Essentials Course. Objectives. Describe the TeamSTEPPS training initiative Explain your organization’s patient safety program Describe the impact of errors and why they occur Describe the TeamSTEPPS framework State the outcomes of the TeamSTEPPS framework.
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Strategies & Tools to Enhance Performance & Patient Safety
If I had a “Magic Wand” and could make changes within my unit or facilityin the areas of patient quality and safety…
Impact of Error:
By 5 years;
medical errors by 50%,
nosocomial by 90%; and
eliminate “never-events” (such as wrong-site surgery)
Cost associated with medical errors is $8–29 billion annually.
“High-performance teams create a safety net for your healthcare organization as you promote a culture of safety."
Embrace patients as valuable and contributing partners in patient care
The ratio of We’s to I’s is the best indicator of the development of a team.
–Lewis B. Ergen
Leaders are responsible to assemble the team and facilitate team events
Anyone can request a brief, huddle, or debrief
Shared Mental Model(Team Outcome)
Process of actively scanning behaviors and actions to assess elements of the situation or environment
… Remember, engage the patient whenever possible.
The state of knowing the current conditions affecting the team’s work
The perception of, understanding of, or knowledge about a situation or process that is shared among team members through communication.
“Teams that perform well hold shared mental models.”
(Rouse, Cannon-Bowers, and Salas 1992)
Process of monitoring the actions of other team members for the purpose of sharing the workload and reducing or avoiding errors
Mutual performance monitoring has been shown to be an important team competency.
(McIntyre and Salas 1995)
I = Illness
M = Medication
S = Stress
A = Alcohol and Drugs
F = Fatigue
E = Eating and Elimination
An individual team member’s responsibility …
“A chain is only as strong as its weakest link.”
Team members foster a climate in which it is expected that assistance will be actively sought and offered as a method for reducing the occurrence of error.
“In support of patient safety, it’s expected!”
“Feedback is the giving, seeking, and receiving of performance-related information among the members of a team.”
(Dickinson and McIntyre 1997)
Good Feedback is—
“Feedback is where the learning occurs.”
Invoked when an initial assertion is ignored…
“Empower any member of the team to “stop the line” if he or she senses or discovers an essential safety breach.”
This is an action never to be taken lightly, but it requires immediate cessation of the process and resolution of the safety issue.
A constructive approach for managing and resolving conflict
D—Describe the specific situation
E—Express your concerns about the action
S—Suggest other alternatives
C—Consequences should be stated
Ultimately, consensus shall be reached.
Often used to manage conflict; however, typically do not result in the best outcome—
“True collaboration is a process, not an event.”
Ineffective communication is a root cause for nearly 66 percent of all sentinel events reported*
* (The Joint Commission Root Causes and Percentages for Sentinel Events (All Categories) January 1995−December 2005)
Remember to introduce yourself…
A strategy used to communicate important or critical information
…On your unit, what information would you want called out?
The transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify, and confirm
Great opportunity for quality and safety
Introduction: Introduce yourself and your role/job (include patient)
Patient: Identifiers, age, sex, location
Assessment: Present chief complaint, vital signs, symptoms, and diagnosis
Situation: Current status/circumstances, including code status, level of uncertainty, recent changes, and response to treatment
Safety: Critical lab values/reports, socio-economic factors, allergies, and alerts (falls, isolation, etc.)
Background: Co-morbidities, previous episodes, current medications, and family history
Actions: What actions were taken or are required? Provide brief rationale
Timing: Level of urgency and explicit timing and prioritization of actions
Ownership: Who is responsible (nurse/doctor/team)? Include patient/family responsibilities
Next: What will happen next? Anticipated changes? What is the plan? Are there contingency plans?
Question, Clarify, and Confirm
GreatOpportunity for Quality and Safety
Pulling it All Together
“The truth of the matter is that you always know the right thing to do. The hard part is doing it.”
TOOLS and STRATEGIES
Advocacy and Assertion
In the preceding section, we learned that teamwork strategies and tools—
“To improve teamwork in your unit, what can you commit to focusing on?”
“The achievements of an organization are the results of the combined effort of each individual.”