Transcript Patient Safety & Quality

Patient Safety through Team
Training in Healthcare
Stephen A. Knych, MD, MBA
Division Chief, Patient Safety and Quality
Office: 407-303-4607
On 9/11/01 The World Changed
…
We Cannot:
• Wait for perfect
information
• Stay in your stovepipes
• Be complacent …
again
• Forget about lessons
learned
• Debate and delay the
issues
• Marginalize solutions
• Dwell on constraints or
concerns
Patient Safety: Scope of
Problem
• Human Costs:
– Estimated as many as 44,000 to 98,000
deaths each year
– More than motor vehicle accidents, breast
cancer and AIDS combined annually
– The total number of deaths that would
occur if a 747 airplane crashed killing all
aboard every other day for one year! **
• Source: “To Err is Human”, Institute of Medicine, 1999 *
• Source: Newhouse et.al., Measuring Patient Safety, 2005**
Patient Safety
• Financial Cost of Medical Errors: $29
billion each year in the United States
alone
• Doctors, patients, insurers and hospital
systems play a role in eradicating errors
Patient Safety: Scope of
the Problem
• 1 out of every 5 people says that they or a family
member experienced a medical mistake
• 51% reported the error as serious
• 28-35% of admissions experience an event that causes
HARM ( IHI, Dec 2007, Global Trigger Tool, Roger,
Resar, MD)
– Source: Commonwealth Fund 2001 Health Care Quality Survey
Patient Safety: CMS Actions
• Serious preventable event—object left in place
during surgery
• Serious preventable event—air embolism
• Serious preventable event—blood
incompatibility
• Catheter-associated urinary tract infections
• Pressure ulcers (decubitus ulcers)
• Vascular catheter–associated infection
• Surgical site infection—mediastinitis after
coronary artery bypass graft surgery
• Hospital-acquired injuries – fractures,
dislocations, intracranial injuries, burn
Patient Safety: Leadership
Role
• “Our systems are too complex to expect
merely extraordinary people to perform
perfectly 100 percent of the time. We as
leaders have a responsibility to put in
place systems to support safe practice.” *
• .90 X .90 X .90 X .90 = .65 or 65% **
• Law of Composite Reliability
•
•
Leadership Guide to Patient Safety, Institute for Healthcare Improvement,
2005*
James Conway, former VP and COO of the Dana-Farber Cancer Institute*
•
Frederick Ryckman, MD, Cincinnati Children’s Hospital **
Patient Safety Culture
• System of shared values (what is
important) and beliefs (how things work)
that interact with a company's people,
organizational structures, and control
systems to produce behavioral norms (the
way we do things around here).
• Webster’s Dictionary online
Team Training - Why Now?
• Significant performance gaps
• Sentinel Events
• Baldrige requires aligned, systematic and
fully deployed approach
• Growing regulatory & national expectations
– Patient Experience on Public Web
– Joint Commission Leadership Std 2009
– NQF Safe Practice 1.3 Requirement
– IHI 5 million Lives Campaign
– CMS New Scope of Work
– ACGME and Professional Organizations
What is the Evidence?
