teamstepps 2013 presentation "create your own simulations and evaluate them"
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Create Your Own Simulations and Evaluate ThemTEAMSTEPPS® NATIONAL CONFERENCE
DALLAS, TX
JUNE 13, 2013
Introductions
o Steve Powell, MS
o Melisa Powell, MS, RN-BC
o Julie Gapstur, RN, BSN
o Daniel Baily, MS
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Objectiveso To know and be able to develop TeamSTEPPS training scenarios
o To understand the process of developing TeamSTEPPS performancemeasures for Simulation
o Identify the role debriefs play in promoting team self-correction, process improvement, and patient safety.
o Recognize the importance of reflection, measurable performance objectives, and psychological safety during the debrief.
o Recognize the importance of empowering individual team members to discuss shared team performance and process outcomes during the debrief.
Program Evaluation of In Situ Simulation-Based Team TrainingMELISSA POWELL MS, RN-BC
Start at the End - Use a Backwards Planning Model
o Start with a needs assessment. Identify best practices.
o Determine what will be acceptable evidence of current performance.
o Examples:
◦ Practice data - Unit data
◦ Published data about clinical performance
◦ Interviews – Focus groups – Unit request
My Storyo Vanderbilt Hospital has a weekly meeting with unit leaders to debrief
all RRT calls that occur on medicine units.
◦ Began to Review all RRT’s called on unit
◦ Appeared to be delays in calling
◦ Nurse were not calling RRT (even when medically appropriate)
What Did the Nurses Say?o “He or she {physician} is right here at the bedside with
me, and that feels very uncomfortable as though it says to the physician that I do not think they are capable.”
o “He or she went to medical school. I didn’t. I’m just a nervous new nurse. They know what they are doing.”
o “The nurses just roll their eyes at me and don’t do anything!”
Desired Outcomes for the Project
Rapid Response called:
1. When Appropriate - Accuracy
2. In a Timely Manner - Timeliness
What I Did Use as a Measure
How frequently was there a delay to call or failure to call
Using Simulation and Video as a Tool for Evaluating Behaviors
Using a Checklist as an Evaluation Tool
Two-Challenge
CUS
Task Assistance
Check-back
Call-outs
SBAR
Unintelligible Communications
Communication
Mutual Support
Positive Instances
Positive Instances
Frequency Count
Using Debriefing as an Evaluation Toolo The Facilitator should role model creating a debrief climate with
psychological safety.
o Learners should be asked to express what they will take forward into their daily practice based on the simulation experience.
o (EXIT TICKET!)
Play Video of Debrief
Program Evaluation
Post code data & # of Failure to Rescue events
Intervention group (100%)
Online Education
Simulation
Debrief
Survey Real event
Post code quality survey
# Failure to Rescue events
Source: Moore’s Method
Post Training Survey
7%
7%
7%
14%
20%
93%
79%
73%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Unit based simulations helped build my confidence in my teammatesfor a real life code situation.
Please rate the simulation as a method to practice/reinforce yourteamwork skills.
Beacuase of this simulation event I have learned new communicationtechniques that I will employ in my practice.
Bottom Quartile 3rd Quartile 2nd Quartile Top Quartile
Strongly Disagree Strongly Agree
Poor Excellent
Strongly Disagree Strongly Agree
Simulation Checklist Resultso BLS skills (80%)
o Procedural knowledge (50%)
o Equipment knowledge (unable to assess during due to SimMan3G barriers)
o Assessment and Intervention (99%)
o Recognizing and Initiating RRT immediately (55%)
o Communication skills
◦ SBAR (20%)
◦ CUS (.1%)
◦ Check Back (34%)
◦ Two-Challenge Rule (0%)
◦ Situation Monitoring including Shared Mental Model knowledge (34%)
.
Number of Delay and/or Failure to Rescue
6
12
23
18
0 5 10 15 20 25
Invervention Unit
Control Unit
January 2010 to July 2010 January 2011 to July 2011
January 2010 to July 2010 January 2011 to July 2011 Percent Change
Invervention Unit 23 6 -117%
Control Unit 18 12 -40%
Performance Outcomes Analysiso Debriefing nurses post intervention yield stronger self reflective ability
o Using concepts such as authority gradient to communicate what they experienced
o Staff now often identifies their own barriers and role in early activation and failure to rescue
Role-play Simulation Exercise
TeamSTEPPS, Simulation and the Power of DebriefsA POWERFUL COMBINATION
JULIE GAPSTUR, RN, BSN
Partnership for Patients AlignmentoAims:
◦ To reduce patient harm by 40 percent by 2013
◦ To reduce hospital readmissions by 20 percent by 2013
Harm includes OB Adverse Events
Our Collaborative Goalso 95% providers and staff participation in a team-based simulation
module
o Increase Labor and Delivery team debriefs following an unscheduled cesarean delivery, after handoff to OR, to 95%
o 5% overall improvement in dimension scores or achievement of 5% or more above the National OB benchmark average on the AHRQ Hospital Survey on Patient Safety Culture
o + other clinical outcomes
Why TeamSTEPPS and Simulation?
Courtesy: Paul Preston, MD Kaiser-Permanente
Simulation and Team TrainingTeams experience the difference between knowing what they are supposed to do & doing what they are supposed to know
What we Did…
Simulation Training
that is focused
on TeamSTEPPS &
DEBRIEFING
Why Debrief?o Teams that debrief effectively
build shared understanding (mental models) and perform up to 40% better
o Guided team debriefs improve performance through self-critique and problem-solving
o Teams that debrief are able to uncover and identify problems earlier than other teams
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Smith-Jentsch, et al., 2008
How we did it….
