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TeamSTEPPS Emergency Department Experience

TeamSTEPPS Emergency Department Experience. Why a teamwork project at Mayo Clinic Emergency Dept.?. Mayo Clinic - Integrated group practice of over 1700 physicians ED in located in largest private hospital in the world – St. Marys / Methodist sites

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TeamSTEPPS Emergency Department Experience

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  1. TeamSTEPPS Emergency Department Experience

  2. Why a teamwork project at Mayo Clinic Emergency Dept.? • Mayo Clinic - Integrated group practice of over 1700 physicians • ED in located in largest private hospital in the world – St. Marys / Methodist sites • 80,000 visits per year; Level 1 trauma center • ED relatively new addition to concept of “group practice” at Mayo

  3. “Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous” Chantler, 1999

  4. Science of Human Factors Human Characteristics • Perception • Memory • Decision-making • Physical Capabilities (skills to do tasks)

  5. Nominal Error Rates(highly predictable) • General error of commission (eg. Misread label) 0.003 • General error of omission in absence of reminders (memory) 0.01 • General error of omission for 10 step process 0.1 • General error of omission when items are embedded in procedure 0.003 (cash card returned before money dispensed) • Staff on different shifts fail to correctly check hardware condition 0.1 unless required by checklist (eg. Defibs) • Monitor fails to recognize an error (vigilance) 0.1 • General error rate given very high stress levels where dangerous 0.25 activities are occurring rapidly

  6. Culture and Human Factors: Mitigated Language Command “Strategy X is going to be implemented.” Team Obligation Statement “We need to try strategy X.” Team Suggestion “Why don’t we try strategy X?”

  7. Culture and Human Factors: Mitigated Language Query “Do you think strategy X would help us in this situation?” Preference “Perhaps we should take a look at one of these Y alternatives?” Hint “I wonder if we could run into any roadblocks on our current course?”

  8. Why do we do this? • Respect • Fear • Embarrassment • “No one likes a backseat driver.”

  9. Culture factors leading to communication errors in medicine: RN—Rule oriented • Uncertainty avoidance • High power distance • Independence versus collaborative culture • Stress of workload • History of tolerance or indifference to disruptive behavior MD—adaptive, independent

  10. Need for Teamwork • Clinical Medicine is extremely complex: • Uncertainty • Incomplete Information • Interruptions and multitasking • Surprises • Human Factors • Mayo tradition is to take advantage of cutting edge knowledge and research

  11. Project #1:Teamwork and Human Factors Training Emergency Department

  12. Interdisciplinary Collaborative: • Department of Emergency Medicine • Mayo School of Continuing Professional Development • Department of Nursing Continuing Education • Resuscitation Committee • Mayo Clinic Quality Committee • Division of Trauma and Critical Care General Surgery • American Institutes for Research

  13. Objectives • Demonstrate an effective model for building multidisciplinary teamwork skills • Multimodal • Interdisciplinary • Specifically address practice gaps • Related to organizational outcomes like safety and satisfaction

  14. Scope of Project (June 2007) • Goals: • Improve communication and teamwork • Prevent potential precursors to medical error • Demonstrate the impact of team training • Create template and expertise for teamwork training on wider scale • Process • To disseminate teamwork training and human factor education to all ED staff • Focus on “Psychology of Change”

  15. Outcomes of Team Competencies • Knowledge • Shared Mental Model • Attitudes • Mutual Trust • Team Orientation • Psychological Safety • Performance • Adaptability • Accuracy • Productivity • Efficiency • Safety

  16. Shift Towards a Culture of Safety

  17. Phase I: Assessment

  18. Step 1: Create Sense of Urgency • Key Stakeholders Identified • ED Medical Leadership • ED Nursing Leadership • All ED Staff Members • Ancillary Department Leadership • Ancillary Department Staff • ED Patients

  19. February/March 2008: Team STEPPS overview sessions delivered to ED Leadership and Ancillary Leadership (Stakeholders)

  20. Step 2: Create a Change Team February 2008 • Multidisciplinary group • Consultant (Attending) MDs • Residents • Mid Level Providers • Nursing Leadership • Operations Staff • Registered Nurses • Respiratory Therapists • Nursing Assistants

