Team STEPPS

Teamwork concepts are introduced that provide specific tools for

improving communication and teamwork, reducing chance of error, and providing safer patient care

A continuous process

is necessary because of the dynamic situations in which teams function. It allows individual team members to maintain their situation awareness and share new and emerging information with other team members to retain a shared mental model. One way to ensure situation monitoring is occurring is through cross monitoring.

Iatrogenic

when a patient dies as a direct result of treatments by a physician, whether it is from misdiagnosis of the ailment or from adverse drug reactions used to treat the illness

Effective Team Leaders

• Are responsible for ensuring that team members are sharing information, monitoring situational cues, resolving conflicts, and helping each other when needed • Manage resources to ensure team performance • Facilitate team actions by communicating through informal exchange sessions • Develop norms for information sharing • Ensure that team members are aware of situational changes to plans

How feedback benefits the team

• Fosters improvement in work performance • Meets the team's and individual's need for growth • Promotes better working relationships • Helps the team set goals for ongoing improvement

Team Leaders should be able to

• Organize the team • Articulate clear goals • Make decisions based on input of team members • Empower team members to speak up and openly challenge, when appropriate • Promote and facilitate good teamwork • Resolve conflict

STEP

-A tool for monitoring situations in the delivery of health care -Components of situation monitoring -Status of the patient -Team members -Environment -Progress toward goal

Avocate for

-The Patient -Invoked when team members viewpoints don't coincide with that of the decision maker

Who can request a brief, huddle, or debrief?

Anyone

Leading cause of preventable patient deaths

Communication failures

DESC Script

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 in terms of impact on established team goals; strive for consensus -Used in the more conflicting scenarios in which behaviors aren't practiced, hostile or harassing behaviors are ongoing, and safe patient care is suffering.

Team structure

Delineates fundamentals such as team size, membership, leadership, composition, identification and distribution.

Knowledge

Shared mental model

Leadership

The ability to coordinate the activities of team members by ensuring team actions are understood, changes in information are shared, and that team members have the necessary resources.

Coordinating Team

The coordinating team is the group responsible for: - Day-to-day operational management - Coordination functions - Resource management for Core Teams

Leaders are responsible to

assemble the team and facilitate team events

Key Recommendation from IOM for health care organizations

establish interdisciplinary team training programs for providers that incorporate proven methods of team training

Situation Monitoring

is the process of actively scanning and assessing elements of the situation to gain information or maintain an accurate understanding of the situation in which the team functions. Situation monitoring is a skill, which implies that it can be trained and developed as discussed earlier.

4 teachable/ Learnable skills of TeamSTEPPS

leadership, mutual support, situation monitoring, and communication

Purpose of Briefs

• They clarify who will be leading the team so that others know to whom to look for guidance • They open lines of communication among team members, ensuring that everyone can contribute their unique knowledge base to the task, and thereby set the tone for the upcoming procedure. Protocols, responsibilities, and expected behaviors are discussed and reinforced so that possible misunderstandings are avoided • They prepare the team for the flow of the procedure, contingency plans, and the means for resolving any unusual Circumstances • By delineating expectations, they reduce disruptive or unexpected behaviors

Things to consider when using DESC

• Time the discussion. • Work on win-win—Despite your interpersonal conflict with the other party, team unity and quality of care are dependent on coming to a solution that all parties can live with. • Frame problems in terms of personal experience and lessons learned. • Choose the location—A private location that is not in front of the patient or other team members will allow both parties to focus on resolving the conflict rather than on saving face. • Use "I" statements rather than blaming statements. • Critique is not criticism. • Focus on what is right, not who is right.

Functions of Team structure

- Assembles a team - Establishes a leader - Identifies team goals and vision - Assigns roles and responsibilities - Holds team members accountable - Actively shares information amongst team members

Functions of Communication

- Coaching feedback routinely provided to team members, when appropriate - Provides brief, clear, specific and timely information to team members - Seeks information from all available sources - Verifies information that is communicated - Uses SBAR, call-outs, check-backs and handoff techniques to communicate effectively with team members

Contingency Teams

- Formed for emergent or specific events - Time-limited (e.g., Code Team, Disaster Response Team, Rapid Response Team) - Composed of team members drawn from a variety of core teams

Functions of Situation Monitoring

- Includes patient/family in communication - Cross monitors fellow team members - Applies the STEP process when monitoring the situation - Fosters communication to ensure team members have a shared mental model

Functions of Mutual support

- Provides task-related support - Provides timely and constructive feedback to team members - Effectively advocates for the patient - Uses the Two-Challenge rule, CUS, and DESC script to resolve conflict - Collaborates with team members

