National Implementation of TeamSTEPPS Program Webinar 10:
Dosing Strategies for TeamSTEPPS™

Moderator: Alex Alonso
May 13, 2009
11:00 am CT

Operator: Ladies and gentlemen, thank you for standing by and welcome to the TeamSTEPPS National Implementation Program Webinar 10: Dosing Strategies for TeamSTEPPS.

During the presentation, all participants will be in a listen-only mode. Afterwards, we will conduct a question-and-answer session. At that time, if you have a question, please press 1 followed by the 4 on your telephone. At any time during the conference, if you need to reach an operator, please press the star 0.

As a reminder, this conference is being recorded Wednesday, May 13th, 2009. I would now like to turn the conference over to Alex Alonso. Please go ahead, sir.

Alex Alonso: Thank you, operator.

I want to go ahead and welcome everyone to our tenth webinar in the series of the National Implementation Program Webinars. Today, we’re fortunate enough to have Laura Maynard from the Duke University health system with us to discuss dosing strategies for TeamSTEPPS.

As a reminder, we ask that you consider others while participating in this webinar. We ask that you please mute your phone to reduce the background noise that you do not put your phone on hold if you have any kind of music or advertisements, and that you recall that any conference call is never better than the worst connection on the call.

At this time, I’d also like to turn it over to my colleague, Cori White, to give you some background on the Live Meeting software.

Cori White: Hi, I know that a number of you have used Live Meeting before but I want to go over it again for those of you who are new with us today. Live Meeting is how we will be doing all of the visual part of our webinar today.

That’s where you’ll see the slides. If you’re unable to get the Live Meeting and are only on the phone, please send us an e-mail at teamsteppswebinars@air.org and I’ll pass on the slides.

For those of you who would like a copy of the slides to print out and that have access to Live Meeting, you can do that at the top right-hand side of your screen. There’s a little icon that looks like three pieces of paper and if you mouse over it, it says handouts.

That’s where you can download the handouts. We provide them both in full-slide format and three slides with space for notes. Also, up in the top right-hand corner of your screen, you’ll see something that says “feedback” with a little colored square next to it.

That’s where you can tell us how you’re feeling about the webinar. It’s a way for you to tell us if you think we’re going too fast or you’re having trouble. The only thing there is that we ask that you don’t use the purple question square because we will not know what your question is.

In order to ask questions – and this is going to be important for those of you who would like to interact with us today – you’ll need to use the Q&A tab at the top of the screen.

It is up kind of on the left and if you click on the Q&A tab, you will be given a space to enter your question. As long as you enter your question there, we will cover it. If it’s something that is very, very individual and more about the operation of Live Meeting, that’s something we will probably answer privately.

Otherwise, we will hold your questions there and cover them at a built-in spot for questions that we have added to our slideshows so that you can enter a question anytime and you’ll get in line to get your question answered.

Again, you need to actually enter your question because if you just raise the little hand or change it to purple, then we’ll know you have a question but we won’t know what it is. Also as the operator mentioned, you may also ask a question on the phone by pressing 1 then 4 and I think that’s all we have. Alex?

Alex Alonso: Okay, thank you. Thank you, Cori. Operator, did you want to say how one can submit their questions via the telephone if they’re not on the Live Meeting software?

Operator: Yes, they can press 1 followed by the 4.

Alex Alonso: Okay. Thank you. So, at this point I want to go over our agenda here today so as usual, we’re going to go ahead and talk a little bit about who we are, what the National Implementation Program for TeamSTEPPS is, then we’re going to get into what is dosing exactly and discuss dosing case studies at Duke as well as how you use dosing to make a sustained effort to make TeamSTEPPS part of your culture.

Finally, we’re going to go ahead and give you some information on how to contact us and contact our facilitator. The American Institutes for Research is the prime contractor in the National Implementation Program for TeamSTEPPS.

We are a not-for-profit, non-partisan D.C.-based research organization that has 11 U.S. offices and 12 international offices focusing on health, education and workforce research.

Our staff includes health services researchers. It also includes nurses and physicians and it includes social and behavioral scientists like me. Our mission is to better society through our research.

The National Implementation Program is a project designed by AHRQ and by the Department of Defense TRICARE Management Activity to create a national infrastructure to support the adoption of TeamSTEPPS through the creation of master trainers and specifically through the quality improvement organization set aside by the 9th scope of work under the CMS contract. Also included in this group is the Patient Safety Improvement Corps organizations.

The goal is really to make training available to all early adopters of TeamSTEPPS and that includes you, most of you who are here on the line, and some of you may even come from organizations such as High Reliability Organizations, partners in the action research network sponsored by AHRQ, and academic medical centers and other types of professional societies or organizations.

The overall goal of the program is to spread TeamSTEPPS and to do so by creating 1200 new master trainers. As you may know by now, the project is supported by four team resource centers.

One is the University of Minnesota. Another is the Creighton University’s medical school. A third is the Carilion Clinic team resource center out of Roanoke, Virginia, and the fourth one is Duke University team resource center.

Laura happens to be a representative of this team resource center and is currently acting as the team resource center lead for all training offered. We have two other organizations supporting us in this project that include former QIO Lumetra and a QIO in the form of Delmarva Foundation here in the Washington area.

We also have two other research organizations providing technical support as we conduct evaluations of our training and the training offered. Those are the Group for Organizational Effectiveness out of Albany, New York and Booz Allen Hamilton out of McLean, Virginia here.

As mentioned several times now, our title sponsors are the Department of Health and Human Services and the Department of Defense and specifically their Agency for Healthcare Research and Quality and the TRICARE Management Activity and the Health Care Team Coordination Program.

The AIR project team is made up of five key individuals: David Baker who is the Project Director and leads the overall TeamSTEPPS program for AIR; myself, I lead certain aspects of the research on this project; Deborah Milne who is the Deputy Project Director for all TeamSTEPPS work here at AIR and leads outreach and user support activities for this specific program – many of you might know Deborah; Cori White who leads administration and supports me in my webinars and research function; and Rachel Greenberg who leads the administrative duties and supports Deborah in outreach and user support.

Nonetheless, we are all an interchangeable team and we are all available to you. Should you want to get a hold of any of us, you can do so by reaching us at 202-403-5000. It’s not up there right now, but you should be able to reach us there. We’ll also provide you our contact information later.

At this point, what I’d like to do is turn it over to Laura. Laura Maynard is an integral part of the Duke University Health System’s chief patient safety office.

She has supported the research involving TeamSTEPPS for quite some time and I’m going to go ahead and turn it over to her so that she can tell you a little bit about what she’s been doing with regards to TeamSTEPPS. Nonetheless, we are very grateful to have you here, Laura.

Laura Maynard: Thank you, Alex, and I’m delighted to be here and to be able to speak to the webinar and all those who are interested in looking at sustainments with TeamSTEPPS.

We want to talk today, want to give you a little overview of what we’re going to talk about when we mention dosing.

This is a piece of implementation planning and implementation follow-through and I want to talk about the variety of ways that you can implement TeamSTEPPS beyond the standard methodologies that we might more readily think of and do that through some case studies of actual activities that we’ve done here at Duke and different ways we’ve been able to utilize TeamSTEPPS in many different settings.

We will talk a little bit about how to determine what’s most effective in which settings and how to use rapid cycle improvement learning cycles, otherwise known as trial and error.

When you put a little planning around trial and error, when you put some intentionality to that, you can actually learn new ways to do implementation and new ways to determine your dosing schedule, so that’s the overview. That’s what we’re going to hope to cover.

This is the implementation timeline that many of you will be very familiar with from your TeamSTEPPS implementation module.

Lots of folks really hate this very busy diagram but I like to use it because it is so incredibly comprehensive and actually gives a map for how to plan implementation.

If folks have all of this really incredible new content and material and they want to go back and do something with it, very often they don’t know how. The “how to” is all spelled-out on this one very busy page.

Dosing as a part of implementation strategy actually fits into Steps 3 and 4 so we’re going to be talking about Step 3 where you define your aim and decide your change type as well as Step 4, how to design a TeamSTEPPS intervention.

What will you use? Which tools? Which strategy? How will you go about actually implementing TeamSTEPPS? So this is going to be in Steps 3 and 4 of the grand plan.

At Step 3 we talk about transformational change versus incremental change and transformational change would be those large initiatives with a staged introduction of the different prioritized tools and strategies.