  21. Phase I: Assessment

  22. Are you interested in Team Work? Background: There is a Team Training project starting in the ED. The overall focus of the project will be to teach skills and strategies that improve teamwork and help reduce errors in the ED. As part of this project, we are seeking staff members that would be interested in helping coach teamwork. What is a coach? A coach will be a “lead by example” person who will help with the Team Training project during their regular hours of work. The coach will be a resource in which others can come to with questions related to the Team Training project in the ED. What are the requirements? Any member of the ED can be a coach. The coaches will be required to attend a one day Master Team Training session. The coach will not be required to attend weekly meetings. However, there may be occasional meetings for the coaches on an as needed basis. Every effort will be made to accommodate coaches on all shifts. What is the status of the Team Training project in the ED? Currently the Team Training project is in the data collection and planning phase. Sufficient data is needed to identify areas of opportunity for Team Training. Once the areas of opportunity have been identified, the plan for the Team Training can begin. Part of this phase includes gathering interested individuals to be coaches for the training which is estimated to begin in the early this fall.

  23. Phase I: Assessment

  24. Teamwork Survey Items and TeamSTEPPS Observations • Observations of Teamwork vs. Perceptions • Ideally, the survey items (perceptions) would be closely related to teamwork observation data • Survey perceptions revealed moderate level of teamwork • Teamwork observations revealed very few team behaviors taking place

  25. Mayo ED Survey (teamwork and communication) • TeamSTEPPS Teamwork Attitude • 5 subscales (6 questions each) • AHRQ HSOPS Factors • 7/9 unit-level subscales (3-4 questions) • Army Medical Daily Teamwork • 1 scale (6 questions) • MEDCOM Organization Citizenship • 1 scale (3 questions)

  26. Pre-Training Survey Findings

  27. Mayo Teamwork Observations • Observations of Teamwork are designed to identify actual performance of team behaviors. • Used the TeamSTEPPS Performance Observation Tool • Pre-Training: 2 observers • Post-Training: 1 additional observer (study novice)

  28. Pre-Training Observations Findings

  29. Gap Analysis and Specific Strategies • 10+ key behaviors needing improvement from observation tool • Information exchange behaviors • Resource utilization behaviors • Conflict management behaviors • Interruptions and distractions

  30. Specific Strategies • Information Exchange • SBAR model for info sharing • Exchanges across “silos” • Multidisciplinary briefs near shift change • Communication protocols for nursing (others) to address physicians • Huddles during treatment or condition changes (?other tools IT or communication board?) • Structured handoff tools for transfer to inpatient

  31. Information Exchange • Specific Recommendations for EMS • Checklist for EMS report to team

  32. Specific Strategies • Resource utilization • Checklist for assessing need to interrupt patient care • Checklist for assessing need to interrupt each other • Identification of coordinating team • Interdisciplinary briefs/huddles for coordinating team • Scheduled • during high volume/code 90

  33. Departmental/Leadership Team Behaviors • Resource Utilization • Conducting debriefings to ensure flow is managed effectively and staff needs are met • Coordination high flow / disaster management states

  34. Specific Strategies • Interruptions and Distractions • Sterile Cockpit times • Checklist for need to interrupt • ??IT solutions • ??communication boards

  35. Specific Strategies • Conflict management • Advocacy and assertion tools • Improving feedback (giving and receiving) • Debriefs

  36. Project #2: Trauma Team Training Multidisciplinary Teamwork: Training Through Simulation

  37. Scope of Project • Baseline State • Multidisciplinary trauma response in ED involves many disciplines (TCGS, ED, Radiology, Lab, etc.). • Roles defined and described through high level leadership meetings and education done within each separate group. • No specific training on teamwork skills. • No opportunity for multidisciplinary team training.

  38. Project Plan • Design, implement and evaluate a multidisciplinary team training curriculum. • Integrate with teamwork training project underway in ED. • Coordinate with Mayo Multidisciplinary Simulation Center to provide high-fidelity experience in “safe” learning environment.

  39. Results

  40. Post-Training Survey Findings

  41. Trauma Sim Progress to Date • 9 quarters completed • Outcome assessment planning • Qualitative assessment • Translation into practice • Through coaching / debriefs • Video reviews (Trauma Center QI) • Observational tool derivation / calibration

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