ntroduction:InstructorSlidesTeamSTEPPSLongTermCareVersion:Module1

Contents

Slide1:IntroductionSlide2:IceBreakerSlide3:SueSheridanVideoSlide4:VideoDiscussionSlide5:ObjectivesSlide6:TeamworkisAllAroundUsProvenResults(OptionalContent)Slide7:EvolutionofTeamSTEPPSSlide8:TeamSTEPPSSlide9:PatientSafetyMovementSlide10:ResidentSafetySlide11:CourseAgendaSlide12:IntroductionsandMagicWandExerciseSlide13:WhyDoErrorsOccur?Slide14:InstituteofMedicineReportImpactofErrorSlide15:MedicalErrorsStillClaimingManyLivesSlide16:TopContributingFactorstoMedicalErrors(OptionalContent)Slide17:WhatComprisesTeamPerformance?Slide18:OutcomeofTeamCompetenciesSlide19:TeamworkActionsSlide20:SupplementalInstructorSlidesSlide21:CourseAgendaTraintheTrainer/CoachSessionSlide22:TeamworkEncompassesCRMSlide23:Background:U.S.ArmyAviationSlide24:U.S.NavyBreakthroughs:TacticalDecisionMakingUnderStress(TADMUS)Slide25:U.S.AirForceCRMHistorySlide26:EightStepsofChange(Kotter)Slide27:RoadmaptoaCultureofSafety

Introduction:InstructionalSlidesSlide1:TeamSTEPPS

TheLongTermCareversionofTeamSTEPPSadaptsthecoreconceptsoftheTeamSTEPPSprogramtoreflecttheenvironmentofnursinghomesandotherotherlongtermcaresettingssuchasassistedlivingandcontinuingcareretirementcommunities.Theexamples,discussions,andexercisesbelowaretailoredtothelongtermcareenvironment.

Time:50minutes

Subsections

Introduction.TheScienceofTeamwork.PatientSafetyMovement.ComponentsofaPatientSafetyProgram.MedicalErrors.TeamSTEPPSFramework.TeamworkActions.

Time:50minutes

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Slide2:IceBreaker

ModuleTime:50minutesIceBreakerTime:50minutesMaterials:

FlipchartorWhiteboardConstructionPaperTapeScissors

Say:

Beforewegetstarted,you'regoingtoteamupwiththeotherpeopleatyourtableandcompleteanicebreakeractivity.

Do:

Demonstratehowtomakethechainsasyouexplain:

Say:

Tomakethechains,cuttheconstructionpaperintostrips,makelinksbytapingtogethertheendsofa

strip,thenloopthenextstripthroughit.Continuethisprocesstomakeachain.

Youhave2minutestocreatethelongestchain.Go.

After2minutes,haveeachgroupdisplaythelengthofitschain.Havethegroupssetthefirstchainsaside.

Now,you'regoingtomakeanewchainhowever,eachofyoumayuseonlyyourlefthand.Youhave2minutes.

After2minutes,haveparticipantsdisplaythelengthoftheirsecondchains.Havethegroupssetthechainsaside.

Now,youhaveonemorechancetomakethelongestchain.However,thistime,youmayuseonlyyourlefthand,andyoumustnotspeak.Youhave30secondstodiscusswithyourgroupbeforebeginningyour2minutes.

Afterthe21/2minutesareup,displaythefinalchains,anddebrieftheexercise.

Discussion:

Startingwiththegroupsthathadthelongestchains,goaroundtheroomaskingtheparticipantsineachgroupthefollowingquestions:

Whattechniquesormethodsdidyouuseforworkingwellasateamwhenmakingthechains?Whathinderedyourgroupinworkingasateam?Howdidtheadditionaltimetoplanaffectyourteam'stechnique?Howdidthelimitedcommunicationchangeit?

Discussion:

Asparticipantsrespond,rephrasetheirresponsesbacktothemasTeamSTEPPSskillsthatwillbecoveredinthetraining.Ifoneoftheskillsisnotbroughtupaftereachgroupresponds,bringupthatskillbrieflyafterward.

Someoneassumingtheleadershiprole:

Pointoutagroupinwhichsomeoneassumedaleadershiproleandhelpedtheteamplanforthetimeswhenteammemberswerenolongerabletocommunicateverbally.Ifnoneofthegroupshadamemberwhodidthis,pointouthowthiswouldhavehelped.

Clearlydefinedteamroles:

Askifanyoftheteamshaddesignatedpeoplewhoagreedtotakeoncertainroles(e.g.,cuttingthepaperstripsortaping).Askifanyonewasstandingaroundwonderingwhattodobecauseaclearlydefinedrolewaslacking.

Mutuallysupporting/helpingotherteammembers

Pointoutsituationsinwhichparticipantshelpedeachother,ratherthensimplywaitonanotherteammember.

Situationmonitoring:

Askifanyoneobservedwhenotherteammemberswerefinishedcuttingstripsofpaperorneededapieceoftape.Askhowthisactionaffectedperformance.

Communication:

Askparticipantsifthetaskbecamesignificantlymoredifficultwithouttheabilitytocommunicateverballywithotherteammembers,inthethirdpartoftheexercise.

