Putting TeamSTEPPS™ Into Practice - Health Care Conference ...

Department of Defense
Patient Safety Program
Putting TeamSTEPPS Into
Practice:
Integrating TeamSTEPPS Into
Simulation
in the
Military Health System (MHS)
Heidi B. King, MS, FACHE
1

Agenda
Background-TeamSTEPPS in the MHS
Where Are We?
Team Resource Centers:
Accelerating Practice Change
Where Are We Going?
…transforming healthcare through team-driven practice
in DoD and beyond…
2

TRICARE Facts
– 9.2 million eligible beneficiaries
– 4.5 million dental enrollees
– 65 military hospitals and 826 medical and dental clinics across
the world
– 132,700 personnel
A Week In The Life:
• 19,600 Inpatient Admissions
• 642,400 Outpatient Encounters (direct care)
• 102,900 Dental Seatings
• 2,100 Births
• 2.2 million Prescriptions
• 3.5 millions Claims Processed
3

#1 Deployment of the
HCTCP to all fixed and
combat casualty care
organizations
Healthcare Team Coordination Program
TeamSTEPPS is the cornerstone
Promote Integration of Teamwork Principles through Optimal Use of Training, Education,
Research, and Collaborative Efforts
#1 Institutionalize teamdriven
care to improve
patient safety
TRAINING
TeamSTEPPS Training
Program
Assessment
Plan, Train &
Implement
Sustainment
#2 Minimum
Establishment of Two
Centers of Excellence
#2 Solidify Collaborative
Partnerships for Safe
Care
FUNCTIONAL AREAS
EDUCATION
Ongoing Efforts: Senior
Leadership Engagement
Online
Curriculum
Skills-based
Learning
Publications
MANDATES
MISSION
GOALS
#3 Expansion of the
HCTCP to include all
major medical specialties
RESEARCH
Team Resource
Centers: ATTC, C-
STARS, National Capital
Area Medical Simulation
Center, & Andersen
Simulation Center –
MAMC, NMCP, Travis
AFB
L&D Longitudinal Study
NAVAIR - Teamwork
Analysis Tools
#4 Investments in
continued research and
development
#3 Support Research
Demonstration Projects
COLLABORATION
Collaboration &
Outreach:
Partnering
Opportunities
Marketing &
Communication
Technical Expert Panel
Consultation
FY07-08
4

Healthcare Team
Coordination Program
• Promotes integration of teamwork principles into practice
through training, education, research, and collaboration
initiatives
– Evidence-based teamwork intervention programs to
MHS direct care facilities and combat care
organizations
– Develops and deploys tools to reduce the potential of
harm to patients while delivering care
• Establishment of Team Resource Centers (Centers of
Excellence)
– Several incorporate simulation
• Since 2007, training incorporated higher fidelity
simulation—lab and in-situ, where feasible
5

