Transcript Slide 1

TeamSTEPPS Simulations: A
Practical Manual
Stephanie N. Sudikoff, MD
Phyllis A. Toor, RN, BSN
Simulation as the Primary
Teaching Strategy for
TeamSTEPPS
Stephanie N. Sudikoff, MD
Director of Simulation
Yale New Haven Health System
SYN:APSE
Center for Learning, Transformation and Innovation
Disclosure
Acknowledgement : No commercial support
Conflicts: No conflicts of interest
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Objective
 Describe learning principles that make simulation
an effective adult learning strategy.
 Describe process of identifying teamwork goals and
objectives and creating applicable scenarios
 Discuss logistical challenges and solutions to
implementation
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Overview of Simulation
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What is Simulation?
Simulation is
a technique – not a technology –
to replace or amplify real experiences
with guided experiences that evoke or replicate
substantial aspects of the real world
in a fully interactive manner.
- David Gaba
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Type of Simulator/Equipment
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Simulation and Experiential Learning
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Scenario Design
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Building a Scenario
Learners
Learning
Objectives
Clinical
Context
Clinical
Context
Critical
Requirements
Boundaries
Targeted
Response
Critical
Trigger Events
Scenario Script and
Measurement Tools
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Building a Scenario
Learners
Learning
Objectives
Clinical
Context
Critical
Requirements
Boundaries
Targeted
Response
Critical
Trigger Events
Scenario Script and
Measurement Tools
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How To Write Learning Objectives
What can you reasonably expect the learner to be able to do at the end
of the program?
Knowledge
Skills
Attitude
• Cognitive : what to know
• Example verbs: identify, list, recall, explain, demonstrate,
address, define, describe, analyze, evaluate, etc.
*avoid – learn, know, understand, appreciate
• Psychomotor: what to do
• Example verbs: arrange, build, construct, design,
deliver, display, fix, operate, sketch, use, perform, etc.
• Affective: what to value
• Example verbs : commit to, challenge, discuss, dispute, follow,
justify, integrate, judge, question, resolve, synthesize, etc.
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Building a Scenario
Learners
Learning
Objectives
Clinical
Context
Critical
Requirements
Boundaries
Targeted
Response
Trigger Events
Scenario Script and
Measurement Tools
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Trigger Events
A prompt to elicit a targeted response by
a learner
• Embed triggers within a scenario
• Allows facilitator to control scenario
events to ensure learning objectives are
met
• Focuses attention on pre-determined
critical events and targeted behaviors
for specific feedback
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Examples
Objective
Targeted Response
Scenario Trigger
Use effective
communication
Use SBAR at handoff
Demonstrate
mutual support
Cross-monitor to
avoid medication
error
Bring an MD in at 2
minutes into the
scenario
Confederate brings
in medication for a
different patient
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Triggers and Video-Based Debriefing
• Fosters selfreflection
• Clarifies what to set
the context for why
• Allows facilitator to
mark video with
Trigger events
7/22/20
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Planning and Implementing
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Shift Towards a Culture of Safety:
Three Continuous Phases
Phase I: Assessment
Goal - To determine readiness to undertake TeamSTEPPS
Initiative.
Key Actions
Department Responsibility
• Collect data to support the need
• Define process(es) to fix
– Culture Survey – Safety Attitudes • Schedule Retreat for Stakeholders
Questionnaire (SAQ)
with SYN:APSE
– Data Measures
• Allocate Resources and Personnel
• Team Perceptions Questionnaire
– Local Leadership and Staff
• Team Observation Tool
– Simulation Center Team
• Dept data - (pt satisfaction scores,
– Performance Management?
