Welcome! Sign-in Sheet – check if you want CME / CNE Name Card (back cover, use marker)

1. Welcome! • Sign-in Sheet – check if you want CME / CNE • Name Card (back cover, use marker) • CME (Physicians & PAs) must complete: • Credit Declaration Form handout • Course Evaluation / Critique (in back of book) • CNE (RNs and others) must complete: • Registration form – page 1 of book • Course Evaluation / Critique (in back of book) • Pagers / Phones on silent

2. TeamSTEPPSTeam Skills Workshop <Insert your name here>

3. Jane and Mother

4. Jaws of life

5. What about my baby girl?

6. ED Arrival

7. Gloves

8. What do you think? If you were the surgeon would you want Rebecca to speak up? Based on the culture you believe exists at your hospital, will Rebecca speak up? …Why or Why Not?

9. Safety Culture Survey Results Staff will freely speak up if they see something that may negatively affect patient care. 81% Benchmark: 76% 19% Most of the time / Always Sometimes / Rarely / Never

10. Safety Culture Survey Results Staff feel free to question the decisions or actions of those with more authority. 56% 44% Benchmark: 48% Most of the time / Always Sometimes / Rarely / Never

11. What do you think? If you were the surgeon would you want Rebecca to speak up? Based on the culture you believe exists at your hospital, will Rebecca speak up? …Why or Why Not? If she does speak up, what will she say?

12. Jaws of life

13. Life Flight

14. What about my girls?

15. ED Arrival

18. Tenerife March 1977

19. KLM Ad

22. Tenerife March 1977

23. …583 dead

24. No matter how well trained, motivated and professional, if humans are involved, ERROR IS INEVITABLE Aviation's Solution: Stop blaming the individual - fix the system, manage error Train team skills and implement hardwired safety systems

25. Similar Root Causes for Error • 70 – 80% of adverse events involve communication failure. • (VA National Center for Patient Safety, 2007) • 72% of reported sentinel events identified human factors as root cause • (The Joint Commission, 2014) Aviation Healthcare 70 – 80% of airline accidents are related to interpersonal communications(Sexton & Helmreich, 99)

26. Team Challenge

27. First Numbers Exercise 1000 1000 1000 30 20 1000 40 1000 10

28. What is yourTeam's answer?

29. Team Challenge Performance Feedback • Communication • Team Management • Recognizing Warning Signs • Decision Making • Debrief These skills require training and a safety system in place

30. Shift to Team System Approach Group of Experts Expert Team Individual focus (clinical skills) Teamwork - loose concept Individual performance Unbalanced workload Having information Self-advocacy Self-improvement Individual efficiency Under-informed, individual decisions Dual focus (clinical & team skills) Teamwork - clear understanding Mutual Support - Team goals Managed workload Sharing information Patient advocacy Team improvement Team efficiency Informed & collaborative Team decisions

31. Program Elements Site Assessment Leadership Development Skills-Based Training

32. Reduced Errors, Increased Safety & Quality Care Team Skills Workshop Debrief Creating a Team Communication Make Decisions Cross-Check & Assertion

33. Program Elements Site Assessment Leadership Development Skills-Based Training Hardwired Safety ToolsSM

34. Hardwired Safety ToolsSM Protocols such as checklists and structured communications that “hardwire” the team skills into daily practices and processes

35. Key Hardwired Safety Tools • Team Briefings • Transfer of Care Reports • Team Debriefings • Concern Reports • Checklists

36. Page 4 - Record Your Thoughts & Turn In at End of Class • Team & Communication Challenges • Patient Safety Concerns • Ideas for Tools

37. Program Elements Site Assessment Leadership Development Skills-Based Training Program Measurement Lifetime Results Hardwired Safety ToolsSM

38. Results that matter.

39. Safer Care

40. Reduced SSI rates .65 .37 .33 .22 2012

41. Reduce Significant Events* GOAL = Increase Number of Variances Reported per Month by 5% GOAL = 0 Significant Events** 87% *Significant Events include Serious Safety Events (SSE), Sentinel Events or any event generating an Root Cause Analysis (RCA). **Data based on all PHI related department numbers, including Cardiovascular Invasive, Noninvasive, Nursing and Admin within Piedmont Atlanta Hospital

42. Reduced Mortality Index 1.09 .77 .73 .68 2012

43. RN Turnover Improved 22.6% $130,750 Saved 3.9% Before After Source: St. Mary's Hospital; ICU

44. What questions do you have?

45. Communication Creating a Team Communication Debrief Make Decisions Cross-Check & Assertion

46. Communication Failures “The single biggest problem in communication is the illusion that it has taken place.” • 80% serious medical errors involve miscommunication between caregivers during transfer of patients. • The average 500-bed U.S. hospital loses $4 million a year as a result of communication inefficiencies. • From the 2015 Crico Strategies Comparative Benchmarking System Report: • Communication factor in 30% of 23,658 malpractice cases 2009-2013 • Communication failures contributed to patient harm in 7,149 cases,: losses incurred = $1.7B Joint Commission Center for Transforming Health Care Journal of Healthcare Management 2010;55(4)265-82 - George Bernard Shaw

47. Communication Malpractice Cases “The single biggest problem in communication is the illusion that it has taken place.” Malpractice Risks in Communication Failures, 2015 Annual Benchmarking Report, Crico Strategies - George Bernard Shaw

48. Barriers to Communication • Preconceptions, assumptions, lack of respect • Ambiguous terms & structure • Workload, stress & fatigue • Distraction & noise • Fear & hierarchy • Turfs / silos

49. Ensure Your Communication is… Precise, concise & timely “Sterile” in critical processes Standardized in structure & terms Acknowledged “Distraction free” in critical processes

50. AcknowledgmentA Critical Communication Skill • Communications not acknowledged are communications that didn’t happen • NASA funded research shows a direct correlation between acknowledgments and reduced errors Message Acknowledgment