Usually you’ll do a train-the-trainer or train your leaders, then train the staff and work through leadership role modeling coaching various ways. Incremental change is more small-scale targeted based on your defined need.

It can be a theme-based use and it can utilize those Plan-Do-Study-Act rapid cycle tests of change, but all change requires some level of sustainment planning that you plan in advance what you are going to do after that initial push in order to keep things happening so that culture change can actually take effect.

So we have broken down at Duke our different methods into whether it was transformational change or incremental change and our examples will fit into these models.

Determining your approach for different settings is largely based in your assessment. The results of that initial assessment are going to help you target the tools that you need and the approaches that might be most successful in that particular area.

Your local steering team - the unit-based or clinic-based or whatever the local area is that’s planning the training - need to own their assessment data. They need to really understand it in order to use it effectively, and that’s not as easy as it sounds.

Survey data or observation data sometimes comes to the group in a format that doesn’t make sense, so one of the ways that you can use your assessment to help determine what to actually do and how to figure out your dosing and how to figure which tools to use where, and how many of them can be based in really understanding that assessment data and that can involve helping people interpret and understand it.

For example, sometimes your survey data will come to you in a form that doesn’t make sense to folks in that it will just give you how many responses you had to each question, so we’ll say okay we had X percent that said “I strongly agree” and X percent that agree and X percent were neutral.

And you go across that whole scale for each and every question, very difficult for a local steering team to look at that and help target what they might want to work on.

Where if you take that same survey data and break it down into the percent of positive responses to that question, you begin to group those questions together so that they are looking at one or two data points rather than a gazillion.

Then they get it into something that they can understand, they can own and they can relate to it. The dosing of training maybe very different based on the needs of that local setting, so you want to start with the need and then develop the approach to meet that need.

Do they want to decrease infection rates? Do they want to decrease their turnaround time, decrease wait time? What is it they’re trying to fix? Or, are you addressing some recent bad events that happened and you want to avoid it happening again? That’s going to take a very different approach and a different set of tools.

Or will the training initiative need to be fitted into another project. If they’re working on reducing bloodstream infections and are part of a collaborative that may be taking a whole bundle of approaches at once.

Will you want your training to fit into that, or is this going to be more of a standalone not as directly related to clinical outcomes and issues, more in terms of decreasing for example staff turnover or addressing some other particular need?

So you look at your assessment information with that local steering team and that will help you focus and determine how do we want to dose this? How do we plan the implementation?

We’ve found though that the process is almost as important as the data. The process of your assessment team, of your steering team, is going to show you an awful lot about what you can and can’t do in that setting. It may help you determine your best approach and what your dosing should be.

For example, if you cannot convene an interdisciplinary steering team, then you’re probably not going to be able to train everyone altogether and you might want to plan how you’re going to do that, because your steering team is a microcosm of that area.

And if they can’t work together, then it’s a sign that you’re going to have some pre-work to do in that unit before you may be ready to do a full-bore training.

If there’s a lot of conflict within the steering team, you may need additional pre-work in order to ease into the TeamSTEPPS tools. You might consider providing early training to the steering team.

We usually use the Essentials Overview - the TeamSTEPPS Essentials Course - for the whole steering team so that they can help choose which tools are most relevant to their needs at that time.

But you may find that they need more than that. They may need to learn and practice specific Mutual Support tools if there’s a lot of conflict on that team prior to being ready to train the entire unit. They may need the DESC script if they’re having a lot of conflict.

If it’s impossible to get them to commit and convene, you may need to do some pre-work and the process of completing that assessment and sharing that assessment data with the steering team can help you determine how you’re going to dose things and whether that steering team itself needs that initial dose before you can go any further.

Determining your approach in part involves looking at your constraints and your limitations. The SWOT analysis, having your steering team look at their strengths and their weaknesses - their opportunities and their threats - can help you determine what constraints are we under in planning our training and in planning our interventions and implementation.

This can be done with or without input from the rest of the group. If the steering team is able to get input from the entire group that’s to be trained, that’s great.

If they can’t and you’re just working with just their input and their ideas about the analysis, even that will help you reveal constraints. For example, the budget may preclude paying people for time off to attend training.

Scheduling difficulties might be just absolutely insurmountable in that area and this is where you have to remember your change management piece and absolutely be relentless with that steering team.

As the barriers arise, don’t stop. As the barriers arise, use those as opportunities to determine how can we get more people on board and how can we use the planning process as a model for what the intervention process will be?

You begin to go ahead and use the tools and strategies of TeamSTEPPS to address the issues in planning. You’re going to want to model SBAR. You’re going to want to model structured communication for that team so that they can learn how to talk to one another in a way that will help you overcome the basic limitation.

You may need to look at situation monitoring - what’s really happening in this team, in this steering team, in this planning process? How can the training be integrated into things that folks are already doing?

We run into a lot of issues with people really wanting to implement TeamSTEPPS and not being able to set aside three or four hours of time for an interdisciplinary group to get together and be trained.

That’s not the only way and to help the steering team see that that’s not the only way and that doesn’t mean we have to stop. We will forge on. We will be relentless and we’re going to find another way to fit this in to activities that are already happening.

Ongoing meetings, ongoing trainings, projects that are already in place that can benefit from the use of TeamSTEPPS skills and strategies. If there’s resistance among the steering team, sometimes a tiny little trial with a very small group like the steering team might be what you need to begin.

Sometimes you just try something. We can call that rapid cycle improvement methodology. Basically you say to the folks, we don’t have to commit to doing this forever. Let’s just try it today and then we’ll talk about it and see what worked and what didn’t and often you try that with the folks on your steering team.

If you’re getting resistance to actually making a change and sometimes we have found in our experience that folks are very open to the idea of let’s have some training.

They’re not very open to the idea of let’s change our practice and change the way we do what we do, and of course your TeamSTEPPS intervention is not going to have any impact on your outcomes unless you’re able to change practice.

So does a little practice change with a very small group. You can do a rapid cycle improvement with a sample size of one or a sample size of two or three. Figure out what the steering team thinks might happen if you do for example a briefing with one team on one day.

Say, well this one team on our unit is going to try a briefing today and then later today we’re going to talk about it and see whether that was helpful or not. That’s a debriefing and you can frame that for them, that talking about it.

So this is similar to the Sprint initiative with the World Health Organization surgical checklist where they’re saying try it in one operating room with one team and see what happens, so you don’t necessarily have to be ready and prepared to go out and do everything to implement across the board and then see if it works.

Sometimes you can help people get into it by doing very small rapid cycle improvements with a very tiny little sample and it grows from there. Are we at a question point?

Alex Alonso: I think we are, Laura. Does anybody have - at this point we want to encourage everyone to ask questions and I think we’ll start with the operator. Do you have any questions, Operator?

Operator: I have no questions at this time.

Alex Alonso: Okay. I’m looking at the question-and-answer box and see that we have no questions submitted just yet, but I want to give it a second or two so folks can submit if they have any.

Cori White: Again, remember to use the Q&A tab at the top of your screen. If you are not in the Live Meeting as I know there are a number of you who are not, you can press one four on your telephone to register for a question. Here we have one that came through through Live Meeting.

This person would like to hear more about overcoming barriers at Duke.

Laura Maynard: Okay. I have many slides coming that are specific examples of our implementations including some that say some pretty large barriers, so we’ll get to that shortly.

Cori White: Okay, thank you. Operator, have we had any questions come through on the phone?

Operator: No questions.

Cori White: Well, here’s another one that we have online. This question didn’t come through completely. If this is your question, then please go back in and finish up the rest of it for us and we’ll get it answered.

All right, so here’s a question about the steering team. “Is it best to create a steering team for each unit or as a team for several areas?”

Laura Maynard: In our experience, we have used a steering team for each unit. We find that the specifics of both implementation and training are unique at the unit level or even within our outpatient settings at the clinic level.

One clinic is going to be very different from the next, so you may end up having both steering teams. If for example you’re doing a hospital-wide implementation, you will have a hospital-level steering team but you’ll probably be more effective if in addition to that, you have a steering team at the unit level that really is familiar with the specific culture in that unit.

Cori White: All right, thank you. There comes the rest of this other question. Thanks so much for updating it. This comment now says “Great thoughts, but one problem with the WHO Sprint is it’s quite important that if people don’t know the reasons for the WHO checklist, then there’s likely to be more resistance to using it.”