• Teamwork is a key initiative within patient safety
that can transform the culture within health care
– 27% reduction in nurse turnover (Dimeglio, 2005)
– 31% to 4% decrease in clinical error (Morey, 2002)
• Communication & other teamwork skills are
essential to prevent & mitigate medical errors
and harm
– 50% Less Adverse Outcomes (Mann 2006)
– 50% Less Post-Op sepsis (Sexton 2006)
RESULTS OF TEAMWORK IN THE
HEALTHCARE ENVIRONMENT
OR Teamwork Climate and Postoperative Sepsis Rates
Length of ICU Stay After Team Training
2.4
(per 1000 discharges)
18
Avg. Length of Stay (days)
16
2.2
14
50
2
1.8
%
Group Mean
12
Re
du
cti
on
AHRQ National Average
10
Low Teamwork
Climate
8
1.6
Mid Teamwork
Climate
6
1.4
4
High Teamwork
Climate
1.2
2
1
June
July
August
Sept
Oct
Nov
Dec
Jan
Feb
March
April
May
0
Teamwork Climate Based on Safety Attitudes Questionnaire
(Sexton, 2006)
Johns Hopkins
(Pronovost, 2003)
Johns Hopkins
Journal of Critical Care Medicine
Adverse Outcomes
Low

High
Indemnity Experience
Pre-Teamwork Training
Post-Teamwork Training
25
20
50%
Reduction
20
15
50%
Reduction
11
10
5
0
(Mann, 2006)
Beth Israel Deaconess Medical Center
Contemporary OB/GYN
Malpractice Claims, Suits, and Observations
11
Believe that decisions of the
“leader” should not be
questioned
50%
40%
30%
Surgeons
Pilots
Surgeons
20%
10%
Pilots
0%
Sexton, BMJ, 2000
TEAM FUNCTION & SAFETY
BEST TEAM
• Least Experience
Surgeon
• Cohesive Team
• Simulation
• Pre case planning
• Debriefing
• Results tracked
• Removed
hierarchy
WORST TEAM
• Most experienced
surgeon
• Team members
changed
• No (de)briefing
• No tracking of
results
• No preplanning
• Hierarchical
Bohmer, R. Harvard Bus.School
High-Performing Teams
Teams that perform well:
–
–
–
–
–
–
–
Hold shared mental models
Have clear roles and responsibilities
Have clear, valued, and shared vision
Optimize resources
Have strong team leadership
Engage in a regular discipline of feedback
Develop a strong sense of collective trust and
confidence
– Create mechanisms to cooperate and
coordinate
– Manage and optimize performance outcomes
(Salas et al. 2004)
14
Definition of a Team
Two (2) or more individuals with specific
tasks that are interdependent who
cooperate and coordinate their activities,
able to adapt and have a shared end goal
Why TeamSTEPPS
• 5 to 7 years DOD world-wide experience
• Civilian Spread funded by AHRQ
– Master TeamSTEPPS Training Free
– National Network
– All Education Material provided at cost
• Based on Evidence-Based Practices
• Growing national recognition and movement
toward TeamSTEPPS
• Florida Hospital joins Pacesetting Hospitals
• UCF-Ed Salas expert mentor and consultant
Outcomes of Team
Performance
• Knowledge
– Shared Mental
Model
• Attitudes
– Mutual Trust
– Team Orientation
• Performance
–
–
–
–
–
Adaptability
Accuracy
Productivity
Efficiency
Safety
Barriers to Team
Effectiveness
TOOLS
and
OUTCOMES
BARRIERS
• Inconsistency in Team
STRATEGIES
Membership
Brief
• Lack of Time
• Lack of Information
Huddle
Sharing
Debrief
• Hierarchy
STEP
• Defensiveness
Cross Monitoring
• Conventional Thinking
Feedback
• Complacency
Advocacy and Assertion
• Varying Communication
Two-Challenge Rule
Styles
CUS
• Conflict
DESC Script
• Lack of Coordination and
Collaboration
Follow-Up with CoSBAR
Workers
Call-Out
• Distractions
Check-Back
• Fatigue
Handoff
• Workload
• Misinterpretation of Cues
• Lack of Role Clarity
• Shared Mental
Model
• Adaptability
• Team Orientation
• Mutual Trust
• Team Performance
• Patient Safety!!
Accelerating Results
Sustainable
Excellence
(Effectiveness)
Monday, July 14, 2008
PERFORMANCE
IMPROVEMENT
Process
Education,
Training &
Competencies
CULTURE
Continuous
Improvement
Cycle
BEHAVIORS
(Based on
Mission & Values)
Just & Fair
Culture
Reliable
Design
Leadership
Structured
Communication
Rapid
Response
Team
Situational
Awareness
Executive
Executive
Patient
Safety
Patient
Safety
WalkRounds
WalkRounds
Mutual
Support
Impact Evaluation
In FY 08-09, TeamSTEPPS will:
Continue to collect quantitative data for Level 1 and Level 2
evaluation
 Develop and implement standardized Level 3 & 4 assessment
tools
 Include sustainment as part of system-wide evaluation
Level 5 – Return on Investment
Was the training worth the cost?
Level 4 – Results
Did the change in behavior positively affect the
organization?
Kirkpatrick’s Model
Level 3 – Behavior / Training Transfer
Did the participants change their behavior on-the-job based on
what they learned?
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?
