Transcript TeamSTEPPS for Surgeons: Opportunities, Challenges and

TeamSTEPPS for Surgeons:
Opportunities, Challenges and Lessons
Learned
Dwight Burney, MD
Andrew Grose, MD, FAOOS
John Webster, MD, MBA, MSEL
A PHYSICIAN’S VIEW OF
TEAMSTEPPS
INSIGHTS AND OBSERVATIONS
John S. Webster, MD, MBA, MSEL
SBAR……..
• 17 years
• 12,000
participants
• 300 hospitals
• 500 units
• 10 years
consulting
25 minutes
TIMELINE: 1996---2014
THE GOOD, BAD, & UGLY
• Evidence based
• Standardized • Time
• Customizable constraints
• Multi-modal • Seemingly
complex
• Requires Resistance
CHANGE
Maximum
Photo
Mirror
?cat-lion?
• Training & coaching
• Organizational
change
• Implementation &
sustainment
• Behavior change
• Physician change
UNDERSTANDING MY ROLE
Over Time…..
SHIFT TOWARDS
A CULTURE OF SAFETY
Implementation planning addresses all phases
INSIGHTS: PHASE I
ASSESSMENT
MOTIVATORS:
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Survey GAPS
RCAs, near-misses
Outcomes
Errors
Personal stories
Regulatory actions
Community
awareness
• Unit-specific
• Data
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Accurate
Meaningful
Personalized
Benchmarked
Patient centric
Difficult to discount
• Available for unit
personnel to interpret
INSIGHTS: PHASE 2
PLANNING, TRAINING, IMPLEMENTATION
• Involve physicians
EARLY in planning
• Create/Recruit
CHAMPIONS
• Unit level focus
• “Wave model”
• Gap/needs analysis
• Wants vs. needs
• “TRAINING”
• 30—50—20 mix
• More interactive,
less didactic
• Stories, examples
• Teach-backs
• Simulation
• Learning….
• Behavior change
INSIGHTS: PHASE III
SUSTAINMENT
• Must implement
before you can
sustain
• Variable progress
and levels
• Expect
disappointments
• ACT short-term;
THINK long-term
• Carrot and stick
• Create/celebrate
successes, stories
• FEEDBACK
• Data
• Personal/professional
• Continuous
improvement
mindset
• Accountability***
INSIGHTS: PHASE III +
MAKE IT STICK: ACCOUNTABILITY
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Setting expectations
Influence strategies
LEADERSHIP
FEEDBACK
Just culture concepts
Inspiration
Outliers…..
• Impact, bylaws,
leaders, Board,
processes
“It is not only what
we do, but also
what we do not do
for which we are
accountable”
John Baptiste Molière
THINK: Patient Centric Care
INTEGRATION
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Department meetings
Committee meetings
Setting expectations
Bylaws
Policies and procedures
Hiring, on-boarding
Credentialing and privileging
Re-credentialing
Incentives and rewards
Meaningful metrics
Feedback
Ultimately:
USING the
STRATEGIES
TOOLS
BEHAVIORS
PRINCIPLES
SOME KEY REFERENCES:
1. Team-training in healthcare: a narrative synthesis
of the literature. Weaver SJ, Dy SM, Rosen MA. BMJ
Qual Saf 2014; 23 359-72
2. Towards a model of surgeons’ leadership in the
operating room. Parker SH, Yule S, Flin R et al. BMJ
Qual Saf 2011; 20 570-79
3. Does teamwork improve performance in the
operating room? A multi-level evaluation. Weaver
SJ, Rosen MA, DiazGranados D, et al. Jt Comm J
Qual Patient Saf. 2010;36 133-142.
4. Improving Patient Safety Through Teamwork and
Team Training. ED: Eduardo Salas and Karen Frush.
Oxford University Press, 2013.
VALUES: WAYS TO APPROACH….
• Evidence based
• Improved outcomes
• Increased satisfaction
• Decreased harm
• Efficiency (fewer hassles)
• Competitiveness
• Solid (meaningful) data
• Clinical leadership
What’s in it for me?
ADVICE FROM INNOVATORS
• Keep it simple
• Keep it fresh
• Keep it fun
• Keep it real
• Keep in relevant
Believing: The HHC Patient Safety Story
A four-part multimedia series, Believing,
uses data, film, photography, and narrative
to chronicle the HHC patient safety journey.
From 2010 TeamSTEPPS
Collaborative
http://believe.nychhc.org/hhc_safety4.html
IMPORTANT QUESTION: DO WE
KNOW WHAT WE DON’T KNOW?
• Human factors
• Medical error
• Structured
communication
• Clinical leadership
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Behavioral literature
Quality and Safety
Handoffs***
Doctor-Patient
Communication
16
MOVING FORWARD…….
