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Katherine Jones, PT, PhD Wendi Nordhausen, RN, BSN Mark Goodridge, RT (R) (CT) PowerPoint PPT Presentation

The University of Nebraska Medical Center AHRQ Annual Meeting Sept. 15, 2009 Measuring Improvement in Hospital Teamwork: Diffusion of TeamSTEPPS in Critical Access Hospitals Katherine Jones, PT, PhD Wendi Nordhausen, RN, BSN Mark Goodridge, RT (R) (CT)

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Katherine jones pt phd wendi nordhausen rn bsn mark goodridge rt r ct l.jpg

The University of Nebraska Medical CenterAHRQ Annual Meeting Sept. 15, 2009Measuring Improvement in Hospital Teamwork: Diffusion of TeamSTEPPS in Critical Access Hospitals

Katherine Jones, PT, PhD

Wendi Nordhausen, RN, BSN

Mark Goodridge, RT (R) (CT)

PHOTO GOES HERE (Need higher resolution


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Our Team

Anne Skinner, RHIA

Robin High, MS, MBA

Andrea Bowen, BA

99 Master Trainers from 24 Critical Access Hospitals

Our Funding

AHRQ Office of Communications and Knowledge Transfer

Nebraska Dept of Health and Human Services

Good Samaritan Health Systems Network

St. Elizabeth CAH Link

Direct funds from 14 Critical Access Hospitals

Medicare Rural

Hospital

Flexibility

Program

(Flex Program)

Acknowledgements

2


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Objectives

  • Describe a collaborative approach to implementing TeamSTEPPS within a state/region

  • Use the AHRQ Hospital Survey on Patient Safety Culture (HSOPS) to plan and evaluate the implementation of TeamSTEPPS

  • Use ‘Diffusion of Innovations,’ Kirkpatrick’s Taxonomy, and decision frame to explain variations in success implementing TeamSTEPPS

  • Implement lessons learned from two Critical Access Hospitals to facilitate adoption of TeamSTEPPS


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TeamSTEPPS Background

  • 05 – 07 AHRQ Partnerships in Implementing Patient Safety Grant (1 U18 HS015822)

    • Purpose: Implement patient safety practices of voluntary medication error reporting and organizational learning in 24 CAHs

    • Aim: Develop organizational infrastructure for reporting and analyzing medication errors needed to identify system sources of error

    • Evaluate impact of this infrastructure change on safety culture with HSOPS

      • HSOPS results revealed need for teamwork


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Implementation Background

  • 3/2008 initial funding through AHRQ Office of Communications and Knowledge Transfer

  • Purpose: Implement the patient safety practice of teamwork and communication training in 25 Critical Access Hospitals

  • Aim: Evaluate impact of TeamSTEPPS training program on safety culture using our rural-adapted version of the AHRQ HSOPS

  • Collaborative funding through 12/2010


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Collaborative Funding


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Implementation Cycle

Cycle I 2007 – 2009 24 CAHs

Cycle II 2009 – 2010 15 CAHs


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Diffusion of TeamSTEPPS in Nebraska

NE TeamSTEPPS 35/65 CAHs, 1 Network Hospital, 3 IA CAHs, 1 LA CAH


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Measuring to Implement TeamSTEPPS

TeamSTEPPS Tools to bridge gap between belief and behavior.

  • Situation Monitoring

  • Mutual Support… Seeking and offering Task Assistance

  • Briefs, Huddles, Debriefs


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Measuring to Implement TeamSTEPPS

TeamSTEPPS Tools to bridge gap between belief and behavior.

  • Advocacy and assertion

  • I’m Concerned, I’m Uncomfortable, Stop the procedure (CUS)


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Measuring to Implement TeamSTEPPS

TeamSTEPPS Tools to improve structured communication across shifts and departments.

  • SBAR, Closed loop communication, Seeking Clarification

  • Huddles and WalkRounds after shift change

  • I PASS the BATON


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Measuring to Evaluate TeamSTEPPS

Team Behaviors Added to HSOPS

  • Use SBARw/in dept

  • Offer task assistance w/in dept

  • Use structured communication (SBAR, I PASS the BATON) across depts

  • Conduct a huddle in response to changing workloads

  • Conduct a debrief for improvement when things don’t go according to plan

Responses

  • Never

  • Rarely

  • Sometimes

  • Most of the Time

  • Always


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Evaluation: Adoption of Behavior


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Implementing TeamSTEPPS atClarinda Regional Health CenterClarinda, IowaMark Goodridge, RT (R) (CT)


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TeamSTEPPS at Clarinda Regional Health Center