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Slide3:SueSheridanVideo

VideoTime:9:55minutesMaterials:

SueSheridanvideo

Say:

Beforewestartthecourse,itisimportanttounderstandwhyresidentsafetyissoimportantandhowteamworkcanmakethedifferencebetweenlifeanddeath.

Do:

Playthevideobyselectingthedirectoriconontheslide.

Ask:

Couldthesetwoincidentshavebeenavoidedifeffectiveteamworkhadtakenplace?

Say:

Thiscourseisaboutmakingsurethatstorieslikethisdonothappen.

Selectthepenguindirectoriconbelowtoaccessthevideo.

OpportunitytoapplyTeamSTEPPStechniquetoimproveoutcome(Flashvideo,9min.,29sec.)(PluginSoftwareHelp)

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Slide4:VideoDiscussion

InstructorNote:Asktheparticipantsthefollowingquestionsbelow.Sampleanswersareprovidedtogenerateadiscussionifparticipantsdonotvolunteeranswers.

Discussion:

Howareresidentsharmedasaresultofmedicalerrors?

Thisquestionismostlyrhetorical.Ifaparticipantquestionsthis,however,statethatyou'llcoverthedataandstatisticsonmedicalerrorinseveralminutes.

Howcanwepreventmedicalerrors?

Ifanyoftheparticipantsanswernegatively,focusthediscussiononimprovementopportunities.

Whatarethesolutions?

Askparticipantstorespondtothisquestion.Iftheirresponsesindicateaskillortechniquetaughtinthecourse,butparticipantsusedifferentterminology,rephrasetheirresponsebacktothemusingtheTeamSTEPPSterminology.

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Slide5:Objectives

Say:

Inthismodule,we'll:

DescribetheTeamSTEPPStraininginitiative.Explainyournursinghome'sresidentsafetyprogram.Describetheimpactoferrorsandwhytheyoccur.DescribetheTeamSTEPPSframework.

StatetheoutcomesoftheTeamSTEPPSframework.

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Slide6:TeamworkIsAllAroundUs

Say:

Teamworktrulyisallaroundus.TheU.S.DepartmentofDefensevaluesteamworkaskeytoitsmissionthustrainingmoreofitsinstitutionsinteamworkthananyothersystemintheworld.

Patientsacrosstheworldaresaferinhealthcaredeliverysystemswhereteamworkprinciplesarepracticedonadailybasis.

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ProvenResults(OptionalContent)

Say:

Throughimplementingteamworkinitiatives,organizationshavefoundpositiveresults.Severalexamplesofthepromisingfindingsare:

Longtermcarefacilitiesparticipatinginaqualityimprovementprogramthatpromotedstaffworkingtogetherasamultidisciplinaryteamtoimprovecommunicationexperienceda48percentreductionintheCMShighriskpressureulcerqualitymeasure(Horn,etal.,2010).Aftertheimplementationofaninterdisciplinarycommunicationtooltoimproverounds,theaveragelengthofICUstayswasreducedby50percent(Pronovost,2003).

Whatmightchangebyimprovingcommunicationamongyourinterdisciplinaryteam?Whatmighthelpmakeimprovements?

Operatingroomswithstaffthatreporthavingagoodattitudetowardteamworkalsohavepostoperativeinfectionrateslessthanhalfofthosewherestaffperceivetheenvironmentasbeingpoorlyconducivetoteamwork.TheoperatingroomswiththehighestratedteamworkclimatesalsohavepostoperativeinfectionrateshalfthatoftheAHRQreportednationalaverageforthePatientSafetyIndicatorrateforpostoperativesepsis,PSI13(Sexton,2006).

Whataboutinfectionswithinyournursinghome?Howcanteamworkhelpreducethespreadofflu,MRSA,etc.?

Healthcareorganizationsthathaveeffectivelyimplementedamedicalteamworksystemhaveobserved:

Adecreasedclinicalerrorratefrom30.9percentto4.4percent,alongwithanincreaseinpositiveattitudestowardteamwork(Morey,2002).A27percentreductioninnurseturnover(DiMeglio,2005).

Althoughtheevidenceisstillevolving,especiallyinlongtermcare,provenresultsfromacutecareandexpertconsensusrecognizethatteamworkplaysacriticalroleinprovidinghealthcare.Theinvestmentofresourcesistrivialcomparedwiththeoverallexpendituresinhealthcareresultingfrommedicalerrors.

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Slide7:EvolutionofTeamSTEPPS

Say:

TeamSTEPPSevolvedthroughcollaborationwithmultiplepartners,witheffortsledbytheDoDPatientSafetyProgram.

PatientSafetyregulationsrelatedtoteamworkpracticesarereviewedroutinelytoensurethattheTeamSTEPPSInitiativeofferssolutionstomeettheseaccreditingrequirements.TheevolutionofTeamSTEPPShasbeenmappedoutinrelationtotheresidentsafetymovement.