rates, time to, freq)
Leadership Retreat
• Key Department Leadership and
Stakeholders
• Review departmental data
• Review commitment
• Prioritize key issues to address
during training and
implementation
Phase II: Planning
Goals – (1) to develop an Action Plan for Initiative
Key Actions
Department Responsibility
• Identify Target Audience
• Create a Change Team
– Leadership
– Identify Faculty
(1MD/1RN per 80 participants)
– Coordinator / Master Scheduler
Key Actions
Department and SYN:APSE
• Train Faculty
• Design the Intervention
• Develop Plan for Testing
Effectiveness
• Develop an Implementation Plan
(Department Specific SBTT)
• Develop Plan for Sustained
Continuous Improvement
Project Coordinator
• Master Schedule
• Ensures full complement of
caregivers
• Sends reminders / confirmations
• 50,000 ft view
Define the Change Team
Supporters / Sponsors
• Senior Leadership
• Interprofessional
Implementers
• Content Experts
• Educators
• Process Improvement
• Technical Support
• Front-Line Leader /
Coordinator
Assign clear roles and responsibilities
Faculty Development:
How will we prepare our facilitators?
What….
• Teamwork Content and
Strategies
• Scenario Implementation
• Debriefing Facilitation
How…
• 8-hour Train the Trainer
• Observe 1-2 Courses
• Co-Facilitate
• Ongoing mentoring and
support
Inter-Professional Facilitation
• Co-Debriefing
• Scope of Practice
• Role Model
RN Facilitator
MD Facilitator
Phase II: Training
Goal – (2) to conduct simulation-based team training (SBTT)
Key Actions
Department and SYN:APSE
• Determine Training Strategy
–
–
–
–
Determine # of Courses / Frequency
Design Clinical Scenarios
Determine Location
Schedule Interdisciplinary
Participants
Total Trained in AED 94% (n = 364)
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152 RNs (Plus 8 Trainers)
66 EDTAs (Plus 2 Trainers)
50 Residents
37 Attendings (Plus 6 Trainers)
11 IAs
30 PA/APRN (Plus 1 trainer)
1 Pharmacist
Time Period = 3 months
Format:
Which option is best for my institution?
• Bolus Dose vs Intermittent
• Unit Specific vs. General
• Consult – one size does not fit all!
• Be flexible
Location:
Where should we conduct the training?
In-Situ
Benefits
• Full Team Training
• Realism / Authenticity
• Cost containment
• Identify latent safety threats
• Discover system flaws
• +/- Expose nearby family
Center
Benefits
• Accessibility of space
• Minimal interruptions
• Retreat-like setting
• Decreased cancellations
• No mixing of equipment /
medications
• Avoid Infection Control Issues
Weinstock PH, Kappus LJ, Garden A, Burns JP. Simulation at the Point of Care Training:
Reduced-cost insitu training via a mobile cart. Pediatr Crit Care Med. 2009; 10(2): 1-6.
Scheduling:
Nothing worthwhile is ever easy….
When strategizing….
• Take an interdisciplinary
approach
• Analyze Patient Flow
• Consider early morning,
late evening
• Be flexible and creative!
Recruitment:
How do we ensure participants come?
Considerations
• Mandatory vs. encouraged
– Define consequences
– Link to annual review
• Non-salaried employees
– Plan staff coverage
– Link to other educational efforts
• Utilize institutional resources / supports
Phase II: Implementation
Goal – (3) implement a TeamSTEPPS Intervention.
Key Actions
Department Responsibility
• Implement Improvement
Intervention
Tools Adopted by AED
• Formal Uninterrupted briefs at
change of shift
• Debriefing at end of shifts
• Problem solving huddles
• Communication Tools
– Call-out / check-back (closed loop
communication) / 2-Challenge / CUS
• Mutual Support / Task Assistance
Phase III:
Sustain, Monitor, Coach, Integrate
Goal - to sustain and spread improvements in teamwork behavior and in
associated clinical processes and outcomes resulting from the Initiative
Key Actions
Department Responsibility with SYN:APSE Support
• Teamwork Coaching
• Integration of tools into Existing Processes
• Reinforcement and Rewards
• Continuous Improvement
• Interval simulation practice with SYN:APSE
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TeamSTEPPS with Simulation
For Surgical Services:
A Practical Model
Phyllis A. Toor RN BSN
Nurse Consultant/TeamSTEPPS Program Manager
Patient Safety Program
United States Army Medical Command
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Objective
• Outline practical examples of both simulation based Train
the Trainer (TtT) and Train the Staff (TtS) models for
Surgical Services Training.
