Department of Defense Patient Safety Program Heidi B. King, MS, FACHE

1. Department of Defense Patient Safety Program Heidi B. King, MS, FACHE Putting TeamSTEPPS™ Into Practice: Integrating TeamSTEPPS™ Into Simulation in the Military Health System (MHS)

2. Agenda • Background-TeamSTEPPS in the MHS • Where Are We? • Team Resource Centers: Accelerating Practice Change • Where Are We Going? …transforming healthcare through team-driven practice in DoD and beyond…

3. TRICARE Facts • 9.2 million eligible beneficiaries • 4.5 million dental enrollees • 65 military hospitals and 826 medical and dental clinics across the world • 132,700 personnel A Week In The Life: • 19,600 Inpatient Admissions • 642,400 Outpatient Encounters (direct care) • 102,900 Dental Seatings • 2,100 Births • 2.2 million Prescriptions • 3.5 millions Claims Processed

4. TRAINING EDUCATION RESEARCH COLLABORATION Team Resource Centers: ATTC, C-STARS, National Capital Area Medical Simulation Center, & Andersen Simulation Center – MAMC, NMCP, Travis AFB Collaboration & Outreach: Partnering Opportunities Marketing & Communication Technical Expert Panel Consultation Ongoing Efforts: Senior Leadership Engagement TeamSTEPPS™ Training Program Online Curriculum Assessment L&D Longitudinal Study NAVAIR - Teamwork Analysis Tools Skills-based Learning Plan, Train & Implement Publications Sustainment Healthcare Team Coordination ProgramTeamSTEPPS™ is the cornerstone MANDATES #1 Deployment of the HCTCP to all fixed and combat casualty care organizations #2 Minimum Establishment of Two Centers of Excellence #3 Expansion of the HCTCP to include all major medical specialties #4 Investments in continued research and development MISSION Promote Integration of Teamwork Principles through Optimal Use of Training, Education, Research, and Collaborative Efforts GOALS #1 Institutionalize team-driven care to improve patient safety #2 Solidify Collaborative Partnerships for Safe Care #3 Support Research Demonstration Projects FUNCTIONAL AREAS FY07-08

5. Healthcare Team Coordination Program • Promotes integration of teamwork principles into practice through training, education, research, and collaboration initiatives • Evidence-based teamwork intervention programs to MHS direct care facilities and combat care organizations • Develops and deploys tools to reduce the potential of harm to patients while delivering care • Establishment of Team Resource Centers (Centers of Excellence) • Several incorporate simulation • Since 2007, training incorporated higher fidelity simulation—lab and in-situ, where feasible

6. Model for Change TRANSFORMATIONAL CHANGE FACTORS Org Level Safety Culture Transparency/Trust Systems-Efficacy Learning Environment “Report Card” Leadership Level Create a sense of urgency Pull together a guiding coalition Develop a change vision and strategy Communicate for understanding and buy-in Empower others to act Product short-term wins Don’t let up Create a new culture Improved Patient Outcomes Improved Staff and Patient Satisfaction Improved Processes Staff Retention Decrease claims $ Individual Level Self EfficacyTraining Motivation Pre-training Experience Level IV: Results Intervention Sentinel Event Pre-TrainingMeasurement -Knowledge-Skills-Attitudes Post-TrainingMeasurement -Knowledge-Skills-Attitudes Training Transfer Tools Methods Level II: Learning Level II: Learning Level III: Behavior Training ((1) Salas E & Cannon-Bowers JA. Training and retraining: A handbook for business industry, government, and the military. Tobias S & Fletcher JD (editors). McMillan: New York, 2000: 312-335.; (2) Kirkpatrick, D. Model for Summative Evaluation. 1976; (3) Kotter JP. Leading change. Boston, Massachusetts: Harvard Business School Press, 1996.) Training Objectives Competencies -Knowledge-Skills-Attitudes Level I: Reactions

7. Five Ways TeamSTEPPS Transforms Culture Establishes names for team behaviors and a common language for addressing “communication” and other teamwork failures Bridges the professional divide and levels the hierarchy Provides ‘actions’/behaviors Increases common mindfulness Engages the patient ‘Acting their way into a new way of thinking’

8. Where Are We Now? Building a culture of quality and safety requires broad transformation-a tenacious commitment to achieving a sustainable effort is changing the way the Military Health System provides care and does business. We have extraordinary success stories and continued opportunities for improvement.