Laura Maynard: I would say that’s probably in some ways the same thing with a TeamSTEPPS intervention in that if folks don’t know why we’re making a change - if you’re making a practice change like implementing interdisciplinary rounds where you’ve always done rounding separately before or something like that, or using SBAR when you telephone the physician at home.

Any change that you make like that, if folks don’t know why we’re making a change, then they tend to be more resistant to it, so if you’re having resistance to a change, try it small-scale like that with one group but make sure that group knows this is why we’re changing this.

Here’s our assessment and that’s why I like to try those little changes with the steering team because they’ve looked at their assessment data and they know, okay, our scores are low here and here and our outcomes are low there, so this is what we’re trying to fix and we’re going to try to fix that by this strategy, by this checklist, or this practice change, so we’ll try it today and see how that went and then we’ll talk about it at the end of the day and then we can tweak it and change it.

We had an example of that in one of our Duke ICU units that tried to change the way nursing handoff was done as a part of their TeamSTEPPS intervention, so they came up with not just a checklist but it was multiple index cards - like a card deck thing - and it was very large and complicated and it really did not work.

So they tried it on a small scale trying to meet a need for standardizing the way that nursing report happened, but the actual methodology was very cumbersome and did not work.

So because it was a pilot with a few people and just trying it, they were very free then to rework it and try it again and do it another way and do it another way until they came up with something that was very effective.

Cori White: Great. Thanks, Laura. The next question is “How many people should complete the assessment?”

Laura Maynard: Wow. That’s tough. That depends on what you’re going to do with the assessment. If you’re doing surveys - we’ve been struggling with this one ourselves - if you’re going to be using survey data like Patient Safety Culture surveys and you’re using that information to help determine an intervention on your unit, if you don’t - if you’re going to use any of that information for research purposes, you’re going to need a 60, 80% return response rate.

So you need to blanket everybody and have that high a response rate, but if you give the survey out and you only get a 30% response rate, what do you do? I think you can still use that information to help you make a change.

It may not be statistically significant anymore. It may not be research-worthy, but take it back to your steering team and say okay, we only got 30% of the people on this unit to answer this question, but here’s what they said.

Does that resonate? Then you take that back to folks and show it to them and say does this make any sense to you? Does this sound like your unit? If they say ‘oh yeah, that’s us’, then you can go ahead and design an intervention around that.

So I would say it’s ideal if everybody takes a survey. It’s ideal if everybody does it. If you can’t get everybody to do it, you work with what you have.

Cori White: Okay. The next question is “What is the difference between the steering team and the guiding team?”

Laura Maynard: For us, there isn’t really a difference. We call it steering team but basically what we intend is that at the unit level, it’s an interdisciplinary group of leaders and it includes both the official leadership as well as the unofficial leadership.

Folks who have influence and impact on that unit but may not be the official leaders as well as the official leaders who come together to plan what are we going to do to address this issue and if TeamSTEPPS is a part of that, how do we implement TeamSTEPPS on our unit?

So whether you call that the guiding team, the steering team, the planning team, whatever, we call it steering team and that’s what they do, but I’m sure there are other terms that it goes by other places.

Cori White: All right. The next question is “How do you leverage success from unit to unit steering committee?”

Laura Maynard: Sometimes it spreads incrementally and sometimes you try to get that more officially. In other words, sometimes it’ll spread word of mouth. If the units are those that interface with one another at all, if the folks have any connection with one another, they bump up against it and see that something is working well and they want that.

So then they will say, how did you get to doing that? How did you decrease the turnaround time? How did you get your communication more effective? So it will sometimes spread that way.

Other times for example, hospital leadership will take it on and say, this has been very successful in this area and we want to spread it house-wide, so we’re going to do that. We will make this initiative go to everyone, so kind of almost an informal versus a formal approach to how it will spread.

Cori White: Okay. The next question is “Would you encourage patient safety representatives in the respective units to be part of the steering team?”

Laura Maynard: Yes. Very much so. That helps ground it in that - in most units in most cases, TeamSTEPPS’ interventions are grounded around patient safety initiatives.

Now, when we get into other Duke examples, you’ll see that we have a few situations where that’s not necessarily the case and - but for the most part it’s helpful to try to ground it in safety issues and so therefore it’s helpful to have those safety folks on the steering team.

Cori White: Okay. The last question we have right now says “We are in the planning phases of doing a specific OR TeamSTEPPS. We plan to invite nursing, surgery, anesthesia, environmental sciences and materials processing. One problem right now is deciding to do an eight-hour presentation but scheduling seems to be a big problem to get all departments’ representation at the event. Do you have any suggestions?”

Laura Maynard: Yes. I would say you would be very fortunate if you can actually get a good solid interdisciplinary group of everybody together for eight hours. That would be pretty amazing especially in an OR setting.

I know of a few. There are places where they have shut down the OR and done that. Not at Duke, but there are some places where I’ve known that to happen but it’s very rare.

You can do shorter and do more of them. Dosing doesn’t have to happen in one eight-hour training session. Think about if you did two four-hour ones spread over a period of time and you introduce some of the concepts now and some of the skills now, had a chance to practice and did some later.

Add it on. How would that work? Can you do two-hour sessions? Can you do some of the training in another way first so that when you come together, it’s more for interaction and practice and you’ve already received your core content in print or online previous to doing that.

Look at a lot of different possible ways of how you can present that material. In some ways it’s more important that you can get everybody together than it is that you can get them there for eight hours, so it’s always turning that over to look at what’s another way to do this? What’s yet another way to do this? How can we meet the same goals with a different format?

Cori White: Thank you. Operator, do we have any questions or any questions at all on the phone?

Operator: I have no questions.

Cori White: All right, well then Laura, it looks like we can move on.

Laura Maynard: Okay and we’ll have another opportunity for questions later on if some more pop up as we go along. Part of the whole incremental versus transformational approach to change happens with when do you go live with a change - if you’re going to switch to beginning to use SBAR for phone calls for example or you’re going to start doing interdisciplinary rounding or something like that?

If you’re doing little tests of change, are you going to let that success spread by word of mouth as the test group becomes very successful and happy and vocal or are you at some point going to mandate - is leadership going to mandate and say okay, this change is now mandatory for everybody.

So that’s a decision that has to be made in planning is when are we going to go live with this change across the board? When will we expect that everyone’s going to do this in our unit, and even after you’ve done that, even after the concepts and practice changes are very well integrated, you’re going to want to continue with refreshers and reviews and new improvement projects?

It will help keep the awareness fresh and enable people to continue to apply the TeamSTEPPS tools to new problems. As new needs come up, you can apply some of the same tools to those new needs and that can be very, very useful for folks without having to go through another whole training session for something new again.

Many new ways to use the same skills and concepts that you’ve already learned. I’m going to share several examples from Duke - an inpatient unit with a transformation model of change, an inpatient unit with incremental, an inpatient unit with what we’re going to call accidental incremental.

This is an interesting one, because that’s one we sort of tried many, many small little approaches and nothing worked for the very longest of time, and then suddenly it did, so we’ll talk about that.

A couple of outpatient examples and some education examples of ways that we are implementing TeamSTEPPS into our interprofessional education. Let’s start with the PICU because that’s where we started here at Duke.

Back in 2005 using some of the earliest versions of TeamSTEPPS, our pediatric intensive care unit wanted to have a transformational change model within the unit.

They trained everyone over a few weeks period of time. They had very strong internal leadership support in the unit, complete support from everyone. They did four-hour trainings - interdisciplinary groupings.

We hired professional consultants to do the training, to do the coaching, to do the observation, to help with the metrics. We chose several different practice changes to try at one time. Rather than just one, they put in a morning huddle. They put in using SBAR in the nursing report.

They structured their hand-offs very clearly with a checklist and did something as a part of their TeamSTEPPS implementation that they called “sterile cockpit” for rounding, which has to do with decreasing the interruptions that are going to happen during rounding.

And the similar way that in the airline industry - in the cockpit, there’s a time period when you’re doing take-off and when you’re doing landing - there’s a timeframe when you don’t talk about anything else and no interruptions are allowed.

They wanted to put that into place around their rounding process, so they did that with a very complex flow chart that has very particular criteria for when you can break into sterile cockpit and when you break out of it, that sort of thing.