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TtT Program Developmental Goals
• Simulation based program
• Easily transferred to training teams
• Low fidelity simulation exercises
• Train in teams familiar environment
• Develop strongest trainers/coaches
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Criteria
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•
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•
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•
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Light on didactic training, heavy on team practice
Easy to use, transferable, customizable
Simulation exercises applicable to the team receiving training
Utilize local resources
Utilize familiar equipment and environment
Briefs and Debriefs
Capture data from case debriefs
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Train the Trainer (TtT)
Traditional TtT
1.
MEDCOM Simulation Based
TtT
Videos
1.
Team Simulation
2.
Real time coaching practice
3.
TtS with Simulation
2. Coaching Workshop
3.
Teach-backs
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Train The Staff (TtS)
Traditional TtS
MEDCOM Simulation Based TtS
1.
TeamSTEPPS
Fundamentals
1.
TeamSTEPPS Essentials
2.
Videos and scenarios
depicting use of tools
2.
On site simulation and teamwork
practice
3. Wrap up
3. All team debrief
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Surgical
Services
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Briefing Title Here
TeamSTEPPS Train the Trainer
3 Day Schedule
Day 1: Fundamentals and Simulation
Day 2: Teach-backs (Train the Staff)
0645-0700 Registration
0700-0715: Leadership Welcome
0715-0900: TeamSTEPPS Fundamentals
0900-0915: Break
0915-1015: TeamSTEPPS Fundamentals
1015-1115: Simulation 101
1115-1215: Lunch
1215-1500: Simulation Building
1500-1600: Simulation set up and practice
AM Session
0645-0700: Registration/Leadership Welcome- (in scrubs, in OR
classroom)
0700-0800: TeamSTEPPS Essentials
0815-1015: Simulations- (in work areas)
1030-1100: Full team debrief- (in classroom)
PM Session
1200-1215: Registration/ Leadership welcome - (in scrubs, in OR
classroom)
1215-1315: TeamSTEPPS Essentials
1330-1530: Simulations- (in work areas)
1530-1600: Full team debrief- (in classroom)
*FOR INSTRUCTOR CANDIDATES- 1600-Instructor Debrief and Prep
for day 3 Coaching
Day 3: Coaching and Implementation Planning
0645-1100 Coaching (in scrubs, in work areas)
1100-1130 Lunch
1200-1545 Implementation and Sustainment Planning
(in classroom)
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Briefing Title Here
Surgical
Services
TeamSTEPPS Train the Trainer
Day 1
Day 1: Fundamentals and Simulation
Day 2: Teach-backs (Train the Staff)
0645-0700 Registration
0700-0715: Leadership Welcome
0715-0900: TeamSTEPPS Fundamentals
0900-0915: Break
0915-1015: TeamSTEPPS Fundamentals
1015-1115: Simulation 101
1115-1215: Lunch
1215-1500: Simulation Building
1500-1600: Simulation set up and practice
AM Session
0645-0700: Registration/Leadership Welcome- (in scrubs, in OR
classroom)
0700-0800: TeamSTEPPS Essentials
0815-1015: Simulations- (in work areas)
1030-1100: Full team debrief- (in classroom)
PM Session
1200-1215: Registration/ Leadership welcome - (in scrubs, in OR
classroom)
1215-1315: TeamSTEPPS Essentials
1330-1530: Simulations- (in work areas)
1530-1600: Full team debrief- (in classroom)
*FOR INSTRUCTOR CANDIDATES- 1600-Instructor Debrief and Prep
