPIRE
• Paper-based, inexpensive, simple
• 30 45 seconds to complete

The team leader and members were respectful,
effective and professional in their communication
and interactions during the case.
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Team Self AssessmentPre-trainingFollow-up

• 6 months
• Valid Surveys N223 N139
• Greater than 10 percent improvement in 23
  questions
• Improvement in all but one
• Greatest improvement
• The team can measure its performance effectively
  (21.5)
• The team members communicate well with one
  another (18.2)

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General Comments

• Interviews
• Noticeable difference in atmosphere and
  climate.
• Better communication at all levels
• Better equipment availability (planning) and less
  frustration/blame
• No negative comments
• Much less anger more respect
• Juniors ARE willing to speak out

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Process Outcome Measures for Effective Teamwork
in Health Care in Development

• Collaborative effort with RAND Corporation thru
  AHRQ
• Purpose
• Develop a set of measures that represent
  important patient safety or quality of care
  outcomes that can be expected to improve as a
  result of effective teamwork in delivering health
  care services

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Shift Towards a Culture of Safety
Teamwork Initiative
PHASE I Climate Preparation
PHASE II Training Implementation
PHASE III Sustainment
Monitor Measure Coach Integrate
T r a i n i n g
Site Assessment
Ready?
Implementation
Culture Survey
SWOT Analysis
Culture Change
Climate Improvement
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Model for Change
TRANSFORMATIONAL CHANGE FACTORS
Org Level
Safety Culture Transparency/Trust
Systems-Efficacy Learning Environment
Report Card
Leadership Level
Lead the Way Establish the Sense of Urgency
Create a Vision or Gain-Plan Prepare Develop a
Coalition-Assess Environment
Communication Process Enable Change to
Last Improve Systems and Structures
Improved Patient Outcomes Improved Staff and
Patient Satisfaction Improved
Processes Staff Retention
Individual Level
Self EfficacyTraining Motivation
Pre-training Experience
Level IV Evaluation
Intervention
Sentinel Event
Pre-TrainingMeasurement -Knowledge-Skills-Attit
udes
Training Transfer
Post-TrainingMeasurement -Knowledge-Skills-Atti
tudes
Methods
Tools
Level III Evaluation
Level II Evaluation
Level II Evaluation
Training
Training Objectives

• ((1) Salas E Cannon-Bowers JA. Training and
  retraining
• A handbook for business industry, government, and
  the military.
• Tobias S Fletcher JD (editors). McMillan New
  York, 2000 312-335.
• (2) Kirkpatrick, D. Model for Summative
  Evaluation 1959
• (3) Kotter JP. Leading change. Boston,
  Massachusetts Harvard Business School Press,
  1996.)

Competencies -Knowledge-Skills-Attitudes
Level I Evaluation
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AHRQ/DoD Teamwork Initiatives

• Expert Panel
• Comprehensive Literature Review
• Edited Handbook
• Journals/Articles
• Presentations
• Patient Safety Officer Team Training Toolkit
• Medical Team Training Curriculum

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Challenges

• Deployments
• Buy-in at all levels of leadership
• Competing priorities
• Sustainment / sticking power
• Measurement
• Transfer of Training
• Effectiveness on patient outcomes

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Key Lessons Learned

• Simplify a critical patient safety initiative on
  an overburdened healthcare system
• Dynamic environment, requires various levels of
  training
• Definitive metrics for all levels of evaluation
• Engage senior leadership prior to training
• On-going coaching of teamwork behaviors
  post-training
• Integration of teamwork principles within other
  PS initiatives in medical facilities and
  institutes of learning

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Teamwork in DoD
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Contact Information

• Heidi King
• Deputy Director, Patient Safety Program
• Program Manager, Health Care Team Coordination
• Heidi.king_at_tma.osd.mil
• 703-681-0064

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BACKUP SLIDES
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Team Intervention in Labor and Delivery
Environment Study

• To determine whether MedTeamsTM training in LD
  Departments can improve
• Maternal and neonatal outcomes
• Process measures - proxy for efficiency of care
• Staff and patient satisfaction
• Cluster-based randomized controlled trial
• Data base Total 45,622 28,356 deliveries pre
  post intervention

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Team Intervention in Labor and Delivery
Environment Study

• Results were inconclusive, except for the 12th
  measure
• Time from decision to incision for a stat
  cesarean section was statistically significantly
  --shorter time in the intervention group (P0.04)
  
• Need for follow-up study
• Assess transfer of training and determine
  sustainability of behaviors
• Site visits, refresher courses evaluate lessons
  learned
• Continue research consortium of 15 military
  civilian hospitals for patient safety research
• Trend data over time

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Study Timeline