CurriculumContributors:

InconjunctionwithseveralFederalagenciesandhighperformanceteams,humanfactors,andcrewresourcemanagementsubjectmatterexperts,severalresearchorganizations,qualityimprovementorganizations,medicalandbusinessschools,universityhealthcaresystems,militarytreatmentfacilities,privatecorporations,hospitals,nursinghomes,healthcarefoundations,andcommunitybasedpracticeshavecontributedtothedevelopmentofTeamSTEPPS.

Theinsightfulinputofthis"teamofexperts"isinvaluableaswestrivetostrengthenasafetynetforourresidents,caregivers,andstaffwithincomplexhealthsystems.

TheEvolutionofTeamSTEPPS...AResearchApproach

Followinganextensiveliteraturereviewofteamworkinhealthcare,apanelofexpertsconvenedin2003toidentifythegoldstandardformedicalteamtraining.ThroughanextensivemodifiedDelphimethodology,keyteamrelatedcompetencieswereidentifiedtoassesseffectivenessofteamsandteamtrainingbasedon20yearsofresearch.Collectiveinputfromthisexpertpanelrecommendedstandardizedtrainingobjectives,guidelines,andfutureresearchchallenges.TheAgencyforHealthcareResearchandQuality(AHRQ)collaboratedwiththeDepartmentofDefense(DoD)toperformanindependentcasestudyofDoDandnonDoDtrainingprograms,whichwasconductedbytheAmericanInstitutesforResearch(AIR).Thiscasestudyanalysisincludedformativeandsummativeresearchmethodslookingatstrengths,weaknesses,andlimitationsofexistingteamtrainingcurricula.Basedonthese

findingsandlessonslearnedfromtrainingevents,theTeamSTEPPScurriculumwasdevelopedandinitiallypilotedinJanuary2005.Basedonmultipleassessmentsandongoingevaluation,TeamSTEPPSwaspilotedandreassessedoveran18monthtimeperiodduringwhich24facilitiesweretrainedandimplementedtheseteamworkprinciples.In2005,450newlytrainedinstructorstrainedseveralthousandsofstaff.Incorporatedintothecurriculumdesignprojectarelessonslearnedfromteamtrainingactivitiescapturedoverthepast8years,andevidencebasedresearchrelativetothescienceofteamwork,humanfactors,andteamperformance,alongwithorganizationalimprovementandchangestrategies.

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Slide8:TeamSTEPPS

Say:

TeamSTEPPSstandsfor:TeamStrategiesandToolstoEnhancePerformanceandPatientSafety.

TeamSTEPPSfocusesonspecificskillssupportingteamperformanceprinciples,includingtrainingrequirements,behavioralmethods,humanfactors,andchangestotheresidentcareculturedesignedtoimprovequalityandresidentsafety.TeamSTEPPSisanothercomponenttohelpsupportandenhancepersoncenteredcare.Itdoesnotworkincompetitionwithotherculturechangeeffortswithinlongtermcare.

Teamworkconceptsareintroducedthatprovidespecifictoolsandstrategiesforimprovingcommunicationandteamwork,reducingchanceoferror,andprovidingsaferresidentcare.

Thiscourseisbasedonevidencederivedfromteamsworkinginhighriskenvironments(i.e.,wheretheconsequencesoferroraregreat).

Morethan25yearsofresearchandevidencehavebeenaccumulatedonteamsandteamperformanceindiverseareas(e.g.,aviation,themilitary,nuclearpower,healthcare,businessandindustry).TeamSTEPPShasevolvedfromresearchinthesehighriskfieldstothehealthcareenvironment,ahighrisk,highstakesenvironmentinwhichpoorperformancemayleadtoseriousconsequencesordeath.

Basedonresearch,weknowwhatdefinesateam,whatteamworkrequires,howtotrainteammembers,andhowtomanageteamperformance.Researchershavelinkedteamtrainingprogramstoimprovedattitudes,increasedknowledge,andimprovedbehavioralskills.

InstructorNote:Addthefollowingtextfortrainthetrainersessions.

Additionalcontentincludeshowtodealwithculturechange(usingDr.Kotter'sEightStepstoChange),changemanagement,customizableimplementationplans,trainerandcoachingskilldevelopment,guidancetodevelopassessmentandevaluationstrategiesusingteamworkmeasurementtools,andconsultation.

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Slide9:PatientSafetyMovement

Say:

Asyoucansee,medicalteamresearchandtrainingbegan4yearsbeforetheonsetofthepatientsafetymovement.TheintegrationofteamworkintohealthcarebytheDoDandforwardthinkingresearchersprecededtheInstituteofMedicine(IOM)reportandregulatoryrequirements.

1995

ThefirstresearchprojectinvolvingtheEmergencyDepartment(ED)wasamultiyearinitiative.EDStudyAmultiyearDoDresearchprojectthatintroducedformalteamworktrainingbasedonaviationCrewResourceManagement(CRW)trainingconceptswasappliedtohealthcare.MedTeamsbeganwitharetrospectiveclosedclaimreviewofEDriskmanagementcases.Itwasdeterminedthat43percentoferrorsresultedfromproblemswithteamcoordination.Inthesecases,aneffectiveteamstructureandcaregiverstrainedinteambehaviorwouldhavemitigatedorprevented79percentoftheidentifiedfailures.