• Simulation
• In-situ learning
• Blended learning
• Professional
training/feedback
• Patient
expectations and
Transparency
• Physician
leadership….
Team STEPPS®:
Engaging Orthopaedic
Surgeons As Safety
Leaders
Team STEPPS® National Conference
June 11, 2014
Minneapolis, MN
DISCLOSURES
• Member, American Academy of Orthopaedic
Surgeons’ Patient Safety Committee; Chair, Section
on Surgical Communication.
• Team STEPPS® Master Trainer
• Core National Faculty Member, AHRQ/HRET
Ambulatory Surgical Safety Project
• National Faculty Member, Institute for Healthcare
Communication, New Haven CT
Primary mission:
Education, Advocacy
Membership: >96% of
all American
orthopaedic surgeons
Core Values: Excellence,
Professionalism,
Leadership, Collegiality,
Lifelong Learning
AAOS AND PATIENT SAFETY
• “Sign Your Site” (prevention of Wrong Site Surgery)
1997
• “Take Care: Patient Safety Is No Accident” 2003
• “Patient Safety Is Job #1”
• AAOS Patient Safety Summit 2012
• “Patient Safety: It Takes A Team” 2014
AAOS SAFETY INITIATIVES - RESULTS
• “Sign Your Site” incorporated into expanded Universal
Protocol in 2008: No decrease in incidence of wrong
site/side/patient surgery
• AAOS Member Survey Respondents 2011:
• Universal Protocol used 90% of the time in hospital OR but
only 54% of the time in ASC
• Reasons for UP/Time Out noncompliance: “time consuming”
most frequent response
• Wrong Site surgery occurrence: 2% in hospital OR, 0.34% in
ASC, 0.01% in office
• 69% had no knowledge of Crew Resource Management
• But 68% believed orthopaedic surgeon should initiate
UP/Time Out
AAOS SAFETY INITIATIVES - RESULTS
• American Board of Orthopaedic Surgery Case Collection
Study 1999 – 2010:
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>1,200,000 surgical cases
76 Wrong Site/Side/Patient surgeries
Wrong spinal level for lumbar laminotomy most common WSS
No change in incidence after initiation of Universal Protocol
18/20 WSS reported after “Sign Your Site” had been marked
preoperatively
J Bone Joint Surg Am. 2012;94:e2(1-12)
MORE RECENTLY….
• Wang, et al. National Trends in Patient Safety for Four
Common Conditions, 2005 – 2011.
• No significant decline in Adverse Event rates for patients with
conditions requiring surgery
• 8% mortality for surgical patients experiencing one or more
Adverse Events (no AE: 1% mortality)
• Significantly longer hospital stays in patients experiencing
Adverse Events
• Many (40%) of the surgical patients had orthopaedic surgery
(hip and knee replacement)
N Engl J Med 370;4:341-51.Jan 23, 2014
NET RESULT?
We had the illusion of organizational leadership in
patient safety but:
No change in surgeon behavior
No change in adverse events
No decrease in WSS
No true organizational safety culture
WHAT COULD AAOS DO THAT WOULD…
• Change surgeon behavior?
• Improve patient safety?
• Improve quality/value of care?
• Create a culture of safety in AAOS?
• Make a difference?
Team STEPPS® PROJECT
John S. Webster MD, MBA, MSEL
John Tongue MD, Past President, AAOS
SURGEON – PATIENT COMMUNICATION
• 350 + “Clinician – Patient
Communication” CME workshops
presented at AAOS Annual
Meetings, to orthopaedic residency
programs, state orthopaedic
societies, orthopaedic subspecialty
societies, and large orthopaedic
practice groups since 2001.
• Dedicated, committed corps of
volunteers (all practicing
orthopaedic surgeons and national
faculty, Institute for Healthcare
Communication)
• More than 6000 orthopaedic
residents, surgeons, PAs have
attended these workshops
• Four hour, interactive, case-based
workshops (very similar in format to
Team STEPPS® “Fundamentals”)
HISTORY OF CSMP
• 1998 Member and Public Survey identified orthopaedic
surgeons as “High Tech, Low Touch”; discordant
perceptions of quality of care - surgeons vs. patients.
(“Teaching orthopaedic surgeons how to be nice to patients?!”)
• John Tongue, MD Chair Board of Councilors and Member
Board of Directors
• Bayer Institute, New Haven CT (now Institute for
Healthcare Communication)
Team STEPPS and CPC ARE ABOUT COMMUNICATION
COMMUNICATION IS CRITICAL FOR…
• Surgeon-Patient:
• Accuracy of
diagnosis
• Patient and surgeon
satisfaction
• Patient Centered
Care
• Shared decision
making
• QUALITY & SAFETY
• Surgeon-Team:
• Shared Mental
Model
• Situational
Awareness
• Satisfaction and
Performance
• Improved Decision
Making
• LEADERSHIP &
SAFETY
AAOS Team STEPPS®
• Goal: conduct “Train the Trainer” courses – met
• Goal: conduct 80 “Fundamentals” workshops – not met
• Volunteer overload due to demand for CSMP and Team
STEPPS?