So a lot of practice changes were all implemented at one time and they used some consistent metrics surveys, observation metrics, and also some outcome measures that they wanted to follow. In the first six months, they were disappointed. They felt like they weren’t really getting any traction.

It was a lot of effort initially to get everyone trained up and then when in six months in, we did another survey and attitudes had not changed all that dramatically and none of the practices were changing all that dramatically and it just wasn’t getting - we were hoping for so much so much sooner and it didn’t really work quite that way.

It took a little longer to really take hold, but it did really take hold and by the end of the first year, the difference between six months and 12 months in was pretty substantial and we began to get some very good results.

Good outcome results. They had a decrease in infection rates during that year. They had a decrease in length of stay. They had increased throughput. Their patient satisfaction scores went up and pretty dramatically exceeded their target that year.

Their work culture survey that first year increased by six of - their positive responses increased by 16% so it’s some really good results and by digging in at that 12-month point and continuing to reinforce all those changes, they began to get much better results in the second and third year.

Now that we’re in the third year- and fourth and on - they’re having some pretty fantastic results and I’m not able to share charts and graphs with you at this point because they’re in the process of publishing some of this.

They’ve been very, very satisfied with what happened and have been able to sustain over the long haul. New staff and new residents who rotate into that unit are informally oriented to TeamSTEPPS through a slide set.

They are informally oriented because it’s not a separate initiative anymore. This is just the way we work here, so when new people come on board and they’re working one-to-one with a preceptor, with other folks in the unit, they very clearly get that.

This is just the way we do it here. This is how we do huddle. This is how we do rounds. This is how we do what we do. It’s not a separate teamwork piece anymore.

The tools and strategies are embedded into the workflow so it’s very natural to them and they are able to sustain it and sustain the results that they’ve had because it has become so well integrated into what they do. So that’s kind of our big transformational example. There’s one chart of just critical lab draw time.

This is one that we were able to share that just shows before their team training and then after their team training how much more quickly they were able to get that critical lab draw done, but they have a lot more results now that are pretty dramatic and that they’re looking forward to sharing.

In our Intensive Care Nursery, they looked over at the pediatric ICU and said well now, that’s really interesting. They’re getting some good results and we interface with them quite a bit and some of the same folks work here as there and how do we do this? What do we want to do?

Very different unit, very different culture, even though they were so similar and so close to one another and interfaced with one another, very different culture there.

So later on after the PICU had been in process with TeamSTEPPS for about two years, after that point the ICN wanted to do a full three-hour training for all their staff and they targeted all their tools that they chose around rounding, because they were having a lot of problems with rounding as an academic medical center and we have residents that need to be taught during rounds.

We have many different impacting factors on that and they were having a hard time getting all the info together because they weren’t doing interdisciplinary rounding.

They also had some interesting nursing resistance to residents examining the patients prior to rounding, so the expectation was there that residents would examine those patients prior to the rounds.

Nurses - many of whom had been there 20 years and we have a resident who’s very fresh and new and not very experienced - the nurses were saying no, you can’t examine that patient right now, and so there’s a lot of conflict and a lot of bad feelings around that so there was some conflict to be resolved.

They also had some efficiency problems that were driving their residents into duty hours violations because rounds were taking so very long, so they decided to focus on that one problem that had many different aspects to it.

They wanted to decrease the length of rounds while increasing the availability of current, accurate patient information. We wanted to have the right patient info but we don’t want it to take so long to get there.

So the tools that they chose to implement were SBAR, to use the SBAR structure for their rounding, to teach assertion appropriately to both the residents and the nurses as well as everybody else there, cross-monitoring - awareness of what’s happening with other folks - and to institute huddles.

The cross-monitoring was interesting in terms of trying to increase their situation awareness, teaching that in terms of when is a good time to see this patient and how can I tell if it’s not a good time and how can I be more aware of what the nurses’ concerns are - the resident can be more aware of - what the nurses’ concerns are about the patients?

How can the nurses be more concerned about ensuring that the residents have the accurate information they need so that the best decisions can get made for the patients?

So they focused all of their training around rounding. One issue, lots of skills that could then later be expanded to focus in other areas besides just rounding, and they had some very good results.

The resident team went from ending their rounds on time 25% of the time to ending them on time almost 100% of the time over a seven-month period. Now as far as accuracy of information - current accurate information being available, they didn’t track that quite as closely.

It’s a little harder to measure that than “did we end on time?” We don’t have a metric on that one but they did find that by doing TeamSTEPPS intervention - by doing that training, they - it made them aware of all the issues that impacted rounds and made them aware of issues that were impacting other factors on their unit as well.

By doing their focus all around rounding, they learned the skills and strategies and techniques that now they’re beginning to be able to expand to look at other issues and other measures that they want to impact, so that was another example.

We also have another example at one of our community hospitals - at Durham Regional Hospital - in the labor and delivery unit. They did a unit-based incremental change but a very different example in that they kind of snuck it in.

They didn’t have as strong a leadership support internally. They had the high-level leadership support but on the unit, folks just felt like they had other issues that needed to be addressed rather than teamwork. They did have some nursing staff who became master trainers, so they were able to integrate a few key tools into a low-fidelity simulation drill.

They began doing drills - not a high-fidelity simulation but just use a little mannequin baby and would when they weren’t terribly busy, call a sudden drill, and have a scenario and they would use it to teach critical skills to their staff.

At the same time, they were embedding SBAR, callouts, checkbacks, the CUS words that I’m concerned - not uncomfortable, this is a safety issue - built all of that into the clinical drills.

They never came out and said we’re doing teamwork training. Let’s learn teamwork skills. All the education happened in the drills and in debriefing the drills and the teamwork and communication skills were just integrated into that.

They weren’t called out as something separate. The drills themselves were quite successful and their staff became more comfortable in dealing with some of the high-risk issues that they were drilling on.

But it was difficult to measure. When we say it was modestly successful, largely that’s because I have almost all anecdotal evidence and no clear connection to outcomes from this, so hard to tell. Anecdotally they say yes, it was successful.

We feel like we learned a lot, and they did learn this is what SBAR is, this is what a callout is, a checkback is, without ever scheduling separate training just for those issues. They integrated it right on in to the clinical drills that they were doing so this is the sneaking it in method of unit-based incremental change.

Now, Duke Heart Center. This is our cardiothoracic unit. This is the one I like to call “accidental incremental”. This is the cardiothoracic ICU and step-down units and early on - two, three, almost three years ago - we tried transformational change there using the model from our PICU and it was not remarkably successful. We could say it flopped.

Basically we did the same assessments. We went in and did the surveys. We went in and did the observations. We brought in the professional consultants. We convened a steering team, and there was never any follow-up.

We could not get a plan for training. We could not get an interdisciplinary steering team to sit in the same room for 10 minutes to plan anything. It just wouldn’t happen. We would schedule it and nobody would show up.

Tremendous resistance among these folks to doing this at that time. So, while great clinical work continued to happen there, that unit - our cardiothoracic ICU step-down unit - they had some real issues that they needed to deal with.

They were having very high nursing turnover, like almost 30% annually; really high. They couldn’t get an interdisciplinary team to sit down together and plan an approach, particularly not an approach that was focused around teamwork.

Just a lot of barriers here and we tried all kinds of little things - bringing in consultants didn’t really help; having consultants come in and observe and give immediate feedback didn’t really help.

We tried little things. We used just the coaching module, just the coaching module from TeamSTEPPS by itself without anything else to train the nursing preceptors, just to try to address that nursing turnover problem that they were having.

Many, many little baby steps and nothing seemed to really take any traction so after about a year or so, the patient safety office kind of backed off a little bit and said, you know, maybe this area is just really not ready for a teamwork intervention at this point.

And during the time that we were beginning some of that, they got a new clinical operations director who at one point finally attended TeamSTEPPS master training and became a master trainer.

So when we had given up on them, she became the master trainer and began pushing this through internal leadership and after a year and a half, almost two years of seeding these different team ideas, I’m going to say something probably politically incorrect but I’m going to quote (Mike Leonard) when he says “This is how surgeons learn, okay?”

We had a lot of cardiothoracic surgeons involved in this process and the way surgeons learn is they go from they first hear it, it’s like “that’s the dumbest thing I ever heard.”

The next phase of surgeon learning is “well maybe, but it'll never work,” and the third phase is, “it was my idea.” And that’s sort of what happened in this setting.

