TeamSTEPPS Implementation Story Series
Edition #1

UNIVERSITY OF NORTH CAROLINA HEALTH CARE

Background

The University of North Carolina (UNC) Health Care System is a not-for-profit, integrated health care system, owned by the State of North Carolina and based in Chapel Hill. It exists to further the teaching mission of the University of North Carolina and to provide state-of-the-art patient care. In September 2007, in partnership with RTI International, UNC Health Care received an Agency for Healthcare Research and Quality (AHRQ) request for task order entitled “TeamSTEPPS™ Adoption in Action”, requiring them to build a cadre of TeamSTEPPS Master Trainers to implement TeamSTEPPS.

Implementing TeamSTEPPS

UNC Health Care initially implemented TeamSTEPPS in three areas:

• Surgical Intensive Care Unit (SICU)
• Pediatric Intensive Care Unit (PICU)
• Respiratory Therapy Department

Interdisciplinary change team leaders from these departments attended National Implementation of TeamSTEPPS Master Training sessions and committed to guide the implementation process, including training and ongoing staff coaching. Other area leaders learned of early TeamSTEPPS successes and requested training. These included:

• Main and Pediatric Emergency Department
• Bone Marrow Transplant Unit
• Labor and Delivery
• Neonatal Intensive Care Unit
• Radiology

The training program consists of a 1-hour TeamSTEPPS online module, two pre-readings, and a 1-hour interactive classroom session with role-play.

Participants' comments reveal how transformative the TeamSTEPPS training has been: "Since TeamSTEPPS training, we think that doing a debriefing after ECMO (extracorporeal membrane oxygenation) is absolutely necessary now. Each time we learn of a way to do it better next time, even if it's as simple as changing the placement of the bed," a SICU attending physician remarked.

Anecdotally, physicians have reported that TeamSTEPPS training has prevented errors during emergent events. One recalled that during a Pediatric Rapid Response Team event on a unit that has a mixed population of adults and children, she called out the drug and dose. The nurse handed her the drug while checking back what she thought she heard the physician say. The physician responded, "Whoa! This is a baby; that's too much."

Challenges/Obstacles

UNC Health Care has found that helping the different units prepare for training, implement it, and sustain the change with limited available resources has been the biggest challenge. Before a unit begins TeamSTEPPS training, motivated individuals from that area become Master Trainers. Thus, multiple people share the responsibility of implementation. To sustain the changes that result from training, one program owner is responsible for ensuring that Master Trainers and coaches have ongoing support. The program owner also ensures timely measurement of success and feedback to staff. UNC Health Care will add a second program owner as part of its efforts to sustain change.

Accomplishments/Lessons Learned

UNC Health Care has trained more than 600 staff and faculty in nine different areas within the organization. Master Trainers with leadership and clinical responsibility in the Operating Room, Air Care (the Critical Care Medical Transport program), and with the Pediatric and Adult Rapid Response Teams also provided introductory training sessions to staff and faculty in these areas. A dedicated program owner and the highly visible support from unit and area nurses, respiratory therapists, and physician leadership contribute to the success of the TeamSTEPPS training.

"I think we learn from our past mistakes. After we all went through TeamSTEPPS training, I’d say we have improved," a UNC Health Care nurse remarked. From my own experience, I was able to think ahead to call a team huddle and briefing before an ECMO cannulation, whereas we wouldn’t have done it before TeamSTEPPS. We now will think ahead to do a time-out and put a sign on the door that says 'sterile procedure in progress,' whereas before TeamSTEPPS we wouldn't have done that. It would’ve been more of a physician responsibility, and now nurses feel more empowered to do that.”

Another TeamSTEPPS participant put it this way: "The TeamSTEPPS training has taught me to effectively coach others. It's taught me to recognize what we're doing poorly and what team members are doing an outstanding job. It's taught me that feedback is good. It's taught me to involve patients and families, not just talk over the patient, but speak to the patient."

UNC Health Care has found that the program "sells itself." It makes sense to staff. Providing training to interdisciplinary groups is yielding optimum training results. "Between the Six Sigma training projects and TeamSTEPPS, we have given our staff a mechanism and built confidence that has led to significantly better patient care. People now have a voice that otherwise would not have been used before," a PICU attending physician remarked.

Next Goals

• Support spread at a pace that matches the resources available.
• Develop a coaching component to train unit-based staff who have not attended Master Training but who are interested in contributing to the program through peer-to-peer coaching of TeamSTEPPS.
• Begin working to incorporate TeamSTEPPS behavior expectations in the hiring, training, and performance review of new and existing staff.