• Overly aggressive goals?
• Goal: gather data to assess impact on patient safety,
safety culture, and outcomes – ??
• Data on patient safety culture and outcomes proprietary,
peer-review protected, and closely held
• Goal: make the programs self-sustaining – CME,
Maintenance of Certification, other educational
products.
SO, WHERE DO WE STAND?
• AAOS has strong evidence-based programs and trained
facilitators for both Surgeon-Patient Communication
and Surgical Teamwork.
• AAOS is a leader among surgical specialty associations
in these “non-technical” competencies.
• “Non-technical skills” are critical components of safety,
quality and value – and offer new educational
opportunities for AAOS
• New Collaborations (AHRQ ASC Safety Project
Orthopaedic Cohort)
• How will we sustain and expand these programs?
THANK YOU!
Dwight W. Burney III
MD
Email:
dwightburney119@g
mail.com
Creating Physician Leadership
for Culture Change
Andrew Grose, MD
Assistant Professor, New York Medical College
Orthopaedic Trauma and Adult Reconstruction
Westchester Medical Center, Valhalla NY
my experience
2011 – present led CRM initiative at
Westchester Medical Center a major
teaching hospital in Hudson Valley,
NY
trained 1000+ MDs, RNs and allied
health professionals in CRM
Physician consultant for Lifewings, LLC,
www.saferpatients.com
Leadership Development,
Risk Assessment,
Hardwired Safety Tool Development
Gawande et al, NEJM 2009
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Surgical Safety Checklist
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20% not easy to use, took too long, didn’t
improve patient safety
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"If you were having an operation, would you want
the checklist used?"
93% said ... YES
Gawande et al., N Engl J Med 2009;360:491-9
we made these people
Inpatient Surgery in the US
gets a solid A
•
NO PREVENTABLE
HARM OCCURS IN 95%
OF SURGERIES IN THE
US!
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THIS LEVEL OF SUCCESS
LEADS TO 780,000
INCIDENCES OF
PREVENTABLE HARM
ANNUALLY IN INPATIENT
SURGERY ALONE
Anderson O, Davis R, Hanna GB, Vincent CA. “Surgical adverse events: a systematic review”. Am J Surgery 2013;206(2):253-62
3 things to fix this
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Give the trench workers help
30-40% of physicians in this country are
SEVERELY burned out
30% of nursing staff is burned out
3 things to fix this
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Give the trench workers help fighting stress
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Provide a context for the use of CRM
there is no such thing as a "routine, uneventful case"
every team must manage external pressures & problems
every team makes mistakes / slips / lapses, and they
must manage these successfully
this is what we do
An Expanded Definition of
CRM
Error
Avoidance
CRM
Skills
Threat
Management
Error
Management
Undesired Patient
State Management
From Sexton & Helmreich
UNDESIRED PATIENT
STATE
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TEAM-BASED - MUST BE LINKED TO TEAM
ERROR
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PROBABLE ADVERSE OUTCOME IF TEAM
DOESN'T MANAGE APPROPRIATELY
UT Threat and Error Management Model
From Sexton & Helmriech
External Threat
Outcomes
Patient condition
Adverse drug reaction
Time pressure
Threat
Management
External Error 
Behavioral/
Procedural
Countermeasures
THREAT TO TEAM
Pharmacy
Diagnosis
Internal Threat
Proficiency
Fatigue, etc.
Mitigated
Inconsequential
Undesired State
Management
Error
Error
Management
Behavioral/
Procedural
Countermeasures
Undesired
Patient State
Behavioral/
Procedural
Countermeasures
Team Error
Adverse/Sentinel
Event
Handling
Procedural
Communication
Latent Threats
Threat and Error Countermeasures
•CRM
skills are best defined as threat and error countermeasures. The following have been validated as critical in
aviation audits:
1.
Team Climate – critical in all areas of crew performance
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2.
Planning – critical in threat management
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3.
SOP briefings, plans stated, workload assignment, and contingency mgmt
Execution – critical in error management
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Leadership, communication environment, and staff briefing
Monitor / cross check, workload mgmt, vigilance, and automation mgmt
Review and Modify – critical in undesired aircraft state management
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Evaluation of plans, inquiry, and assertiveness
Why Develop Such a Model?
Use to systematically analyze
where risk occurs BEFORE an
incident
•we
want to know the
answer to the
questions:
•where
is the cheese?
•where
are the holes?
3 things to fix this
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Give the trench workers tools to fight stress
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Provide a context for the use of CRM
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DEBRIEF
thanks for listening
what questions do you
have for me?