Our clinical operations director (Mary Lindsey) began working with these folks and drove them toward teamwork enhancement. She focused their training on their issues.

She was actually able to go to these folks - first separately then starting to get them together in interdisciplinary settings - and framed not let’s do teamwork, but framed their problems based on their assessment as we’ve got really inexperienced staff on this unit.

We’ve got - the majority of our nurses have less than two years of experience and even our preceptors remain at a novice skill level in an incredibly complex system where every patient may have multiple attending physicians.

So how are these inexperienced staff folks supposed to know what to do and how to do it? There’s a lot of confusion. She then showed them that up against the fact that they had incredibly high acuity patients.

Their case-mix index was 12.5. Their step-down units had a case-mix index higher than most ICUs. Really complex, really high acuity patients, really inexperienced nursing staff.

Then she bounced that up against the fact that they had really lousy results in their work culture and safety culture surveys from 2004 to 2008, including things like the statement here on the slide from the safety culture survey.

On the statement that says physicians and nurses work together as a well-coordinated team, 32% of the nurses agreed with that statement and 80% of the physicians agreed with that statement, so there was this major disconnect and she was able to show that to them in the same context as inexperienced staff, high acuity patients, complex setting, poor survey results, disconnect in perceptions - what shall we do?

Well, they decided to apply some of the TeamSTEPPS tools, so they focused on using the critical language - I’m concerned, I’m uncomfortable, this is a safety issue. Here at Duke we also used critical language called “I need clarity” which is another way of saying stop the line, I see something dangerous.

SBAR and huddles. They did something very interesting in that they trained in silos. When they started looking as a steering team at how can we implement these tools into our setting to address these issues, no way they were going to be able to get interdisciplinary groups together.

So she trained the nursing staff separately, the support staff separately, and the physicians separately. But then they were able to work and practice those skills in teams and that’s only possible due to some really strong internal coaches.

She had two or three folks including herself on the unit who knew these skills inside out and backwards and were sufficiently assertive and in an appropriate and respectful way to be able to coach in the moment, in reality.

So that when someone would nudge or look, she would say, “Do you need to say, “I need clarity”?” and she would coach them to be able to do that. She could coach people to do things in SBAR.

She coached the huddles. She would say “we need to do a huddle at this point.” When she was told “we don’t have time,” she said “do it anyway I’ll time you.” And they did it, and she asked them “how long do you think that took”, and they said, “Oh, two minutes anyway, the two minutes that we don’t have.”

She said “it took 21 seconds.” She could coach strongly because she was an integral member of the team in the unit frontline working with them, and its working.

They are measuring their outcomes. The anecdotal evidence is strong. They have strong physician champions for this project now including some of the cardiothoracic surgeons.

They have a good strong interdisciplinary team and they are happy with their results that they’re getting from their team training initiative; very positive attitude. Very positive reactions so far and the culture on that unit is completely turning around very, very dramatically.

We all expect that their work culture and safety culture surveys for ’09 are going to be dramatically different results from what we’ve been seeing in the past four years.

So that’s an example of sort of accidental incremental. We planted the seeds. We gave up and internal leadership took those seeds and began to grow to a point where boom, they could have a transformational change as a result of it.

And they did their training dosing in a very different way. We don’t recommend doing it in a non-interdisciplinary setting but because they had those strong internal coaches, they could train in silos and yet practice in teams and be coached in teams and its working.

We also have some outpatient examples of ways we have utilized TeamSTEPPS. Small-scale single tools for the most part. In Duke’s primary care, in our clinic settings, they - primary care leadership do regular patient safety walk rounds.

They go out to the clinics to be present, to monitor and assess. They use a checklist. They look at certain patient safety issues and they ask staff questions about safety.

Well, in order to keep the staff and the clinic physicians from being intimidated by leadership folks coming out and asking these questions and looking around, they taught those folks some basic assertion skills so that they would be more comfortable speaking up to the leaders about potential safety risks.

That skill then could be carried over into their clinical practice because once they had learned it in the setting of the walk rounds, they had it. They had practice in how to speak up about safety issues, so that they could then carry that over into other scenarios.

Staff was encouraged to speak up and they were recognized positively in the walk rounds when they did so, so that could carry over as an advocacy for patients and as assertion.

Another example we have in an outpatient setting is home care and hospice. They integrated the TeamSTEPPS concepts into existing safety initiatives. Again, small-scale implementation of specific tools into initiatives that are already happening.

They do check back in their pharmacy, and so they taught just the checkback skill in their pharmacy interactions. The home health nurses use SBAR when they call physicians specifically.

They did the coaching workshop for their team leads and their quality and safety core team, as you can see a theme, we tend to use that coaching module for various things even in areas that haven’t had TeamSTEPPS or haven’t had it yet because it helps pave the way and get people used to the idea of giving feedback appropriately to one another and exceeds that idea of teamwork for a group.

They did basic assertion training for their staff. They do it at the beginning of every leadership walk round session. At home care and hospice, their senior leadership goes out into the homes and does a home visit with their staff as their leadership safety walk round.

At the beginning of each one of those, they do a little bit of education and coaching with both the patient, the family and the staff person on please speak up.

I want you to be assertive about any patient safety issues that you know of, if anything’s happening that you’re not comfortable with, you know, I’m here to hear that so I really encourage that assertion.

Even in that setting which is very different from an inpatient setting, they’re utilizing several of the TeamSTEPPS concepts and tools but they’re just embedding them into particular safety initiatives. So, what questions about that part?

Cori White: The first question we have is, were the residents more satisfied during their ICN training experience?

Laura Maynard: We have not actually assessed that, so as far as looking at satisfaction survey scores - that sort of thing - anecdotally the ones that were there during the change period, I’d say yes and no.

They were more satisfied with having a structure for being able to get information about their patients, but they were maybe less satisfied with a lot of the onus being put on them to learn a new skill and to frame things in SBAR for example.

It’s kind of a mixed bag with that very first group who were involved in the training. Once the changes were implemented in the ICN and it was just the way they do business, I would be interested in seeing whether their residents are showing more satisfaction with that rotation than with others now, and we really don’t have data on that.

Cori White: Okay. That’s the last question we have online for the moment. Again, if you have a question and you’re connected through Live Meeting, please use the Q&A tab at the top of your screen in order to enter the question and we’d be happy to answer it. Operator, do we have any questions on the phone line?

Operator: I have no questions.

Cori White: Great. Again, if you would like to ask a question on the phone, please press 1 and then 4 and you’ll get in line for one. I guess if we have no questions at this time, we can move on.

Laura Maynard: Okay, thanks.

Operator: Pardon me for the interruption. We do have a question here. Please proceed.

Participant: Couple of questions. On the CMI and the ICU, did you really mean 12.5 or did you mean 1.25? A second question...

Laura Maynard: It really is 12.5.

Participant: Oh, okay. Second question regarding your comment about the nurses' resistance to the doctors’ examining the patient. I didn’t quite understand that, and my third question is what’s happened to your nurse turnover since you’ve implemented this process?

Laura Maynard: Okay. In the ICN project, the nursing resistance was that we had the residents would be coming around prior to rounding and would want to - in the intensive care nursery - wake up the babies or interrupt the babies when they were with the family.

The nurses were saying no. You’re going to see them during rounds. You’re going to examine them then. I don’t want you to do it now and then, and so they were kind of resisting letting the residents mess with the babies at that point.

That’s changed some. It’s not happening in nearly the same way as it was anymore and it also was a mutual respect issue that they were doing that in ways that were not necessarily helpful. Again, not everybody, not across the board, but that was an ongoing issue there in that unit.

That’s something that has improved as a result of the teamwork intervention, both in terms of the nursing staff being more respectful in general to the team and with structure around this is when we will see the patients and we will have some situational awareness around when’s a good time and when is a time we should come back and not bother the baby again right now.

That was that issue. The third question was in regard to nursing turnover, and I don’t have the data from the ICN. That wasn’t so much of an issue there. That was more of an issue on our cardiothoracic ICU and step-down and it’s too soon to tell yet.

We don’t have this year’s turnover data to compare with the previous year’s yet. They have just implemented this TeamSTEPPS major transformational initiative since February.

So while they’re in a lot of enthusiasm and a lot of good things happening, no real results yet from that in terms of impacting turnover. We’re assuming that it will but so far we don’t have data to back that up.