19992001

InstituteofMedicinereportToErrIsHumanwaspublished,drawingwidespreadattentionfromthegovernment,media,andhealthcareprofession.AsaresponsetotheIOMreport,PresidentClinton'sExecutiveMemoonImprovingHealthCareQualityrequestedareportfromQuIC:"Therefore,IherebydirecttheQualityInteragencyCoordinationTaskForce,toreporttomeasetofrecommendationsonspecificactionstoimprovehealthcareoutcomesandpreventmedicalerrorsinboththepublicandprivatesectorsinamannerthatisconsistentwiththestrongprivacyprotectionswehaveproposed."

2003

InstituteofMedicinereleases"PatientSafety:AchievingaNewStandardforCare."

2004

The100KLivesCampaignwasaninitiativetoengageU.S.hospitalsinacommitmenttoimplementchangesincareproventoimproveresidentcareandpreventavoidabledeaths.Thecampaignwassuccessfulandexceeded100Klivessaved!(June2006).

2005

PatientSafetyandQualityImprovementActissigned,requiringtheDepartmentofHealthandHumanServicestoestablishaprocessforthevoluntaryandconfidentialreportingofmedicalerrorstopatientsafetyorganizations.

TeamSTEPPSpilotcurriculumwasdevelopedandextensivelyfieldtestedin19trainingsessionsthroughouttheDepartmentofDefensehospitalsandclinics.Over440physicians,nurses,andtechniciansbecameInstructorsin2005,withmorethan5,000participantstrainedbytheseInstructors.

InstructorNote:ItisimportanttodiscusswiththeaudiencewhyTeamSTEPPSissoimportantandisnotanother"program"or"flavoroftheweek."TeamSTEPPSallowsallstaffateveryleveltobesurethepatient/resident'ssafetycomesfirst.Itmaynotbenecessarytosharealltheabovetimelinehistorywithyouraudience.Instructorsshouldusediscretionandsharethemostrelevantfactsapplicabletotheiraudience.

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Slide10:ResidentSafety

Say:

Let'slookatthevariouscomponentsthataredesignedtohelpsupportresidentsafetyandhowalloftheseeffortssupportandcreateapersoncenteredcareenvironmentforresidents.

InstructorNote:Usetheexistingslidetopromptdiscussiononthevariouscomponentsofpersoncenteredcareandhowresidentsafetycontributestothisconcept.

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Slide11:CourseAgenda

CustomizableContentInstructorNote:Withinthetrainthetrainer/coachsupplementalinstructorslides,thecourseagenda

willbedifferent.Inessence,thecourseagendafortheTeamSTEPPSfundamentalscourseisaninitialcomponentofthetrainthetrainer/coachcurriculum.

Say:

Wewillbecoveringsevenmodulesduringthenextfewhours.

IntroductionOverviewandscienceofteamperformancebeginninginaviationandmigratingtohealthcare.TeamStructureFirststepinimplementingateamworksystem.Delineatesfundamentalssuchasteamsize,membership,leadership,identification,anddistribution.LeadershipIdentifieskeybehaviorsthatleadersneedforensuringthatteamsperformeffectivelyandattaindesiredoutcomes.Introducebrief,huddle,anddebriefskills.SituationMonitoringTogainormaintainanaccurateawarenessorunderstandingofthesituationinwhichtheteamisfunctioning.Resultsinsituationawarenessandultimatelyasharedmentalmodelamongteammembers.MutualSupportBackupbehaviorthatallowsteamstobecomeselfcorrecting,distributeworkload

effectively,andregularlyprovidefeedback.Introducespecificapproachestomanagingconflict.Eachteammemberbecomesapartofthesafetynet.CommunicationFocusisonhowtocommunicateeffectivelythroughstandardizedinformationexchangestrategiessuchasSBAR,checkback,callout,handoff,andchecklists.SummaryPullingItAllTogetherThismoduleprovidesanopportunityforparticipantstoreviewandanalyzeavideocasestudy.Alowfidelitysimulationisthenconductedbydifferentgroupsthissimulationincorporatesthevariousteamworkskillspreviouslyintroduced.

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Slide12:IntroductionsandMagicWandExcercise

Time:15minutesMaterials:

MagicWandExerciseSheetTapeFlipchart(optional)

InstructorNote:DirectparticipantstotheMagicWandexercisesheet,andgivethem2to3minutes

tocompleteit.Beforeopeningthefloortotheparticipants,setthetoneoftheanswersbyprovidinganexamplewithresidentsafetyimplications,thengoaroundtheroomandaskeachparticipanttorespondin

turn.Astheyrespond,recordtheproblemsononesheetoftheeaselpadandthesolutionsonanother.

Say:

Ifyouhada"magicwand"andcouldmakechangeswithinyourunitorthefacilitytoimprovethequalityofcareprovidedorresidentsafety,whatactionswouldyoutake?

