TeamSTEPPS Implementation Story Series
Edition #4

KALEIDA HEALTH

Background

Kaleida Health is the largest health care provider in Western New York, serving the area's eight counties with state-of-the-art technology and comprehensive health care services. Kaleida has more than one million visits from sick or injured patients annually. Women and Children's Hospital of Buffalo is the Western New York region's only pediatric hospital and one of Kaleida's five acute care hospitals.

Implementing TeamSTEPPS

In September 2008, bedside staff RN helped to create a multidisciplinary communication initiative. Despite excellent outcomes in the pediatric intensive care unit (PICU), staff morale was low, nurse turnover was high, and a number of bedside procedures and "road trips" could have gone more smoothly. Parents and staff provided significant feedback on the unit's need to change its approach to optimize patient care and safety.

While researching communication, an article from Pediatric Emergency Medicine, "Multidisciplinary Team Training and the Art of Communication," provided information about TeamSTEPPS in the last paragraph. This sparked a genuine staff interest.

A core group of interested individuals started a "change team" that then developed a clear vision from which to proceed: Together, Caring for Your Family as Our Own. Networking began, specifically with Dr. Karen Frush, Chief Patient Safety Officer of Duke University Health System, and through a conference call with Lily Thomas, Vice President, System Nursing Research, Northshore Jewish Healthcare System, and Long Island, NY.

The group earned strong support from both its hospital and health system senior leadership early in the initiative. In March 2009, 10 Master Trainers were trained at Duke:

Two Senior Respiratory Therapists:

1. Supervisor/Transport Team Coordinator
2. Pediatric/Neonatal Transport Therapist

Three Doctors:

1. Chief Patient Safety Officer
2. PICU Attending/Medical Director of the STAT Team (Women and Children's Hospital of Buffalo), who is also a medical intensive care unit attending at Buffalo General Hospital, Kaleida Health
3. First year PICU Fellow

Five Registered Nurses (RNs):

1. Director of Nursing Practice of Kaleida
2. RN Nursing Supervisor
3. PICU/STAT Team RN
4. Director of Quality and Patient Safety RN
5. Bedside PICU staff RN

The National Implementation of TeamSTEPPS training was refreshing and inspiring. Recognizing that Duke's initial implementation was in the PICU and that much of their focus was very similar to the Women and Children's Hospital of Buffalo PICU's made TeamSTEPPS stand out even more as a solution to improving patient care and safety. Discussing cultural and generational aspects of caregivers was key in recognizing where communication can be challenged and directly affect patients.

Master trainers conducted staff training in May 2009. Coaches were trained first in 4-hour sessions, which included written Situation, Background, Assessment, Recommendation (SBAR) scenarios. Coaches completed evaluation forms after the session. The TeamSTEPPS Fundamentals course was provided for direct patient caregivers in 3-hour sessions, which included everyday picture descriptions for SBAR and used face-to-face debriefs after the session. The TeamSTEPPS Essentials training course occurred the following week. About 60 percent of staff was trained prior to rollout.

The PICU at Women and Children's Hospital of Buffalo implemented TeamSTEPPS on June 6, 2009.

Challenges/Obstacles

One of the biggest challenges the PICU faces is a lack of buy-in and shared sense of urgency. Further, some staff members do not clearly recognize that the PICU has a communication problem. Other challenges have been implementing daily briefs, huddles, and debriefs in a very busy and challenging PICU. Lack of understanding of TeamSTEPPS has been significant for those who have not yet attended training.

The PICU staff members that have been trained in Team STEPPS addressed incomplete buy-in and lack of a shared sense of urgency by using open, multidisciplinary discussion, a continuous process that has been shown to be effective. Staff also redefined feedback during implementation, and delineating appropriate avenues for feedback has led to staff empowerment to do more problem solving on every level.

Accomplishments

Briefs, including pre-round briefs, huddles, and debriefs, along with SBAR are becoming parts of daily practice. Staff members have been empowered through these tools to speak up, and they feel like valued members of the team. For example, during the second week of implementation, staff members experienced a surge of high patient acuity, specifically extracorporeal membrane oxygenation patients that needed isolation. This heightened staff members' awareness of the need to communicate clearly.

Each month, trainers offer the Fundamentals course, coaches meetings to debrief and plan, change team meetings, meetings for the team that attended Master Training, and a progress e-mail to the administration. Hospital-wide, Master Trainers have trained key staff from pharmacy, X-ray, nutrition, security, nurse's aides, housekeeping, secretarial services, equipment management, and administration.

Lessons Learned

1. Nurses and physicians perceive "assessment" in SBAR differently. Nurses tend to present a physical assessment, and physicians look for an assessment of the situation.
2. Briefs, huddles, and debriefs are effective. The times when staff members think they do not have time to conduct briefs, huddles, and debriefs are often the times when patients could benefit from them the most; in TeamSTEPPS, timing is everything.
3. Listening is key. Listen to those co-workers who are hesitant to buy into TeamSTEPPS; they often have valuable suggestions and insights. Listen to family, as they are part of the team, and can provide an important perspective. And finally, listen carefully to what is being said by your team and engage in check back.
4. Assumptions can be detrimental; don't assume you know what someone means if it is not clear, or that they understood what you said as what you meant.
5. An owner needs to be assigned to follow through on suggestions gathered during briefs.
6. The channels for different types of feedback need to be clearly defined.

Next Goals

Over the next 6 months:

1. Strengthen concepts of TeamSTEPPS strategies and tools through effective coaching.
2. Improve and implement call-outs and check-backs.
3. Develop better handoff processes.
4. Look at other units within the site to implement TeamSTEPPS after completing a readiness assessment.
5. Be available to facilitate training at other sites within the Kaleida System (especially with AHRQ extending training opportunities for 2 more years at one of the National Implementation of TeamSTEPPS training facilities nationwide).
6. Strengthen TeamSTEPPS understanding with a grand rounds presentation by Dr. Karen Frush, Chief Patient Safety Officer of Duke University Health System, in October 2009.

The persistence of the multidisciplinary group of Master Trainers and unification around the importance of improving patient care seem to be the factors that contribute most to the success of TeamSTEPPS.

For further information about these TeamSTEPPS implementation stories, please call (312) 422-2609 or E-mail  AHRQTeamSTEPPS@aha.org.