TeamSTEPPS
Pilot/Research Project at
Celebration Health
Current Status – report
from the work of the FH
(system, CH, WP) and UCF
Research Teams
Celebration Health
OR Pilot Milestones
•
•
•
•
•
•
•
Assessment/Project Charter/Metrics – Feb
Baseline Observations – Mar
Instructor Training – Mar
Coach/Mentor Training- Mar
Start Project – Apr
On-Going Observations – Apr - Dec
Complete Pilot Project – Dec 2008
Phased Implementation
• Phase 1 (April – June)
 OR – wheels in to wheels out
 Mon – Fri, 7:30 – 3:30 start times
 General Surgery, Orthopedic, Bariatric Surgical
Teams
• Phase 2 (July – August)
 Disseminate to all surgeons
 24/7 includes all cases, emergent, weekend, holiday
• Phase 3 (handoffs & transitions) (Aug – Dec)
 Pre-op to OR
 OR to PACU
TeamSTEPPS Current Status
– Phase 1 baseline completed
• 3 complete surgical teams trained
• Orthopaedics, Bariatric Surgery, Minimally
Invasive General Surgery teams
• 4 hours of Fundamentals Training
• 3 surgeons, 1 PA, 1 First Assist
• 6 nurses and scrub techs
• 18 anesthesiology providers (CRNA/MD)
• 35 CH Council members 1hr Essentials
• FH sent 13 people for 2.5 day Master
Trainer Certification
TeamSTEPPS Current Status
– Phase 1 baseline completed
• Observations of 30 surgical cases at CH
and 30 surgical cases at WP (control
group)
• Baseline surveys included
– AHRQ Patient Safety Culture Survey
– *ORMAQ (assess attitudes towards teamwork
and current perceptions of teamwork)
– Stress
– Job satisfaction
*Operating Room Management
Attitudes Questionnaire (ORMAQ)
– Others
TeamSTEPPS Current Status
– TeamSTEPPS training completed - General
reactions were positive
TeamSTEPPS Reactions to Training Survey
100%
90%
Percentage
80%
52
70%
60%
50%
81
94
83
81
81
71
94
Strongly/Agree/
Agree/Somewh
at Agree
Neither
40%
30%
20%
29
10%
0%
7
1. The training
was well
organized.
6
13
10
10
19
19
2. The training
3. As a result of
4. I believe that
5. I am confident
6. As a result of
7. I am likely to
8. I would
content (materials, the training, I feel this training will that I can use the
training, I feel
apply the tools
recommend this
videos,
confident that I am
help my
knowledge that I
more confident
provided in this
training to the
demonstrations, prepared to train
organization
learned on the job. about my ability training to a variety others at work.
etc.) was
others to use
immprove patient
towk effectively in a of situations on
appropriate.
TeamSTEPPS.
safety.
team.
the job.
Question
Strongly
Disagree/Disag
ree/Somewhat
Disagree
TeamSTEPPS Current Status
Trainee comments included:
•
•
•
•
“Better ways to collaborate and facilitate
communication.”
“Improving communication, decreasing barriers based
upon hierarchy.”
“Great training - needs to be given to all staff - mostly
surgeons”
“More interaction and exercise ‘hearing’ about it, is
way different than performing it.”
Did training meet your expectations, why or why not?”
•
•
“Yes. Good information. Patient safety is our ultimate
goal. It needs to be preserved above all.”
“Yes, it actually exceeded my expectations since
practical examples were used throughout.”
TeamSTEPPS Current Status
•
What we Learned
– OR team members do find TeamSTEPPS
training helpful and find the concepts viable
for their work.
– Simulation or practice is important to training
effectiveness and perceptions of trainees that
they are ready to implement teamwork
behaviors covered in training in the OR.
– It is vital the physicians champion training
efforts with their team, their buy-in is crucial
to success.
TeamSTEPPS Current Status
•
Next Steps
–
–
–
–
Impact of training on culture, stress, teamwork
perceptions and actual behavior in the OR will be
analyzed in August
Cost Analysis is underway for current Project
Follow up is scheduled for Oct-Nov 2008. It will
consist of observations and surveys
2009
–
–
–
–
–
Spread to different location and/or service line?
Continue evaluation at different location and/or service line?
Implement simulation as part of future training roll-out
Implement formalized coaching plan for future roll-out
Develop a “GLITCH” database for system-wide use
Patient Safety
“Knowing
is not enough; we must
apply. Willing is not enough; we
must do”
Goethe
QUESTIONS?
THANK YOU FOR THE
INVITATION TO SPEAK TO YOU
TODAY!