Implementing Team Training at Duke

1. Implementing Team Training at Duke Karen Frush, BSN, MD Chief Patient Safety Officer Duke Medicine

2. THE JOURNEY • PICU • Peri-operative Services • GSK Collaborative • NCHA Collaborative • Comprehensive Implementation across Duke Medicine

3. Team Training: One more initiative?? • Time and workload • Adding one more assignment onto everything else • Best model? • Lack of data to demonstrate improved outcomes • Many consultants and approaches • Required for all team members? • Logistics: Shut down the ORs? • Cost vs benefit

4. Teamwork Training ProcessPhase I: Pre-intervention • Chose to work with consultants • Gathered pre-training data • Knowledge test • Attitude: Sexton Teamwork and Safety Climate survey • Behavior: Conducted Real-time Observations • Outcome data • Processes • Clinical outcomes • Analyzed Secondary Measures • Staff satisfaction and work culture • Patient satisfaction

5. Teamwork Training ProcessPhase II: Training • Unit leaders involved with planning and implementation (J Mericle, J Meliones, K Mistry) • 3 sessions to accommodate shifts • Multidisciplinary group sessions • Physician, nurse, and human factors facilitators • Interactive session with hands-on tools • Feedback allowed for further development • Focused training for action at unit level • Focused on tools and techniques to address unit’s issues

6. Focused Unit Training Tools • Handoff Communication • SBAR: structured language • Critical Language • “I need clarity”: assertion • “Sterile Cockpit” • Focused attention • Limit interruptions during Rounds • Huddles for better planning • White Boards

7. Teamwork training processPhase III: Implementing change • Leadership role models • Multi-disciplinary (internal) coaches • Interval observations, coaching by consultants • Active participation of consultant experts in unit-based safety team meetings • Phone calls at unit leaders’ preferred time, to review concerns and discuss barriers • Train-the-trainer model used for new staff

8. Teamwork Training ProcessPhase IV: Comprehensive Evaluation • Immediate feedback of training session • Change in Knowledge • Change in Attitude: Survey • Behavior Change: Observations • Process or Practice Changes • Impact on Clinical Outcomes • Secondary measures

9. TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL • Patient satisfaction survey. • Complication rate based on AHRQ PSI. • Length of hospital stay. • Adverse drug events. • Patients’ claims. • Staff satisfaction survey. • Nurse turnover rates. Level 4 – Results: whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment. Level 3 – Behavior: whether participants change their behavior back in the workplace as a result of training. • Observation of teamwork behaviors during routine patient care. • Teamwork knowledge test. • Survey of attitude towards teamwork. • Survey of self-perceived communication skills. Level 2 – Learning: whether the training results in an increase in knowledge, skills or attitudes. Level 1 – Reaction: how did participants react to the training? • Post-training reaction survey

10. Team Training Results: Will this training impact the way you do business? % Not Sure Prob. Def.

11. Team Training Results: Would you recommend this course to your co-workers? % Not Sure Prob. Def.

12. TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL • Patient satisfaction survey. • Complication rate based on AHRQ PSI. • Length of hospital stay. • Adverse drug events. • Patients’ claims. • Staff satisfaction survey. • Nurse turnover rates. Level 4 – Results: whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment. Level 3 – Behavior: whether participants change their behavior back in the workplace as a result of training. • Observation of teamwork behaviors during routine patient care. • Teamwork knowledge test. • Survey of attitude towards teamwork. • Survey of self-perceived communication skills. Level 2 – Learning: whether the training results in an increase in knowledge, skills or attitudes. Level 1 – Reaction: how did participants react to the training? • Post-training reaction survey

13. PICU Post-Training Survey Responses Summary. Question: “The physicians and nurses here work together as a well-coordinated team (Fisher Exact Test p value=0.011)”

14. PICU Post-Training Survey Responses Summary. Question: “I know the proper channels to direct questions regarding patient safety in this clinical area (p value=0.007)”

15. TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL • Patient satisfaction survey. • Complication rate based on AHRQ PSI. • Length of hospital stay. • Adverse drug events. • Patients’ claims. • Staff satisfaction survey. • Nurse turnover rates. Level 4 – Results: whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment. Level 3 – Behavior: whether participants change their behavior back in the workplace as a result of training. • Observation of teamwork behaviors during routine patient care. • Teamwork knowledge test. • Survey of attitude towards teamwork. • Survey of self-perceived communication skills. Level 2 – Learning: whether the training results in an increase in knowledge, skills or attitudes. Level 1 – Reaction: how did participants react to the training? • Post-training reaction survey

16. Overall Teamwork in PICU (p value=0.0001, fisher’s exact test)

17. TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL • Patient satisfaction survey. • Process or practice changes. • Length of hospital stay. • Adverse drug events. • Patients’ claims. • Staff satisfaction survey. • Nurse turnover rates. Level 4 – Results: whether the training has affected process or outcomes, such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment. Level 3 – Behavior: whether participants change their behavior back in the workplace as a result of training. • Observation of teamwork behaviors during routine patient care. • Teamwork knowledge test. • Survey of attitude towards teamwork. • Survey of self-perceived communication skills. Level 2 – Learning: whether the training results in an increase in knowledge, skills or attitudes. Level 1 – Reaction: how did participants react to the training? • Post-training reaction survey

19. OR – PICUHand-Off Turnaround Time: Before and After Intervention Turnaround Time (minutes) Observations

20. Operational Changes, Improvements in outcomes • Time to critical labs drawn at hand-off • Briefings and debriefings implemented; SBAR communication for nursing report, telephone communication • Decrease in infection rates • Decrease LOS and increased throughput • Patient Satisfaction score exceeded target (Press Ganey) • Work Culture survey score increased

21. Implementing TeamSTEPPSacross Duke Medicine • TeamSTEPPS has helped us overcome some initial barriers to team training • 4 phase approach to be undertaken throughout high acuity areas at DUH, DRH and DRaH • Training with specific tools and concepts (modules) in intermediate units and non-clinical areas • Collaborative with UNC SoM, SoN • Assertion and speaking up • TeamSTEPPS and simulation, virtual training