TeamSTEPPS Implementation Story Series
Edition #2

NEW YORK CITY HEALTH AND HOSPITALS CORPORATION

Background

The New York City Health and Hospitals Corporation (HHC) is the largest municipal health care system in the Nation, serving 1.3 million New Yorkers, one-third of whom are uninsured. HHC provides one million emergency room visits and five million outpatient clinic visits annually. It supplies 41 percent of the city's mental health inpatient services. HHC is comprised of 11 acute care hospitals, four long-term care facilities, six diagnostic and treatment centers, a certified home health agency, and a managed care entity, Metroplus. There are more than 39,000 clinical and nonclinical staff members.

In 2006, HHC declared a bold vision for patient safety: to be acknowledged as one of the safest health care systems in the Nation by 2010. Patient safety is a core strategic pillar and priority for HHC, and TeamSTEPPS implementation aligns with that corporate goal.

Implementing TeamSTEPPS

In February 2008, the TeamSTEPPS journey began. Ten HHC staff members traveled to Roanoke, Virginia, to become Master Trainers. When they returned from training, their first step was to obtain senior leadership buy-in. Mary Salisbury, RN, president of The Cedar Institute, provided HHC senior management an overview of the team training concept. One hundred forty-seven senior clinical and administrative leaders participated in the TeamSTEPPS forum. After the session, all 21 facilities and the home health agency were charged with developing an action and implementation plan.

Now, 1,210 HHC staff members have been exposed to TeamSTEPPS. After completing the training, some members of the interdisciplinary teams commented:

• "(The) multidisciplinary team approach to improve patient care and outcomes will make me appreciate teamwork even more."
• "The session definitely made me more sensitive to the importance of effective, reasonable, and polite 'conversation' with peers and patients."
• "The most important part of TeamSTEPPS training is the reminders that communication is the key to patient safety - reminders that all staff members have something to contribute."

Challenges/Obstacles

HHC found that its biggest challenge in implementing TeamSTEPPS was in devising a cost-effective and efficient plan to send individuals from 22 different organizations to an off-site TeamSTEPPS Master Training program. Each facility had to identify a group of individuals who would serve as TeamSTEPPS leaders. To overcome the logistical challenge and financial expenditure (staff time, travel, meals, and lodging), HHC decided to bring TeamSTEPPS Master Training to one of the system's networks.

HHC contacted the American Institute of Research for assistance, and David P. Baker, Ph.D., and Karyn D. Baum, M.D., came to Lincoln Medical and Mental Health Center and provided training to the Generations+/Northern Manhattan Health Network. In 2 ½ days, 33 Master Trainers passed through the course.

Accomplishments/Lessons Learned

Thus far, HCC has produced 59 Master Trainers. Portions of the TeamSTEPPS modules have been implemented by every facility, one of which introduced their employees to CUS ("I'm concerned, uncomfortable, this is a safety issue") and to the two-challenge rule. Several facilities have introduced TeamSTEPPS to specific teams, such as the obstetrics/prenatal/labor and delivery team; intensive care unit team (medical, surgical, and coronary care); the emergency department team; the preoperative team; and the Comprehensive Psychiatric Emergency Program team.

One factor that made TeamSTEPPS readily accepted by senior leadership and the clinical staff is that it is an evidence-based teamwork system. The biggest lesson learned was to consider and address the financial implications of the TeamSTEPPS Master Training program, including staff time, travel, meals, and hotel expenses. Launching this project requires a budget allocation.

Once clinical teams were exposed to TeamSTEPPS, they embraced the tools and strategies. In fact, one OB/GYN chief stated that, "TeamSTEPPS training has stimulated the team to desire daily interdisciplinary team rounds, regardless of the activities on the unit." The preoperative team has been implementing briefing and debriefing before and after each case. It has been very rewarding to see the positive effects that TeamSTEPPS training has brought to the HHC organization.

Next Goals

HHC's next steps are to:

• Implement TeamSTEPPS in at least one service line at each facility.
• Work to spread the TeamSTEPPS training system wide.
• Incorporate TeamSTEPPS strategies into HHC's Advanced Learning Institute to develop high fidelity simulation experiences for new and incumbent staff.

In addition, HHC would like to begin the evaluation process in areas that have already implemented TeamSTEPPS by using the the following:

• Observation of clinical staff.
• AHRQ Hospital Patient Safety Culture Survey results.
• Aggregate data on clinical outcomes.

BUTLER COUNTY HEALTH CARE CENTER

Background

Butler County Health Care Center (BCHCC) is a 25-bed critical access hospital, located in David City, Nebraska, a small town with a population of 2,500. Six physicians and two physician assistants staff two adjacent physician clinics. The center is equipped with the latest technologies and a well-trained staff. A county-owned hospital, it serves the health care needs of Butler County and its surrounding communities.

Implementing TeamSTEPPS

BCHCC was working on a project to reduce medication errors. By studying error reports and the results of root cause analyses, the organization learned that poor communication was the most frequent cause of mistakes. The organization's staff needed to find a way to work as a team, not as independent health care providers. TeamSTEPPS training was identified as a way to help BCHCC overcome communication barriers and improve workplace culture.