GEORGIA MEDICAL CARE FOUNDATION (GMCF)

Background

The Georgia Medical Care Foundation (GMCF), established in 1970, is a not-for-profit, physician-sponsored organization dedicated to continuously improving health care. For more than 20 years GMCF has served as the Medicare Quality Improvement Organization (QIO) for Georgia through a contract with the Centers for Medicare and Medicaid Services. GMCF received TeamSTEPPS Master Trainer preparation training through the National Implementation of TeamSTEPPS project in anticipation of Medicare’s 9th Scope of Work as a recommended intervention to reduce hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA).

Implementing TeamSTEPPS

GMCF recognized the TeamSTEPPS training as a natural fit for developing teams across all of its care settings. Its first opportunity to train health care providers occurred in fall 2008 with members of the Georgia Healthcare Association, the State’s largest nursing home association. By using the model for building skills in the four domains of situation monitoring, leadership, communication, and mutual support, the QIO linked the concepts to nursing home patient safety initiatives to reduce the use of restraints and decrease the incidence of pressure ulcers.

The next steps included monthly patient safety teleconferences. The Eight Steps of Change and John Kotter’s Our Iceberg is Melting: Changing and Succeeding Under Any Conditions became the building blocks for the call structure. In the initial sessions, leaders covered the tenets for change strategies, and providers reported on how their teams were implementing the strategies. A TeamSTEPPS facilitator then responded to audience questions, providing guidance on the strategies while referencing the book characters.

TeamSTEPPS training participants’ comments have been positive. “We like the SBAR and CUS tools and can apply them right away. Learning communication techniques was very helpful for our team, and working through scenarios and role-playing helped keep the sessions fun and interactive. GMCF knew the training was a hit too, as participants readily ordered the free AHRQ packets of TeamSTEPPS materials. We sent in over 100 requests from facilities the first month!”

Hospital teams are scheduled to be trained on MRSA improvements next.

Challenges/Obstacles

• Competing priorities is among the biggest challenges in health care. There are multiple patient safety initiatives (e.g., the Institute for Healthcare Improvement’s 5 Million Lives Campaign), which use the same concepts with a slight variation in terminology. It is an ongoing challenge to establish a vocabulary that is essential to changing the patient safety culture of an organization.
• Another challenge is linking the education and changes in the organization to measurable indicators that accurately reflect those changes and their impact on patient safety. Conducting the AHRQ Culture of Patient/Resident Safety Surveys at baseline and after training and intervention will be a good measure of the program’s success. The surveys will encounter the same challenges of competing resources that the training has, but GMCF hopes the surveys will be positively received.
• Adapting the materials to demonstrate application to the nursing home environment is also a challenge.

GMCF continues to reinforce providers’ training through communications that use the TeamSTEPPS vocabulary. The organization has become knowledgeable of other patient safety initiatives and developed a crosswalk between concepts when confusion developed. The newly trained QIO staff members who have backgrounds in the nursing home quality improvement field have helped to make these adjustments, enabling GMCF to appeal to Georgia’s nursing home professionals. The positive aspects of participation as a method to work smarter, not harder, are continuously reinforced.

Accomplishments/Lessons Learned

TeamSTEPPS training has become an ongoing initiative as GMCF works towards quality improvements and patient safety. Cross-setting meetings with hospitals and nursing homes are beginning to experience this, as these health care providers work toward communication and handover management improvements.

The fact that all GMCF trainers have embraced the concepts and are a committed, dynamic group has contributed to the success of the TeamSTEPPS program. The trainers’ enthusiasm for this work helps to create a positive and successful environment for change. Everyone finds value in team building, but staff members have been limited in their ability to find strategies to implement improvements. TeamSTEPPS shows them how to do this in health care, and everyone can benefit.

Next Goals

GMCF will continue to use TeamSTEPPS and build on the Eight Steps of Change within the health care settings in which it works. In April 2009, the organization reinforced the training given to nursing homes at their regional meeting last year. These sessions focused on improving trust within the team and techniques to improve communication and hand-offs. In May and June 2009, leaders from hospitals that are part of the MRSA reduction initiative will be trained. Hospital trainers will then take this material back to their facilities and receive coaching from GMCF staff.

For further information about these TeamSTEPPS implementation stories, please contact us at TeamSTEPPScontact@air.org.