9. How Are We Changing the Culture? • Our approach*: • Spread: Actively disseminating best practice and knowledge about TeamSTEPPS • Impact: Assess TeamSTEPPS impact at several levels • Sustainability: Locking in the progress that sites have already made and continually build upon it Spread, impact and sustainability take time and commitment. *Based in part on the Institute for Healthcare Improvement (IHI) framework for helping to improve performance

10. COMMUNICATIONS (FY 2008) • 9 Peer Reviewed Publications • Outcome Measures for Effective Teamwork in Inpatient Care (Technical Report) • #1 visited page on the DoD Patient Safety web site & #1 resource from search engine to web site • 16 presentations TRAINING (FY 2008) INTEGRATION (FY 2008) PARTNERSHIPS • Trained 36 MTFs at 50 on-site sessions • Created 481 trainers/coaches • Over 12,000 CEU/CME granted • Saved $1.4M in training/travel dollars (over 2 yrs) • Incorporated in simulation exercises • Integrated multi-module TS curriculum (USUHS) • Operation Iraqi Freedom combat support hospital implementation • Developing strategic communications plan for the campaign to ‘improve communication’ for safer care • Developed 3 online learning modules • Federal: AHRQ/DoD National Implementation (20 training sessions, 503 civilians TS Master Trainers) • 2nd Annual Technical Expert Panel (36 patient safety thought leaders in attendance) • South Australia Dept of Health piloted TS handoff initiative • Held multiple pre-conference workshops at national conferences • CMS 9th Scope of Work (QIOs) • American Association for Family Physicians (AAFP)collaboration • National Patient Safety Foundation toolkit • International Reach (Nat’l Implementation in Taiwan) Spread At-A-Glance Within DoD Beyond DoD

11. Impact: Evaluation Plan Level 5 – Return on Investment Was the training worth the cost? Level 4 – Results: Did the change in behavior positively affect the organization? Level 3 – Behavior / Training Transfer Did the participants change their behavior on-the-job based on what they learned? Organizational Factors Level 2 – Learning: What skills, knowledge, or attitudes changed after training? By how much? Level 1 – Reaction: Did the participants like the training? What do they plan to do with what they learned? Individual Pre-training Experiences & Attitudes Kirkpatrick’s Model

12. Organizational Success Factors Supportive organizational culture & learning climate Shared vision (leadership to frontline) Visible leadership support Peer and subordinate support Reinforcement, rewards, recognition Minimal delay between training and practice on job On-going training – coaching, refresher, new staff Commitment to measurement and on-going improvement Sustainment (integration) plan Resource availability

13. “Why Can’t We Make This Work?” • Opportunity to Perform • Practice, Implement, then Measure • Front-line Support • Climate of Learning • Progress Updates • Forum to Discuss • Train, Refresh, and Inform • Team Coaches

14. Where We Are Going? …Simulation is critical to changing culture, however, we are applying scientific principles, instructional design methodology with clear learning outcomes and team performance measurement tools …only then can simulation and practice change be aligned

15. Mobile OB Emergencies Simulator Andersen Simulation Center

16. MOBILE OB SIMULATOR • Created mobile platform (2006) that can accomplish the following: • Run simulations on actual L&D units in 20+ hospitals • Provide a standardized curriculum • Evaluate both Teamwork and Technical proficiency • Integrate a no-fault debriefing tool • Be able to monitor progress over time • Inexpensive (~$25K/unit); cost effective compared to average OB malpractice claim ($2.5M/claim)

17. MOBILE OB SIMULATOR • Obstetric emergencies: • Shoulder dystocia • Postpartum hemorrhage • Eclampsia • Emergency cesarean section • Breech vaginal delivery • Operative vaginal delivery • Neonatal Resuscitation • Incorporates TeamSTEPPS training and evaluation tools into the scenarios and debriefing