BCHCC began implementing TeamSTEPPS incrementally, starting with a small, close group; building success with that group; and then expanding to other areas. The Surgery Department was chosen, and two tools were selected: CUS ("I'm concerned, uncomfortable, this is a safety issue") and the two-challenge rule. The Magic Wand exercise was used in the first meeting, during which the group identified safety problems that were rooted in exchanges with other departments and staff members. After a few sessions, it was evident that a global approach was needed to improve patient safety. Culture change in the organization was identified as a priority. The TeamSTEPPS team "huddled" and reset their goals and resources to achieve that change.

Training began with supervisors and managers. During a supervisor retreat, TeamSTEPPS fundamentals were taught in a 4-hour session. Supervisors were encouraged to read Our Iceberg is Melting by John Kotter to prepare for the culture change. After evaluating this phase of the training, the TeamSTEPPS team realized that more support for TeamSTEPPS was required, so five more Master Trainers were added, including a member of the medical staff. To increase its effectiveness, training became more interactive and class size was limited to 14 participants. A series of two half-day training sessions for all employees was scheduled during a 4-week period to intensify the training and results. Training was held off site to minimize distractions and lend a sense of priority to the sessions. Finally, training groups were implemented across departmental lines.

Response to this second set of training was impressive. The Magic Wand exercise opened an understanding of each participant's obstacles and developed buy-in and ownership for TeamSTEPPS. Extensive use of videos and exercises varied the pace of training and invited participation. Each employee received a TeamSTEPPS pocket guide for reference and was encouraged to keep it handy. The post-training evaluations were very positive with comments such as, "I thank the people responsible for giving all of us an opportunity to attend this workshop. It makes everyone feel important, no matter what your job is. We are all employed by BCHCC and are all one team. Thanks!"

Challenges/Obstacles

Dedicating the time and resources to train all employees and to keep TeamSTEPPS alive and active in the organization is a challenge. BCHCC's board of directors and administration are committed to TeamSTEPPS. The next challenge is to demonstrate the value of the program to the medical staff as hospital employees improve the quality and safety of patient care through teamwork.

The hospital has an enthusiastic team of Master Trainers who provide training and coaching. Without constant reinforcement and the instilling of the TeamSTEPPS tools as new habits, the old, less desirable habits will return. The Master Trainers brainstorm to come up with ideas to keep TeamSTEPPS in front of the staff. For example:

• BCHCC has a stuffed penguin mascot/scout, "YaYa," that travels around the hospital, building situational awareness. He moves to a different location each week, carrying a sign that holds the name of a TeamSTEPPS tool or strategy. There is a weekly prize drawing for employees who complete a form listing (1) where they found YaYa, (2) what his message is, and (3) what the message means (how or where can it be used). There's a bit of excitement and mystery associated with YaYa and a bit of healthy competition in finding him. The explanation of YaYa's tools have been complete and detailed, showing either the staff learned well or are diligently looking in their Pocket Guides to refresh their memories.
• Knowing that poor communication was a major cause of error and confusion in the hospital, another cartoon penguin character, "Didga U. Know," was created. His purpose is to alert staff about new policies or other important information. When Didga is posted at building entrances to give staff a heads-up, it is their responsibility to seek out the new information.
• Because of remodeling, there is a temporary, unfinished wall in the hospital dining room that was made into a TeamSTEPPS graffiti wall. Its artwork and text reinforce TeamSTEPPS tools and strategies. Staff members are invited to share their team success stories by posting them on the wall.
• A "Play and Learn" TeamSTEPPS session is held the first Friday of every month. Sessions feature a tool or strategy and an opportunity to practice using it. Along with the featured tool, simple team-building exercises are conducted. The "Play and Learn" is set up in the staff cafeteria during break times, and treats are used to encourage participation.
• BCHCC developed a DVD to introduce TeamSTEPPS to new hires as part of their orientation. It explains the concept of teamwork and the tools and vocabulary of TeamSTEPPS so individuals will understand the team tools when they are used. As new hires are added, they are trained in TeamSTEPPS Fundamentals in group settings. A quarterly Fundamentals training in two 4-hour sessions is held to ensure all employees have the same training and understanding of the TeamSTEPPS concepts.

Accomplishments/Lessons Learned

All 100-plus employees at BCHCC have received TeamSTEPPS Fundamentals training. Comments on the graffiti wall documents its success.

• "We had three admits that were really involved, and all on the floor jumped in, helped with duties of other patients, stayed late. The WHOLE TEAM worked together well. Sue covered an ER from her office, the lab returned several times, Kathy B. ran down charts. Great work!!"
• "I feel (and I've talked with other nurses who feel the same) that after TeamSTEPPS, it seems that everyone is MORE willing to jump in and help out co-workers. The ATTITUDE has seemed to change in most. It is great to work with teammates with good and helping attitudes!!"

This success is a result of the full support and commitment by hospital administration and the board of directors. TeamSTEPPS tools are useful regardless of job or situation. Coaches and trainers acknowledge that the TeamSTEPPS concept needs to be kept active. They work continuously to keep the TeamSTEPPS message familiar and in the forefront.

Next Goals

BCHCC plans to extend TeamSTEPPS training to local physicians and their staffs and area nursing homes so a team orientation for coordinated health care is built in the community.

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