Discussion:

FrompartAontheexercisesheet:

Relativetoteamwork,whatproblemsdoyouhaveinyourunitorfacilitythatmakeprovidingsafe,qualitycaremoredifficult?

FrompartBontheexercisesheet:

Whatchangeswouldyoumakewithyour"magicwand"tosolvethese,ortohelpimprovethequalityandsafetyofthecarethatyouprovide?

InstructorNote:Ifparticipantsbringuptopicsperipheraltoresidentsafetyorquality,suchasimprovedparkingorsalaries,promptthemwithdirectingquestionstogetarelevantresponse:

Ask:

Haveyoueverwitnessedsomethingthatyouthoughtwasasafetyissueandthatyoubelievedyouwereunabletoaddressyourself?Why?Howwouldyouhavechangedthesituationifyouhadamagicwand?

Do:

Aftertheparticipantshaveresponded,wrapupthediscussion.

Say:

Inthiscourse,wewillprovideyouwithsometoolsandstrategiestohelpyouactualizethesechanges.Changeswillnotoccurovernight,butyoucangraduallymakeimprovementstothesafetyofyourresidentsandthequalityofcarethatyouprovide.

InstructorNote:Displaythesheetswiththeresponsesaroundtheroom,andreferencethe"WishList"duringthecoursepresentation.Linkidentifiedissuestotheskillortechniquebeingpracticedthatmaymitigatetheproblemoraccomplishthegoal.

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Slide13:WhyDoErrorsOccur?

Say:

Thescienceofhumanfactorsrecognizesthatamajorityoftheseerrorsstillaffectunitsthatareeffectivelypracticingteamwork.However,ineffectiveteams,mistakesarecaught,addressed,andresolvedbeforetheycompromiseresidentsafety.

InstructorNote:Thefollowingtermsaredefinedbelow.

Excessiveprofessionalcourtesygivingsomeoneofhigherrankorstatustoomuchrespectordeferencesothatitaffectsthelevelofhealthcaretheyreceive.Mayalsooccuramongteammembershavinghigherrankorstatus,resultinginahesitancyofteammemberstopointoutdeficienciesinperformance.Haloeffectoccurswhensomeoneelse's"great"reputationorextensiveexperiencecloudsourjudgment.PassengersyndromeTeammembersexperience"passengersyndrome"("justalongfortheride")whentheyabdicateresponsibilitybecausetheybelievesomeoneelseisincharge.HiddenagendaWhenateammembermakessuggestionsordecisionsoninformationordesiresofwhichtheremainderoftheteammaybeunaware.Anexampleofhiddenagendaisaperson'sstrongdesiretogetoffworkearlyoravoidaprocedureinwhichheorsheispoorlytrained.ComplacencyWhenindividualsand/orteamsbecomecomfortablewiththemostroutinetothemostdifficultorcriticaltasks.Becomesahazardwhenindividualsandteamslosetheirvigilanceandsituationawareness.Highriskphaseaprocedureortimeinwhichamedicalmishapislikelytohappen(e.g.,shiftchange).Task(target)fixationaconditioninwhichanindividual'sand/orteam'sfocusonataskmayimpairtheirdecisionmakingormakethemobliviousto"thebigpicture."Itisgenerallyprecipitatedbyarealorperceivedpressuretoperform,orbyworkload/stressrelatedissues.

InstructorNote:Thefollowingtermsaredefinedbelow.

Strengthofanideaanunconsciousattempttomakeavailableevidencefitapreconceivedsituation.Oncepeoplegetcertainideasintheirheads,itcanbedifficultorimpossibleforthemtoalterthatidearegardlessofhowmuchconflictinginformationisreceived.Hazardousattitudeswaysofthinkingandviewingtheworld(e.g.,antiauthority,impulsiveness,invulnerability,machismo,orresignation).LimitedEnglishproficiencypersonswhoareunabletocommunicateeffectivelyinEnglishbecauseEnglishisnottheirprimarylanguage.

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Slide14:InstituteofMedicineReportImpactofError

Say:

Publicreactiontotheproblemofmedicalerrorsreachedacriticalmassduringthe1999publicationofToErrIsHuman,whichconcludedthatmedicalerrorscauseupto98,000deathsannually.Thisreportgeneratedademandforactionthatwasheadedbythegovernment,themedia,andthehealthcareprofession.FormerPresidentClintonestablishedaQualityInteragencyCoordination(QuIC)TaskForcetodevelopacoordinatedFederalplanforreducingthenumberandseverityofmedicalerrors.AmongQuIC'srecommendationswasthewidespreadadoptionofhumanfactorstraining,suchasCrewResourceManagement,forimprovingmedicalteams'performance.Theirdutiesincludedthefollowing:

Identifycausesoferrors.Developerrorreductionstrategies.Distributeeffectivestrategies.

OptionalDiscussion:

Howdoesthismakeyoufeelasahealthcareconsumer?

Doesitmakeyouthinkdifferentlyaboutthecareprovidedinadoctor'soffice?Hospital?Howabouthereinyournursinghome?Howdoesthisinspireyoutothinkandactdifferently?

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Slide15:MedicalErrorsStillClaimingManyLives

Say:

Sowherearewenow,morethan5yearslater?