Benefits of Teamwork

- Reduce clinical errors -Improve patient outcomes -Improve process outcomes -Increase patient satisfaction -Increase staff satisfaction -Reduce malpractice claims

Functions of leadership

- Utilizes resources efficiently to maximize team performance - Balances workload within the team - Delegates tasks or assignments, as appropriate - Conducts briefs, huddles, and debriefs - Empowers team members to speak freely and ask questions

Performance

-Adaptability -Accuracy -Productivity -Efficiency -Safety

Cross monitoring is

-An error reduction strategy that involves: -Monitoring actions of other team members -Providing a safety net within the team -Ensuring mistakes or oversights are caught quickly and easily

I'M SAFE

-Assess your own conidtion for work -Illness -Medication -Stress -Alcohol and rugs -Fatigue -Eating and elimination

Tools and Strategies of TeamSTEPP

-Brief -Huddle -Debrief -STEP -Cross monitoring -Feedback -Advocacy and assertion -CUS -DESC Script -Collaboration -SBAR -Call out -Check back -Hand off

Team Events are accomplished through

-Briefs -Huddles -Debriefs

Debrief Checklist

-Communication clear? -Roles and responsibilities understood? -Situation awareness maintained? -Workload distribution equitable? -Task assistance requested or offered? -Were errors made or avoided? -Availability of resources? -What went well, should change, should improve?

Students and working professionals should develop and maintain proficiency in five core areas

-Delivering patient-centered care, -Working as part of interdisciplinary teams, -Practicing evidence-based nursing, -Focusing on quality improvement and -Using information technology.

Example of check back

-Doctor: "Give 25 mg Benadryl IV push" -Nurse: "25 mg Benadryl IV push" -Doctor: "Correct"

Assess Environment

-Facility Information -Administrative information -Human resources -Triage acuity -Equipment

Assess level of team memebers

-Fatigue -Workload -Task performance -Skill -Stress

Assert a corrective action in a

-Firm and respectful manner -Make an opening -State the concern -Offer a solution -Obtain an agreement

Task Assistance

-Form of mutual support -Team members protect each other from work overload situations -Effective teams place all offers and requests for assistance in the context of patient safety -Team members foster a climate where it is expected that assistance will be actively sought and offered

I PASS the BATON (hand off)

-I Introduction—Introduce yourself and your role/job (include patient) -P Patient—Name, identifiers, age, sex, location -A Assessment—Presenting chief complaint, vital signs, symptoms, and diagnosis -S Situation—Current status/circumstances, including code status, level of uncertainty, recent changes, response to treatment -S Safety Concerns—Critical lab values/reports, socioeconomic factors, allergies, alerts (falls, isolation, etc.) THE -B Background—Co-morbidities, previous episodes, current medications, family history -A Actions—What actions were taken or are required? Provide brief rationale -T Timing—Level of urgency and explicit timing and prioritization of actions -O Ownership—Who is responsible (nurse/doctor/team)? Include patient/family responsibilities -N Next—What will happen next? Anticipated changes? What is the plan? Are there contingency plans?

CUS

-I am Concerned -I am Uncomfortable -This is a Safety issue

3rd leading cause of death

-Iatrogenic -Medical Errors

Barriers to TeamSTEPP

-Inconsistency in team membership -Lack of time -Lack of info sharing -Hierarchy -Defensiveness -Conventional thinking -Complacency -Conflict -Varying communication styles -Lack of coordination and follow up with co workers -Distractions -Fatigue -Workload -Misinterpretation of cues -Lack of role clarity

Feedback

-Information provided for the purpose of improoving team performance

Situation Awareness

-Is the state of knowing the conditions that affect one's work. It is a detailed picture of the situation. -Note: Situation awareness (SA) is not a static "thing" or concept. Because the situation and context in which the situation exists are dynamic and ever-changing, team members must continually assess relevant components of the situation and update their individual SA.

Cross monitoring

-Is used by fellow team members to help maintain situation awareness and prevent errors -"watching each other's back,"

Multi-Team System

-Key component: patient -Core team -Coordinating Team -Contingency Teams

Team Competency Outcomes

-Knowledge -Attitudes -Performance

Example of Call out

-Leader: "airway status?" -Resident: "airway clear" -Leader: "Breath sounds?" -Resident" "Breath sounds decreased on the right"

Attitudes

-Mutual trust -Team orientation

Assess Status of Patient

-Patient Hx -Vitals -Meds -Physical Exam -Plan of care -Psychosocial

Team Events Include

-Planning -Problem Solving -Process Improvement

Brief

-Planning -Short session prior to start to discuss team formation, assign essential roles, est. expectations and climate, anticipate outcomes and likely contingencies

Purpose of Huddle

-Problem solving -Hold ad hoc, "touch-base" meetings to regain situation awareness -Discuss critical issues and emerging events -Anticipate outcomes and likely contingencies -Assign resources -Express concerns

Debrief

-Process improvement -Informal information exchange session designed to improve team performance and effectiveness, after action review

Outcomes of TeamSTEPPS

-Shared mental model -Adaptability -Team orientation -Mutual trust -Team performance -Patient safety

SBAR

-Situation -Background -Assessment -Recommendation -Technique for communicating critical information that requires immediate attention and action concerning a patients condition -Provides a vehicle for individuals to speak up and express concern in a concise manner.

