Patient Safety StrategyTeamSTEPPS

Dr Olufemi AinaConsultantAesculapius Healthcare Consultants

About Us

Competencies in Healthcare Project Management, Business Development, Idea Generation, Process Improvement, Financial Management and Healthcare Quality Management.

Master Trainers in TeamSTEPPS Patient Safety Strategies, Certified by the US. Department of Defense and Agency for Healthcare Research and Quality (AHRQ)

Certified Project Managers with Project Management Institute (PMI) in the United States.

Certified Quality Management and Process Improvement Experts with American Society of Quality (ASQ) .

USAID SHOPS (Strengthening Health Outcomes though Private Sector) Trainers on Financial Management for Medical Directors

Our Services

Only TeamSTEPPS Provider in Nigeria

Hospital Quality Management and Process Improvement

Hospital Business Advisory and Financial Management

Tailored Capacity Development for Healthcare Professionals

Hospital Marketing and Branding Service

Outsourced Hospital Management

Personal Experience

Young NYSC dr. in a GH, Lagos many years ago: ordered IM drugs, nurse uncomfortable, even though gave lower dose- respiratory arrest, called and answered promptly.

Young Father in a PH, Lagos: 2 years ago: overworked nurse (esp. with reports), set up IV line, suction didn’t work, sucked manually

Quality and Safety

Quality: the degree of the realisation of the reasons that the patient has come to the care hospital e.g. patient comes to for an operation.

Safety:results which are not the reasons for the patient coming e.g. ‘not catching an infection’ and he is implicitly confident he will not run the risk of this happening.

To a certain extent, ‘safety’ thus concerns ‘anti-quality’.

Classification of Medical ErrorsNear Miss is defined as an act could have harmed the patient but did

not do so as a result of: chance e.g. patient received a contraindicated drug but did not

experience an adverse drug reaction prevention e.g. a potentially lethal over-dose was prescribed, but a

nurse identified the error before administering the medication mitigation e.g., a lethal drug overdose was administered but

discovered early and countered with an antidote.

Adverse Events cause harm to patients—causing a large number of injury, disability, and death.

errors of commission e.g., prescribing a medication that has a potentially fatal interaction with another drug the patient is taking.

errors of omission (e.g., failing to prescribe a medication from which the patient would likely have benefited, which may pose an even greater threat to health.

WHO- Patient Safety Practice Processes or structures which, when applied,

reduce the probability of adverse events resulting from exposure to the health-care system across a range of diseases and procedures.

Healthcare-associated infection is a global problem with over 1.4 million people suffering at any given time.

Medical errors result in numerous preventable injuries and deaths.

Inadequate Patient Safety Data in African Region

WHO- African Region

Adverse events 4% to 16% of all hospitalized patients

Developing Countries estimated 5% to 10% of patients acquire one or more infections

Risk 2 to 20 times higher than in developed countries.

Sentinel Events Surgical Care- > 50% of Adverse Events, Unsafe injections, blood and medicines

African Countries Mali 18.9%, Tanzania 14.8%, Algeria 9.8%

Drugs 25% of medicines are counterfeit, poly-pharmacy, inappropriate use of antimicrobials; overuse of injections, lack of prescription guidelines, inappropriate self-medication, non-adherence to dosing regimes.

Patient Safety Movement

9

2006

Patient Safety and Quality

Improvement Act of 2005

Executive Memo from President

DoD MedTeams®

ED Study

Institute for Healthcare

Improvement

100K lives Campaign

“To Err is Human” IOM Report TeamSTEPPS

1995 1999 2001 2003 2004 2005

JCAHO National

Patient Safety Goals

Medical Team Training

Institute of Medicine Report

Impact of Error: 44,000–98,000 annual deaths

occur as a result of errors

Medical errors are the leading cause, followed by surgical mistakes and complications

More Americans die from medical errors than from breast cancer, AIDS, or car accidents

7% of hospital patients experience a serious medication error

10

Cost associated with medical errors is $8–29 billion

annually.