In2005,anarticlepublishedintheJournaloftheAmericanMedicalAssociation(JAMA)indicatedthatdespitethecallsfora50percentreductioninmedicalerrorsover5years,"Asmanyas98,000Americansstilldieeachyearbecauseofmedicalerrors,despiteanunprecedentedfocusonpatientsafetyoverthelastfiveyears[...]andthedeathratehasnotchangedmuch."

However,therewerealsosomepromisingfindings,accordingtoLeapeandBerwick.Reductionsofcertaintypesoferrorrelatedillnessesanddeathsoccurred.

AccordingtotheJAMAarticle,teamtraininginLaborandDeliveryhasledtoa50percentreductioninharmfuloutcomesinprematuredeliveries,suchasbraindamage.Computerizingprescriptionshasledtoan81percentreductioninmedicationerrors,placingapharmacistonthemedicalteamhasresultedina6678percentreductionofpreventableadversedrugevents,andimplementingrapidresponseteamshasledtoa15percentdecreaseincardiacarrests.

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Slide16:TopContributingFactorstoMedicalErrors(OptionalContent)

Say:

Nowthatwe'refamiliarwithhowprevalentmedicalerroris,let'sexaminethecausesofit.Theinformationonthesliderepresentscausalfindingsorcontributingfactorsfromsignificantmedicalerrorsexperiencedinallcaresettings,includingnursinghomes.Oftenthesemedicalerrorsare"reportable"totheStatehealthdepartmentanditistheresponsibilityofthecaresettingtodetermineitscauseandcontributingfactors.

Ofthemedicalerrorsvoluntarilyreportedovera10yearperiod,thetopcontributingfactorhasbeeninadequatecommunication.Integratingteamworkprinciplesintodailypracticecanhelpmitigateerrors.

InstructorNote:Anotheroptionistocreateaslidethatshowsanunderstandingofmedicalerrorsorsurveyresultsinyournursinghome,includingtrendingdatafromthepastcoupleofyears.

OptionalDiscussion:

Canyouthinkofnegativeevents(medicalerrors,deficiencies,accidents)inyournursinghomethatoccurredbecauseofinadequatecommunication?Whatwouldhavemadethesituationdifferent?Whatwouldyousuggesttoincreasecommunicationandteamworkinyournursinghome?

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Slide17:WhatComprisesTeamPerformance?

KeyPoint:

Theframeworkconsistsoffourcoreskills:leadership,mutualsupport,situationmonitoring,andcommunication.

Say:

TeamSTEPPSiscomposedoffourteachablelearnableskills:leadership,mutualsupport,situationmonitoring,andcommunicationthecoreoftheTeamSTEPPSmodel.Theredarrowsdepictatwowaydynamicinterplaybetweenthefourskillsandtheteamrelatedoutcomes.Interactionbetweentheoutcomesandskillsisthebasisofateamstrivingtodeliversafe,qualitycare.

Encirclingthefourskillsistheresidentcareteam,whichrepresentsnotonlytheresidentanddirectcaregivers,butalsothosewhoplayasupportiverolewithinthehealthcaredeliverysystem.

TeamcompetenciesrequiredforahighperformingteamcanbegroupedintothecategoriesofKnowledge,Skills,andAttitudes(KSAs).Teamrelatedknowledgeresultsinasharedmentalmodelattitudesresultinmutualtrustandteamorientation.Adaptability,accuracy,productivity,efficiency,andsafetyaretheoutcomeofahighperformingteam.

TeamSTEPPSisanevidencebasedframeworktooptimizeteamperformanceacrossthehealthcaredeliverysystem.

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Slide18:OutcomesofTeamCompetencies

Say:

Teammemberspossessingstrongleadership,situationmonitoring,mutualsupport,andcommunicationskillstypicallyyieldimportantteamoutcomes.Theinterrelationshipsarethefoundationofastrongcontinuousimprovementmodel:Theknowledge,skills,andattitudesofteamworkwillcomplementclinicalexcellenceandimproveresidentoutcomesbyusingfeedbackcyclesandclearlydefinedtoolstocommunicate,plan,anddeliverbetterqualitycare.

Knowledge:Teamsthatconsistofteammemberswithstrongleadership,situationmonitoring,mutualsupport,andcommunicationcapabilitiesyieldimportantteamoutcomeslikeasharedawarenessaboutwhatisgoingonwiththeteamandprogresstowarditsgoal.Teammemberswillalsobefamiliarwiththerolesandresponsibilitiesoftheirteammates.Attitudes:Whenyouworkinteamsinwhichthememberspossessgoodleadership,situationmonitoring,mutualsupport,andcommunicationskills,teammembersaremorelikelytohaveapositiveexperienceyouwillenjoyworkinginteamsandtrusttheintentionsofyourteammates.Performance:You'llbeabletoadapttochangesintheplanofcare.Teammemberswillknowwhenandhowtobackupeachother.You'llbemoreefficientinprovidingcareyouwillhaveaplan,andyouwillknowwhoissupposedtodowhat,andhowtheyaresupposedtodoit.Finally,yourteamwillbesafer,allowingtheteamtomorereadilyidentifyandcorrecterrors,iftheyoccur.