for day 3 Coaching
Day 3: Coaching and Implementation Planning
0645-1100 Coaching (in scrubs, in work areas)
1100-1130 Lunch
1200-1545 Implementation and Sustainment Planning
(in classroom
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Surgical
Services
Simulation
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MASTER
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Briefing Title Here
TeamSTEPPS Train the Trainer
Day 2
Day 1: Fundamentals and Simulation
Day 2: Teach-backs (Train the Staff)
0700 Registration (in ACU’s or Business Casual, in Rascon
Building)
0730-0745: Leadership Welcome
0745-0815: MEDCOM Pilot
0815-0915: TeamSTEPPS Essentials
0915-0930: Break
0930-1015: Debrief Tracking Tool
1015-1115: Simulation 101 (Training)
1115-1215: Lunch
1215-1500: Simulation Building
1500-1600: Simulation set up and practice ( players to be
present)
AM Session
0645-0700: Registration/Leadership Welcome- (in scrubs, in OR
classroom)
0700-0800: TeamSTEPPS Essentials
0815-1015: Simulations- (in work areas)
1030-1100: Full team debrief- (in classroom)
PM Session
1200-1215: Registration/ Leadership welcome - (in scrubs, in OR
classroom)
1215-1315: TeamSTEPPS Essentials
1330-1530: Simulations- (in work areas)
1530-1600: Full team debrief- (in classroom)
*FOR INSTRUCTOR CANDIDATES- 1600-Instructor Debrief and
Prep for day 3 Coaching
Day 3: Coaching
0645-1100 Coaching (in scrubs, in work areas)
1100-1200 Lunch
1200-1600 Implementation and Sustainment Planning
(in classroom)
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TtT Day 2: Teach-backs
Surgical Services Day 2 TtS OR Simulation Training Agenda Template
Afternoon Sessions
Suite 1-Dental
Suite 3-Gen Surg
Trainer Candidate: CPT SM
Master: Mr B
Master Trainer: LTC F
Physician
Dr IO
Physician
COL FD
Anesthesia
MS. MG
Trainer Candidate: Mr VD
Anesthesia
Dr RI
Nurse
Dental Tech
Dental Tech
Tech-CMS
Nurse
Tech
Tech-CMS
Ms HD
SPC BD
Ms HD
Ms JS
Ms KG
Mr SH
Master Trainer: MAJ Morton
Physician
Dr GS
SPC KL
Suite 2-Podiatry
Trainer Candidate: MAJ N and Dr N
Master Trainer: Chris Smith
Physician
Dr M
Anesthesia
Anesthesia
Nurse
Tech
Tech-CMS
Mr. RT
Ms KT
SPC HW
SPC AP
PACU
Trainer Candidate: MAJ PT and SPC
LM
Master Trainer: P. Toor
Physician
Unit Clerk
Nurse
Nurse
Nurse
Tech
Tech
Dr IP
SPC RT
LTC R
Ms J
LT CJ
SPC JT
Mr. MT
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TtT Day 2: Teach-backs
Part 2: Simulation
Rules of Engagement
• Treat the simulation as you would a normal case
*Exceptions: intubation, medications, invasive procedure
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Briefing (OMFS)
Title Here
Setting: OR
Oral Macular
Facial Surgeon
Case
Scenario
Scenario: 32 yr old male
requiring IVRO, was
consented for a
BSSO. Surgery is
listed as BSSO on
the OR schedule.
Setting: OR suite, pt in
holding. Nurse,
Techs and
Anesthesia in room
setting up. Surgeon
comes in to check
room.
Expected Team
Behaviors
Triggers for use of tools
1. Start of case
Brief
2. Consented incorrectly
Advocacy, Huddle, Two Challenge rule
3. Tech’s anticipation is slow
IMSAFE, Mutual Support, Check Back
4. Surgeon is requesting incorrect
instruments that have a singular
use
Two Challenge Rule, CUS,
5. Incorrect patient x-ray
Situational Awareness, Mutual Support,
Advocacy, Assertion, Huddle, Two
Challenge
5. Closing Skin
Debrief
Note to Proctor: Have
mock chart ready
with incorrect
consent.