Federal Action:

By 5 years;

medical errors by 50%,

nosocomial by 90%; and

eliminate “never-events” (such as wrong-site surgery)

Medical Errors Still Claiming Many Lives

By Elizabeth Weise, USA TODAY

As many as 98,000 Americans still die each year because of medical errors.

The researchers blame the:

Complexity of Health Care Systems

Lack of Leadership

Reluctance of to admit Errors

Billing System that Reward Errors

11

05/18/2005

…little progress towards the goal

Leape and Berwick,JAMA May 2005

Hospitals have taken steps to reduce medical errors and injuries.

Examples:

Computerized prescriptions: 81% decrease in errors.

Including pharmacist in medical team: 78% decrease in preventable drug reactions.

Team training in delivery of babies: 50% decrease in harmful outcomes — such as brain damage — in premature deliveries.

Source: Journal of the American Medical Association

Improvements

Joint Commission Sentinel Events

12

Why Do Errors Occur—Some Obstacles

Workload fluctuations

Interruptions Fatigue Multi-tasking Failure to follow up Poor handoffs Ineffective

communication Not following

protocol 13

Excessive professional courtesy

Halo effect Hidden agenda Complacency High-risk phase Task (target)

fixation

The Components of a Patient Safety Program

14

“Initiative based on evidence derived

from team performance…

leveraging more than 25 years

of research in military, aviation,

nuclear power, business and industry…to acquire team

competencies”

15

Team Strategies & Tools to Enhance Performance & Patient Safety

TeamSTEPPS Curriculum Contributors

16

•Department of Defense

•Agency for Healthcare Research and Quality

•Research Organizations

•Universities

•Medical and Business Schools

•Hospitals—Military and Civilian, Teaching and Community-Based

•Healthcare Foundations

•Private Companies

•Subject Matter Experts in Teamwork, Human Factors, and Crew Resource Management (CRM)

Background: US Army Aviation

Army aviation crew coordination failures in mid-80s contributed to 147 aviation fatalities and cost more than $290 million

The vast majority involved highly experienced aviators

Failures were attributed largely to crew communication, workload management, and task prioritization

17

US Navy Breakthroughs: Tactical Decisionmaking Under Stress (TADMUS)

Cross-Training Stress Exposure Training Team Coordination

Training (CRM) Scenario-Based Training

and Simulation Team Leader Training Team Dimensional Training Team Assessment

18

US Air Force CRM History Mid to Late 80s AF

bombers and heavy aircraft started CRM training

1992 Air Combat Command developed Aircrew Attention Management /CRM Training

By 1998, CRM deployed uniformly across the AF

Steady decline in human factors based mishaps since CRM training deployed

AF Medical Service adapted training, rolled out in 2000

19

DoD Team Research and Innovations

Non-Healthcare• Combat Information

Centers• Joint Forces

Operations• Army Special Forces• Tank, Submarine, and

Air Crews

20

CRM

TeamHealthcare

ED, OR, L&D, ICU, Dental Whole Hospital Combat Casualty Care

…striving to be a high reliability healthcare system…

21

Indemnity Experience

20

11

0

5

10

15

20

25

Malpractice Claims, Suits, and Observations

Pre-Teamwork Training Post-Teamwork Training

Adverse Outcomes

50%Reduction

50%Reduction

(Mann, 2006) Beth Israel Deaconess Medical CenterContemporary OB/GYN

1

1.2

1.4

1.6

1.8

2

2.2

2.4

June July August Sept Oct Nov Dec Jan Feb M arch April M ay

Avg

. Len

gth

of S

tay

(day

s)

Length of ICU Stay After Team Training OR Teamw ork Climate and P ostoperative Seps is Rates

(per 1000 discharges)

Group Mean

Low Teamwork Climate

Mid Teamwork Climate

High Teamwork Climate

0

2

4

6

8

10

12

14

16

18

AHRQ National Average

Teamwork Climate Based on Safety Attitudes Questionnaire

Low High(Sexton, 2006)Johns Hopkins

(Pronovost, 2003)Johns HopkinsJournal of Critical Care Medicine

Results of Teamwork System50% reduction in adverse outcomes

Average length of ICU stay reduced by 50%

27% reduction in Nurse turnover

Decreased clinical error rate from 30.9% to 4%

Reduction by 50% in post-op sepsis rate

Teamwork Actions

Recognize opportunities to improve patient safety

Assess your current Organizational Culture and existing Patient Safety Program components

Identify teamwork improvement action plan by analyzing data and survey results

Design and implement initiative to improve team-related competencies among your staff

Integrate TeamSTEPPS into daily practice.