Noamountofteamworkcancompensateforclinical/technicalproficiency.Thefoundationofteamworkbuildsontechnicalproficiencyandprotocolcompliance.

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Slide19:TeamworkActions

InstructorNote:Thefirstfourbulletsareactionsthatshouldbeaccomplishedbythechangeteammembersandfutureresidentsafetyinstructorswhoattendedthetrainthetrainer/coachsession.Thefinalbulletissomethingthatshouldbetaughttoallparticipantswhoattendthefundamentalstraining.

Say:

Recognizeopportunitiestoimproveresidentsafety.Assessyourcurrentorganizationalcultureandexistingcomponentsthatsupportresidentsafety.Identifyateamworkimprovementactionplanbyanalyzingdataandsurveyresults.Designandimplementaninitiativetoimproveteamrelatedcompetenciesamongyourstaff.IntegrateTeamSTEPPSintodailypractice.

Highperformanceteamscreateasafetynetforyournursinghomeasyoupromoteacultureofsafety.

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Slide20:SupplementalInstructorSlides

CustomizableContentInstructorNote:Theremainingslidesinthismoduleshouldbeincludedforonlythetrainthe

trainer/coachsessions,toprovideadditionalbackgroundonTeamSTEPPSoriginandoverviewofthetrainingsessionforthenext2days.

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Slide21:CourseAgendaTraintheTrainer/CoachSession

CustomizableContentInstructorNote:Usethisslideforthetrainthetrainer/coachsessioninadditiontotheFundamentals

courseagendatoprovidetrainthetrainer/coachparticipantswiththedifferencebetweenthetwocourses.

Thecoursemanagementsessionistypicallyconductedintheimplementationmodule.However,ifyouhavesometimeattheendofdayone,youcanfilltheremainingtimewiththecoursemanagementsession.

Say:

Duringthenextfewdays,wewillgothroughthefundamentalsmodules.Inaddition,wewilldiscussandengageinactivitiesinsupportofthechangemanagement,coaching,andimplementationoftheTeamSTEPPScriticalskillsandtools.

Finally,aspotentialtrainersandcoaches,youwillbegivenanopportunitytoconductapracticeteachingsessionofanassignedmoduleonthefinalday.Atthecompletionofthiscourse,youwillbeequippedtofacilitateandtrainintheTeamSTEPPScurriculum.Furthermore,youwillbecontinuallysupportedtosucceedthroughreinforcement,practice,networking,andfeedback.

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Slide22:TeamworkEncompassesCRM

Say:

Inthepast25years,morethan$100millionhasbeeninvestedinteamperformanceandsafetyresearchandinnovations.

Militaryaviationledthewaytowarddramaticimprovementinflightsafety.CommercialaviationinstitutedCrewResourceManagement(CRM)inthelate1970safterseveralhighprofileairlinercrashes.CommercialaviationhasundergonemultipleiterationsofCRMandhasdevelopedanextraordinarycultureofsafetyandatrackrecordofsuccess:2002,2003,2004zerodeathsforjetairlineoperationsintheUnitedStates.

CRMiscurrentlyinthe"threatanderror"managementphase.

Themilitaryhastransitionedwhatwaslearnedfromthecombatteams,militaryaviation,andotherhighriskteamstothehealthcareenvironment.

Sincethelate1990s,asignificantnumberofpersonnelpracticinginmilitaryhospitalshavebecomecertifiedmedicalteaminstructorsandthousandsofcaregivershavebeentrainedonteamworkprinciples.

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Slide23:Background:U.S.ArmyAviation

Say:

Toprovideabackgroundtosupportevidencebasedteamperformance,itishelpfultounderstandthescienceofteamperformancewithinthemilitary.

Armyaviationcrewcoordinationfailuresinthemid80scontributedto147aviationfatalitiesandcostmorethan$290million.Thevastmajorityinvolvedhighlyexperiencedaviators.

Failureswereattributedlargelytocrewcommunication,workloadmanagement,andtaskprioritizationerrors.

Thesefailuresledtothedevelopmentofanexportableaircrewcoordinationtrainingandevaluationsystem,resultinginanestimatedannualsavingof15livesandnearly$30million.Recentrealworlddatashowedsavingscloseto$60millionperyear.

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Slide24:U.S.NavyBreakthroughs:TacticalDecisionmakingUnderStress(TADMUS)

Say:

Awatershedmomentformilitaryteamtrainingresearchcamein1998,afterthenavalwarshipUSSVincennesfiredinadvertentlyonanIraniancommercialairlineroverthePersianGulf.Whatresultedwasamultiyear,milliondollarresearchprogramtoformallystudyteamworkandteamtraininginterventions.Theprogram,knownasTacticalDecisionMakingUnderStress(TADMUS),beganin1990andledtheNavytobreakthroughadvancesinteamtraining.