Roles: 1. Oral Macular Facial Surgeon (OMFS), 2. Two OMFS Techs, 3. Nurse 4. Anesthesia
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Scenario:
Oral Macular Facial Surgeon (OMFS) Case
Action Expected/ TS Tool
or Strategy
Action
Demonstrated
1.Brief Prior to Start
YES
NO
2. Advocacy, Huddle, Two
Challenge rule
YES
NO
3. IMSAFE, Mutual Support,
Check Back
YES
NO
4. Two Challenge Rule, CUS
YES
NO
5. Situational Awareness,
Mutual Support, Advocacy,
Assertion, Huddle, Two
Challenge
YES
NO
6. Debrief
YES
NO
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Notes
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Setting: OR
Surgery scheduled : Bilateral Sagittal Split Osteotomy (BSSO)
Role: OMFS
Instructions for scenario:
You have multiple back to back cases today. You are behind schedule and plan
for this to be a speedy surgery. You have not had a chance to see the patient
yet, but you go into the room to ensure everything is set to go.
When surgery is underway: request incorrect instruments that have a singular
use.
Please behave out of character and act upset and impatient with staff.
Otherwise, proceed as you usually would for this case.
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Setting: OR
Surgery scheduled : Bilateral Sagittal Split Osteotomy (BSSO)
Role: Nurse
Instructions for scenario:
Settle patient in the OR suite. Provide care as usual.
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Setting: OR
Surgery scheduled : Bilateral Sagittal Split Osteotomy (BSSO)
Role: Tech 1
Instructions for scenario:
Set up room for the IVRO.
You are sluggish today because you came into work sick.
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Setting: OR
Surgery scheduled : Bilateral Sagittal Split Osteotomy (BSSO)
Role: Anesthesia
Instructions for scenario:
From your interview with the patient, you understand that the case today to be
intraoral vertical ramus osteotomy (IVRO).
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Setting: OR
Surgery scheduled : Bilateral Sagittal Split Osteotomy (BSSO)
Role: Tech 2
Instructions for scenario:
Care for patient as per protocol.
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Surgical
Services
Simulation
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MASTER
to Insert
Briefing Title Here
TeamSTEPPS Train the Trainer
Day 3
Day 1: Fundamentals and Simulation
Day 2: Teach-backs (Train the Staff)
0700 Registration (in ACU’s or Business Casual, in Rascon
Building)
0730-0745: Leadership Welcome
0745-0815: MEDCOM Pilot
0815-0915: TeamSTEPPS Essentials
0915-0930: Break
0930-1015: Debrief Tracking Tool
1015-1115: Simulation 101 (Training)
1115-1215: Lunch
1215-1500: Simulation Building
1500-1600: Simulation set up and practice ( players to be
present)
AM Session
0645-0700: Registration/Leadership Welcome- (in scrubs, in OR
classroom)
0700-0800: TeamSTEPPS Essentials
0815-1015: Simulations- (in work areas)
1030-1100: Full team debrief- (in classroom)
PM Session
1200-1215: Registration/ Leadership welcome - (in scrubs, in OR
classroom)
1215-1315: TeamSTEPPS Essentials
1330-1530: Simulations- (in work areas)
1530-1600: Full team debrief- (in classroom)
*FOR INSTRUCTOR CANDIDATES- 1600-Instructor Debrief and Prep
for day 3 Coaching
Day 3: Coaching
0645-1100 Coaching (in scrubs, in work areas)
1100-1200 Lunch
1200-1600 Implementation and Sustainment Planning (in
classroom)
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Surgical Services Departments Trained
• Program Pilot Conducted June 2012:
Results to date:
–
–
–
–
–
–
Decreased delays by 50%
Decreased instrumentation issues by 18%
Decreased preference card issues by 60%
Decreased scheduling Issues by 50%
Increased productivity by 22%
Increased room utilization by 16%
• 3 additional hospital OR’s trained
• 5 additional trainings scheduled for 2013
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Hospital Teams Are Left With:
• Culture change plan for integration, sustainment and
communication
•
Experienced TeamSTEPPS Coaches and Trainers
• Library of their own simulation exercises
• New TtS agenda to include simulation
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Lessons Learned
• Pre-course planning is critical
• Leadership engagement is not negotiable
• Prep the attendees
• Multidisciplinary planning team is a must
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Lessons Learned
• Work within existing unit processes and practice
• Have data management plan prior to training
• Accountability though reporting
• Planning Team Coaching post-implementation
• Flexibility is key
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Questions
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