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.
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
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
Two Senior Respiratory Therapists:
- Supervisor/Transport Team Coordinator
- Pediatric/Neonatal Transport Therapist
- Chief Patient Safety Officer
- 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
- First year PICU Fellow
Five Registered Nurses (RNs):
- Director of Nursing Practice of Kaleida
- RN Nursing Supervisor
- PICU/STAT Team RN
- Director of Quality and Patient Safety RN
- 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
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.
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.
- Nurses and physicians perceive "assessment" in SBAR differently. Nurses tend to
present a physical assessment, and physicians look for an assessment of
- 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.
- 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.
- 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.
- An owner needs to be assigned to follow through on suggestions gathered during briefs.
- The channels for different types of feedback need to be clearly defined.
Over the next 6 months:
- Strengthen concepts of TeamSTEPPS strategies and tools through effective coaching.
- Improve and implement call-outs and check-backs.
- Develop better handoff processes.
- Look at other units within the site to implement TeamSTEPPS after completing a readiness
- 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).
- Strengthen TeamSTEPPS understanding with a grand rounds presentation by Dr. Karen
Frush, Chief Patient Safety Officer of Duke University Health System, in October
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.