TeamSTEPPS Essentials Training
Training on HOW TO DEBRIEF
Use multiple levels of Simulation Fidelity
Familiarization with Simulation devices
Faculty Simulation exercise
Participant Simulation exercises
Simulation evaluation
Building the Scenario
“Show and Tell”
The Simulation Event
Mama Natalie - Low Fidelity
Pre-Simulation Briefing
Pre-Simulation Briefing by Facilitator
1. Introduce Staff
2. Review Roles
3. Review Equipment
4. Review Goals
Shoulder Dystocia –High Fidelity with SimMom™
What is a Debrief?Debriefs are team events used to:
◦ Review individual and team performance
◦ Identify errors made
◦ Recognize best practices
◦ Develop a plan to improve
◦ Promote continuous learning and process improvement
36
DEBRIEFS ARE NOT JUST FOR SIMULATION!
Structured Debrief Checklist
1. What went well, and why?
2. What didn’t go so well, and why?
3. What would we do differently?
FOCUS ON TEAM SKILLS!
Remember, redirect debrief if the focus is on processes, ‘simisms’, or clinical skills
Tips for Debriefing
Be a FACILITATOR, not an INSTRUCTOR –
Get Them To Talk
Keep it Simple – Three Questions
Show the Video –
When Needed (if team is unable to self reflect.)
Be Comfortable with Silence
Focus on Team Skills –
NOT Clinical Skills – Redirect the Debrief if Needed.
ApplicationWhat will it take to implement debriefs with your team?
◦ Identify a facilitator.
◦ Give all team members a voice in the process.
◦ Treat debriefs as learning opportunities, not opportunities for assigning blame.
◦ Focus on process improvement and future performance.
Teamwork Actionso Conduct debriefs.
o Empower team members to speak freely and provide feedback.
o Focus on teamwork and task work processes.
o Use a tool to evaluate team performance and facilitate discussion.
o Record and trend team performance.
Simulation Learnings – ‘Ah-Ha’ Moments1. Tell them, show them, let them practice
2. Make sure your facilitators are not only content experts, but well seasoned facilitators
3. Stick to the script in debriefing
4. Plan in advance – but be flexible
5. Make it fun! Don’t be surprised if you see laughing – this is “serious play!”
6. Don’t be afraid of improvisation
Implementation Confidence –Training Site #4
N = 22
Simulation Confidence – Training Site #2
N = 16
TEAMS THAT DEBRIEF –PERFORM BETTTER!
Looking through the Windshield instead of the Rear View Mirror
Helps turn your team of experts…
into an expert team
Q & A
Referenceso Bandura. (2001). Social cognitive theory: An agentic perspective. Annual Review of Psychology, 52(1), 1.o Clancy, C. M. (2007). TeamSTEPPS: assuring optimal teamwork in clinical settings. American journal of medical quality, 22(3), 214.o Gaba, D. M. (2004). The future vision of simulation in health care. Quality & Safety in Health Care, 13(suppl 1), i2.o Holzman, R. S. (1995). Anesthesia crisis resource management: real-life simulation training in operating room crises. Journal of clinical
anesthesia, 7(8), 675.o Kolb, D. A. (1983). Experiential Learning: Experience as the Source of Learning and Development (1st ed.). Prentice Hall.o Miller, K. K. (2008). In situ simulation: a method of experiential learning to promote safety and team behavior. The Journal of perinatal
& neonatal nursing, 22(2), 105.o Moore, D. E., Green, J. S., & Gallis, H. A. (2009). Achieving desired results and improved outcomes: Integrating planning and
assessment throughout learning activities. Journal of Continuing Education in the Health Professions, 29(1), 1–15. doi:10.1002/chp.20001
o Nunnink, L. (2009). In situ simulation-based team training for post-cardiac surgical emergency chest reopen in the intensive care unit.Anaesthesia and intensive care, 37(1), 74–8.
o Peberdy, M. A., Callaway, C. W., Neumar, R. W., Geocadin, R. G., Zimmerman, J. L., Donnino, M., Gabrielli, A., et al. (2010). Part 9: Post–Cardiac Arrest Care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency CardiovascularCare. Circulation, 122(18 suppl 3), S768–S786. doi:10.1161/CIRCULATIONAHA.110.971002
o Rogers, E. M. (1995). Diffusion of innovations. Free Press.o Rudolph, Jenny, W. (2006). There’s No Such Thing as “Non-judgmental” Debriefing: A Theory and Method for Debriefing with Good
Judgement. Simulation in Healthcare, 49–55.o Salas, E., DiazGranados, D., Klein, C., Burke, C. S., Stagl, K. C., Goodwin, G. F., & Halpin, S. M. (2008). Does Team Training Improve Team
Performance? A Meta-Analysis. Human Factors: The Journal of the Human Factors and Ergonomics Society, 50(6), 903–933. doi:10.1518/001872008X375009
o Small, S. D. (2008). Demonstration of high‐fidelity simulation team training for emergency medicine. Academic emergency medicine, 6(4), 312.
o Vanderbilt Policy Rapid Response Team Activation Policy number CL 30-08.16o Vanderbilt Policy Cardiopulmonary Resuscitation Policy number CL 30-08.21.