Org Level
Leadership Level
Individual Level
Safety Culture
Transparency/Trust
Pre-Training
Measurement
-Knowledge
-Skills
-Attitudes
Model for Change
TRANSFORMATIONAL CHANGE FACTORS
Create a sense of urgency
Pull together a guiding coalition
Develop a change vision and strategy
Communicate for understanding and buy-in
Pre-training Experience
Level II: Learning
Tools
Intervention
Trainin
g
Methods
Training Objectives
Competencies
-Knowledge
-Skills
-Attitudes Level I: Reactions
Post-Training
Measurement
-Knowledge
-Skills
-Attitudes
Systems-Efficacy
Learning Environment
Empower others to act
Product short-term wins
Don’t let up
Create a new culture
Self Efficacy
Training Motivation
Level II: Learning
Training
Transfer
Improved
Patient
Outcomes
Improved Staff
and Patient
Satisfaction
Improved
Processes
Staff
Retention
“Report Card”
Decrease claims $
Level III: Behavior
Level IV: Results
Sentinel Event
((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. 1976;
(3) Kotter JP. Leading change. Boston, Massachusetts: Harvard
Business School Press, 1996.)
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Five Ways TeamSTEPPS
Transforms Culture
Establishes names for team
behaviors and a common
language for addressing
“communication” and other
teamwork failures
Bridges the professional
divide and levels the
hierarchy
Provides ‘actions’/behaviors
Increases common
mindfulness
Engages the patient
‘Acting their way into a
new way of thinking’
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Where Are We Now?
Building a culture of quality and safety
requires broad transformation-a tenacious
commitment to achieving a sustainable
effort is changing the way the Military
Health System provides care and does
business.
We have extraordinary
success stories and
continued opportunities
for improvement.
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How Are We Changing the Culture?
• Our approach*:
– Spread: Actively disseminating best practice and
knowledge about TeamSTEPPS
– Impact: Assess TeamSTEPPS impact at several
levels
– Sustainability: Locking in the progress that sites
have already made and continually build upon it
Spread, impact and
sustainability take time
and commitment.
*Based in part on the Institute for Healthcare Improvement (IHI) framework for helping to improve performance
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Spread At-A-Glance
Within DoD Beyond DoD
TRAINING (FY 2008)
Trained 36 MTFs at 50 on-site sessions
Created 481 trainers/coaches
Over 12,000 CEU/CME granted
Saved $1.4M in training/travel dollars (over 2 yrs)
COMMUNICATIONS (FY 2008)
9 Peer Reviewed Publications
Outcome Measures for Effective Teamwork in Inpatient
Care (Technical Report)
#1 visited page on the DoD Patient Safety web site & #1
resource from search engine to web site
16 presentations
INTEGRATION (FY 2008)
Incorporated in simulation exercises
Integrated multi-module TS curriculum (USUHS)
Operation Iraqi Freedom combat support hospital
implementation
Developing strategic communications plan for the
campaign to ‘improve communication’ for safer care
Developed 3 online learning modules
PARTNERSHIPS
Federal: AHRQ/DoD National Implementation (20
training sessions, 503 civilians TS Master Trainers)
2 nd Annual Technical Expert Panel (36 patient safety
thought leaders in attendance)
South Australia Dept of Health piloted TS handoff
initiative
Held multiple pre-conference workshops at national
conferences
CMS 9 th Scope of Work (QIOs)
American Association for Family Physicians (AAFP)
collaboration
National Patient Safety Foundation toolkit
International Reach (Nat’l Implementation in Taiwan)
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Impact: Evaluation Plan
Level 5 – Return on Investment
Was the training worth the cost?
Level 4 – Results: Did the change in
behavior positively affect the organization?
Level 3 – Behavior / Training Transfer
Did the participants change their behavior on-thejob
based on what they learned?
Organizational Factors
Level 2 – Learning: What skills, knowledge, or
attitudes changed after training? By how much?
Level 1 – Reaction: Did the participants like the training?
What do they plan to do with what they learned?
Individual Pre-training Experiences & Attitudes
Kirkpatrick’s Model
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Organizational Success Factors
• Supportive organizational culture & learning climate
• Shared vision (leadership to frontline)
• Visible leadership support
• Peer and subordinate support
• Reinforcement, rewards, recognition
• Minimal delay between training and practice on job
• On-going training – coaching, refresher, new staff
• Commitment to measurement and on-going
improvement
• Sustainment (integration) plan
• Resource availability
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“Why Can’t We Make This Work?”
• Opportunity to
Perform
– Practice, Implement,
then Measure
• Front-line Support
• Climate of Learning
– Progress Updates
– Forum to Discuss
– Train, Refresh, and
Inform
• Team Coaches
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Where We Are Going?
…Simulation is critical to changing culture,
however, we are applying scientific
principles, instructional design
methodology with clear learning outcomes
and team performance measurement tools
…only then can simulation
and practice change be aligned
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Mobile OB Emergencies
Simulator
Andersen
Simulation Center
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MOBILE OB SIMULATOR
Created mobile platform (2006) that can
accomplish the following:
Run simulations on actual L&D units in 20+ hospitals
Provide a standardized curriculum
Evaluate both Teamwork and Technical proficiency
Integrate a no-fault debriefing tool
Be able to monitor progress over time
Inexpensive (~$25K/unit); ( ~$25K/unit); cost effective compared to
average OB malpractice claim ($2.5M/claim)
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MOBILE OB SIMULATOR
Obstetric emergencies:
Shoulder dystocia
Obstetric emergencies:
Postpartum hemorrhage
Eclampsia
Emergency cesarean section
Breech vaginal delivery
Operative vaginal delivery
Neonatal Resuscitation
Incorporates TeamSTEPPS training and
evaluation tools into the scenarios and
debriefing
Incorporates
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National Capital Area Medical
Simulation Center (NCAMSC)
• Designated Team Resource Center since 2005
• Supporting projects:
– Team Training for Wide Area Virtual Environment
– Fundamental Laparoscopic Surgery
– Pediatric and OB SBT
– Reserve Unit TeamSTEPPS
training
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Credits: Chang Ha Lee
Sofia del Castillo
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Integrated Team Training
Multidisciplinary
and Forward
Surgical Teams
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US Army Trauma Training Center
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STRUCTURE
• Defined the team
• Defined the chain of cmd.
•The team leader was in
charge
PLANNING
• Established a clear plan
• Identified roles
• Conducted rehearsal(s)
COMMUNICATION
•Performed “Call outs”
followed by “Echoes”.
•Verbalized Vital Signs
• Performed a clear
“hand-off”
IMPROVEMENT
• Conducted an AAR
• Discussed ways to
improve
• Devised an improvement
plan
/3
/3
/3
/3
Subtotal= /12
Total Score= /58
EXECUTION
TEAM LEADER
M __ mechanism
A __ assess GCS
P __ primary survey
F __ FAST exam
A __ ABG/labs
S __ secondary survey
T __ timeout/problem list
• ANESTHESIA
O __oxygen (applied oxygen)
X __apex apex base base
(breaths)
Y __ yes/no (H&P)
G __ gauge (large bore IV)
E __ eyes, ears (examined
eyes/ears)
N __nose, neck neuro check
(exam)
•NURSE
V __ vital signs
I __ IV meds
T __ temperature (room)
A __ alert key personnel
L __ lab results (call out)
S __ safety
• LEFT MEDIC
L __ IV line placed
E __ exposed patient
F __ Foley catheter
T __ temp obtained
• RIGHT MEDIC
R __ remove clothing
I __ inline stabilization
G __ gear collected
H __ hold pressure
T __ tubes sent to lab
/7
/6
/6
/4
/5
Subtotal= /28
AIRWAY
Secured airway
Identified problem (s)
Init. timely intervention (s)
BREATHING
Assessed lung sounds
Identified problem (s)
Init. timely intervention (s)
CIRCULATION
Assessed B/P & pulse
Identified problem (s)
Init. timely intervention (s)
DISABILITY
Assessed GCS
Identified injuries
EXPOSURE
Assessed dorsum (log
roll)
Prevented hypothermia
Evaluated head to toe.
VITALS
Obtained temperature
Obtained pulse rate
Obtained respiratory rate
Obtained blood pressure
/3
/3
/3
/2
/3
/4
Subtotal= /18
ATTC Tool
NOTES
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
Start:_______________
Primary Done:_______
Secondary Done:_____
Finish:________
Observer:____________
Event:_______________
Date:________________
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= GO =NO/GO