Assess progress towards goal

-Status of teams patients? -Established goals of team? -Task/actions of team? -Plan still appropriate?

Call out

-Strategy used to communicate important information -Informs all team members simultaneously during emergent situations -Helps team members anticipate next steps -Importation to direct responsibility to a specific individual responsible for carrying out the task

TeamSTEPPS

-Team Strategies and Tools to Enhance Performance and Patient Safety -Evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and other teamwork skills among healthcare professionals.

5 Key Principles of TeamSTEPPS

-Team Structure -Leadership -Situation monitoring -Mutual support -Communication

Hand off

-The transfer of information (along with authority and responsibility) during transition in care across the continuum, to include an opportunity to ask questions, clarify, and confirm -Strategy designed to enhance information exchange during transitions in care

Feedback should be

-Timely (given soon after the target behavior has occurred) -Respectful (focus on behaviors not person attributes) -Specific ( be specific about what behaviors need correcting) -Directed towards improvement (provide direction for future improvement) -Considerate ( consider a team members feelings and deliver negative information with fairness and respect)

Hand off includes

-Transfer of knowledge and info about the degree of uncertainty -Response to treatment -Recent changes in condition and circumstances -The plan of care

Assessment

-What do I think the problem is? "Breath sounds are decreased on the R side with acknowledgement of pain. Would like to rule out pneumothorax"

Situation

-What is happening with the patient? " I am calling about Mrs. Jose in room 25. Chief complaint is SOB of new onset"

Background

-What is the clinical background or context? "Patient is a 62 year old female post OP day 1 from abdominal surgery. No prior Hx of cardiac or lung disease"

Reccomendation

-What would I do to correct it? "I feel strongly the patient should be assessed now. Are you available to come in?"

Brief Checklist

-Who is on our team? -All members understand and agree upon goals? -Roles and responsibilities are understood? -What is our plan of care? -Staff and providers availability throughout the shift? -Workload among team members? -Availability of resources?

TeamSTEPPS focuses on

-pecific skills supporting team performance principles, including training requirements, behavioral methods, human factors, and cultural change designed to improve quality and patient safety

Check Back Steps

1. Sender initiates message 2. Receiver accepts the message and provides feedback 3. Sender double checks to ensure that the message was received

How many deaths are from non-error adverse effects of medications?

106,000

How many deaths are from unnecessary surgery?

2,000

How many deaths are from other errors in hospitals?

20,000

How many deaths are from medication errors?

7,000

How many deaths are from infections?

80,000

Collaboration

Achieves a mutually satisfying solution resulting in the best outcome -Win- Win - Win for patient care team (patient, team members, and team ) -Commitment to a common mission -Meet goals without compromising relationships -True collaboration is a process not an event -Involves full and open communication

Huddle

Ad hoc planning to reestablish situation awareness, reinforce plans already in place and assessing the need to adjust the plan

Core Team

Core teams consist of team leaders and team members who are involved in the direct care of the patient. Core team members include direct care providers (from the home base of operation for each unit), and continuity providers (those who manage the patient from assessment to disposition, for example, case managers). The Core team is based where the patient receives care.

Who was TeamSTEPPS developed by?

Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality (AHRQ)

Communication

Process by which information is clearly and accurately exchanged among team members.

Check Back

Process of employing closed- loop communication to ensure that information conveyed by the sender is understood by the receiver as intended

Common mission of collaboration

Safe and improved care of patient

Mutual Support

The ability to anticipate and support other team members' needs through accurate knowledge about their responsibilities and workload.

Two Challenge Rule

When an initial assertion is ignored: -It is your responsibility to assertively voice concern at least 2 times to ensure it has been heart -The team member being challenged must acknowledge If the outcome is still not acceptable: -Take a stronger course of action -Utilize supervisor or chain of command This empowers all team members to "stop the line" if they sense or discover an essential safety breach

Shared mental models

are the result of each team member maintaining his or her situation awareness and sharing relevant facts with the entire team. Doing so helps ensure that everyone on the team is "on the same page."