23

“High-performance teams create a safety net for your healthcare organization as you promote a culture of safety."

…Improved teamwork and communications…

Ultimately, a culture of safety

Teamwork Is All Around Us

24

Knowledge Shared awareness about what is going on in the Team

and progress towards its goals. Team members are familiar with Roles and Responsibilities of their Teammates

Attitudes Team members have a positive experience, enjoy

working in teams and trust intention of Team mates

Performance Team members know when and how to back each other

up, be more efficient in providing care, and more readily identify and correct errors if they occur

Components of Team Performance

Outcomes of Team Competencies

Knowledge Shared Mental Model

Attitudes Mutual Trust Team Orientation

Performance Adaptability Accuracy Productivity Efficiency Safety

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Team Structure

Leadership

Situation Monitoring

TeamSTEPPS Modules

Mutual Support

Communication

Team Structure

First step in implementing a teamwork system is Team Development

Delineates fundamentals such as team size, membership, leadership, identification and distribution

Check the ratio of ‘WE’s to ‘I’s to assess Team Development

Patients are part of the Care Team

Members anticipate needs of others, adjust to each other’s actions and have a shared understanding of plan of care

Leadership

Team Leaders impact effectiveness by: changing behaviours motivating members coordinating processes facilitating problem-solving

Leaders need to ensure Teams perform effectively and attain desired outcomes

Leaders monitor, diagnose and treat Teams

Tools include brief, huddle, and debrief

Situation Monitoring

To gain or maintain an accurate awareness or understanding of every situation in which the team is functioning

Results in a shared mental model among team members

Elements include STEP:Situation of PatientTeam MembersEnvironmentProgress towards Goals

Mutual Support

Also known as Back-up behaviour :allows teams to become self-correcting, distribute workload effectively and regularly provide feedback

Specific approach to conflict resolution

Each team member becomes part of the Safety Net

Communication

Most important component of Team Management.

Standardized information exchange strategies- SBAR, Check-back, Call-out, Handoff, and Checklists

Complete, Clear, Brief, Timely

Roadmap to a Culture of Safety

33

Catalytic event drives need for

change

Build team, strategy, buy-in,

establish goals

Implement Action Plan, Train,

Empower Others

TeamSTEPPSChange

Coaching

I’m staying right here. Yeah they’ll

be back.

What are they

doing?Why

do we need chang

e?

Jt. Comm.

Status

QUOFUTURE

Errorville

Celebrate wins! Staying the

courseSustaining

Develop Action Plan

Test Interventio

n(Outcomes)

Monitor, Integrate, Continuous Process

Improvement

Prepare the Climate

Profile of Patient Safety Officers

Advocates of Teamwork

Dynamic Presenters

Viewed as Leaders amongst peers

In positions that allow flexibility

What We Do

Fundamentals Course and Implementation Workshop for Hospital Leadership and Steering Committee

Assessing your Hospital in Patient Safety and Healthcare Team Functioning

Training your Healthcare Professionals in TeamSTEPPS Strategies

Developing your Quality Champions as TeamSTEPPS Coaches

Regular Assessment and Onsite Support

Certify Hospitals as TeamSTEPPS Hospitals

Contact Us

Phone- 08052064317, 08023277559

Website- www.aesculapiusvn.com

Facebook: Aesculapius Healthcare Consultants

LinkedIn- Aesculapius VN

Twitter- @AesHealthCon

Email- aesculapiusvn@gmail.com, info@aesculapiusvn.com

Thank You Aesculapius Healthcare Consultants