How the TEA Works:
Contract Details:
1.Developed under Contract N61339-07-D-
0001,“Tools for Training, Assessment, Analyses, and
Debriefing of Medical Teams Performance”
2.Contact: Scott Tannenbaum, Ph.D., The Group for
Organizational Effectiveness, Inc. 518.456.7738
x102; scott.tannenbaum@groupoe.com
Team Effectiveness Accelerator
(TEA)
-- The Group for Organizational Effectiveness, Inc. (gOE)
-- TRICARE Mgmt Activity, DoD Patient Safety Program
-- Naval Air Warfare Center, Training Systems Division
Rationale:
1. Teamwork is essential for safe and effective medical practice
2. Teams with shared understanding collaborate and perform more effectively
(30+ studies)
3. Teams that debrief effectively build shared understanding and perform
better (up to 40%). Unfortunately, debriefs are often not conducted or not
done optimally (e.g., don’t discuss teamwork)
4. Premise: A well-designed TEA can efficiently guide teams through
debriefs to enhance collaboration and performance
What is the Team Effectiveness Accelerator (TEA):
1. A simple-to-use web-based tool that allows a team to quickly diagnose
“gaps” such as: a) disagreement about roles, priorities, etc., b) loss of
situation awareness, c) inaccurate knowledge and d) lack of teamwork
behaviors
2. The TEA then efficiently guides the team through a targeted debrief to
rectify those gaps
Status of the Effort and Next Steps
1. The first TEA has been developed for use by Trauma Teams (military and
civilian versions)
2. Based on thorough shared coordination requirements analysis with SMEs
3. Applicable for use with TeamSTEPPS Program
4. Will soon begin testing and provide early access
5. In the future, we will likely expand access to more institutions and develop
TEAs to cover other medical domains