Cori White: All right. Thanks. We did have one pop in online. It says “In your transformational change model in the PICU, what enabled the unit to stay on course, especially over a many-years timeframe?”

Laura Maynard: Probably a couple of things. One was success breeds success so that as they got good outcomes and good results from the changes that they made, that provided the kind of feedback that enabled them to maintain those changes and keep doing those things. The other key piece was leadership commitment.

The leadership of that unit was extremely committed to doing this. They felt strongly that if they could hang in there, they would get a good response and they were not going to give up on the teamwork initiative even during that first six months when it didn’t seem to be bearing much fruit initially. They were committed to it, so I think leadership support is one of the biggest things that can help push something on through.

Cori White: Okay, thank you. We do have one person in our Q&A tab who has just done the little raise your hand icon. Again, we ask that you type your question into the Q&A tab or else we don’t know what it is in order to answer it.

There’s also a question about where you can find the PowerPoint presentation slides. Again, there is an icon at the top right-hand side of your screen that looks like three pieces of paper.

If you roll over it, it says handouts and that’s where you can download the handouts. If you are unable to download them there, please send us an e-mail at teamsteppswebinars@air.org and that’s webinars, plural, just to make sure that we get the e-mail.

Well, now I have two people who just have their hands raised. Please, I’m not going to call you out by name, but we do need you to write-in your entire question or else we cannot call on you.

Now we have a comment. This person says “This is one of the best discussions of the value of using TeamSTEPPS in a flexible fashion. Whether or not you use an incremental change or transformational change, one of the most important implementation strategies is to start TeamSTEPPS with some concrete change that proves valuable for everyone. This then leads the way for more invasive steps, tools and concepts.” Well, thank you very much for your feedback. We always appreciate it.

Laura Maynard: Yes, and I would just agree with that completely. That has certainly been our experience here.

Cori White: All right. Operator, do we have any more questions on the phone?

Operator: Yes, I do have a question on the line. Please proceed.

Participant: Yes, I was interested in the cardiothoracic unit training and the fact that they would only do it in silos and I was interested if they noticed that the culture has changed or there has been more acceptance, if they’re more willing to train together now?

Laura Maynard: Not yet. A lot of that has to do with the kind of problems you’ll run into in a lot of units with scheduling. It’s very difficult to get everybody together all at the same time and now that they’re finding some success with training in the silos, I doubt if they’re going to move forward to doing training altogether.

But because they focused on a few skills and each group really bought into those skills and uses them and because they have the strong internal coaching, it works.

Everybody comes out of their training and into their actual work and knows that oh yeah; we are supposed to use SBAR in this setting. Okay. Here’s somebody telling me, remember? That’s not the situation.

Put the situation first and they do it and they can take the coaching because everybody has the same background, same framework for it, even though they learned it together so they’re actually doing their training kind of on-the-spot, in the midst of their work.

They’re doing that integrative part that a lot of folks do through role-play. They’re actually doing it in real-time.

Participant: Thanks.

Cori White: Do we have any other questions on the phone?

Operator: We have no other questions.

Cori White: All right, it looks like we have no other questions in Live Meeting. Again, if you have a question, please type it into our - oh, they just keep popping up. You guys are full of great questions today.

“Would you be willing to expand on how the “I need clarity” tool was used in the heart center and how that differs from CUS?”

Laura Maynard: We use it to supplement CUS and we use it as a stop-the-line comment so if somebody sees something that they think might be dangerous or if they just don’t understand what’s going on enough to know whether it’s dangerous or not but they’re concerned, it’s a way of saying I’m concerned but you can say clarity in front of a patient or a family member without them necessarily getting upset about it.

It’s not an upsetting comment just to say “I need clarity” and everybody pulls aside to huddle. That’s pretty much how it’s used if somebody wants to question something rather than saying are you sure that’s the right dose, they’ll say “I need clarity” and it’s a way to do that without undue alarm. It’s just a code phrase.

Cori White: All right. The next question is “Did the CV unit use other socializing events?”

Laura Maynard: I’m not sure I understand the question completely.

Cori White: Okay.

Laura Maynard: I’m not sure what they mean by other socializing events, but no - actually no, they didn’t. If what you mean is anything other than their specific training in silos, they didn’t. They haven’t done any other activities altogether other than just integrate the actual skills on the job.

Cori White: Okay. If that doesn’t answer your question, we encourage you to clarify and we’ll come back to it. The next comment is “it seems to me that the themes of mutual support, mutual respect, situation awareness and situation monitoring, and joint accountability for the patient’s safety outcomes being the shared mental model, when these themes are strongly woven through the use of dosing, the culture teams may indeed come about.”

Laura Maynard: Yes, and I would agree with that. I would agree with that, that it’s almost like you’re weaving the language and the concepts into what you already do.

So this isn’t an add-on of some sort. This is the way we practice medicine. This is the way we practice nursing. This is what we do. So yeah, I would tend to agree with that.

Cori White: Okay. The next one is, “are there any common physician concerns or frustrations that might be used as the core problem that they should tackle to better engage them in the TeamSTEPPS training?”

Laura Maynard: Our experience has been that that differs from unit to unit and sometimes from specialty to specialty, so you really have to find a way to ask them that, and not necessarily in terms of what would you like to see accomplished through team training as much as what would you like to improve around here?

What would make it more possible for you to do your work in an effective, safe manner? What do you need? And asking those sort of questions will get you at things usually that can be addressed through teamwork.

We found a big difference in asking people “What’s your concern here? What are the safety concerns? What are the efficiency concerns? What do you need here? What would make life easier on this unit and what would make life more effective in your healthcare and more safer for your patients?” And then go from there to build out, particularly in engaging the physician.

You have to ask and it’s helpful if you can get one champion who is willing to do the asking. Sometimes you have to just cultivate the one person who may have read about this sort of thing elsewhere or who is involved in a lot of quality improvement initiatives or research otherwise. Someone who’s a likely candidate to get on board. They’re the best one to go back to their peers and ask, “What do we need here? What’s going to help?”

Cori White: Okay. The next question - oh, this is a good one. “How did having a Master’s in Divinity help you help the steering teams?”

Laura Maynard: Interesting. You know, that is a good one. Same way it helps with most anything else you do. My education taught me listening skills, basic counseling psychology type skills, and basic communication skill and that’s the same things you use to work with any group and facilitate any group anywhere so I would say that’s probably the best answer for that.

Cori White: Okay. The next one says “Our experience is that the discrepancy between nurses’ and doctors’ view of teamwork is universal. Nurses think its poor and doctors think it’s great. It presents a huge barrier for getting docs involved in transformational change. Do you have some thoughts?”

Laura Maynard: Yeah. I would agree that from what I’ve seen, that does tend to be fairly universal, usually not quite as marked as it was in that one unit, not that drastic a difference, but there’s often a difference in the way teamwork is perceived.

I think a better approach - for the nurses who are not perceiving the teamwork to be so great, enhancing teamwork is a good end in itself, but you’re going to have a hard sell convincing people who already believe the teamwork is pretty good that know other people don’t see it that way.

Now sometimes just that type of assessment and survey data will help them see that. Just to see the answer to that question and realize, whoa, other people don’t see it the way I see it. That can help sometimes.

Other times it really helps instead of framing it in terms of teamwork, frame it in terms of what’s the need here? What’s the patient’s safety issue here? It’s not that we’re enhancing teamwork for the sake of enhancing teamwork.

We’re enhancing teamwork to deliver better care and to keep these patients safer in these highly complex settings; an example being in that cardiothoracic unit.

It wasn’t as easy to get those surgeons and other physicians on board when we just said high nursing turnover, unhappy nurses, teamwork lousy, but when we said inexperienced nurses, high acuity patients, very complex setting, high risk - how do we address that?

That was a whole different package. They could perceive the need in a different way, so sometimes you need to ground it more in the clinical need and less in the teamwork need. The teamwork need will take care of itself anyway, once you apply these skills and these concepts to it.

Cori White: All right. That looks like maybe the last one through Live Meeting. Operator, have we had any more questions come up on the phone?

Operator: I have no questions.

Cori White: All right. Laura, it looks like you can move on.

Laura Maynard: Okay. We have another piece of dosing that we’re looking at at Duke and that has to do with teaching folks about the TeamSTEPPS concepts, not just in clinical settings but to incorporate this throughout their professional education.