  • Critical Access Hospital – 25 Beds

  • Average daily census 7- 8

  • Census can vary from 4 -14 in 24 hours

  • 85% of services are out-patient

  • 400-500 ED visits per month

  • 600-700 specialty clinic visits per month

  • 225 employees – FT & PT

Page County Iowa

Pop. 15,664

Density 32/sq mi


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TeamSTEPPS Training—Master Trainers

  • 3 Master Trainers trained April 2008 with UNMC Collaborative

    • Senior Staff member

      • Elaine Otte COO

    • Frontline staff

      • Mark Goodridge RT (R) (CT)

      • Jennifer Chambers RN (ED)


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TeamSTEPPS Training—Leadership

Leadership Development Training

  • Department managers

  • Senior Staff members

  • Board of Trustees

  • Fundamentals Course

  • One time training session off campus

  • Managers required to submit action plans to COO

Role Play during Leadership Development


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TeamSTEPPS Training—All Staff

  • Nov & Dec 2008

  • 15 – 20 staff per class

  • All classes interdisciplinary

  • Essentials course

  • Team building exercises

  • Goal to train all staff within 2 weeks by Master Trainers & Education Director

Team Building Exercise during Staff Training


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We Defined TeamSTEPPS as a Change

  • We created a Sense of Urgency

    • Results from the 2006 Patient Safety Survey

    • Sue Sheridan video

  • We ensured staff viewed TeamSTEPPS as consistent with our mission to provide exceptional care in a safe environment

  • TeamSTEPPS is better than our “old way of communicating”

    • Shared stories of impact of our “old way”

    • TeamSTEPPS videos and role playing


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We Obtained Management Support

  • Senior leaders are educated and supportive of the TeamSTEPPS initiative

    • COO trained as Master Trainer

  • The board is educated and supportive of the TeamSTEPPS initiative

    • Included in the Leadership Fundamentals Training Session

  • Medical Staff education—in progress; goal is to shift from “I” to “We”


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Our Champions Led the Way

  • Mark (Radiology) & Jennifer (Nursing)- front line champions

    • Led the organization by training staff & mentoring department managers

    • Use TeamSTEPPS language

    • Overcome resistance by engaging key employees and managers


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Resources Used for Implementation

  • UNMC’s support

    • conference calls

    • sharing tools

    • Lessons Learned Conference Nov 2008

  • Senior Staff support

  • Funds allocated for the program by COO

Our Poster at UNMC Lessons Learned Conf

Nov. 2008


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We are Sustaining TeamSTEPPS

  • “Not a flavor of the month”

  • Senior Staff and Board of Trustees buy-in

  • Use TeamSTEPPS tools and language—role models

  • Focus on Debriefs for drills and code alerts

  • Part of new employee orientation

    • COO introduces concept to all new employees

    • Biannual Essentials Course

    • All receive a pocket guide


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Lessons Learned and Next Steps

  • Support of Board of Trustees

    • Attended Leadership training

  • Next Steps

    • Medical Staff training

    • Sustainment – Use TeamSTEPPS tools in specific areas

    • Communicate use of TeamSTEPPS by professional organizations (AORN)


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We are Measuring to Identify Improvement

  • How do we know our training program resulted in change in culture, learning and behavior?

    • Data from HSOPS

    • Observed Changes in process and behavior


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Implementing TeamSTEPPS atChase County Community HospitalImperial, NebraskaWendi Nordhausen, RN, BSN


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TeamSTEPPS at Chase County Community Hospital

  • 25 Bed – Critical Access Hospital

  • Average Daily Census – 2 to 6 patients

  • Staff 105 employees

  • Attached clinic

  • 3 physicians, 2 physician assistants, 2 nurse practitioners

Chase County

Pop. 3,269

Density 4/sq mi


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TeamSTEPPS Training

  • 4 Master Trainers - April 23 - 25th, 2008 as part of UNMC Collaborative

  • Included ALL staff and medical staff

  • Board informed

  • Included all modules in Fundamentals Course– adapted to our specific needs

  • Offered 4 to 5 times each week in 60 – 90 minute sessions for 7 weeks

  • Included one 6 hour make-up day


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We Defined TeamSTEPPS as a Change

  • We created a sense of urgency…

  • We ensured staff viewed TeamSTEPPS as consistent with our mission and vision

  • We ensured staff saw TeamSTEPPS as better than our “old way of communicating”

    • Started with SBAR and trauma debriefs


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We Obtained Management Support

Senior leaders are educated and supportive of the TeamSTEPPS initiative

The board is educated and supportive of the TeamSTEPPS initiative

Medical Staff is educated and supportive of the TeamSTEPPS initiative


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Our Champions Led the Way

CEO – Master Trainer, Leader

Physician - QI background

Linda (Resp. Therapist), Lori (Lab Coord.), Wendi (QI Coordinator) – Interdisciplinary Master Trainers