Medical Team Performance Assessment Tool (MTPAT)
TeamSTEPPS TeamSTEPPS - - MTPAT MTPAT Team Team
Alion Science and Technology
American Institutes for Research
TRICARE Mgmt Activity, DoD Patient Safety Program
Naval Air Warfare Center, Training Systems Division
Contract Details:
1.Developed under Contract N61339-07-D-0001,“Tools for
Training, Assessment, Analyses, and Debriefing of Medical
Teams Performance”
2.Contact: Tom Carolan, Ph.D., Alion Science and Technology.
517.347.6117; tcarolan@alionscience.com
Background
Background
TeamSTEPPS TeamSTEPPS is a teamwork methodology and curriculum
designed to improve patient safety for health care organizations.
Scenario-based training with performance observation,
assessment and post exercise team debrief provides a promising
approach for building team coordination skills in the context of
clinical performance.
Scenario design and measurement best practices include
constructing scenario events and performance measures around
specific training objectives and then structuring debrief around
these objectives and events.
What What is is MTPAT? MTPAT?
A software application that provides capabilities to support
evaluation, debrief, and analysis of healthcare team performance
in training and operational environments.
An architecture to support an event based training and
assessment approach where assessment items are linked to
scenario events.
Integrates ntegrates the TeamSTEPPS TeamSTEPPS principles and skills so that
military and civilian medical teams can rapidly record, assess,
and analyze teamwork performance evidence and provide timely
feedback and debrief.
Supports coordinated evaluation of technical and teamwork skills.
Ultimately, MTPAT MTPAT can provide an evidence base from which
medical teams can measure and continually improve their
performance, thereby reducing medical errors and improving
patient safety.
Current Current Status Status
MTPAT MTPAT prototyped for Trauma and Labor & Delivery.
Events and assessment item content developed for Trauma and
Labor and Delivery domains based on document analysis,
observations and interviews with subject matter experts.
Testing and review in progress with participant facilities

Simulation As A Training Strategy
• Establish the vision, goals and objectives
• Determine the model
– In-center
– In-situ
• Establish the needed resources
– Simulation Center
• Staff - clear vision, roles & responsibilities
• Equipment
– Participating department
• Clear vision and expectations for participation
• Staff release time
• Develop event-based scenarios
• Expect results
• Debrief and educate on awareness
25

Understanding Teams
Determine the performance outcomes you
expect to see, then:
• Develop learning outcomes
• Train teamwork competencies
• Define and determine diagnostic
measures
26

Needed Links in
Simulation-Based Team Training…
Tasks & KSAs
Performance
History
Learning
Outcome
Scenarios &
Events
Rosen et al, 2008
Feedback
Measures
27

Understanding Performance
The behaviors sought should drive the
simulation goals
Select measurement tools based on goals of
simulation/assessment criteria
Measure what is important, not what is easy
Performance Observation Tools
SMARTER Approach (Simulation Module for
Assessment of Resident Targeted Event Responses)
Communication and Teamwork Skills (CATS)
Others
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SMARTER-Team
Focus on teaching points
Define specific learning objectives
Choose clinical context to frame scenario development
Develop set of targeted KSA’s to capture pre-defined
learning objectives and core competencies
Craft scenario to ensure team members have
opportunity to display targeted KSA’s
Define set of targeted responses
Create diagnostic measurement tools
Create scenario script
Rosen, et al
29

Understanding Debriefing
Center debriefing around the chosen teaching points
e.g. “Did the leader
Specify the goals to the team?”
Coordinate team efforts?”
Cross-monitor team members?”
Resolve conflict?”
Focus discussion on communications and interactions
with team members
Keep discussion focused on team behaviors, minimize
clinical discussions use scenarios that
Stress rapid team responses and coordination of care
Straightforward diagnoses with clear and easily determined
treatment
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Resources
• Simulation-Based Training for Patient Safety: 10
Principles That Matter (Salas et al, 2008)
• Measuring Team Performance in Simulated-Based
Training: Adopting Best Practices for Healthcare (Rosen
et al, 2008)
• SMARTER-Team: Adapting Event-based Tools for
Simulation-based Training in Healthcare (Rosen et al,
2008)
• Promoting Teamwork: An Event-based Approach to
Simulation-based Teamwork for Emergency Medicine
Residents (Rosen et al, 2008)
• Does Team Training Work? Principles for Healthcare
(Salas et al, 2008)
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For More Information
• http://dodpatientsafety.usuhs.mil/teamstepps
• http://teamstepps.ahrq.gov/
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