18. National Capital Area Medical Simulation Center (NCAMSC) • Designated Team Resource Center since 2005 • Supporting projects: • Team Training for Wide Area Virtual Environment • Fundamental Laparoscopic Surgery • Pediatric and OB SBT • Reserve Unit TeamSTEPPS training

19. Credits: Chang Ha Lee Sofia del Castillo

20. Integrated Team Training Multidisciplinary and Forward Surgical Teams

21. US Army Trauma Training Center

22. STRUCTURE • Defined the team • Defined the chain of cmd. • The team leader was in charge /3 • EXECUTION • TEAM LEADER • M __ mechanism • A __ assess GCS • P __ primary survey • F __ FAST exam • A __ ABG/labs • S __ secondary survey • T __ timeout/problem list • ANESTHESIA • O __oxygen (applied oxygen) • X __apex apex base base (breaths) • Y __ yes/no (H&P) • G __ gauge (large bore IV) • E __ eyes, ears (examined eyes/ears) • N__nose, neck neuro check (exam) • NURSE • V __ vital signs • I __ IV meds • T __ temperature (room) • A __ alert key personnel • L __lab results (call out) • S __safety • LEFT MEDIC • L __ IV line placed • E __ exposed patient • F __ Foley catheter • T __ temp obtained • RIGHT MEDIC • R __ remove clothing • I __ inline stabilization • G __ gear collected • H __ hold pressure • T __ tubes sent to lab ATTC Tool /3 /7 NOTES ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________________________________ ________________________ ________________________ Start:_______________ Primary Done:_______ Secondary Done:_____ Finish:________ Observer:____________ Event:_______________ Date:________________ /3 • PLANNING • Established a clear plan • Identified roles • Conducted rehearsal(s) /3 /3 /6 • COMMUNICATION • Performed “Call outs” • followed by “Echoes”. • Verbalized Vital Signs • Performed a clear • “hand-off” /3 /2 /6 /3 • IMPROVEMENT • Conducted an AAR • Discussed ways to • improve • Devised an improvement • plan /3 /4 /4 /5 Subtotal= /12 Subtotal= /18 Total Score= /58 Subtotal= /28 = GO =NO/GO

23. Team Effectiveness Accelerator (TEA) -- The Group for Organizational Effectiveness, Inc. (gOE) -- TRICARE Mgmt Activity, DoD Patient Safety Program -- Naval Air Warfare Center, Training Systems Division How the TEA Works: • Rationale: • Teamwork is essential for safe and effective medical practice • Teams with shared understanding collaborate and perform more effectively (30+ studies) • Teams that debrief effectively build shared understanding and perform better (up to 40%). Unfortunately, debriefs are often not conducted or not done optimally (e.g., don’t discuss teamwork) • Premise: A well-designed TEA can efficiently guide teams through debriefs to enhance collaboration and performance • What is the Team Effectiveness Accelerator (TEA): • A simple-to-use web-based tool that allows a team to quickly diagnose “gaps” such as: a) disagreement about roles, priorities, etc., b) loss of situation awareness, c) inaccurate knowledge and d) lack of teamwork behaviors • The TEA then efficiently guides the team through a targeted debrief to rectify those gaps • Status of the Effort and Next Steps • The first TEA has been developed for use by Trauma Teams (military and civilian versions) • Based on thorough shared coordination requirements analysis with SMEs • Applicable for use with TeamSTEPPS Program • Will soon begin testing and provide early access • In the future, we will likely expand access to more institutions and develop TEAs to cover other medical domains • Contract Details: • Developed under Contract N61339-07-D-0001,“Tools for Training, Assessment, Analyses, and Debriefing of Medical Teams Performance” • Contact: Scott Tannenbaum, Ph.D., The Group for Organizational Effectiveness, Inc. 518.456.7738 x102; scott.tannenbaum@groupoe.com