ResultsfromtheTADMUSprogramhaveledtothefollowing:

Advancedunderstandingofteamknowledge,skill,andattituderequirements.Reliableandvalidmeasuresofteamprocessesandoutcomes.Newtrainingstrategiesforenhancingteamwork.

TheNavy'sAircrewCoordinationTrainingProgramsarebasedonCRMprinciples.Theobjectiveistointegratethefollowing:

Instructionintheseeightbehavioralskills(i.e.,missionanalysis,assertiveness,decisionmaking,communication,leadership,adaptability,flexibility,andsituationawareness)throughoutNavyandMarineCorpsaviationtraining.Thegoalhasbeeneffectiveapplicationofthesebehavioralskillsintooperationalaviationprocedures,whereappropriate.

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Slide25:U.S.AirForceCRMHistory

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TheAirForceIndividualandTeamTrainingToolsandEvaluationTechniquesProjectsetnewperformancestandardsinteamworkintheU.S.AirForceTankerAircrews,includingthefollowing:

Maintaininganatmospherethatfacilitatesteamwork.Backingupeachother.Coordination.Groupproblemsolving.Informationflow.(AirForceArmstrongLaboratory199599).

InstructorNote:TrainerswithintheDepartmentofDefensemaywanttoreviewatimelineofevents.

Atimelineofevents:

Midtolate1980sAFbombersandheavyaircraftstartedCRMtraining.1992ACC(Luke/TyndallAFB)developedAAAMP(AircrewAttentionManagement/CRMTraining)forF16/F15andexpandedtoA10/F111/F15E.BeforethefirstCombatAirForces(CAF)CRMcontract,AETCusedbluesuitandothercontractresourcesforCRMtraining.1996ACCcontractedCRMtrainingfortheentirecommand.1997USAFCRMSteeringCommittee,ACCpresentedaplantocombineCRMtrainingrequirementsunderonecontractforallMAJCOMS,standardizedCRMtraining,andsavedmoneybycombiningresources/manpower.1998USAFEsolesourcedCRMtraining.ACC,PACAF,USAFE,andtheAETCLukeandTyndallFTUsagreedtoformtheCAFCRMcontractin1998

SinceinceptionofCRMtraininginU.S.AirForce,evidencehasshownprogrameffectivenessbasedona

steadydeclineinhumanfactorbasedmishaps.

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Slide26:EightStepsofChange(Kotter)

Say:

Let'sbehonestchangeistough.Peopleoftenhaveadifficulttimeshiftingtoanewenvironment,especiallyinenvironmentsthatrequirestrictregulationsandprocedurestoeffectivelycareforresidents.Wewillspendsometimeonunderstandingchange.

Dr.JohnKotter,whowrotethebookOurIcebergIsMelting,ChangingandSucceedingUnderAdverseConditions,proposeseightstepsthatleadtoasuccessfulchange.

Thefirstphaseinimplementingchangeincludessettingthestage:

Step1:Createasenseofurgency.Helpothersseetheneedforchangeandtheimportanceofactingimmediately.Step2:Pulltogethertheguidingteam.Makesurethatapowerfulgroupisguidingthechangeonewithleadershipskills,credibility,communicationsability,authority,analyticalskills,andasenseofurgency.

Thesecondphaseinimplementingchangeincludesdecidingwhattodo:

Step3:Developthechangevisionandstrategy.Clarifyhowthefuturewillbedifferentfromthepastandhowyoucanmakethatfutureareality.

Thethirdphaseinimplementingchangeincludesmakingithappen:

Step4:Communicateforunderstandingandbuyin.Ensurethatasmanyothersaspossibleunderstandandacceptthevisionandthestrategy.Step5:Empowerotherstoact.Removeasmanybarriersaspossiblesothatthosewhowanttomakethevisionarealitycandoso.Step6:Produceshorttermwins.Createsomevisible,unambiguoussuccessesassoonaspossible.Step7:Don'tletup.Pressharderandfasterafterthefirstsuccesses.Berelentlesswithinstitutingchangeafterchangeuntilthevisionbecomesareality.

Thefinalphaseinimplementingchangeincludesmakingitstick:

Step8:Createanewculture.Holdontothenewwaysofbehavingandmakesuretheysucceeduntiltheybecomeapartoftheverycultureofthegroup.

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Slide27:RoadmaptoaCultureofSafety

Say:

Thesestepsandactivitiesformahighlevelroadmaptocreateacultureofsafety.Theyprovideanoutlineforavisionandstrategy.IntheChangeManagement:HowToAchieveaCultureofSafetymodule,we'lldiscussthesestepsinmoredetailandbegintoapplytheEightStepsofChangetoournursinghome.

Wealsowillfocusonhowtobeaneffectivecoachandintegrateteamworkbehaviorsintothenursinghomeanddevelopanimplementationplan,toincludedevelopingateamimprovementactionplan.Havingaroadmapcustomizedtomeetthefacility'scurrentcultureisparamounttothesuccessoftheTeamSTEPPSinitiative.

InstructorNote:Dependingontheimplementationplan,someorganizationsmayelecttohave

designatedinstructorsteachTeamSTEPPStostaff,withselectedcoacheswithindifferentworkareasinyourfacility.