So we’re studying and considering what’s the right dosing for students? When should they have it? What should be introduced before they ever enter a clinical setting? What’s more effective after they’ve had some clinical experience? What needs to be repeated throughout their course of work?

If you’re a student in the school of nursing or the school of medicine, when do you need TeamSTEPPS to happen initially? When should you have some follow-up? What do you need before you get out there on a clinical unit?

What do you need to prepare you for the fact that you may go into a clinical unit that doesn’t use any TeamSTEPPS concepts or methods and what will you do then to help keep your patients safe?

What skills do you need for that? How does TeamSTEPPS fit into the bigger picture of patient safety and quality improvement education? So we’re working a lot right now with small pilot projects, tests, learning, trying to answer some of those questions.

Some of the studies and projects that were done around that are pretty interesting. In the school of medicine, we do a patient safety clinical core. It’s a one-week session, all on patient safety with our second-year school of medicine students and it’s their first introduction to TeamSTEPPS.

They get the TeamSTEPPS through an overview web course so they have a web series, like a little - it’s not really a webinar - it’s a presentation online and it has the slides, it has video clips.

It has interactive questions and they see that, then they do a team-based learning exercise using video clips from the TeamSTEPPS CD so that’s their first introduction in second-year medical school.

Then we get folks on into an interprofessional education. We had a grant funded study in 2007 for interprofessional, interinstitutional study of teamwork education.

We worked with UNC and we worked with the school of nursing and school of medicine from both schools using TeamSTEPPS in lectures, in audience response system, in role-plays and in high-fidelity simulation.

It was a large fascinating study, very complex. Here are some photos from that first experience where we had over 300 students, about 70 faculties, many, many support staff on hand. We ran ten high-fidelity simulators at the same time. Turned them over and did ten sessions again to get all students in that cohort through.

We developed scenarios that used the exact same scenario for learning the concepts whether it was in lecture, in an audience response system lecture, in a role-play setting, or in a high-fidelity simulation setting.

So we did all that to study the different impacts on learning. Did they learn the TeamSTEPPS content differently based on those different modalities? That’s what we were studying.

We evaluated that using this Kirkpatrick Evaluation Model of results basically and we used this model to evaluate our TeamSTEPPS training across the board, whether it’s in clinical settings or in the schools to look at reaction, learning, behavior and results.

The reaction is basically what was your reaction to the training? Did you like the training? What did you think of it? So it’s like a satisfaction with the training survey.

Then we looked at learning. Did your knowledge increase, usually based on a knowledge test and self-perceived skills? Then we look at behavior changes that have to be based in an observation of their teamwork behaviors during patient care or during a simulation.

Then results. Has there been any impact as a result of this training? Have we improved quality at all? Have we reduced adverse events, decreased costs, any return on investment, etc.? Have we affected any of the outcome measures based on this?

That’s the way we try to evaluate our training across the board and we were looking at that with the students as well. Interestingly enough, as a result of that study just kind of on the side, the knowledge test results indicated that while everybody gained in knowledge over time from pretest to post-test, no one cohort gained significantly more than another which was interesting.

That was not what we were anticipating. We really thought the more interactive ones would increase learning far more than the less interactive ones. That was not the case.

We also looked at attitude survey results and again, pretty much the same thing. All this boils down to saying everybody’s attitude improved over time. No one cohort had an increase in attitude - in safety attitude - that was significantly higher than the others.

Taking that information, we went into the next year of this same interprofessional education model and tried to make it more sustainable, tried to make it more something that folks could do more easily. We didn’t have the grant funding anymore.

The initial project was extremely costly and in terms of faculty and student time. Without the grant funding, it wasn’t going to be possible to continue it and part of the purpose was to develop something replicable that other folks could use.

In 2008, we scaled it way down and did the same basic process separately on each campus - Duke and UNC. We eliminated the high-fidelity simulation and we developed a webcast that has an overview of the TeamSTEPPS content, has examples and language adapted for students.

We still use it although it’s very imperfect. E-learning is a really popular, sustainable way to do this. There’s only the initial cost. There’s not an enduring cost.

We still use this webcast even though it’s pretty clunky and we’re hoping that better ones will be available very soon, but the link for it is up there and if you download your slides so that you have them, feel free to go to that link and use that webcast as you wish.

It’s kind of an interesting tool and again, it’s designed pretty specifically for students. It’s about 45-50 minutes long and it gives similar to TeamSTEPPS essentials overview but geared towards students.

Then in 2009, the grant funding was all gone and we wanted to continue doing something in an interdisciplinary session for students from our school of nursing and school of medicine.

We wanted to continue it but we didn’t have any funding for that, so we continued to use the webcast as prework and because of scheduling difficulties, we held this in the evening so that we could get folks together interdisciplinarily and we did another session where we used team-based learning for their small group work rather than role-play.

So we wanted to try to keep the content and experiences available for the students in an interdisciplinary format but we had to find a way to make it more sustainable so we had to do it in the evening to get everybody together and the key is that you get small groups of folks together so that medical and nursing students are interacting with one another around the topics of healthcare teamwork.

And team-based learning seemed to be really the way to go with that so just one quick slide on team-based learning. It’s another method to teach TeamSTEPPS content and while we’ve only tested it in the schools so far, it’s kind of promising as a way to teach clinicians also.

We use the same case scenarios that we developed for the interprofessional training in 2007 and taking those same cases, we adapted them into this methodology.

Team-based learning, it includes a first activity where you have an individual readiness assessment test, so that’s just a quick test of content mastery from the webcast.

You watch the webcast at home or you can do your reading at home, then you come into class and individually you take a little 10-question knowledge test.

Then you do that same test as a group so you’re assigned to a small group that mixes up students - doctors and nursing students - and do the readiness test together.

Well you’ve already done it individually so now you have to start using some team skills and communication skills to figure out well, I answered A to that one and you guys are all saying B. How can we work this out?

How can we come to consensus on what our group answers are? So the groups were directed to achieve consensus. They had scratch-off answer sheets that they used to identify all the correct answers which they liked.

They find that fun. You get a star when you get to the right one so you know you haven’t got to the right one and you have to keep scratching till you get the little star, so we did the group readiness assessment.

Then you debrief that and you talk about it and in your debriefing, you talk about not only the content but also the group process. How did you come to that decision? How did you reach consensus? What team skills, what communication skills did you use to do that?

Then there’s a longer session of group application questions where within their small group, we presented questions to them that had more than one correct answer and the group had to come to consensus on an answer and it was a low-fidelity audience response system.

They had signs that had letters, A, B, C, and when we would ask them to do so, the groups would hold up their answer letter so everybody hold up your answer and someone had an A and someone had a C and everybody could see that immediately.

Then you have the group’s debate. Well, why did you pick this answer? Why did you pick that answer? That really brought out some good, good discussion because the questions are designed in such a way as to have more than one correct answer but some are slightly more correct than others.

They’ve very subtle, so debate ensues and the groups have a chance to work that out and you can give them feedback not only on the content but again, on their process of working together as a group and communicating so it was pretty effective.

They enjoy doing it. It’s pretty high-energy. It’s very inexpensive. It takes far fewer faculties than doing role-play. It seems to - we’re not sure, we don’t have the results back from this year yet - but we’re hoping that they will increase their knowledge at the same rate as the students did in previous years.

No chance to actually practice and role-play the team skills, so there’s a weakness to it, but it may yet be something that’s effective for students and there may be some application of team-based learning to folks learning these concepts in a clinical setting as well.

We’re also looking at using TeamSTEPPS across the continuum of education. We want to move in this coming year into introducing some of these core concepts into our undergraduate schools, as well as partnering with the community college allied health programs in our area to begin to bring patient safety education including TeamSTEPPS there.

Continue to figure out what’s the best dosing schedule in schools of nursing and medicine, to then continue TeamSTEPPS in some manner through graduate medical education, through CEU and CME for clinicians, and into leadership education for folks who are hospital and health system leaders.

We’re doing a lot of studying this year on how can we best dose TeamSTEPPS from the time folks very first begin to have some consideration of healthcare as a possible profession right on through to becoming senior leaders in that field?

What do they need to know about teamwork and communication as related to patient safety in that regard, so we’re pretty excited about the future of looking at this and what that might be like.

So what further questions based on dosing in educational settings?

Cori White: All right. The question that we have right now is “Can you clarify the teamwork attitude survey tool that you used in your interprofessional student education? The previous team assessment questionnaire tool provided by AHRQ or the newer and thankfully shorter and TeamSTEPPS-specific T-TAQ?”