24. Background TeamSTEPPS™ is a teamwork methodology and curriculum designed to improve patient safety for health care organizations. Scenario-based training with performance observation, assessment and post exercise team debrief provides a promising approach for building team coordination skills in the context of clinical performance. Scenario design and measurement best practices include constructing scenario events and performance measures around specific training objectives and then structuring debrief around these objectives and events. What is MTPAT? A software application that provides capabilities to support evaluation, debrief, and analysis of healthcare team performance in training and operational environments. An architecture to support an event based training and assessment approach where assessment items are linked to scenario events. Integrates the TeamSTEPPS™ principles and skills so that military and civilian medical teams can rapidly record, assess, and analyze teamwork performance evidence and provide timely feedback and debrief. Supports coordinated evaluation of technical and teamwork skills. Ultimately, MTPAT can provide an evidence base from which medical teams can measure and continually improve their performance, thereby reducing medical errors and improving patient safety. Current Status MTPAT prototyped for Trauma and Labor & Delivery. Events and assessment item content developed for Trauma and Labor and Delivery domains based on document analysis, observations and interviews with subject matter experts. Testing and review in progress with participant facilities Medical Team Performance Assessment Tool (MTPAT) TeamSTEPPS™ - MTPAT Team • Alion Science and Technology • American Institutes for Research • TRICARE Mgmt Activity, DoD Patient Safety Program • Naval Air Warfare Center, Training Systems Division • Contract Details: • Developed under Contract N61339-07-D-0001,“Tools for Training, Assessment, Analyses, and Debriefing of Medical Teams Performance” • Contact: Tom Carolan, Ph.D., Alion Science and Technology. 517.347.6117; tcarolan@alionscience.com

25. Simulation As A Training Strategy • Establish the vision, goals and objectives • Determine the model • In-center • In-situ • Establish the needed resources • Simulation Center • Staff - clear vision, roles & responsibilities • Equipment • Participating department • Clear vision and expectations for participation • Staff release time • Develop event-based scenarios • Expect results • Debrief and educate on awareness

26. Understanding Teams Determine the performance outcomes you expect to see, then: • Develop learning outcomes • Train teamwork competencies • Define and determine diagnostic measures

27. Needed Links in Simulation-Based Team Training… Rosen et al, 2008 Tasks & KSAs LearningOutcome Scenarios &Events Measures PerformanceHistory Feedback

28. Understanding Performance • The behaviors sought should drive the simulation goals • Select measurement tools based on goals of simulation/assessment criteria • Measure what is important, not what is easy • Performance Observation Tools • SMARTER Approach (Simulation Module for Assessment of Resident Targeted Event Responses) • Communication and Teamwork Skills (CATS) • Others

29. SMARTER-Team • Focus on teaching points • Define specific learning objectives • Choose clinical context to frame scenario development • Develop set of targeted KSA’s to capture pre-defined learning objectives and core competencies • Craft scenario to ensure team members have opportunity to display targeted KSA’s • Define set of targeted responses • Create diagnostic measurement tools • Create scenario script Rosen, et al

30. Understanding Debriefing • Center debriefing around the chosen teaching points e.g. “Did the leader • Specify the goals to the team?” • Coordinate team efforts?” • Cross-monitor team members?” • Resolve conflict?” • Focus discussion on communications and interactions with team members • Keep discussion focused on team behaviors, minimize clinical discussions use scenarios that • Stress rapid team responses and coordination of care • Straightforward diagnoses with clear and easily determined treatment

31. Resources • Simulation-Based Training for Patient Safety: 10 Principles That Matter (Salas et al, 2008) • Measuring Team Performance in Simulated-Based Training: Adopting Best Practices for Healthcare (Rosen et al, 2008) • SMARTER-Team: Adapting Event-based Tools for Simulation-based Training in Healthcare (Rosen et al, 2008) • Promoting Teamwork: An Event-based Approach to Simulation-based Teamwork for Emergency Medicine Residents (Rosen et al, 2008) • Does Team Training Work? Principles for Healthcare (Salas et al, 2008)

32. For More Information • http://dodpatientsafety.usuhs.mil/teamstepps • http://teamstepps.ahrq.gov/