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We are Sustaining TeamSTEPPS

  • Employees know TeamSTEPPS is a priority

    • Use the tools and language

    • Scenarios brought to manager & dept meetings

  • TeamSTEPPS changed day to day processes

    • SBAR

    • Trauma Debriefs

  • Our organization supports and

    rewards involvement in TeamSTEPPS


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Resources Used for Implementation

  • UNMC conference calls

  • Administrative Support

  • Lessons Learned Conference

  • Critical Access Hospital Network Meeting

  • Additional Master Trainers could make a difference

Our Poster at UNMC Lessons Learned Conf

Nov. 2008


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Lessons Learned and Next Steps

Most effective aspect of implementation- trained all staff in Fundamentals

Least effective aspect…change team function

Current and Future Focus – Orient new employees, Quarterly refresher courses, higher level of implementation and integration of the tools.


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We are Measuring to Identify Improvement

  • How do we know our training program resulted in change in culture, learning and behavior?

    • Data from HSOPS

    • Observed Changes in process and behavior… mails structured by SBAR, conversations about “processes” and communication


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Measuring to Evaluate for IndividualHospitals and the CollaborativeKatherine Jones, PT, PhD


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Measuring to Evaluate

Kirkpatrick’s Taxonomy

of Training Criteria

Alliger et al. A meta-analysis of the relations among training criteria. Personnel

Psychology. 2006, 50: 341-358.


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Rural HSOPS Spring 2009

  • Population Surveyed

    • 24 Hospitals evaluate impact of TeamSTEPPS Implementation 2008 – 2009 (2,137 respondents)

    • 13 Hospitals obtain baseline prior to TeamSTEPPS Implementation (1,328 respondents)

    • Added Teamwork Related Items to HSOPS

  • Overall Response Rate for 37 Hospitals

    3465/4601 = 75.3%

  • Range 51% - 96%


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Added HSOPS Knowledge & Behavior Items

Knowledge

  • Teamwork experience

  • Define brief

  • Define SBAR

  • Define CUS

  • Apply CUS

Behavior

  • Use SBARw/in dept

  • Offer task assistance w/in dept

  • Use structured communication (SBAR, I PASS the BATON) across depts.

  • Conduct a huddle in response to changing workloads

  • Conduct a debrief for improvement when things don’t go according to plan


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BELIEF

Huddle

Task

Assist

BELIEF

Advocate

2 Challenge

CUS


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Decision Frame Revealed in HSOPS

  • Decision frame: mental structures people use to organize the world

    • Reference point changes with knowledge

  • If behaviors change to reflect change in knowledge… Belief may not change

    • Consider item level scores not just dimension scores to track change over time

  • If behavior not consistent with new knowledge…HSOPS results less positive after training

    • Seek higher standard based on new knowledge

      Tversky A, Kahneman D. Science. 1981;211:453-458.

      Wright G. Goodwin, P. Strategic Management Journal, Strat Mgmmt J. 2002;23:1059-1067.


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Change

In Frame?

Debriefs


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Evaluation: Training - Knowledge


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Evaluation: Knowledge - Behavior


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Evaluation: Behavior - Safety


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Measuring Improvement Summary

r = 0.79

r = 0.52

r = 0.59


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Diffusions of Innovation Theory

  • Explains why training/knowledge does not always result in changes in behavior

  • Change clearly defined; better than old way

    • Trialable, Observable

  • Management is supportive;

    • Change is a clear priority and is rewarded

    • Resources are available

  • Champion(s) overcome resistance

  • Policy/procedure/job descriptions sustain

  • Effectiveness is evaluated

    Rogers EM. Diffusion of Innovations. 5th ed. New York: Free Press; 2003.

    Helfrich et al. Med Care Res Rev. 2007;64:279-303.

    Saint S et al. Jt Comm J Qual Patient Saf. 2009;35:239-246.


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Summary and Next Steps

  • Collaboration across state and local organizations can leverage resources to diffuse TeamSTEPPS across a state and region

  • Use AHRQ HSOPS to plan and evaluate TeamSTEPPS as a patient safety innovation

  • Diffusion of innovations theory, Kirkpatrick’s Taxonomy of Training Criteria, and decision frame are concepts needed to interpret measurement of teamwork with HSOPS

  • Next Steps: More training, physician engagement, link teamwork to patient outcomes


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Contact Information

Katherine Jones, PT, PhD

[email protected]

Wendi Nordhausen, RN, BSN

[email protected]

Mark Goodridge, RT (R) (CT)

[email protected]

Web site where safety culture tools and rural-adapted version of HSOPS are posted

www.unmc.edu/rural/patient-safety


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