Laura Maynard: Ah. Either one of those would have been good to use, especially the newer one would have been great. What we actually used was something that was designed by the researchers at UNC specifically for students.

Its questions are not as clinically based. They’re more based theoretically and from the perspective of nursing and medical students. It’s called CHIRP and I can’t remember what all the letters stand for, but it was a very specifically-designed attitude assessment for that project.

Cori White: Well, great. Again, if you have a question, we ask that you please type it in in Live Meeting. That way we can address it. Otherwise, if you’re unable to access Live Meeting, you can press the one four on your telephone to register for a question. Operator, do we have any questions lined-up on the phone?

Operator: I have no questions.

Cori White: All right. We’re giving you just a little bit of time to get your questions all typed in. I’m seeing them pop up here. It looks like we’ve got a bunch. The next one is, “Is there any evidence that students and/or residents can push attendings or faculty into team behaviors by the student resident modeling the behavior?”

Laura Maynard: We haven’t seen any evidence of that yet and we see that they are very resistant to do that, so what we try to focus on are again ways that are less threatening for them to raise a concern if they truly see something that they think is dangerous, and the expectation of teamwork so that they can model it to whatever extent is possible, but there is a barrier there.

If you have students coming out and residents coming out into clinical settings that don’t have good teamwork skills, all the studies that I’ve seen so far indicate they lose those skills pretty quickly and they lose any interest in pushing that forward if it’s not a part of the culture they come into.

Cori White: Okay. This question says “What is high-fidelity simulation?”

Laura Maynard: High-fidelity simulation uses a mannequin that is hooked up through computers such that when you make a clinical intervention on this mannequin, it actually responds to very similar to the way that a real patient would.

It has a blood pressure. It has a heart rate. It has a temperature. It hooks up to the monitors. You can see everything that’s happening with it.

It’s usually used in teaching clinical skills but is also very useful in teaching the teamwork skills around that.

Cori White: Okay. The next question is “In the knowledge test results, how is it done? How did you get this data? In the role-play, how was it evaluated?”

Laura Maynard: Okay. In the knowledge test, we gave pre- and post- tests that were knowledge tests based on the learning benchmarks in TeamSTEPPS. Some of the same questions, some very similar questions, some questions that were made up to be in that same basic format, so very brief case, multiple-choice questions.

We used different questions but same concepts being tested upon for pre and post to compare the knowledge. The role-play assessments were done based on a behavior observation tool. Similar to the one that’s in the TeamSTEPPS material but shorter and focused more specifically on the scenario that was being used in the role-play.

Within each role-play setting, we have four students doing the role-play and four observing, and the ones observing would use that scoring sheet to evaluate.

In the first year, we actually were able to videotape those that were doing the high-fidelity simulations and so that we could look at those tapes later using that same observation instrument to score the teamwork behaviors on those.

Cori White: Okay. This one I think is actually a question for Alex.

Alex Alonso: Yes.

Cori White: It says okay, it says when will the free training for this program end?

Alex Alonso: This is a question that I cannot answer at this time. I do know that AHRQ and the Department of Defense have received this question on occasion and are working toward a response.

So unfortunately, I cannot offer a concrete answer at this time but I will say that Jim Battles at AHRQ and Heidi King at DoD have received this question on numerous occasions and are working toward a response for that.

Cori White: All right. The next question is “Can the team model work as well when the medical staff refuse to let hospital staff use their first names? Will assertion skills overcome that culture in your experience?”

Laura Maynard: I think it can work when you’re not using first names and I think you can enhance culture and develop more teamwork even when that doesn’t happen. We don’t always at Duke, focus on the first-name thing and often don’t focus there first.

We do focus on mutual respect, so we bring that concept forward and if within the unit folks feel like it’s a sign of mutual respect to use all first names with one another, then yeah. They can decide as a group that that’s a change they want to make.

Usually they don’t. Most of the changes are more focused around patient care issues and those sorts of ‘What do we call each other and is there a hierarchy difference between folks?’ issues.

We haven’t addressed that as directly because we find greater success in improving mutual support and improving mutual respect by focusing on the patient rather than by focusing on what we call each other. I don’t think that that’s getting around it.

I don’t think that that’s copping out in that regard but maybe sometimes it is. I’m trying to think if there were a scenario where that was really important to the nursing staff and the medical staff really refused to entertain the idea, my hunch on that would be there’s something underneath that, that that’s a symptom rather than a cause.

I would want to start talking to folks and doing more assessment there to figure out what’s the issue here and how’s that going to affect your patients? What’s the impact going to be on patient safety?

Cori White: Okay. This person has a comment that says “We have implemented TeamSTEPPS with resident-led sessions, which has been very successful at our organization.” I guess –maybe if they want to expand more on that, we could get them on the phone.

The next question we have says “Going back; could we get a look at the sterile cockpit flow chart materials?”

Laura Maynard: I’ll have to check and see if I can make that available or not. Again, a lot of the detail of what was done in the pediatric ICU is being published, and so they’re not wanting to too widely share too much of the data and too many of the details about their process until they can get that into print, but I can check and see.

Cori White: Okay.

Alex Alonso: Cori, I’m going to tackle the next one which is “What was the contact phone number given at the beginning of the program?” There was no contact phone number given in the slides at the beginning of the program but I’m going to go ahead and give it to you now by jumping forward.

You’ll see here that we have some resources as far as where you can find TeamSTEPPS which includes the teamstepps.gov website, the TeamSTEPPS guide to action which is available on both these websites.

The other one which is the dodpatientsafety.usuhs.mil site and you’ll note that at the DoD patient safety site, you’ll also be able to find numerous resources including some that were sent to me here today like the TeamSTEPPS modules online as well as all the videos online and you can access that anywhere worldwide.

Let’s see here. Here is our contact information. You can reach us through any one of these individuals including myself; I’m Alex Alonso at 202-403-5000. You can also reach us at teamsteppscontact@air.org or teamsteppswebinars@air.org.

At this time, Cori, I’m going to turn it over to you to do the polls and say thank you to Laura and to everyone for having attended. Cori, go ahead and get the polls going.

Cori White: Yes. We have two quick poll questions for you today and these just sort of give us an idea of how we’re doing. We ask them at the end of every webinar. We’d like your feedback on how we’re doing.

So the first question that we have is how useful is the information provided here to you, and that should be open for voting. I’ll give you just a minute to answer or continue asking questions if you have more questions.

We have a comment that says they really enjoyed Laura’s presentation and I’m sure that she loves that feedback.

Laura Maynard: Yes, thank you.

Cori White: So I want to make sure I pass that on. It looks like the voting has sort of stabilized so I’m going to...

Alex Alonso: Go ahead and close the poll.

Cori White: ...close this and I’ll show you the results. Looks like most of you found it pretty useful and we appreciate that. The second question that we would like to ask you is would you recommend these webinars to other people and for those of you in shared rooms, I say that you will have to fight for who gets to the computer first to answer.

While we’re having the poll questions answered, operator, do we have any other questions lined up on the phones?

Operator: No, I have no questions.

Cori White: Okay. It looks again like your responses have stabilized. I’m going to close the poll and show you the results. It looks like many of you would recommend us to others and again, we appreciate that. Thank you very much.

We’re going to give you just another 30 seconds to get questions typed in because we do want to be able to address all of your questions live because we know that that helps some people.

We’re just getting some feedback. Thank you very much for your feedback through this Q&A tab.

Alex Alonso: We do want to thank you all for your feedback and I do want to say that Laura, we do really appreciate you providing this information here today and I will let you know that the feedback that we’re receiving thus far had reinforced that the Duke experience is a very common experience and it’s something that folks really can take and learn from and so we’re grateful that you were here today.

Laura Maynard: Thank you very much. It’s a delight to be able to be here.

Alex Alonso: All right, folks. At this point, I’m going to say goodbye since we’re running two minutes over. Thank you again for attending. There will be a webinar on June 17th, Wednesday, June 17th from noon to 1:30 and that will be the next webinar in the series and that one deals specifically with simulations and recurrency training of TeamSTEPPS.

So as you can see, we’re following the sustainment theme and we look forward to seeing you then. Take care.

Operator: Ladies and gentlemen, that does conclude the conference call for today. We thank you for your participation and ask that you please disconnect your lines.